Management of asystole and PEA

Guidelines for the treatment of cardiopulmonary arrest caused by asystole or PEA are contained in the universal advanced life support algorithm.

Treatment for all cases of cardiac arrest is determined by the presence or absence of a rhythm likely to respond to a countershock. In the absence of a shockable rhythm "non-VF/VT" is diagnosed. This category includes all patients with asystole or PEA. Both are treated in the same way, by following the right-hand side of the algorithm.

When using a manual defibrillator and ECG monitor, non-VF/VT will be recognised by the clinical appearance of the patient and the rhythm on the monitor screen. When using an automated defibrillator, non-VF/VT rhythms are diagnosed when the machine dictates that no shock is indicated and the patient has no signs of a circulation. When the rhythm is checked on a monitor screen, the ECG trace should be examined carefully for the presence of P waves or other electrical activity that may respond to cardiac pacing. Pacing is often effective when applied to patients with asystole due to atrioventricular block or failure of sinus node discharge. It is unlikely to be successful when asystole follows extensive myocardial impairment or systemic metabolic upset. The role of cardiac pacing in the management of patients with cardiopulmonary arrest is considered further in Chapter 17.

As soon as a non-VF/VT rhythm is diagnosed, basic life support should be performed for three minutes, after which the rhythm should be reassessed. During this first loop of the

Pulseless electrical activity in a patient with acute myocardial infarction. Despite an apparently near normal cardiac rhythm there was no blood pressure (BP)

PEA can be a primary cardiac event or secondary to a potentially reversible disorder

Cardiac arrest

Precordial thump, if appropriate

Basic life support algorithm, if appropriate

Attach defibrillator/monitor -?-

Assess rhythm

± Check pulse

Non-VF/VT

CPR 3 minutes (1 minute if immediately after defibrillation)

During CPR, correct reversible causes If not done already:

• Check electrode/paddle positions and contact

• Attempt/verify: Airway and O2, intravenous access

• Give adrenaline (epinephrine) every 3 minutes

• Consider: Amiodarone, atropine/pacing, buffers

Potentially reversible causes

• Hypovolaemia

• Hyper- or hypokalemia and metabolic disorders

• Hypothermia

• Tension pneumothorax

• Toxic/therapeutic disturbances

• Thromboembolic or mechanical obstruction

The advanced life support algorithm for the management of non-VF cardiac arrest in adults. Adapted from Resuscitation Guidelines 2000, London: Resuscitation Council (UK), 2000

algorithm, the airway may be secured, intravenous access obtained, and the first dose of adrenaline (epinephrine) given. If asystole is present atropine, in a single dose of 3 mg intravenously (6mg by tracheal tube), should be given to block the vagus nerve completely.

The best chance of resuscitation from asystole or PEA occurs when a secondary, treatable cause is responsible for the arrest. For this reason the search for such a cause assumes major importance. The most common treatable causes are listed as the 4Hs and 4Ts at the foot of the universal algorithm. Loops of the right-hand side of the algorithm are repeated, with further doses of adrenaline (epinephrine) given every three minutes while the search for an underlying cause is made and treatment instigated.

If, during the treatment of asystole or PEA, the rhythm changes to VF (which will be evident on a monitor screen or by an automated external defibrillator advising that a shock is indicated) then the left-hand side of the universal algorithm should be followed with attempts at defibrillation.

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