1. 1 Case 5 Asystole © 2001 American Heart Association

2. 2 Case 5: Asystole?

3. 3 Case Scenario You are checking a 64-year-old woman after she collapsed in the hospital parking lot. Hospital personnel have started CPR, but no ACLS intervention has been initiated. You overhear a relative state, “She was on her way to her last oncology clinic appointment.”

4. 4 Learning Objectives Verify that the flat line seen on the ECG monitor is indeed “true asystole” (an electri- cally silent heart) and not some other rhythm (eg, fine ventricular fibrillation) masquerading as a flat line or an operator error that creates a flat line (ie, “asystole”) on the monitor screen when in fact another rhythm is present. Apply the ACLS Approach (the Primary and Secondary ABCD Surveys) to a patient in asystole.

5. 5 Learning Objectives (cont’d) Discuss the relative merits of adequate ventilation—not IV buffer therapy—as the mainstay of acidosis treatment. Describe why successful resuscitation in asystole requires identification of a treatable cause. The team leader must rapidly and energetically focus on the differential diagnosis of asystole.

6. 6 Learning Objectives (cont’d) State the most common reversible conditions associated with asystole. (Reversible causes of asystole are not limited to those on the following slide.) Note that these conditions are the same conditions that should be identified or ruled out when PEA develops.

7. 7 Causes: H’s and T’s Hypoxia (CNS events) Hypokalemia/hyperkalemia (and other electrolytes) Hypothermia/hyperthermia Hypoglycemia/hyperglycemia Hypovolemia (tank/anaphylaxis, gravid)

8. 8 Causes: H’s and T’s (cont’d) Trauma Tamponade Thrombosis (pulmonary) Thrombosis (coronary) Tablets (ODs, drugs, etc) Tension (pneumothorax, asthma)

9. 9 Learning Objectives (cont’d) Recognize that asystole usually represents a confirmation of death rather than a “rhythm” to be treated. Describe the criteria that clinicians should follow for stopping resuscitative efforts.

10. 10 Skills Objectives Provide airway maintenance and ventilation because adequate ventilation is the mainstay of asystole care while trying to identify the reversible cause. Conduct a rapid “Secondary D” (assessment of asystole and its causes). Recognize indications for stopping resuscitative efforts.

11. 11 Primary ABCD Survey A = Airway: open the airway B = Breathing: check breathing, provide positive-pressure ventilations C = Circulation: check circulation, give chest compressions D = Defibrillation: assess for and shock VF/pulseless VT

12. 12 Secondary ABCD Survey A = Airway: place airway device as soon as possible B = Breathing: confirm airway device placement by physical exam (primary tube confirmation) B = Breathing: confirm airway device placement by secondary tube confirmation (end-tidal CO 2 and/or EDD) B = Breathing: secure airway device to prevent dislodgment (use commercial tube holders) B = Breathing: confirm effective oxygenation and ventilation

13. 13 Secondary ABCD Survey (cont’d) C = Circulation: establish IV access C = Circulation: identify rhythm C = Circulation: administer rhythm and condition-appropriate drugs D = Differential Diagnosis: search for and treat identified reversible causes (Think!)

14. 14 Asystole Algorithm AAirway : open the airway BBreathing : provide positive-pressure ventilations CCirculation : give chest compressions CConfirm true asystole DDefibrillation : assess for VF/pulseless VT, shock if indicated Primary ABCD Survey Focus: basic CPR and defibrillation Check responsiveness Activate emergency response system Call for defibrillator Rapid scene survey: is there any evidence that personnel should not attempt resuscitation (eg, DNAR order, signs of death)?

15. 15 Asystole Algorithm (cont’d) AAirway : place airway device as soon as possible BBreathing : confirm airway device placement by exam plus confirmation device BBreathing : secure airway device; purpose-made tube holders preferred BBreathing : confirm effective oxygenation and ventilation CCirculation : confirm true asystole CCirculation : establish IV access CCirculation : identify rhythm  monitor CCirculation : give medications appropriate for rhythm and condition DDifferential Diagnosis : search for and treat identified reversible causes Secondary ABCD Survey Focus: more advanced assessments and treatments

16. 16 Asystole Algorithm (cont’d) Transcutaneous pacing: If considered, perform immediately Epinephrine 1 mg IV push, repeat every 3 to 5 minutes Atropine 1 mg IV, repeat every 3 to 5 minutes up to a total of 0.04 mg/kg Asystole persists Withhold or cease resuscitation efforts? Consider quality of resuscitation? Atypical clinical features present? Support for cease-efforts protocols in place?

17. 17 Case 5: Asystole Active search for “do not attempt resuscitation” (DNAR) orders/status Explicit criteria for stopping Death certification in the field Prohibition on transporting failed ACLS with CPR

18. 18 Case 5: Asystole Family presence at resuscitation efforts Survivor support plans More formal death notification