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Victims of sudden cardiac arrest who present with asystole as the initial rhythm have an extremely poor prognosis (10% survive to admission, 0 % to 2% survival-to-hospital discharge rate

About

• Asystole accounts for 40%, of cardiac arrests
• Asystole represents the terminal rhythm of a cardiac arrest.

Aetiology

• Asystole typically results from decompensation of prolonged ventricular fibrillation arrest
• May occur after defibrillation of VF/VT

Clinical

• GCS 3 No pulse not breathing
• Telemetry shows a flat line

ECG

• Rate: no ventricular activity seen or =6/min; so-called “P-wave asystole" occurs with only atrial impulses present to form P waves
• Rhythm: no ventricular activity seen; or =6/min
• PR: cannot be determined; occasionally P wave seen, but by definition R wave must be absent
• QRS complex: no deflections seen that are consistent with a QRS complex

Differentials

• Check lead placement to ensure not fine VF

Management

• ABCDE, Give Oxygen, Commence CPR
• Ensure IV access (or consider intraosseous).
• Consider intravenous adrenaline/epinephrine 1mg IV or Vasopressin
• When considering terminating care of a patient in asystole, the rhythm should be confirmed in two separate leads
• If rhythm changes to VF/VT (shockable rhythm) Consider Immediate Defibrillation. Go To VF/VT
• Atropine is no longer recommended by the American Heart Association (AHA) for asystole

Consider reversible causes

• Hypovolemia: consider rapid bolus of IV fluid. Check haemoglobin/hematocrit. If anaemia or massive haemorrhage, give blood
• Hypoxia: Increase O₂, to 100% high flow. Confirm connections. Check for bilateral breath sounds. Suction ET tube and reconfirm placement. Consider chest X-ray.
• Hydrogen ion (acidosis): If profound, consider Sodium Bicarbonate IV.
• Hypokalaemia: Give IV Potassium
• Hyperkalemia: Give Calcium Chloride and 50% Dextrose and Insulin 10 units IV. Monitor glucose. Also Sodium Bicarbonate IV
• Hypothermia: Active warming by forced air blanket, warm IV fluid, raise room temperature. Consider cardiopulmonary bypass.
• Tension pneumothorax: Unilateral breath sounds, possible distended neck veins and deviated trachea (late signs). Perform emergent needle decompression (2nd intercostal space at a mid-clavicular line) than chest tube placement. Call for a chest x-ray, but do NOT delay treatment.
• Tamponade (cardiac): Consider placing TOE or TTE to rule out tamponade. Treat with pericardiocentesis.
• Toxins: Consider medication error. Confirm no infusions running and volatile anaesthetic off.
• Thrombosis (both pulmonary and coronary): Consider TEE or TTE to evaluate the right ventricle. Consider fibrinolytic agents or pulmonary thrombectomy

References

• Asystole

Revisions