From the Guidelines
Ventricular standstill is a life-threatening cardiac emergency that requires immediate intervention with CPR, administration of epinephrine, and atropine, as well as urgent temporary pacing, to prevent high morbidity and mortality and improve quality of life. It occurs when the ventricles of the heart completely stop contracting, resulting in no cardiac output and cessation of blood circulation. This condition is typically fatal within minutes if not treated. According to the American College of Cardiology/American Heart Association guidelines 1, prompt resuscitative measures, including chest compressions, atropine, vasopressin, epinephrine, and temporary pacing, should be administered to treat ventricular asystole.
The European Resuscitation Council guidelines 1 also emphasize the importance of detecting and treating reversible causes of cardiac arrest, including ventricular standstill, and highlight the poor prognosis of asystole. Some key points to consider in the management of ventricular standstill include:
- Immediate initiation of CPR to maintain blood circulation and oxygenation
- Administration of epinephrine (1 mg IV every 3-5 minutes) to stimulate the heart
- Use of atropine (1 mg IV for bradycardic arrest) to increase heart rate
- Urgent temporary pacing to restore a viable cardiac rhythm
- Identification and treatment of underlying causes, such as severe electrolyte disturbances, drug toxicity, myocardial infarction, and advanced heart block.
Ventricular standstill can be recognized on ECG by the absence of QRS complexes with only P waves visible, or complete absence of all electrical activity (asystole). The prognosis is extremely poor without immediate intervention, with survival rates below 10% even with prompt treatment 1. Therefore, prompt and aggressive management of ventricular standstill is crucial to improve outcomes and reduce morbidity and mortality.
From the FDA Drug Label
Atropine abolishes various types of reflex vagal cardiac slowing or asystole The drug also prevents or abolishes bradycardia or asystole produced by injection of choline esters, anticholinesterase agents or other parasympathomimetic drugs, and cardiac arrest produced by stimulation of the vagus. Atropine also may lessen the degree of partial heart block when vagal activity is an etiologic factor In some patients with complete heart block, the idioventricular rate may be accelerated by atropine; in others, the rate is stabilized.
The significance of ventricular standstill is that it can be abolished by atropine, which prevents or abolishes bradycardia or asystole produced by various factors, including vagal stimulation. Atropine can also stabilize the heart rate in patients with complete heart block. 2
From the Research
Definition and Characteristics of Ventricular Standstill
- Ventricular standstill is an electrophysiologic phenomenon characterized by the absence of ventricular activity or contraction 3
- It is the result of the lack of impulse formation in ventricles or the failure of impulse transmission to ventricles 3
- Ventricular standstill is considered a ventricular fibrillation equivalent and is associated with a high mortality rate 4
Clinical Significance and Treatment
- The condition should be treated as a cardiac arrest, with resolution of precipitating factors 3
- There are no set guidelines on the treatment of ventricular standstill, and swift and sound clinical judgment is required 3
- The use of vasopressin and epinephrine has been studied in the treatment of cardiac arrest, including ventricular fibrillation and asystole 5, 6, 7
- Vasopressin may be more effective than epinephrine in patients with asystole, and the combination of vasopressin and epinephrine may be more effective than epinephrine alone in the treatment of refractory cardiac arrest 7
Prognosis and Outcomes
- The longer the duration of ventricular standstill, the poorer the prognosis 4
- Recurrent episodes of ventricular standstill can have life-threatening consequences 3, 4
- The use of clinical tools in assessing ventricular standstill is crucial in determining the appropriate treatment and improving patient outcomes 4