ACLS - Asystole/PEA 

Updated: Mar 21, 2014
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Advanced Cardiac Life Support (ACLS): Asystole/Pulseless Electrical Activity (PEA)

1. Initial evaluation [1, 2, 3]

  • Activate emergency response system
  • Basic life support (BLS) algorithm

2. Initial intervention

  • Start high-quality cardiopulmonary resuscitation (CPR)
  • Administer oxygen if hypoxemic
  • Attach monitor/defibrillator
  • Monitor blood pressure and oximetry
  • Identify and treat reversible causes

3. Check rhythm

  • Shockable rhythm = VF/VT
  • Nonshockable rhythm = asystole/ PEA

4. Initial treatment of asystole/PEA

  • Continue CPR for 2 minutes
  • Obtain intravenous (IV)/intraosseous (IO) access
  • Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2)

5. Administer vasopressor (epinephrine q3-5min)

6. Check pulse and rhythm (every 2 minutes)

  • If nonshockable, return to step 4
  • If shockable, follow ventricular tachycardia (VT)/ventricular fibrillation (VF) algorithm
  • Rotate chest compressors

Drug therapy

See the list below:

  • Epinephrine 1 mg IV/IO q3-5min
  • Vasopressin 40 units IV/IO can replace first or second dose of epinephrine
  • Flush medications with 20 mL fluid after and elevate extremity for 10-20 seconds
  • Combining medications is not recommended and may cause harm
  • Routine use of sodium bicarbonate is not recommended

CPR quality

See the list below:

  • Push hard and fast (>100/min)
  • Allow complete chest recoil
  • Minimize interruptions in compressions
  • Avoid excessive ventilation
  • Rotate compressor every 2 minutes
  • Compression-to-ventilation ratio of 30:2
  • Continuous compressions if advanced airway present
  • If PETCO 2 < 10 mm Hg, attempt to improve CPR quality
  • If diastolic pressure < 20 mm Hg, attempt to improve CPR quality

Advanced airway

See the list below:

  • Supraglottic advanced airway or endotracheal (ET) intubation
  • Waveform capnography to confirm and monitor ET tube placement
  • Ventilation every 6-8 seconds asynchronous with compressions
  • Stop CPR for no longer than 10 seconds for the placement of an advanced airway

Reversible causes

See the list below:

  • H's: hypovolemia, hypoxia, H+ (acidosis), hypokalemia, hyperkalemia, hypothermia
  • T's: toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary, coronary)

Return of spontaneous circulation

See the list below:

  • Pulse and blood pressure present
  • Abrupt sustained increase in PETCO 2 (typically >40 mm Hg)
  • Spontaneous arterial pressure waves with intra-arterial monitoring