Asystole Case Teaching

Now, in this scenario, we have a 30-year-old female who was found unconscious in her office by co-workers. Witnesses report that she was emotionally distraught and she may have had a problem with a chronic illness that used different pain pills. The patient appears cyanotic and seems to be unresponsive. First, the team leader directs an assistant to check for responsiveness using a tap and shout. The patient does not respond to taps and shouts, so you would want to call a code or ask for additional help depending on your area of practice. The code is called and the team is on their way. Now we want to assess for a carotid pulse and for breathing as we begin gathering appropriate equipment that may already be in the room or close by. As we check for a carotid pulse and breathing, we find no pulse and the patient is not breathing. It's at this time that we would want to place a CPR board under the patient, or if it's in a hospital bed with a CPR button, activate it so that the bed will deflate and make the surface as rigid as possible. CPR is now initiated. And as additional assistance or the code team arrives, we are able to direct each of the team members to their respective roles or be assigned roles if they are all equally trained. As the team leader begins to take the leadership role, they direct the recorder to please record times, treatments given, and any associated notes per protocol. A compressor will be assigned along with a monitor defibrillator. A reminder is given to perform CPR at 30 compressions at 2-2.4 inches deep and at a rate of between 100-120 compressions per minute. The airway person is also assigned and directions to prepare to ventilate are given. "Please prepare a basic airway adjunct and ventilate with 100% oxygen delivered via bag valve mask at 12 breaths per minute," is a good example of how that may sound. This would be a good time to begin thinking about an advanced airway, if protecting the airway or if oxygenation with a basic airway is insufficient. To obtain near 100% oxygenation, we will turn the oxygen regulator at 15 liters per minute and allow the bag valve mask reservoir to fill prior to ventilations being delivered. At this time, the leader calls everyone to stand clear while analyzing the rhythm. We see that the patient appears to be in asystole. In this case, it's important that we double check some easy things to correct with this type of ECG rhythm. The first one is that we check to see if all the leads are on correctly and attached with good contact. Is there sufficient power to the ECG? Is the amplitude setting correct so as to determine asystole versus fine V-Fib? If all these are answers are yes, and they're working properly, the team leader may continue. At this time the team leader states, "Let's keep giving high quality CPR." Because there isn't a shockable rhythm now, we move to the IV access or an IO access in order to begin medication and fluid therapy. In our scenario, an 18 gauge antecubital IV is established. At this time, the team leader should call for 1mg epinephrine at 1:10,000 to be delivered IV push then flushed with 20cc's of normal saline. This ensures that the medication is in the central circulatory system. Remember, CPR should still be in progress and should not be stopped for the delivery of medications. After CPR has been in progress for some time, the recorder says, "About two minutes has gone by." It is at this time that the compressor should be switched with the monitor/defibrillator. Now would be a good time to do a quick look at the monitor for changes. This should not take any longer than 10 seconds before the shock is delivered or CPR is resumed if there is no change in the rhythm. The team leader states, "It appears the patient is still in asystole, so let's continue with CPR." Now is a good time to consider an advanced airway. The team leader states, "Let's prepare for intubation and attach capnography." The team leader requests an advanced airway using an endotracheal tube. It's measured at a number 7 and is placed with a stylet. The ET balloon is inflated after the tube is passed between the vocal cords of the patient, and lung sounds are auscultated for ET tube placement accuracy. Both upper lobes and over the stomach is checked to ensure that the tube is in the trachea and not in the esophagus. Tube placement is accurate and lung sounds are equal and good bilaterally. There are no stomach sounds. The team leader states, "CPR quality is good. Let's ensure we're monitoring capnography." As CPR has been in progress for a while, the recorder states that it's been about four minutes since epi was first given. The team leader should now call for a second dose of epi 1 mg of 1:10,000 IV push flushed with 20cc of normal saline. Remember to change compressors every two minutes or upon noticeable fatigue to ensure adequate CPR compressions throughout the whole code. Encourage the CPR compressor that compressions are looking good or make any suggestions to improve quality throughout. Once initial treatments have been started, it's important to ask the team to help in considering why this patient went into asystole. To do this, we should consider the reversible H's and T's. These include hypovolemia, hypoxia, hydrogen ion, which is acidosis, hypo or hyperkalemia, tension pneumothorax, cardiac tamponade, toxins, cardiac or coronary thrombosis. It's important to remember that as healthcare professionals, we can't know when a person may experience a survival that goes against all scientific reason, and so we should regularly rescue with great enthusiasm. But, it's also important to note many studies have shown that asystole represents what is termed to be the final rhythm. In other words, cardiac function and electrical activity have diminished over time until there is no perceivable electric or mechanical activity and the patient is now biologically or permanently dead. Unless there are special circumstances like hypothermia or drug overdose, prolonged resuscitation efforts beyond 20 minutes are usually unnecessary and futile. The team leader may consider stopping resuscitation if the ETCO2 is less than 10 after 20 minutes of high quality CPR and all treatments have been exhausted.