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Asystole Medication

  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Dec 26, 2015

Medication Summary

Parasympathetic influences during cardiopulmonary arrest have not been elucidated fully, and clinical benefits of atropine have never been confirmed.

Atropine is no longer recommended by the American Heart Association (AHA) for asystole and pulseless electrical activity (PEA).

High-dose epinephrine (0.20 mg/kg) may improve the hemodynamics of cardiopulmonary resuscitation (CPR), thereby increasing the rate of return to spontaneous circulation; however, this agent has not been demonstrated to influence the final clinical outcome. Therefore, high doses are no longer are recommended for children or adults.

Adenosine antagonists, such as aminophylline,[23] have been investigated but have not been shown to be clinically useful.


Anticholinergic agents

Class Summary

The goal in using anticholinergic agents is to enhance sinoatrial (SA) activity and to improve conduction through the SA or atrioventricular (AV) node by reducing vagal tone via muscarinic receptor blockade. This is effective only if the site of the block is within the SA or AV node. For patients with infranodal block, anticholinergic therapy is ineffective, and it may increase a Mobitz II second-degree block to a higher degree of block or a third-degree block.

Atropine IV/IM (Atropine, Sal-Tropine, AtroPen)


Atropine is a parasympatholytic agent used to eliminate vagal influence on the SA and AV nodes. This agent is not effective for infranodal third-degree heart block, PEA, and asystole.


Adrenergic agonists

Class Summary

Adrenergic agents can produce constriction of skeletal and vascular muscle.

Epinephrine (Adrenaline, EpiPen)


Epinephrine is considered the single most useful drug in cardiac arrest; however, some authorities question its clinical effectiveness in humans This agent is used to increase coronary and cerebral blood flow during cardiopulmonary resuscitation (CPR) and may enhance automaticity during asystole. In addition, epinephrine can be used for bradycardia in adult and pediatric patients.

Vasopressin (Pitressin)


Vasopressin has vasopressor and antidiuretic hormone (ADH) activity. This agent increases water resorption at the distal renal tubular epithelium (ADH effect) and promotes smooth muscle contraction throughout the vascular bed via stimulation of V1 receptors (vasopressor effect). Vasoconstriction is increased in splanchnic, portal, coronary, cerebral, peripheral, pulmonary, and intrahepatic vessels.

Contributor Information and Disclosures

Sandy N Shah, DO, MBA, FACC, FACP, FACOI Cardiologist

Sandy N Shah, DO, MBA, FACC, FACP, FACOI is a member of the following medical societies: American College of Cardiology, American College of Osteopathic Internists, American College of Physicians, American Osteopathic Association, Society for Cardiovascular Angiography and Interventions, American Society of Nuclear Cardiology, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Department of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, National Association of EMS Physicians

Disclosure: Medical Director for: SironaHealth.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Edward Bessman, MD, MBA Chairman and Clinical Director, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard M Caggiano, MD, FACEP Adjunct Faculty, Department of Medicine, University of Washington School of Medicine; Chief Medical Officer, Pullman Regional Hospital

Richard M Caggiano, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

  1. Gold RS, Pollard Z, Buchwald IP. Asystole due to the oculocardiac reflex during strabismus surgery: a report of two cases. Ann Ophthalmol. 1988 Dec. 20(12):473-5, 477. [Medline].

  2. Moonie GT, Rees DL, Elton D. The oculocardiac reflex during strabismus surgery. Can Anaesth Soc J. 1964 Nov. 11:621-32. [Medline].

  3. Locatelli ER, Varghese JP, Shuaib A, Potolicchio SJ. Cardiac asystole and bradycardia as a manifestation of left temporal lobe complex partial seizure. Ann Intern Med. 1999 Apr 6. 130(7):581-3. [Medline].

  4. van der Lende M, Surges R, Sander JW, Thijs RD. Cardiac arrhythmias during or after epileptic seizures. J Neurol Neurosurg Psychiatry. 2016 Jan. 87 (1):69-74. [Medline].

  5. Bognolo DA, Rabow FI, Vijayanagar RR, Eckstein PF. Traumatic sinus node dysfunction. Ann Emerg Med. 1982 Jun. 11(6):319-21. [Medline].

  6. Gray WA, Capone RJ, Most AS. Unsuccessful emergency medical resuscitation--are continued efforts in the emergency department justified?. N Engl J Med. 1991 Nov 14. 325(20):1393-8. [Medline].

  7. Engdahl J, Bang A, Lindqvist J, Herlitz J. Can we define patients with no and those with some chance of survival when found in asystole out of hospital?. Am J Cardiol. 2000 Sep 15. 86(6):610-4. [Medline].

  8. Richman PB, Nashed AH. The etiology of cardiac arrest in children and young adults: special considerations for ED management. Am J Emerg Med. 1999 May. 17(3):264-70. [Medline].

  9. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009 Mar 24. 119(11):1484-91. [Medline]. [Full Text].

  10. Niemann JT, Cairns CB. Hyperkalemia and ionized hypocalcemia during cardiac arrest and resuscitation: possible culprits for postcountershock arrhythmias?. Ann Emerg Med. 1999 Jul. 34(1):1-7. [Medline].

  11. Niemann JT, Stratton SJ, Cruz B, Lewis RJ. Outcome of out-of-hospital postcountershock asystole and pulseless electrical activity versus primary asystole and pulseless electrical activity. Crit Care Med. 2001 Dec. 29(12):2366-70. [Medline].

  12. Ewy GA. Cardiac resuscitation--when is enough enough?. N Engl J Med. 2006 Aug 3. 355(5):510-2. [Medline].

  13. Barthell E, Troiano P, Olson D, et al. Prehospital external cardiac pacing: a prospective, controlled clinical trial. Ann Emerg Med. 1988 Nov. 17(11):1221-6. [Medline].

  14. Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J. Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders. Acad Emerg Med. 2010 Mar. 17(3):269-75. [Medline].

  15. Cummins RO, Austin D Jr. The frequency of 'occult' ventricular fibrillation masquerading as a flat line in prehospital cardiac arrest. Ann Emerg Med. 1988 Aug. 17(8):813-7. [Medline].

  16. Resuscitation Council [UK]. Spurious asystole when using manual defibrillators and monitoring through the defibrillator paddled. Resusitation Council [UK]. 2002. 1-2.

  17. Lin JL, Lim PS, Leu ML, Huang CC. Outcomes of severe hyperkalemia in cardiopulmonary resuscitation with concomitant hemodialysis. Intensive Care Med. 1994. 20 (4):287-90. [Medline].

  18. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002 Feb 21. 346(8):557-63. [Medline].

  19. Testori C, Stertz F, Behringer W, et al. Mild therapeutic hypothermia is associated with favourable outcome in patients with cardiac arrest with non-shockable rhythms. Resuscitation. 82 [9]:1162-1167.

  20. Wenzel V, Krismer AC, Arntz HR, et al. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. 2004 Jan 8. 350(2):105-13. [Medline].

  21. Gueugniaud PY, David JS, Chanzy E, Hubert H, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008 Jul 3. 359(1):21-30. [Medline].

  22. Vukov LF, White RD. External transcutaneous pacemakers in prehospital cardiac arrest. Ann Emerg Med. 1988 May. 17(5):554-5. [Medline].

  23. Mader TJ, Smithline HA, Gibson P. Aminophylline in undifferentiated out-of-hospital asystolic cardiac arrest. Resuscitation. 1999 Jun. 41(1):39-45. [Medline].

  24. Billi JE, Zideman DA, Eigel B, et al. Conflict of interest management before, during, and after the 2005 International Consensus Conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. 2005 Nov-Dec. 67(2-3):171-3. [Medline].

  25. ECC Committee. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005 Dec 13. 112(24 Suppl):IV1-203. [Medline].

  26. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2. 122(18 Suppl 3):S640-56. [Medline].

  27. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010 Oct 19. 122(16 Suppl 2):S250-75. [Medline].

  28. Morrison LJ, Visentin LM, Kiss A, Theriault R, Eby D, Vermeulen M, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006 Aug 3. 355(5):478-87. [Medline].

  29. Sau A, Mereu R, Taraborrelli P, et al. A long-term follow-up of patients with prolonged asystole of greater than 15s on head-up tilt testing. Int J Cardiol. 2016 Jan 15. 203:482-5. [Medline].

  30. Pokorney SD, Radder C, Schulte PJ, et al. High-degree atrioventricular block, asystole, and electro-mechanical dissociation complicating non-ST-segment elevation myocardial infarction. Am Heart J. 2016 Jan. 171 (1):25-32. [Medline].

  31. Estock JL, Curinga HK, Li A, Grieve LB, Brackney CR. Comparison of chest compression interruption times across 2 automated devices: a randomized, crossover simulation study. Am J Emerg Med. 2016 Jan. 34 (1):57-62. [Medline].

  32. Attin M, Wang L, Soroushmehr SM, et al. Digitization of electrocardiogram from telemetry prior to in-hospital cardiac arrest: a pilot study. Biol Res Nurs. 2015 Aug 27. [Medline].

  33. Ewy GA, Bobrow BJ, Chikani V, et al. The time dependent association of adrenaline administration and survival from out-of-hospital cardiac arrest. Resuscitation. 2015 Nov. 96:180-5. [Medline].

Rhythm strip showing asystole.
Rhythm strip showing ventricular fibrillation.
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