Considerations

• Are resuscitative efforts appropriate given low chance of success?
• Is there a DNR or signs of death?
• If resuscitative efforts given; review list of reversible causes (listed at bottom)

First Steps

• Call for code cart/defibrillator
• Apply monitor, get BVM with high flow O₂ attached, Establish IV [2^nd or 3^rd staff member to do this while CPR being performed]
• If out of hospital, activate EMS
• If in hospital, activate code team

If resuscitative efforts indicated

1. Open airway, give breath, start CPR
2. 5 Cycles of High Quality CPR (each cycle is 30 compressions then 2 breaths via BVM). CPR to continue uninterrupted until efforts cease or resuscitation successful.
3. Once IV is established, administer epinephrine or vasopressin [dosing below]. May also use atropine [dosing below].
   
   Epinephrine Dosing
   1 mg IVP or 2-2.5 mg ETT administered every 3-5 minutes until efforts cease or are successful (IV preferred).
   
   Vasopressin Dosing
   40 units IVP (may replace either 1^st or 2^nd dose of epinephrine with vasopressin if desired). If vasopressin used, next dose of epinephrine is 10 minutes after vasopressin.
   
   Atropine Dosing
   1 mg IVP (preferred)or 2-3 mg ETT administered every 3-5 minutes until maximum cumulative IV dose of 0.04 mg/kg.
4. After EVERY 5 cycles of CPR [1 cycle = 30 compressions then 2 breaths (approx 2 minutes)] check rhythm and confirm asystole in two leads.
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. Chances of meaningful neurologic recovery with asystole is low.

Reversible Causes of Asystole

• Poisoning such as beta blockers, TCA's, Digoxin
• Metabolic causes such as hyperkalemia, hypokalemia, acidosis
• Trauma such as tension pneumothorax, tamponade, aortic rupture
• Hypovolemia such as severe dehydration or massive hemorrhage
• Hypoxia
• Hypothermia
• Hypoglycemia
• Cardiac Tamponade
• Myocardial Infarction or Pulmonary Embolus

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