# asystole



## dave3189 (Jan 12, 2010)

I was hoping someone can clarify asystole for me.  I was taught in my Basic course that asystole basically equals death.  Defib will not help as it is not a shockable rhythm due to the fact that there is no electrical activity.  However, in reading different material I seem to come across protocols for treating asystole, IE: Epi, Atropine, etc.  Does defib not work, but meds do?
Thanks in advance for your help!


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## johnrsemt (Jan 12, 2010)

yes,  in theory drugs can help when a patient is in asystole.

in real life, very few patients survive asystole.

Atropine is used for bradycardia  (low heart rate)  and asystole is the ultimate low heart rate.  Also, Epinephrine is used in all forms of cardiac arrest.


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## 18G (Jan 12, 2010)

Asystole is the complete absence of mechanical and electrical activity of the heart. It can be a presenting rhythm but is commonly the last in line of progression of V-tach, V-fib, and ultimately asystole. The more time that passes, the greater the chance of the patient going into asystole. Without perfusion of the hearts cells, the cells lose their ability to survive to generate electrical impulses. 

Asystole is not shocked because there is nothing to shock. Remember that defibrillation actually causes the chaotic electrical activity of v-fib and V-tach to cease so that the hearts natural pacemaker will hopefully restart in a rhythmic fashion that is capable of producing cardiac output (ie blood flow and pulse).

Asystole is treated with medication (epinephrine and atropine). 

*Epinephrine* is administered for its alpha effect. Epi causes a systemic constriction of the blood vessels (increases peripheral vascular resistance) so as to increase coronary and cerebral perfusion pressures. Basically, it improves blood return and aids in oxygenation of the heart and brain. This is why it is given in all cardiac arrests. It also lowers the threshold for defibrillation - makes the heart more apt to respond to electrical shocks since the hearts cells have increased perfusion and CPR becomes more effective. 

*Atropine* is a "cant hurt, might help" medication. It has not really been proven to have great effect with aystole but it cant hurt so why not try it. Atropine blocks the effects of excessive acetylcholine from the parasympathetic nervous system. So if the arrest is mediated by excessive acetylcholine release it may help. It also allows the sympathetic system to dominate. 

*Pacing* is another treatment that may work for aystole as well. It is recommended in the witnessed arrest patient that goes into aystole. If you can gain mechanical capture, you will be able to restore pulse and blood pressure.


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## Aidey (Jan 12, 2010)

Pacing was removed when they did the 2005 ACLS guidelines, wasn't it?


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## 18G (Jan 12, 2010)

Pacing is in our protocols for provider witnessed asystole.


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## Aidey (Jan 13, 2010)

Interesting. I double checked just to be sure. ACLS did take it out and no longer recommends as of the 2005 update.


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## reaper (Jan 13, 2010)

Yes, Pacing has been gone for a while now.


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## MrBrown (Jan 13, 2010)

We removed pacing and atropine about three years ago because of a lack of efficacy


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## Shishkabob (Jan 13, 2010)

While pacing WAS taken out, it's one of those things that's like "Well, nothing else worked, might as well give it a shot", as explain to me by an ER attending


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## TomB (Jan 13, 2010)

This is where we could all do a lot better when it comes to how we approach ACLS in general. Let me quote something directly out of the 2005 AHA ECC guidelines:

"The survival rate from cardiac arrest with asystole is dismal. During a resuscitation attempt, brief periods of an organized complex may appear on the monitor screen, but spontaneous circulation rarely emerges. As with PEA, _*the hope for resuscitation is to identify and treat a reversible cause*_."

It doesn't matter what type of arrhythmia (or arrest rhythm) we're dealing with. You should always consider the Hs and Ts before reaching for medications.

Tom


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## LondonMedic (Jan 13, 2010)

TomB said:


> It doesn't matter what type of arrhythmia (or arrest rhythm) we're dealing with. You should always consider the Hs and Ts before reaching for medications.


I see it differently, the ALS protocol, including drugs, buys you time to consider and investigate the Hs & Ts.


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## alphatrauma (Jan 13, 2010)

Correct me if I'm wrong, (unless in medic school) but it appears that the OP is a Basic... the only protocol he/she should be concerned with or initiating is calling for ALS and good quality ventilations/compressions.


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## NomadicMedic (Jan 13, 2010)

MrBrown said:


> We removed pacing and atropine about three years ago because of a lack of efficacy



Is the removal of Atropine for your asystole protocol based on a study?
As far as I know both AHA and ILCOR still recommend atropine up to 3mg for asystole and PEA.


Pharmacotherapy Considerations in Advanced Cardiac Life Support

William E. Dager, Pharm.D., FCSHP; Cynthia A. Sanoski, Pharm.D.; Barbara S. Wiggins, Pharm.D.; James E. Tisdale, Pharm.D.

The gist was, "Epinephrine and atropine are the primary agents used for the management of asystole and pulseless electrical activity."

I know that the prognosis for asystole is poor, however, the article quotes a study showing "A large retrospective analysis in 170 patients with asystole that was resistant to epinephrine found a significantly higher rate of resuscitation associated with atropine (14%) compared with placebo (0%)."

Food for thought.


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## 18G (Jan 13, 2010)

> Correct me if I'm wrong, (unless in medic school) but it appears that the OP is a Basic... the only protocol he/she should be concerned with or initiating is calling for ALS and good quality ventilations/compressions.



Why? Just because he may only be able to practice on a BLS level does not mean he should limit his knowledge. Who cares if he cant give the drugs. The more you learn now the better off you will be later on. 

As a Paramedic, you should perceive yourself as being in a role to teach Basics all that you can and not advocating with absurdity that a Basic is not able to comprehend how medications work and when they are indicated. 

Based on your mentality, don't you ever worry about anything that a physician does that is beyond your scope. Because it is way beyond you.


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## AnthonyM83 (Jan 13, 2010)

alphatrauma said:


> Correct me if I'm wrong, (unless in medic school) but it appears that the OP is a Basic... the only protocol he/she should be concerned with or initiating is calling for ALS and good quality ventilations/compressions.



You mentioned two things there. "Concerned with" and "initiating". While not required, it is almost expected that a basic starts self-learning and familiarizing himself with the basics of what ALS does. This will help him get more learning out of each call, even if all the ALS procedures are left to ALS. Additionally, learning can help him with "ALS assist" procedures. That's the concerned part. 

The not initiating part, I agree with.


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## traumamama (Jan 13, 2010)

Mmm. talking about flatline on this thread prompted me to ask you all this question. We were toned out the other day to a 63 yoa male unconscious and unresponsive with no pulse. They lived about 8 miles from town. (we are 60 miles from the closest hospital) The guy had been outside cutting wood and the rp did not know how long he had been down; maybe 30 minutes- he had been w/o anything for 15 minutes before we got there. We attached the aed, analyzed, flatline. No shock advised. He was gray, eyes fixed and dialated, and he was showing some lividity. I knelt down to run the summary and looked at the aed and saw some beats on the monitor-the aed allowed us to shock him once-we did cpr for another 20 minutes and then called it. he went right back into flat line after that. + cardiac hx with 7 way by pass, htn, high cholesterol, insulin dependent diabetes, morbidly obese...anyone else ever have this type of call? flatline then shockable?


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## Shishkabob (Jan 13, 2010)

Could have been very fine VFib or just a random electrical activity.

Can't tell without seeing it though.


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## traumamama (Jan 13, 2010)

we called our medical director and sent the strip to him-it was all pretty weird. i never had it happen before and i hope it never happens again. i kept expecting him just to sit up and smile like the stupid commercial on tv


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## AnthonyM83 (Jan 13, 2010)

Yes, I've worked a witnessed cardiac arrest with first arrest rhythm of PEA that turned into PEA, then sinus tach w/ a pulse after 3 rounds of epi/atr. After ROSC, only frequent EPI and BICARB would reverse the frequent bouts of bradycardia tha turned into PEA.


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## traumamama (Jan 14, 2010)

this guy had been down for so long though and with the lividity and all-we don't have drugs we can push and we had not started cpr-flatline-no shock advised. i did a witnessed arrest one night-shocked the guy twice and he is still thanking me today. that was a strange one too-he had been bitten by a rattler the week before. after the two shocks he had super human strength and became super combative. Hw lifted my partner and i off the gurney with his legs as we were trying to hold him down and started reciting math facts and speaking gibberish. saving him was the biggest high i've ever had


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## JPINFV (Jan 14, 2010)

alphatrauma said:


> Correct me if I'm wrong, (unless in medic school) but it appears that the OP is a Basic... the only protocol he/she should be concerned with or initiating is calling for ALS and good quality ventilations/compressions.



...because discussing resuscitation past an AED is obviously a violation of the Paramedic Secrets Act of 1966! Maybe they can find a spot at Club Gitmo for him for violating the secrets!


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## mct601 (Jan 14, 2010)

I can honestly say I've learned some valuable knowledge in this thread. I knew atropine and epi were given for cardiac arrests, but did not know why.


and I'm glad there are people willing to take the time to share their knowledge on a subject matter. I'm always willing to listen.


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## LondonMedic (Jan 14, 2010)

MrBrown said:


> We removed pacing and atropine about three years ago because of a lack of efficacy


Who is 'we'?


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## s4l (Jan 16, 2010)

LondonMedic said:


> Who is 'we'?



I assume whichever department he is with.


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## LondonMedic (Jan 16, 2010)

s4l said:


> I assume whichever department he is with.


Or country?

I would question departments unilaterally changing resus guidelines, in europe we have the Resus Council (www.resus.org) standardise the guidelines. The end result is that wherever you go and whoever you work with you'll be doing the same thing. I would suggest that an arrest is not the time to be arguing over who's guidelines we're following and what we're going to do next?


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## Aidey (Jan 16, 2010)

Welcome to the US....most places have put their personal touch on the AHA ACLS guidelines, or don't even use them at all. 

Our protocols list the general steps and then add at the bottom "or current AHA ACLS standards". It definitely is not standardized.


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## Veneficus (Jan 16, 2010)

LondonMedic said:


> Or country?
> 
> I would question departments unilaterally changing resus guidelines, in europe we have the Resus Council (www.resus.org) standardise the guidelines. The end result is that wherever you go and whoever you work with you'll be doing the same thing. I would suggest that an arrest is not the time to be arguing over who's guidelines we're following and what we're going to do next?



Are we looking at the same website? The one where the primary link is online degrees advertising a masters degree in as little as 15 days from work experience?


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## JPINFV (Jan 16, 2010)

I believe he's trying to point to www.resus.org.uk


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## kittaypie (Jan 16, 2010)

san bernardino still has pacing protocols for asystole. don't know how effective it is though.


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## LondonMedic (Jan 17, 2010)

JPINFV said:


> I believe he's trying to point to www.resus.org.uk


Yer, thanks.


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## MrBrown (Jan 17, 2010)

LondonMedic said:


> Who is 'we'?



new zealand


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## SammyGirlMedic (Jan 17, 2010)

kittaypie said:


> san bernardino still has pacing protocols for asystole. don't know how effective it is though.



In my area, we still have pacing in our current protocol. We also have the little sentence at the end that says, "Or current AHA ACLS guidelines."


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## dave3189 (Jan 18, 2010)

I always here everyone posting how forums like this are all about improving our industry.  I hear a lot about how to present yourself and professionalism.  Yet, there were quite a few silent ALS folks on this thread after the comment about what a Basic should concern themselves with in regard to cardiac arrest.  As I pointed out in a pvt message to alphatrauma, I'm not intending to get some atropine and start acting outside my scope by administering it to patients.  I am simply eager to learn so I can eventually go to the next level.  The idea that that a Basic should be discouraged from asking questions and educating themselves is absurd!  I have a feeling that although nobody is saying much, there are a lot of ALS people on this thread that would agree with me.  If the purpose of this site is really to help train, educate and mentor EMS professionals, than people should feel comfortable and should be encouraged to ask these questions.


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## AnthonyM83 (Jan 18, 2010)

dave3189 said:


> Yet, there were quite a few silent ALS folks on this thread after the comment about what a Basic should concern themselves with in regard to cardiac arrest.  As I pointed out in a pvt message to alphatrauma, I'm not intending to get some atropine and start acting outside my scope by administering it to patients.  I am simply eager to learn so I can eventually go to the next level.  The idea that that a Basic should be discouraged from asking questions and educating themselves is absurd!  I have a feeling that although nobody is saying much, there are a lot of ALS people on this thread that would agree with me.  If the purpose of this site is really to help train, educate and mentor EMS professionals, than people should feel comfortable and should be encouraged to ask these questions.



When I read your post, I thought I had missed other posts where you had been flamed for asking your question. Reviewing it, though, alphatrauma is the ONLY one who made such a comment, and some who backed you up, so there really shouldn't be any reason to feel uncomfortable asking questions. Alphatrauma was obviously a random outlier. That's probably why not many others stepped up to defend you, because you didn't need defending. If he had gone off on you or others had agreed with him, I'm sure many others would have stepped in.

So, no worries, just keep doing as you do


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## 18G (Jan 18, 2010)

Alphatrauma's comment was out of line. Don't ever hesitate to ask  questions regardless of what level they pertain to.


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## alphatrauma (Jan 18, 2010)

*dave3189*

Okay... deep breath

My statement was not saying that one should not attempt to further themselves educationally. 

You wanted enlightenment on asystole and the practical application of Epinephrine and Atropine. While my statement/reply may have been abrasive, there was a point.

Considering you seemed to be having difficulty grasping the concept of asystole, one can draw a reasonable conclusion that your basic understanding of the heart's anatomy/physiology is flawed. Is it your lack of comprehension or lack of quality instruction? Regardless, the result is the same. 

That being said, how do you (or anyone else) possibly think you will gain any REAL knowledge or practical/functional understanding of ALS interventions by what is posted in this thread? Do yourself a favor and learn the right way... from those who are actually qualified to teach! Anyone can post anecdotal tidbits, local protocols and wiki pages. I would argue that you tighten up the fundamentals in your scope before adding weight to an already questionable foundation.

That being said, you have every right to pursue whatever avenues you wish to augment your training/lust for knowledge. And please don't assume that lack of universal acquiescence equates to some notion of intellectual propriety.


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## JPINFV (Jan 19, 2010)

alphatrauma said:


> You wanted enlightenment on asystole and the practical application of Epinephrine and Atropine. While my statement/reply may have been abrasive, there was a point.
> 
> Considering you seemed to be having difficulty grasping the concept of asystole, one can draw a reasonable conclusion that your basic understanding of the heart's anatomy/physiology is flawed. Is it your lack of comprehension or lack of quality instruction? Regardless, the result is the same.


Then start basic and work up. If I'm explaining something and I'm not sure where the questioner's knowledge base is, then I'll start with more general topics. For example, on another forum a question came up regarding pulmonary physiology and H2CO3, including why H2CO3 will spit out a hydrogen. Since I didn't know what the OP's base level of knowledge, I started out with a quick explanation of what a catalyst does. Then I did a real basic introduction to the chemistry to expain the basics of acid/base theory. I'd like to delude myself that that had more impact on a person asking a question than "Don't worry about it, it's above your pay grade."



> That being said, how do you (or anyone else) possibly think you will gain any REAL knowledge or practical/functional understanding of ALS interventions by what is posted in this thread? Do yourself a favor and learn the right way... from those who are actually qualified to teach! Anyone can post anecdotal tidbits, local protocols and wiki pages. I would argue that you tighten up the fundamentals in your scope before adding weight to an already questionable foundation.



You never know. On the same board there's a story about a medic catching a dystonic reaction months after a scenario was posted. The medic ran the patient presentation through medical control first, but the physician agreed and gave the order for Benadryl. Similarly, there's enough smart people on here that anything that doesn't pass the sniff test will get called out quickly.


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## dave3189 (Jan 19, 2010)

Last time I checked, the EMT-Basic course curriculum does not go into detail about the success rates and ACLS methods of resuscitation for patients in asystole. That being said, I'm not going to waste anymore time and energy on this topic.  It is clear to me (and now to the last couple posters) that for whatever reason, you have a chip on your shoulder.  You’re embarrassing yourself and your profession!


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## alphatrauma (Jan 19, 2010)

That's you're opinion, and you are perfectly entitled to such... 

be well


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