Asystole
Asystole or “flatline”
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 puslesless arrest 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»
Jeff, I know that asystole is non shockable, but I am confused why. I do understand that when we shock v tach or v fibb we are doing so to interupt the abnormal pattern and let the heart correct itself, and we dont shock in asystole because there is no rhythm to interrupt and let correct.
But isn’t shocking better than nothing? So why do we treat it with no shock? What harm can it do to shock someone who is dead?
Also, why does Epi work for asystole? All it does is activate beta receptors on the myocardial tissue, how would that work better than providing an electric stimulus of sort? Thanks
A heart that has no electrical activity cannot be stunned and will not respond to defibrillation. The pacemakers are not functioning and therefore “resetting” them with defibrillation will do not good.
Epinephrine is used with the pulseless arrest algorithm (asystole) not because it causes the electrical conduction of the heart to restart, but it is used for it’s vasopressor qualities. The purpose of epinephrine is to help increase cardiac output during cardiac arrest.
If you find a patient in asystole their chances of resuscitation are very unlikely. Usually before asystole presents, the patient will have already been in some other arrhythmia (VT, VF, Complete Block, etc.) Asystole is usually seen at the end. The heart is essentially dead.
I cannot recall a single code where a patient was in asystole and was successfully resuscitated.
Kind regards,
Jeff
I love this site. I have studied more from your site than the book. Will let you know how I do on test!!!
As a soldier in the United States Army, at times very difficult to renew certifications especially when in austere environments’ but the fact is this website has become a great teaching tool. In keeping us relevant and ready. I find that you have created possibly one of the best teaching platforms that I have ever seen. Great Job…will encourage my fellow medics, nurses, physicians to view and utilize your site. Great Job, Jeff.
Hi Jeff, Why will pacing possibly reverse asystole when you have pacing wires? (2010 AHA Guidelines for CPR and ECC, part 12.15, pg S849) but TCP is not used/recommended in the ACLS PEA/Asystole Algorhythm? Thanks, Jon
I checked the reference you gave and it did not provide any more detail than stating what you stated above. The reference and abstract (518) cited did not provide details either.
Here is what I think about the question.
Pacing wires directly placed within the myocardial tissue are and would be much more effective for delivering an electrical conduction than TCP. I guess this would increase the potential to reverse asystole and bradycardia.
The reason why TCP is not any longer recommended for asystole is that research collected has shown that it is not effective for reversal of asystole.
I was actually involved in a code where the patient died but the pacemaker continued firing. Even after the patient was expired he had a fairly decent looking rhythm on the monitor, but he had no myocardial contraction.
The pacemaker actually had to be deactivated.
Kind regards,
Jeff
what is the maximum dose of epinephrine that we can give if rhythm is VT/VF / asystole?
There is no maximum dose. Epinephrine is quickly metabolized by the body.
Kind regards,
Jeff
Jeff,
This is the second time I have used your site for recertification. After my first couple of experiences with ACLS, I find your site really helpful and actually enjoyable. I’m an RN First Assistant who used to mostly rely on the anesthesiologist in the room for all this information. Now I feel I understand the big picture in a code. I am very grateful.
Gerry Dunphy
My man Jeff, you are the “one”, thanks for the decent price and most importantly for the job you’ve done. kind regards.
Thanks for the encouraging feedback. God bless.
Thank you. it is really helpful.
If you can’t tell whether it is asystole or fine ventricular fibrillation, how should you proceed? Go ahead and shock?
Yes, if you are unsure and you think that you are dealing with fine VF you should shock and then begin CPR.
Kind regards,
Jeff
(i hope this can help ^^) if you are in doubt, there is a “size” button on the machine, which you can push to make the rhythm bigger and clearer. at that point, it can help the reader interpret and decide whether its a fine VF or ASYSTOLE…hope it does help…i always rely on this site for every question and doubt i encounter during actual codes…jeff and chris are doing a great job..
Good comment, Mylee. Just remember that not all machines revert to the default size, so if yours isn’t fairly new, be sure to resize back to normal before you shut it off..
We normally pull off the road, turn off the inverter/any other electrical devices that may interfere with capture, and allow for 30 secs or so to get a steady read on the monitor.
Jeff’s note: This was in reference to the following question that was recently asked:
“If you are in the back of an ambulance with movement/vibration from vehicle and/or roads, how would you distinguish between the two rhythms?”
If you are in the back of an ambulance with movement/vibration from vehicle and/or roads, how would you distinguish between the two rhythms?
This is a great question, and I do not know the answer. I have no personal experience with out of hospital scenarios. I will try and find out an answer for you.
Kind regards,
Jeff
What’s the role of atropine in asystole?
Atropine no longer has a role in the asystole algorithm. It was removed in the 2010 guidelines because the research had shown that it is not effective for changing outcomes with asystole. —Kind regards, Jeff
Why can’t asystole be shocked?
Defibrillation or “shock” actually stuns the heart and cause temporary asystole and resets the pacemaker of the heart. Shocking asystole does nothing because the pacemaker is not firing in the first place and therefore cannot be reset. For defibrillation to work, you first need a heart that has a working electrical impulse.—Kind regards, Jeff
What Teresa may be getting at is the “fine VF” issue. If you’re not sure whether it’s fine VF or asystole, what would be the downside of shocking?
If you think that what you see is find VF go ahead and shock. There really is not a downside to shocking. If in doubt and you think you are dealing with fine VF, Shock.—Regards, Jeff
will let you know how it turns out, but this is fantastic stuff!
Great learning tool. Thanks a lot. You are doing a fantastic job here.
Great videos. Commentary on the defibrillator screen is a great learning tool. And I did have sound (music) with the videos.
Can the AED be overridden to administer a shock for fine VF if it mistakenly reads asysstole?
Some AED’s have this feature.
May I assume that fine VF will call for VF/VT algorithm? FIne VF is therefore shockable. Correct?
Yes, Shock fine VF. Jeff
This is very helpful to get ready for my
ACLS test.
Is there suppose to be sound?
Hi jodi. No these short videos do not have any sound. Jeff
I can’t seem to get the sound from the ACLS Rhythm series.
The EKG Rhythm videos do not have sound. Thanks, Jeff