Asystole is characterised by ventricular standstill on the ECG but a mistaken diagnosis must be avoided since fibrillation can be more successfully treated. An ECG example of asystole is shown in Figure RS.12.

Bls Algorithm Rcuk

Figure RS.5

The ALS algorithm for the management of cardiac arrest in adults © RCUK 97 Ref. Kloeck W, Cummins R, Chamberlain D, Bossaert L, Callanan V, Carli Pt et al.

The Universal ALS Algorithm. An Advisory Statement by the Advanced Working Group of the International Liaison Committee on Resuscitation. (ILCOR) Resuscitation 1997; 34:109-111

Causes of asytole include:

• Acute hypoxia and hypovolaemia (both treatable)

• Myocardial ischaemia (usually severe and terminal)

• Electrolyte imbalance

• Drug overdosage

If asystole is diagnosed monitor gain should be increased and all lead connections checked to ensure accurate diagnosis. The ECG monitor should be switched to lead II, and then another lead considered in case the directional vector of the fibrillation waveform happens to be perpendicular to the sensing electrode, therefore, being hidden. If there is any doubt that the rhythm may be fine VF, a pre cordial thump may be given and the initial three shock sequence followed as in the VF algorithm. After these shocks or if asystole is definitely the presenting rhythm, the airway should be secured and IV access established early. The algorithm for treatment of asystole is shown in Figure RS.5. As in the other algorithms, adrenaline is given to support adequate cerebral and coronary perfusion.

Strong cholinergic activity may depress the function of the sino-atrial and atrioventricular nodes, especially when sympathetic stimulation is reduced, for instance by infarction or beta blockade.

Atropine may increase the chance of successful resuscitation therefore full atropinisation (3 mg IV) is still recommended. Pacing should be considered if there has been any evidence of electrical activity such as occasional QRS complexes. Sodium bicarbonate may be given if there is evidence of a severe acidosis.

Electromechanical Dissociation (EMD)

EMD describes mechanical asystole with an undetectable pulse, but accompanied by the presence of an ECG trace which can vary from being near normal to a bizarre agonal pattern. Primary EMD carries a very poor prognosis and reflects profound myocardial pump failure. Secondary EMD carries a better prognosis if potentially reversible causes are considered and treated early. See Figure RS.6.

If specific treatment of any of the above fails to produce an immediate output, or the EMD is deemed to be a primary event, the algorithm (Figure RS.5) should be followed, including three minute CPR cycles, with intubation and IV cannulation performed early, and adrenaline given as an adjunct to basic life support.









Cardiac tamponade

Pulmonary embolism



other causes


Electrolyte imbalance

Drug overdose

Figure RS.6

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