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Show full transcript for What is Asystole? video

Asystole means that there is no discernible electrical activity in the heart that can be seen on the ECG monitor and there also isn't any pulse. Survival rates are very poor when a child or infant is in asystole, and for this reason, it's always important to emphasize the prevention of injuries and the aggressive treatment of illnesses that can lead to cardiac arrest.

In this lesson, we'll cover the steps you should take to try and resuscitate a pediatric patient in asystole. And at the end of the lesson, we'll include circumstances in which survival rates and resuscitation efforts fare better than the average.

Pro Tip #1: As a healthcare provider, it's vital to focus on early recognition and treatment of all respiratory distress, respiratory failure, and shock BEFORE it deteriorates into cardiac arrest. Identifying and treating preventable causes for the cardiac arrest, such as using the H's and T's, is equally crucial when it comes to saving the life of an injured or ill child.

Taps and Shouts

If you have a patient who appears unresponsive, begin by tapping and shouting to verify. If the patient is still unresponsive at this point, you should:

  • Call in a code in a hospital setting
  • Get assistance from another advanced life support unit or higher level of transportation in pre-hospital settings

Assess for the ABC's

At this point, you'll want to begin assessing for signs of circulation and breathing. Begin by checking the patient's pulse.

In children, check for the carotid pulse. In infants, check for the brachial pulse. And observe the patient's face and chest, while you do, for any signs of normal breathing.

High Quality CPR

At this point, if the patient is still unresponsive, isn't breathing normally, and has no pulse, begin performing high quality CPR immediately and with as few interruptions as possible.

Perform CPR in cycles of 15 chest compressions at a depth of 1/3 the depth of the chest at a rate of 100 to 120 compressions per minute.

This should be followed by 2 rescue breaths, and make sure it's enough to get the patient's chest to rise and fall. Chest compression depth will vary based on the patient's size, so these are merely averages:

Child chest compressions – about 2 inches in depth.
Infant chest compressions – about 1.5 inches in depth.

And remember, to ensure the quality of CPR being performed remains high, change the compressor every 2 minutes – or sooner if needed – to avoid fatigue, which often leads to less than optimal CPR compressions.

The airway person should be measuring the patient and preparing the proper size basic airway adjunct and ventilating the patient with 100 percent oxygen delivered via a bag valve mask at 15 liters per minute.

Defibrillator pads should be applied right away after the compressions and rescue breaths have begun. After which, the team leader will tell everyone to stand clear while the AED analyzes the patient's rhythm.

If the patient is in asystole, it's important to double check some things that may be affecting this type of ECG rhythm by asking yourself the following questions:

  • Are all the leads on correctly?
  • Are all the leads attached to the patient with good contact?
  • Does the ECG have a sufficient power supply?
  • Is the amplitude set correctly to determine asystole vs. fine VFib?

If you can answer yes to all the above, the team leader should make sure the team knows to continue providing high quality CPR, as asystole is not a shockable rhythm.

Establish IV or IO Access

Now is the proper time to move to establishing IV or IO access in order to begin administering medications and replacing fluids.

It's helpful to have a length-based color-coded resuscitation tape, like a Broselow tape, so you can determine quickly and efficiently the weight of the patient for calculating drug doses and the correct size of resuscitation equipment you'll need.

An example: The average nine-month-old would measure within the red area of a length-based resuscitation tape. If the patient falls within this red area, you can quickly estimate their weight to be around 8kg (17-18 pounds), which lets you know that you'll need a 22-24 gauge IV catheter or an 18-15 gauge IO needle.

Administering Medications

After an IV or IO has been established, the team leader should call for an epinephrine concentration of 1:10,000 at .01mg/kg via IV or IO push, followed by 20cc of normal saline. This will ensure that the medication gets into the central circulatory system.

Pro Tip #2: It's important to continue to perform chest compression while the medication is being given in order to help circulate it properly, as well as ensuring that the patient is getting the best circulation of oxygen to vital organs and tissues. And finally, it's important for basic life support to minimize CPR breaks while giving medications or starting an advanced airway.

In circumstances where IV or IO access isn't available, but you have an endotracheal tube in place, epinephrine could be administered via the ET tube, however the ratio of the medication will be different – a concentration of 1:1000 at .1mg/kg.

Pro Tip #3: Medications delivered via an ET tube are not as desirable as via IV or IO as the results are not as predictable. However, the potential benefit of the medication outweighs any negatives regarding the method of delivery.

Insert Advanced Airway

After initial treatment has begun, it's a good time to insert an advanced airway if you haven't done so already.

After an ET tube or another advanced airway is in place, move to continue performing chest compressions, but the breaths will now change to 1 breath every 6 seconds. And remember to switch compressors every 2 minutes and/or when the compressor calls for a switch. When the switch is announced, the airway person would finish the next breath.

Before the next rescuer begins compressions, this is a good time for a quick look at the monitor for any changes in the patient's rhythm. But this should take no longer than 10 seconds. And CPR should be quickly resumed if there aren't any changes.

Capnography should also be attached at this time to monitor the quality of the compressions and gas exchange. And repeated doses of epinephrine can be given at .01mg/kg of 1:10,000 via IV or IO push every 3-5 minutes.

Once initial treatments have begun, it's also important to ask yourself and the team to consider the causes for the asystole, especially any reversible H's and T's such as:

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (acidosis)
  • Hypokalemia
  • Hyperkalemia
  • Tension pneumothorax
  • Cardiac tamponade
  • Toxins
  • Cardiac thrombosis
  • Coronary thrombosis

Pro Tip #4: As a healthcare provider, it's important to remember that you won't know when a patient will survive, even when it goes beyond all scientific reasoning. So, rescue with confidence and enthusiasm and know that miracles do sometimes happen.

A patient in asystole is there because all cardiac function and electrical activity have diminished over time. At this point, the patient is biologically dead. However, there are some circumstances, such as poisoning and hypothermia, that will warrant longer resuscitation efforts than others.

For instance, if a child drowns in icy cold water, survival can be possible after being underwater for as long as 40 minutes and after CPR efforts have lasted greater than two hours.

When drowning occurs in icy water, rewarming to a core temperature of at least 30 degrees Celsius (86 degrees Fahrenheit) is recommended before CPR efforts are terminated, as the heart is often unresponsive to resuscitative efforts until the core temperature is increased.

It's never an easy decision for a team leader to stop resuscitation efforts, especially with infants and children. However, after all available treatment options have been considered and attempted, potential reversible causes have been exhausted, and special circumstances have been taken into account, the decision to stop resuscitation will be necessary.