asystole

[dave3189]

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!

 

[johnrsemt]

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.

 

[18G]

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.

 

[Aidey]

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

 

[18G]

Pacing is in our protocols for provider witnessed asystole.

 

[Aidey]

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

 

[reaper]

Yes, Pacing has been gone for a while now.

 

[MrBrown]

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

 

[Shishkabob]

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

 

[TomB]

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

 

[LondonMedic]

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.

 

[alphatrauma]

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.

 

[NomadicMedic]

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.

 

[18G]

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.

 

[AnthonyM83]

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.

 

[traumamama]

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?

 

[Shishkabob]

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

Can't tell without seeing it though.

 

[traumamama]

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

 

[AnthonyM83]

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.

 

[traumamama]

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