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Asystole: Treatment & Medication
Updated: Jul 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Prehospital Care
- The only 3 drugs recommended or acceptable by the American Heart Association (AHA) for adults in asystole are epinephrine, vasopressin, and atropine. In spite of full vagolytic doses of atropine (0.03 mg/kg) and high-dose epinephrine (0.20 mg/kg), or the use of vasopressin 40 units (U), few patients survive to leave the hospital neurologically intact. Atropine is no longer recommended in young children and infants in asystole but can be considered in adults with slow pulseless electrical activity (PEA) rhythms.
- If spontaneous circulation has not been restored, administering vasopressin 40 U IV for the first 2 doses or followed by epinephrine given at the physician's discretion has recently showed some promising if mixed results.
- A recent study showed that more patients survived to hospital discharge, although the neurologic status of the patients at discharge was not clearly stated. Further analysis has suggested a tendency for a worse neurological outcome in those who received vasopressin, many of whom ended up in a vegetative state. The number of patients with asystole in the study was 528. Of those, 12 patients in the vasopressin group survived to discharge compared with 4 in the standard therapy group. In this study, the odds ratio stated may not be statistically significant. The study also showed a nonstatistically significant trend toward worse results for ventricular fibrillation (VF) and PEA.5
- Gueugnaiud and colleagues found in a larger comparison study between epinephrine alone and epinephrine with vasopressin 40 units that there were no significant differences between groups in terms of return of spontaneous circulation, survival to hospital discharge, 1 year survival, or good neurological recovery among survivors at hospital discharge.6
- The advanced cardiac life support (ACLS) 2005 guidelines allow vasopressin 40 IU IV as a one-time dose treatment option in VF and asystole. It can be given either before epinephrine or after the first dose of epinephrine.
- Transcutaneous pacing (TCP), even when used immediately, has not altered meaningful survival (ie, functional lifestyle) significantly. However, when no metabolic deficit exists, such as in a cardiac arrest preceded by a conduction or impulse generation disorder (ie, primary asystole), immediate use of TCP may be lifesaving.
Emergency Department Care
Mainstays of ED treatment are providing oxygenation and ventilation via endotracheal intubation and circulation via CPR, attempts at transcutaneous or transvenous pacing (that have some small potential to be fruitful in primary asystole that has just occurred), and administration of pharmacologic agents.
- A case has been reported of a long but successful resuscitation from asystole of a patient who was hyperkalemic secondary to renal failure. The treatment included calcium chloride to reverse the physiologic effects of hyperkalemia and insulin and glucose to lower serum potassium levels. This cannot be recommended routinely for all cases of asystolic arrest.
- Electrical defibrillation should not be applied indiscriminately to the patient in asystole. This is not only fruitless, but also detrimental, eliminating any possibility of recovering a rhythm. Asystole following electrical defibrillation has an even worse outcome than that in a patient whose first documented rhythm was asystole. One caution is that, following defibrillation, a brief spurious asystole can occur using manual monitoring through the defibrillator paddles. This does not occur with the rhythm monitoring leads or hands-off monitor pads. If not taken into consideration, it could lead to a delay in defibrillation, when indeed VF is present.
Medication
Parasympathetic influences during cardiopulmonary arrest have not been elucidated fully, and the clinical benefits of atropine have yet to be confirmed. Atropine can be used for asystole, but the AHA now states that its use should be considered. High-dose epinephrine (0.20 mg/kg) may improve the hemodynamics of CPR, thereby increasing the rate of return to spontaneous circulation; however, it has not been demonstrated to influence the final clinical outcome. Therefore, these doses no longer are recommended for children or adults. Adenosine antagonists, such as aminophylline, have been investigated but have not been shown to be clinically useful.
Anticholinergic agents
The goal in using these agents is to enhance sinoatrial activity and to improve conduction through the SA or AV node by reducing vagal tone via muscarinic receptor blockade. This is effective only if the site of block is within the SA or AV node. For patients with infranodal block, this therapy is ineffective. It may increase a Mobitz II second-degree block to a higher degree of block or a third-degree block.
Atropine (Atropair, Isopto, Atropisol)
Parasympatholytic agent used to eliminate vagal influence on SA and AV nodes. Not effective for infranodal third-degree heart block.
Adult
1 mg IV/IO, may repeat dose up to 3 mg total, or 0.03 mg/kg, which is completely vagolytic
If no IV/IO access is available, administer 2 or 2.5 mg via an endotracheal tube (ET); this is a less reliable method and should only be used as a last resort; dose should be followed (a "flush") with 5 mL of normal saline flush and 5 ventilations should be provided; a minimum dose of 0.1 mg IV/IO should be given to avoid centrally mediated paradoxical parasympathomimetic effect
Pediatric
Pediatric bradyasystolic arrest: Not recommended
Symptomatic bradycardia with a pulse unresponsive to oxygen and fluids: 0.02 mg/kg IV/IO
Children: 0.1 mg IV minimum dose; not to exceed 0.5 mg; maximum total dose 1 mg
Adolescents: 0.1 mg IV minimum dose; not to exceed 1 mg; maximum total dose 2 mg
If no IV or IO access exists, give 0.03 mg/kg ET; the same holds for this route as stated above when applied to pediatrics
None for this indication
None when indicated for symptomatic sinus bradycardia or Mobitz type I second-degree heart block; contraindicated in Mobitz type II second-degree heart block; generally not effective for infranodal third-degree heart block
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adds to tachydysrhythmia if a rhythm resumes, especially when used with sympathomimetic agents; may potentially lower the VF threshold (theoretical and only an issue if perfusing rhythm present)
Adrenergic agonists
These agents can produce constriction of skeletal and vascular muscle.
Epinephrine (Adrenaline)
Considered the single most useful drug in cardiac arrest. Used to increase coronary and cerebral blood flow during CPR. May enhance automaticity during asystole. Can be used for bradycardia in adult and pediatric patients.
Adult
1 mg IV/IO; 2-2.5 mg ET if not given IV/IO; range was 0.01-0.20 mg/kg depending on standard-dose or high-dose epinephrine protocols (high doses no longer recommended by AHA)
Pediatric
0.01 mg/kg IV/IO; alternative, 0.10 mg/kg ET if no IV/IO access (high-dose [0.20 mg/kg] no longer recommended by AHA)
None for this indication
None for this indication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May result in tachydysrhythmia if rhythm resumes; this is additive to effects of atropine or other sympathomimetic agents
Vasopressin (Pitressin)
Has vasopressor and ADH activity. Increases water resorption at distal renal tubular epithelium (ADH effect) and promotes smooth muscle contraction throughout vascular bed via stimulation of V1 receptors, thus the vasopressor effect. Vasoconstriction is increased in splanchnic, portal, coronary, cerebral, peripheral, pulmonary, and intrahepatic vessels.
Adult
40 IU IV once, although some studies suggest a repeat dose of 40 IU (not an AHA recommendation)
Pediatric
Not established
None for this indication
None for this indication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May result in hypertension and bradycardia if a rhythm resumes
More on Asystole |
| Overview: Asystole |
| Differential Diagnoses & Workup: Asystole |
Treatment & Medication: Asystole |
| Follow-up: Asystole |
| Multimedia: Asystole |
| References |
| Further Reading |
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Further Reading
Clinical guidelines
Advanced life support. In: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005 Nov 29;112(22 Suppl):III25-54. [601 references]
Keywords
flat line, asystole, cardiac arrest, heart attack, cardiac standstill, pulseless electrical activity, PEA, primary asystole, secondary asystole, bradyasystolic rhythm, bradydysrhythmia, bradyasystole, asystolic cardiopulmonary arrest, asystolic cardiac arrest
Treatment & Medication: Asystole