Note: Your progress in watching these videos WILL NOT be tracked. These training videos are the same videos you will experience when you take the full ProACLS Recertification program. You may begin the training for free at any time to start officially tracking your progress toward your certificate of completion.
In this lesson, we're going to let you play the role of team leader during a cardiac emergency – asystole. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 30-year-old female patient who was found unconscious in her office by coworkers. Witnesses tell you that she was emotionally distraught and may have had a chronic illness, as well as using different pain pills.
By the time you find her, she appears cyanotic and seems to be unresponsive. You direct a member of your team or an assistant to check her responsiveness using taps and shouts and you get no response. You call in a code or ask for additional help depending on your situation and area of practice.
Your initial assessment recap:
- 30-year-old female
- Found unconscious
- Appears cyanotic
- Is unresponsive
Let's assume the scene is safe and your personal protective equipment is in place. You begin by instructing a member of your team to check for a carotid pulse and signs of normal breathing as you all begin gathering the appropriate equipment, which may or may not already be in the room. Your team finds no pulse and no signs of breathing.
Someone in the team either places a CPR board under the patient or if she's on a hospital bed with a CPR button, you activate it at this time. Doing so will deflate the bed and create a hard surface, which will aid CPR efforts. CPR is initiated.
Now is the time when you'll take a leadership role and assign team member roles. You begin by directing the recorder to record all times, treatments, and any other associated and relevant notes for that protocol.
You assign a compressor and a monitor/defibrillator and remind the team that high quality CPR must be given – 30 compressions at 2 to 2.4 inches deep and at a rate of 100 to 120 compressions per minute followed by 2 rescue breaths.
You assign an airway person and directions to begin ventilations. An example of exactly how you might do this, especially if you're not used to being team leader is: Please prepared a basic airway adjunct and ventilate with 100 percent oxygen delivered via bag valve mask at 12 breaths per minute.
Remember, now is a good time to begin thinking about advanced airways if protecting the patient's airway is important or if oxygenation with basic airways is insufficient.
In order to obtain 100 percent oxygenation, you need to turn the oxygen regulator to 15 liters per minute and allow the bag valve mask reservoir to fill prior to giving ventilations.
During CPR, the monitor/defibrillator team member is preparing the patient for defibrillation – the ECG monitor and defibrillator pads are placed on the patient appropriately and as soon as ready, you'll give directions to your team to pause CPR to check the patient's underlying rhythm.
You tell everyone, stand clear while the rhythm is analyzed. It indicated that the patient is in asystole. You decide to double-check that everything is working by asking yourself and the team the following questions:
- Are all the leads on correctly?
- Are all the leads attached to the patient with good contact?
- Does the ECG have a sufficient power supply?
- Is the amplitude set correctly to determine asystole vs. fine VFib?
All answers point to the patient being in asystole and you instruct your team to continue providing high-quality CPR. While CPR resumes, you prepare the team for medications delivery.
Pro Tip #1: Since asystole is not a shockable rhythm, you move immediately to gaining IV (or IO) access via an 18 gauge in the antecubital and call for 1mg of epinephrine 1:10,000 concentration via IV push flushed with 20cc of normal saline – to ensure the medication gets into the patient's central circulatory system. And perhaps most importantly, you instruct your team to continue CPR while the medication is being administered.
The recorder team member states, It's been 2 minutes.
You instruct the compressor and monitor/defibrillator to switch positions to have a fresh compressor at all times. This switch should occur at least every 2 minutes or sooner if you recognize insufficient compressions due to fatigue.
You take a quick look at the monitor to see if there any changes in the patient's rhythm – no longer than 10 seconds – before deciding if you need to deliver a shock or continue with CPR. You tell the team that the patient is still in asystole and to continue with high quality CPR.
At this time, you decide to secure an advanced airway to maintain the airway, give synchronous compressions with rescue breaths, and have the ability to monitor capnography.
As the team leader, you request an advanced airway using an endotracheal tube. Someone on the team measures for it and inserts a #7 endotracheal tube with a stylet. The ET tube balloon is inflated after it passes between the vocal cords and lung sounds are oscillated for ET tube placement accuracy.
Pro Tip #2: Both upper lobes and over the stomach are checked to ensure proper placement of the tube – in the trachea and not the esophagus. If you cannot detect any stomach air sounds and there are good breath sounds bilaterally, you know that the ET tube is in the correct spot. And it is.
You tell your team, CPR quality looks good. Let's make sure to monitor capnography.
The recorder calls out, It's been 4 minutes since the first dose of epi.
You call for a second dose of epinephrine at 1mg 1:10,000 concentration via IV push followed by 20cc of normal saline. The medications team member repeats the order and you confirm it's correct.
You keep an eye on chest compressions and remember to change compressors every 2 minutes or if you notice fatigue setting in to ensure adequate compressions throughout the code. You tell your team that CPR is looking good or you make suggestions for improvements.
At this time, you encourage suggestions from your team as to why this patient may be in asystole. You consider the H's and T's:
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypokalemia
- Hyperkalemia
- Tension pneumothorax
- Cardiac tamponade
- Toxins
- Cardiac thrombosis
- Coronary thrombosis
Pro Tip #3: As a healthcare professional, you never know when a patient will survive against all odds and scientific reasoning. For this reason, you instruct your team to work with enthusiasm and high expectations throughout the resuscitation.
However, it's also important to understand that studies have shown that asystole represents what's termed, the final rhythm. In other words, cardiac function and electrical activity have diminished over time until there is no perceivable electrical or mechanical activity in the patient. At which point, the patient, is biologically or permanently dead.
Unless there are special circumstances, as provided in the last lesson's Word section, such as hypothermia or drug overdose, a prolonged resuscitation effort beyond 20 minutes is usually futile.
As the team leader, you may have to consider stopping resuscitation, especially if the EtCO2 is less than 10 after high quality CPR and all other treatment options have been exhausted.
