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Now we're gonna talk about asystole. Asystole means that there is no discernible electrical activity in the heart that can be seen on an ECG monitor, and there's no pulse. Survival rates are very poor when a child or infant is in asystole. This is the reason so much emphasis is placed on prevention of injuries and aggressive treatment of illnesses that could lead to cardiac arrest. In addition, a healthcare provider needs to focus on early recognition and treatment of respiratory distress, respiratory failure and shock, before they actually cause cardiac arrest. Identifying and treating preventable causes of cardiac arrest using the H's and T's is crucial to saving the life of an ill or injured child. If you have a patient that appears unresponsive, start by tapping and shouting to verify. Call for more advanced care. In a hospital setting, this might include calling a code. And in a pre-hospital setting, this may include getting assistance from another ALS unit, if needed, or getting a higher level of transportation. Next, we're going to assess circulation and breathing by checking for a carotid pulse on a child or a brachial pulse on an infant. We should look at the face and the chest at this time for signs of breathing. For a patient with no pulse, CPR should be initiated immediately. For a child or infant, we're gonna give two-person CPR with high quality CPR, and those need to be performed with as few of interruptions as possible by giving cycles of 15 compressions at least one-third the depth of the chest at a rate of 100 to 120 per minute, followed right away by two rescue breaths. Now the depth is going to be about two inches, and on an infant, about one-and-a-half inches. The compressor needs to be changed every couple minutes to avoid fatigue. The airway person would measure and prepare a proper-sized basic airway adjunct and ventilate with 100% oxygen delivered via bag valve mask at 15 liters per minute. Two breaths would be given after each set of 15 compressions. The defibrillator pads should be applied right away, now that compressions and breaths have begun. At this time, the leader calls everyone to stand clear while the rhythm is analyzed. If the patient is in asystole, it's important to double-check some easy things to correct this type of ECG rhythm. First, are all the leads on correctly and are they all attached with good contact? Is there sufficient power given to the ECG? Is the amplitude set correctly so as to determine asystole versus fine v-fib? And if all these are answered yes and working, now the team leader may continue. At this time, the team leader states let's keep giving high-quality CPR because asystole is not a shockable rhythm. Now is the time to move to the IV or IO access in order to begin medications and fluid replacement. A very helpful tool in resuscitation is a length-based, color-coated tape, such as a Broselow tape. It can help advanced care providers to determine things very quickly and efficiently, like a child's weight for calculating drug doses, and for selecting the correct sizes of resuscitation equipment. For example, an average nine-month-old would measure within the red` area of a color-coded, length-based resuscitation tape. Now if they're in the red, that would estimate that the infant's weight to be about eight kilograms. It would also tell us that a 22 to 24-gauge IV catheter should be used, or that an 18 to 15-gauge IO needle should be used. Now when the IV or the IO is established, the team leader should call for 0.01 milligrams per kilogram of Epinephrine, 1:10,000, to be delivered IV or IO push. And then remember it's important to flush that medication with 20 cc of normal saline. This ensures that the medication gets into the central circulatory system. It's also important that compressions are being given with the medication in order to get it properly circulated. It also makes sure that the person is getting the best circulation of oxygenation, and we're not taking breaks of CPR while trying to administer medications or start an advanced airway. All of these things are vitally important when it comes to basic life support. Now in the circumstance that an IO or an IV is not available but an endotracheal tube is in place, Epi could be given down the ET tube, but the ratio of that medication is gonna be different. We're gonna deliver it 0.1 milligrams per kilogram but 1:1,000. Medications delivered via the ET tube is not as desirable as IO or IV because the results are not as predictable. However, the potential benefit of the medication outweighs the risk. Now after initial treatment, it is a good time to insert an advanced airway. After an ET tube or another advanced airway is in place, you would move to continuous compressions. Breaths would change to one breath every 2-3 seconds. Also, remember to switch compressors every two minutes. When the compressor calls for a switch, the airway person would finish a breath. Before the next rescuer begins compressions, it is a good time to do a quick look at the monitor for changes. This should take no longer than 10 seconds before CPR is resumed if there is no change in the rhythm. Capnography should also be attached to monitor compression quality and gas exchange. Repeated doses of Epinephrine 0.01 milligrams per kilogram of 1:10,000 IV or IO push should be given every three to five minutes. Once initial treatments have been started, it's important to ask the team to help in considering potential causes of why this patient went into asystole. To do this, we should consider the reversible H's and T's. These include hypovolemia, hypoxia, hydrogen ion, (which is acidosis), hypo or hyperkalemia, tension pneumothorax, cardiac tamponade, toxins, cardiac thrombosis, or a coronary thrombosis. It's important to remember that as a healthcare professional, we cannot know when a person may experience a survival that goes against all scientific reason. And so we rescue with enthusiasm. But it's also important to note that many studies have shown that asystole represents what is termed the final rhythm. In other words, cardiac function and electrical activity have been diminished over time until there's no perceivable electric or mechanical activity, and the patient is biologically or permanently dead. However, some circumstances, such as poisoning or hyperthermia, warrant a longer resuscitation effort than others. For example, with victims of drowning in icy water, survival can sometimes be possible after being under water for as long as 40 minutes and prolonged CPR efforts of greater than two hours. When drowning occurs in ice water, rewarming to a core temperature of at least 30 degrees Celsius is recommended before CPR efforts are terminated. This is due to the heart being unresponsive to resuscitative efforts until the core body temperature is increased. It is never an easy decision for a team leader to stop resuscitation efforts, especially for an infant or a child. However, after all the viable treatment options have been attempted, the potential reversible causes have been exhausted, special circumstances have been taken into account, and the patient still remains in asystole, a decision to stop resuscitation will be necessary.
Asystole means that there is no discernible electrical activity in the heart that can be seen on the ECG monitor and there also isn't any pulse. Survival rates are very poor when a child or infant is in asystole, and for this reason, it's always important to emphasize the prevention of injuries and the aggressive treatment of illnesses that can lead to cardiac arrest.
In this lesson, we'll cover the steps you should take to try and resuscitate a pediatric patient in asystole. And at the end of the lesson, we'll include circumstances in which survival rates and resuscitation efforts fare better than the average.
Pro Tip #1: As a healthcare provider, it's vital to focus on early recognition and treatment of all respiratory distress, respiratory failure, and shock BEFORE it deteriorates into cardiac arrest. Identifying and treating preventable causes for the cardiac arrest, such as using the H's and T's, is equally crucial when it comes to saving the life of an injured or ill child.
If you have a patient who appears unresponsive, begin by tapping and shouting to verify. If the patient is still unresponsive at this point, you should:
At this point, you'll want to begin assessing for signs of circulation and breathing. Begin by checking the patient's pulse.
In children, check for the carotid pulse. In infants, check for the brachial pulse. And observe the patient's face and chest, while you do, for any signs of normal breathing.
At this point, if the patient is still unresponsive, isn't breathing normally, and has no pulse, begin performing high quality CPR immediately and with as few interruptions as possible.
Perform CPR in cycles of 15 chest compressions at a depth of 1/3 the depth of the chest at a rate of 100 to 120 compressions per minute.
This should be followed by 2 rescue breaths, and make sure it's enough to get the patient's chest to rise and fall. Chest compression depth will vary based on the patient's size, so these are merely averages:
Child chest compressions – about 2 inches in depth.Infant chest compressions – about 1.5 inches in depth.
And remember, to ensure the quality of CPR being performed remains high, change the compressor every 2 minutes – or sooner if needed – to avoid fatigue, which often leads to less than optimal CPR compressions.
The airway person should be measuring the patient and preparing the proper size basic airway adjunct and ventilating the patient with 100 percent oxygen delivered via a bag valve mask at 15 liters per minute.
Defibrillator pads should be applied right away after the compressions and rescue breaths have begun. After which, the team leader will tell everyone to stand clear while the AED analyzes the patient's rhythm.
If the patient is in asystole, it's important to double check some things that may be affecting this type of ECG rhythm by asking yourself the following questions:
If you can answer yes to all the above, the team leader should make sure the team knows to continue providing high quality CPR, as asystole is not a shockable rhythm.
Now is the proper time to move to establishing IV or IO access in order to begin administering medications and replacing fluids.
It's helpful to have a length-based color-coded resuscitation tape, like a Broselow tape, so you can determine quickly and efficiently the weight of the patient for calculating drug doses and the correct size of resuscitation equipment you'll need.
An example: The average nine-month-old would measure within the red area of a length-based resuscitation tape. If the patient falls within this red area, you can quickly estimate their weight to be around 8kg (17-18 pounds), which lets you know that you'll need a 22-24 gauge IV catheter or an 18-15 gauge IO needle.
After an IV or IO has been established, the team leader should call for an epinephrine concentration of 1:10,000 at .01mg/kg via IV or IO push, followed by 20cc of normal saline. This will ensure that the medication gets into the central circulatory system.
Pro Tip #2: It's important to continue to perform chest compression while the medication is being given in order to help circulate it properly, as well as ensuring that the patient is getting the best circulation of oxygen to vital organs and tissues. And finally, it's important for basic life support to minimize CPR breaks while giving medications or starting an advanced airway.
In circumstances where IV or IO access isn't available, but you have an endotracheal tube in place, epinephrine could be administered via the ET tube, however the ratio of the medication will be different – a concentration of 1:1000 at .1mg/kg.
Pro Tip #3: Medications delivered via an ET tube are not as desirable as via IV or IO as the results are not as predictable. However, the potential benefit of the medication outweighs any negatives regarding the method of delivery.
After initial treatment has begun, it's a good time to insert an advanced airway if you haven't done so already.
After an ET tube or another advanced airway is in place, move to continue performing chest compressions, but the breaths will now change to 1 breath every 6 seconds. And remember to switch compressors every 2 minutes and/or when the compressor calls for a switch. When the switch is announced, the airway person would finish the next breath.
Before the next rescuer begins compressions, this is a good time for a quick look at the monitor for any changes in the patient's rhythm. But this should take no longer than 10 seconds. And CPR should be quickly resumed if there aren't any changes.
Capnography should also be attached at this time to monitor the quality of the compressions and gas exchange. And repeated doses of epinephrine can be given at .01mg/kg of 1:10,000 via IV or IO push every 3-5 minutes.
Once initial treatments have begun, it's also important to ask yourself and the team to consider the causes for the asystole, especially any reversible H's and T's such as:
Pro Tip #4: As a healthcare provider, it's important to remember that you won't know when a patient will survive, even when it goes beyond all scientific reasoning. So, rescue with confidence and enthusiasm and know that miracles do sometimes happen.
A patient in asystole is there because all cardiac function and electrical activity have diminished over time. At this point, the patient is biologically dead. However, there are some circumstances, such as poisoning and hypothermia, that will warrant longer resuscitation efforts than others.
For instance, if a child drowns in icy cold water, survival can be possible after being underwater for as long as 40 minutes and after CPR efforts have lasted greater than two hours.
When drowning occurs in icy water, rewarming to a core temperature of at least 30 degrees Celsius (86 degrees Fahrenheit) is recommended before CPR efforts are terminated, as the heart is often unresponsive to resuscitative efforts until the core temperature is increased.
It's never an easy decision for a team leader to stop resuscitation efforts, especially with infants and children. However, after all available treatment options have been considered and attempted, potential reversible causes have been exhausted, and special circumstances have been taken into account, the decision to stop resuscitation will be necessary.