Asystole: treat or terminate?

Asystole or cardiac flatline indicates the absence of electrical activity. When asystole is the presenting rhythm in cardiac arrest, resuscitation rates are dismally low. Several mitigating factors can make a real difference. Patient age, concurrent pathology, known treatable causes, and length of arrest are all variables that can influence resuscitation rates.

Asystole is best treated with immediate high quality CPR and a search for an underlying cause. A key component of the medical history includes determination of the patient's possible Do-Not-Resuscitate status, known patient wishes, and family wishes. Each patient should be treated with all reasonable resuscitation efforts when applicable, but it must be understood that asystole is often a sign that the patient has died....permanently.

Part of our difficulty lies in deciding what constitutes a reasonable resuscitation effort. Each case is unique and the determination of "reasonable" depends on the situation, the patient, and the response to initial therapies.

Consider two extremes. In one case your asystolic patient is 89 years old and has an extensive medical history including prior cardiac disease, diabetes, debilitating arthritis, and neurological consequences from a stroke. The second case is a six-year old child just pulled from a cold swimming pool in a witnessed immersion event with asystole on the monitor. These two cases are clearly going to produce two very different resuscitation events. The child's event will involve prolonged attempts using every available therapy to restore a perfusing rhythm. Children have been resuscitated more than an hour after arrest in this circumstance. The adult's resuscitation, though just as important, will be maintained for a much shorter duration and terminated much earlier if therapies do not produce noticable effects. Elderly adults simply do not respond well to therapies after prolonged periods of ventricular asystole.

The decision to continue or terminate in both instances should be made by the most experienced and knowlegable parties involved. Many factors need to be considered. It is common practice to consult with the entire resuscitation team before making the termination decision. A quick survey of the team with the question, "Does anyone have any ideas or any additional information that we should consider before we terminate our efforts?" will tap into the combined experience and expertise of all members of the team.

What do you do when asystole is the presenting arrest rhythm? Respond with immediate high quality CPR, American Heart Association treatment protocols, a diligent search for an underlying treatable cause and be prepared to terminate the event if a response to therapy is not seen after a reasonable effort.