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asystole

Asystole generally occurs as a terminal rhythm in a patient with severe underlying cardiac disease. Likelihood of resuscitation is low. (also see sinus arrest) Etiology: - hypoxia - hyperkalemia, hypokalemia - pre-existing acidosis - drug overdose* - hypothermia * patient's medications not of immediate importance [5] Special laboratory: - electrocardiogram - point-of-care ultrasound - lack of cardiac activity portends poor prognosis [4] Management: - CPR until defibrillator is available - confirm asystole in more than one lead - if rhythm is unclear, possibly VF, defibrillation - if asystole is confirmed, continue CPR - intubate, establish IV access (IV access takes precedence) - consider possible causes & initiate appropriate treatment - consider immediate transcutaneous pacing - considered a class IIb intervention - epinephrine*, 1 mg IV push, repeat every 3-5 minutes - administration of 1st dose within 1 to 3 minutes [3] - vasopressin 40 IU IV may be better than epinephrine [2] - atropine 1 mg IV push, repeat every 3-5 minutes up to 3 mg - if no response, consider - high dose epinephrine 2-5 mg IV push every 3-5 min; 1 mg, 3 mg, 5 mg 3 minutes apart; 0.1 mg/kg every 3-5 min - NaHCO3 if appropriate [3] - NaHCO3 not indicated early in resuscitation - acidosis is generally secondary to inadequate ventilation, - dose is 1 meq/kg IV followed by 0.5 meq/kg every 0 min - termination of efforts * closed-loop communication employed [5]

Related

sinus arrest/pause

General

bradyarrhythmia (bradycardia)

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 177-178
  2. Journal Watch 24(4):29, 2004 Wenzel V et al, A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 350:105, 2004 PMID: 14711909 McIntyre KM, N Engl J Med 350:179, 2004
  3. Young K cites BMJ article For Cardiac Arrest with Nonshockable Rhythm, Quicker Epinephrine Is Better. Physician's First Watch, May 22, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  4. Gaspari R et al. Emergency department point-of-care ultrasound in out-of- hospital and in-ED cardiac arrest. Resuscitation 2016 Sep 27 PMID: 27693280 http://www.resuscitationjournal.com/article/S0300-9572(16)30478-6/abstract
  5. NEJM Knowledge+