1. Initial Actions:
• Open airway
• Give breath
• Start CPR without delay
• 100% O₂ by BVM (initially)
• Code cart
• Establish IV/IO
• Monitors (Rhythm, Oximetry, BP)
• In hospital, activate code team
• Out of hospital, activate EMS
• Look at reversible causes of Asystole/PEA below and treat if present
2. 5 Cycles of High Quality CPR (each cycle is 15 compressions then 2 breaths via BVM with 2 rescuers). CPR to continue uninterrupted until efforts cease or resuscitation successful.
3. Administer epinephrine (repeat q3-5 minutes):
• IV/IO: 0.01 mg/kg (1:10,000 = 0.1 mL/kg)
• ETT: 0.1 mg/kg (1:1,000 = 0.1 mL/kg)
4. After EVERY 2 minutes check pulse/rhythm. If condition changes, apply the protocol for that condition.
5. Consider placing advanced airway after initial 5 cycles of CPR. If placed, secure the tube, confirm placement by breath sounds, visualization of cords, CO₂ monitor or esophageal detector device. Once advanced airway placed, give 8-10 breaths/minute and provide continuous CPR (no pausing for breaths).
6. Consider cessation of efforts after reasonable trial of therapy with no positive response. Meaningful recovery is rare if no positive response seen after 10 minutes of resuscitative efforts and no reversible cause is identified.

Reversible Causes of Asystole/PEA

• Most common causes of asystole/PEA in children are hypoxia or hypovolemia; in general, application of high flow oxygen and fluid bolus should be attempted
• Hypoglycemia (especially in newborns)
• Hypothermia
• Poisoning such as beta blockers, TCA's, Digoxin
• Metabolic causes such as hyperkalemia, hypokalemia, acidosis
• Trauma such as tension pneumothorax, cardiac tamponade, aortic rupture
• Myocardial Infarction or Pulmonary Embolus

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.