Transcript Case 5 - Tripod.com

Case 5
Asystole
© 2001 American Heart Association
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Case 5: Asystole?
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Case Scenario
You are checking a 64-year-old woman after she
collapsed in the hospital parking lot. Hospital
personnel have started CPR, but no ACLS
intervention has been initiated. You overhear a
relative state, “She was on her way to her last
oncology clinic appointment.”
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Learning Objectives

Verify that the flat line seen on the ECG
monitor is indeed “true asystole” (an electrically silent heart) and not some other rhythm
(eg, fine ventricular fibrillation) masquerading
as a flat line or an operator error that creates a
flat line (ie, “asystole”) on the monitor screen
when in fact another rhythm is present.
 Apply the ACLS Approach (the Primary
and Secondary ABCD Surveys) to a patient
in asystole.
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Learning Objectives (cont’d)


Discuss the relative merits of adequate
ventilation—not IV buffer therapy—as the
mainstay of acidosis treatment.
Describe why successful resuscitation in
asystole requires identification of a treatable
cause. The team leader must rapidly and
energetically focus on the differential
diagnosis of asystole.
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Learning Objectives (cont’d)

State the most common reversible conditions
associated with asystole. (Reversible causes of
asystole are not limited to those on the
following slide.) Note that these conditions are
the same conditions that should be identified
or ruled out when PEA develops.
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Causes: H’s and T’s
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Hypoxia (CNS events)
Hypokalemia/hyperkalemia
(and other electrolytes)
Hypothermia/hyperthermia
Hypoglycemia/hyperglycemia
Hypovolemia (tank/anaphylaxis, gravid)
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Causes: H’s and T’s (cont’d)
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Trauma
Tamponade
Thrombosis (pulmonary)
Thrombosis (coronary)
Tablets (ODs, drugs, etc)
Tension (pneumothorax, asthma)
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Learning Objectives (cont’d)
Recognize that asystole usually
represents a confirmation of
death rather than a “rhythm” to
be treated. Describe the criteria
that clinicians should follow for
stopping resuscitative efforts.
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Skills Objectives

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Provide airway maintenance and ventilation
because adequate ventilation is the mainstay
of asystole care while trying to identify the
reversible cause.
Conduct a rapid “Secondary D” (assessment
of asystole and its causes).
Recognize indications for stopping
resuscitative efforts.
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Primary ABCD Survey
A = Airway: open the airway
B = Breathing: check breathing,
provide positive-pressure
ventilations
C = Circulation: check circulation,
give chest compressions
D = Defibrillation: assess for and
shock VF/pulseless VT
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Secondary ABCD Survey
A = Airway: place airway device as soon as possible
B = Breathing: confirm airway device placement by
physical exam (primary tube confirmation)
B = Breathing: confirm airway device placement by
secondary tube confirmation (end-tidal CO2
and/or EDD)
B = Breathing: secure airway device to prevent
dislodgment (use commercial tube holders)
B = Breathing: confirm effective oxygenation
and ventilation
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Secondary ABCD Survey (cont’d)
C = Circulation: establish IV access
C = Circulation: identify rhythm
C = Circulation: administer rhythm and
condition-appropriate drugs
D = Differential Diagnosis: search for and treat
identified reversible causes (Think!)
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Asystole Algorithm
A
B
C
C
D
Primary ABCD Survey
Focus: basic CPR and defibrillation
• Check responsiveness
• Activate emergency response system
• Call for defibrillator
Airway: open the airway
Breathing: provide positive-pressure ventilations
Circulation: give chest compressions
Confirm true asystole
Defibrillation: assess for VF/pulseless VT, shock if indicated
Rapid scene survey: is there any evidence that personnel should not
attempt resuscitation (eg, DNAR order, signs of death)?
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Asystole Algorithm (cont’d)
Secondary ABCD Survey
Focus: more advanced assessments and treatments
A
B
B
B
C
C
C
C
D
Airway: place airway device as soon as possible
Breathing: confirm airway device placement by exam plus confirmation device
Breathing: secure airway device; purpose-made tube holders preferred
Breathing: confirm effective oxygenation and ventilation
Circulation: confirm true asystole
Circulation: establish IV access
Circulation: identify rhythm  monitor
Circulation: give medications appropriate for rhythm and condition
Differential Diagnosis: search for and treat identified reversible causes
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Asystole Algorithm (cont’d)
Transcutaneous pacing:
If considered, perform immediately
Epinephrine 1 mg IV push,
repeat every 3 to 5 minutes
Atropine 1 mg IV,
repeat every 3 to 5 minutes
up to a total of 0.04 mg/kg
Asystole persists
Withhold or cease resuscitation efforts?
• Consider quality of resuscitation?
• Atypical clinical features present?
• Support for cease-efforts protocols in place?
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Case 5: Asystole
Active search for “do not attempt resuscitation”
(DNAR) orders/status
 Explicit criteria for stopping
 Death certification in the field
 Prohibition on transporting failed ACLS with CPR
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Case 5: Asystole
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Family presence at resuscitation efforts
Survivor support plans
More formal death notification
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