Asystole

Asystole appears as a flat line on the ECG and suggests complete absence of electrical activity.
In arrest situations known or suspected to be associated with hyperkalemia, calcium gluconate
should be administered. Regular insulin at 0.2 U/kg, followed by glucose at 12 g/U of insulin,
diluted to 25%, temporarily reduces serum levels of potassium. Epinephrine or vasopressin, with
or without atropine can be administered in an attempt to generate impulses. Fine ventricular
fibrillation may look like asystole, and for this reason, open-chest heart massage and direct
observation of myocardial activity are warranted early with this arrhythmia; if fibrillation is
visualized, defibrillation is indicated.

Ventricular Fibrillation

This rhythm implies that multiple foci within the ventricles are firing rapidly and independently,
resulting in no coordinated mechanical activity. There are no ventricular contractions and no
cardiac output. The goal is to abruptly stop the electrical activity and allow one strong (hopefully
normal) electrical rhythm to take over. Defibrillation is more successful when there are few,
strong foci (coarse fibrillation) than when there are multiple, weak foci (fine fibrillation).

Pulseless electrical activity or PEA (also known by the older term electromechanical
dissociation)
The ECG tracing can be normal or show an arrhythmia (commonly a bradyarrhythmia of
ventricular or supraventricular origin), but the heart has no muscular activity associated with the
electrical activity, ie, no contractions and no cardiac output and, subsequently, no pulses. In this
arrhythmia, it is vital that thoracic auscultation be performed in tandem with central pulse

(femoral arterial) palpation and ECG evaluation. There are no heart sounds or pulse activity.
However, severe hypovolemia, pericardial effusion, and significant accumulation of fluid or air
in the pleural cavity can prevent detection of normal heart sounds. The ECG associated with
these conditions demonstrates tachyarrhythmias, in contrast to the usually normal or slow rate of
PEA. Atropine and epinephrine or vasopressin may be given in an attempt to correct this
arrhythmia. Defibrillation may be attempted with pulseless ventricular tachycardia.

Drugs and Defibrillation Used in Cardiopulmonary Resuscitation

Drug

Dosagea

Indications

Epinephrine Low dose (0.01 mg/kg) every 3 Asystole, ventricular fibrillation,

5 min early in CPR; high dose PEAb
(0.1 mg/kg) after prolonged
CPR; 10 times the dose may be
required when given
intratracheally
Atropine

0.1 mL/5 lb (0.5 mg/mL

solution)

Sinus bradycardia, asystole, or PEA

associated with high vagal tone

Sodium
bicarbonate

1 mEq/kg (1 mEq/mL solution) Severe metabolic acidemia associated

with prolonged (>1015 min)
cardiopulmonary resuscitation efforts
(must be adequately ventilated to be
effective), hyperkalemia

Calcium
gluconate

1 mL/510 kg (2% solution

without epinephrine)

Routine use not recommended; treat

cases with documented hypocalcemia
(or severe hyperkalemia)

Amiodarone 5 mg/kg

Refractory ventricular fibrillation or

pulseless ventricular tachycardia

Magnesium
sulfate

30 mg/kg

Hypomagnesemia, torsades de
pointes

Lidocaine

24 mg/kg

Pulseless ventricular tachycardia,

ventricular fibrillation resistant to
defibrillation

Vasopressin

0.40.9 U/kg

Combined with or as a substitute for

epinephrine every 35 min (asystole,
bradycardia, PEA)

Naloxone

0.020.04 mg/kg

To reverse opioids

Defibrillation 46 joules/kg external

(monophasic), 24 joules/kg
external (biphasic), 0.21
joules/kg internal

Single shock, resume CPR efforts

immediately after for one cycle (2
min), dose escalation may occur

Dosage should be doubled if given via intratracheal route.

PEA = pulseless electrical activity