Emergent Management of Asystole Workup

  • Author: Richard M Caggiano, MD, FACEP; Chief Editor: David FM Brown, MD   more...
 
Updated: Aug 8, 2011
 

Approach Considerations

Asystole is generally a diagnosis made via ongoing cardiac monitoring or electrocardiogram (ECG) and physical examination with pulselessness. Pulse oximetry may be used during resuscitation to monitor the effectiveness of forward flow or cardiopulmonary resuscitation (CPR); however, usually flow is too inadequate for the sensor to register any results.

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Potassium level and ABG

A potassium level may be useful if deemed appropriate and results are immediately available.

Arterial blood gas (ABG) analysis may be used to obtain rapid reporting of potassium level in many institution's laboratories. In addition, ABG results may also help to evaluate the ventilatory and acid-base status of the patient as well as the hemoglobin level. Note that if the patient is in full arrest, a blood gas level does not accurately reflect the pH status of the tissues.

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Echocardiography

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Echocardiography

For documentation purposes, in addition to including rhythm strips from 2 separate leads identifying asystole, bedside ultrasonography may be useful to confirm cardiac standstill. The heart may be viewed via either a subxiphoid view or an intercostal view and wall motion, or lack thereof, observed. An image of 2-dimensional echocardiography taken over time in M-mode may be taken, saved, and included in the medical record. This will further document lack of heart wall motion.

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Continuous Cardiac Monitoring

Asystole is best determined in 2 separate cardiac leads. This helps protect against reading a flat line due to lead malfunction incorrectly as asystole, as well as helps in differentiating fine ventricular fibrillation (VF), particularly in an isoelectric lead, from asystole (see the following images).

Rhythm strip showing asystole. Rhythm strip showing asystole. Rhythm strip showing ventricular fibrillation. Rhythm strip showing ventricular fibrillation.

Eliminate a possible diagnosis of VF, which may masquerade as asystole, by checking 2 leads perpendicular to each other. In spite of this caveat, Cummins et al found that using a flat-line protocol based on a 3-lead check, occult VF was documented in only 3 (2.5%) of 118 asystolic patients, indicating that VF masquerading as asystole is uncommon.[14] Technical problems were much more common, observed in 10 patients (8%).[14]

Exclude the possibility of lead misplacement by always checking for the presence of a pulse.

Spurious asystole can be seen when using manual defibrillator paddles to monitor the rhythm.[15] This is usually very brief, but nevertheless, can be avoided by switching to monitoring leads, especially after several successive shocks.

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Contributor Information and Disclosures
Author

Richard M Caggiano, MD, FACEP  Adjunct Faculty, Department of Medicine, University of Washington School of Medicine; Director of Emergency Services, Chief Medical Officer, and Assistant Director of Trauma Services, Pullman Regional Hospital; Medical Physician Director, Whitman County, Washington

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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

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

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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

  2. Moonie GT, Rees DL, Elton D. The oculocardiac reflex during strabismus surgery. Can Anaesth Soc J. Nov 1964;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. Apr 6 1999;130(7):581-3. [Medline].

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

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

  6. 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. Sep 15 2000;86(6):610-4. [Medline].

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

  8. 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. Mar 24 2009;119(11):1484-91. [Medline]. [Full Text].

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

  10. 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. Dec 2001;29(12):2366-70. [Medline].

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

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

  13. 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. Mar 2010;17(3):269-75. [Medline].

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

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

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

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

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

  19. 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. Feb 21 2002;346(8):557-63. [Medline].

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

  21. 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. Nov-Dec 2005;67(2-3):171-3. [Medline].

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

  23. 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. Nov 2 2010;122(18 Suppl 3):S640-56. [Medline].

  24. 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. Oct 19 2010;122(16 Suppl 2):S250-75. [Medline].

  25. 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. Aug 3 2006;355(5):478-87. [Medline].

 
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Rhythm strip showing asystole.
Rhythm strip showing ventricular fibrillation.
 
 
 
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