Asystole

Asystole or “flatline”

EKG Asystole Rhythm Strip

Asystole is not actually a true rhythm but rather is a state of no cardiac electrical activity. The main treatment of choice for asystole is the use of epinephrine and CPR.

Asystole is treated using the right branch of the pulseless arrest algorithm. Click below to view the pulseless arrest algorithm diagram. When done click again to close the diagram.
Pulseless Arrest Algorithm Diagram.

During asystole, there is no blood flow to the brain and other vital organs. This results in very poor outcomes if resuscitation is successful.

If asystole is visualized on the monitor, you should ensure that all leads are connected properly. If all leads are properly connected, you should rapidly assess for any underlying causes for the asystole.

As with pulseless electrical activity (PEA), asystole can have possible underlying causes which can be remembered using the H’s and T’s mnemonic.

In the following video, asystole is depicted on the defibrillator monitor and suggestions for treatment are given. Please allow several seconds for the video to load.


Pop-Quiz

Question: What can sometimes be mistaken for asystole during a code?
click here for answer



fine ventricular fibrillation. Another way you can help determine the difference between asystole and fine VF is to increase the signal gain on the monitor. Increasing the signal gain will help you visualize any electrical impulses that indicate fine VF.

Comments

  1. kim says

    Individual 61 with no documented risk factor history of cardiovascular disease, but family history-father with IDDM, no personal physician, but had been informally checking BP > 1 year with recent increase in home BP monitoring, ( occasions of BP 180/90-100), developed 3 days of described “severe heartburn” type pain, started after late night restaurant meal. Prior to chest pain, history of admitted cannabis use, occasional remote history of other drug use. Also with one episode of syncope following cannabis use on recent vacation. After intermittent three day history of chest pain, with some improvement from antacids and PPI use, went to work and experienced witnessed collapse on the job. Co-worker stated individual suddenly developed chest pain, clutched chest, took two deep breaths and experienced syncope. Arrival of paramedics with initial rhythm of asystole. According to ED records, ACLS protocol initiated with epi in field, intubation CPR. NO return of viable rhythm. No shock given rushed to ED where continued CPR short lived because Ultrasound at bedside revealed no cardiac activity. Code called. Question(s): Nothing in record suggests that your rec. for checking for fine VF with witnessed arrest was done ( increase signal, assume VF and give one shock only in attempt to see if this initiates perfusing rhythm). Given history, could this essentially healthy individual have benefited from shock? Cause of death most likely massive MI v PE? HTN harbinger of ensuing sudden cardiac death? Possible prolonged QT syndrome? Thanks

    • says

      Looking with ultrasound will allow you to see the heart fibrillation. If it wasn’t fibrillation get then no benefit to shock. If < 10 min from arrest and presence of fine v fib, a shock can’t hurt. The closer to arrest the more likely the shock would be effective. Kind regards, Jeff

  2. Alexisboz says

    After the 1st rounds of CPR are given, 1st shock is given, and CPR is restarted, then epi is given every 3-5 min. Is this for a max of 2 doses before 2nd shock is given, more CPR, and then amioderone is given?

    • says

      The epinephrine can be repeated every 3-5 minutes and can be given as many times as necessary. There is no max limit on epinephrine. Epinephrine is basically on its own time table after the first dose, and is given every 3-5 minutes regardless of what else is going on during the code.
      Please let me know if you have any other questions about this.

      Kind regards,
      Jeff

  3. jan black says

    I am scheduled to take ACLS skills tomorrow. I was sent the AHA pre test course which involves MANY icons but are difficult to locate everything you need. Any suggestions?

    • says

      I’m not sure I understand the question you are asking could you please clarify what information you are trying to locate. Also, are you talking about information on this this website or the AHA website.
      Kind regards,
      Jeff

  4. NHIEN HOANG says

    Hi, how many dose of epi do we give to the pt with PEA? It said that vassopresin can be given to replace 1st or 2nd dose of epi. How long should we wait to give the next epi dose after vassopresin? Do we only give 1 dose of vassopresin during the emergency? Thanks.

    • says

      There is no limit on the number of doses of epinephrine that can be given. It can be give every 3-5 minutes. If you give a replacement dose of vasopressin, you can give epinephrine after 3-5 minutes. This keeps thing easy to remember and is per the AHA protocol.

      Kind regards,
      Jeff

  5. sam says

    Hi Jeff

    I have a question. For asystole, we administer 1mg of Adrenaline* straightaway during CPR, and then every 3-5 minutes. (every 2nd loop)
    Why is the timing every 3-5minutes? Why can this not be every two minutes?
    Sorry if this is a dumb question.
    I asked my Senior Registrar last night and she told me it may be this is the time needed to circulate the Adrenaline systemically or ?half life of drug?
    (*Australia never use the word Epinephrine, so apologies if I quoted Adrenaline)

    • says

      The half-life of epinephrine is 2 minutes. This is why you give the medication every 3-5 minutes.
      It is the same with vasopressin. The half-life of vasopressin is 20 minutes. This is why it can be given only one time during a code as a replacement for the first or 2nd dose of epinephrine.

      Kind regards,
      Jeff

  6. kelboyz says

    is it fair to say that VF and VT are both in the category of PEA but are known to respond to defibrillation while other forms of PEA do not?

    • says

      This would be true for pulseless VT but not VF. PEA is any ORGANIZED rhythm that does not have a pulse. VF is not considered an organized rhythm. VT is considered an organized rhythm. Technically, VT is a type of PEA but it is included with VF on the left branch of the cardiac arrest algorithm because it responds well to defibrillation as you stated.

      Kind regards,
      Jeff

    • says

      Defibrillation should not be applied indiscriminately to the patient in asystole. When a patient is given an unsynchronized shock (defibrillation) this induces asystole so that the heart will reset and hopefully restart a normal firing pattern.

      Shocking asystole, will cause the heart to become less responsive to CPR and may possibly eliminate any possibility of recovering a rhythm with CPR efforts. Only used defibrillation on pulseless VT or VF.

      Kind regards,
      Jeff

  7. Lee NR says

    I think you should mention if any asystole you’re unsure of, you can zoom the rhythm or increase sensitivity on the monitor to look for minimal electrical activity with rhythm.

    • says

      Yes they are both pulseless. You can’t always be sure that you are doing the right thing because you cannot always be sure you are dealing with VF or asystole. One way is to evaluate the situation. If you are dealing with a patient who was found unresponsive, is cool to touch, cyanotic, and the time of cardiac arrest is not known you are probably dealing with asystole. If the arrest was witnessed and it has been a very short time since the collapse there is a good chance you are dealing with fine VF. A health care provider might try increasing the signal gain on the defibrillator if it does not waste much time, but if in doubt. Shock the patient once. If it is asystole, you will get no response. If it is fine VF, it could save their life.

      Kind regards,
      Jeff

    • says

      It really depends on a lot of factors. If there is a reversible factor that can be identified (H and T’s) then asystole can be reversed and every effort should be made to reverse any reversible factors.
      Also, you have to take into consideration the length of time that the patient has been in asystole. There are too many factors to say that a code with asystole should last “ “ about of time. Or “ “ is to long for a code when asystole is present.
      One thing that I have been told it that the patient in asystole should be warm and dead. This means that you have effectively circulated the patients’ blood through your CPR efforts and there has been no response from the patient.
      Carefully consider any H and T’s that could be causing an asystole before you give up and call a code. Use good team communication to work together to determine when it is best to stop a code.

      Kind regards,
      Jeff

  8. pinx_cute20@yahoo.com says

    I’m going to take my acls next week..im quite nervous since it is my first time to take this..im searching in the internet for a understandable tool for my study guide, and luckily i found this site .. im praying and hoping for a positive result..wish me luck..thanks..

    • says

      Good luck to you with certification. You will do great!
      Make sure to use the checklist in the download library to ensure that you cover all of the material on the website. You can leave a comment on the home page to let me know how your certification goes.

      Kind regards,
      Jeff

  9. says

    If rhythm on monitor is asystole do I have still to check pulse ? Or start CPR immediately.
    Checking rhythm on monitor alone is enough or we need to check pulse for PEA ?

    • says

      A pulse check is always a good idea, but it should not take longer than 10 seconds. If you cannot feel a pulse within 10 seconds, start CPR.
      If you saw a rhythm change from pulseless VT or VF to asystole then you would not need to check for a pulse. You would continue CPR with rhythm checks between each 5 cycles of CPR.

      Kind regards,
      Jeff

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