From the Guidelines
Pacing-induced asystole should not be treated with pacing as a standard approach, instead, focus on high-quality CPR, securing the airway, establishing IV access, and administering epinephrine 1mg IV every 3-5 minutes. Asystole represents a complete absence of electrical activity in the heart, and external pacing typically does not benefit patients in true asystole 1. The most recent and highest quality study, published in 2019, supports this approach, stating that transcutaneous pacing has not shown a benefit in patients with cardiac arrest caused by asystole 1.
Key Considerations
- Identify and treat potential reversible causes using the H's and T's framework (Hypoxia, Hypovolemia, Hydrogen ion/acidosis, Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis-pulmonary, Thrombosis-coronary) 1.
- Transcutaneous pacing may be considered only in specific situations where asystole is very recent or potentially a result of high-degree AV blocks, but outcomes are generally poor 1.
- Resources should instead be directed toward effective CPR, medication administration, and addressing underlying causes rather than attempting pacing in most asystole cases 1.
Treatment Approach
- Focus on high-quality CPR, with chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions, and avoiding excessive ventilation 1.
- Secure the airway, establish IV access, and administer epinephrine 1mg IV every 3-5 minutes 1.
- Consider the use of other medications, such as atropine, only in specific situations, as their effectiveness in asystole is limited 1.
From the FDA Drug Label
Atropine Sulfate Injection, USP in clinical doses counteracts the peripheral dilatation and abrupt decrease in blood pressure produced by choline esters ... Adequate doses of atropine abolish various types of reflex vagal cardiac slowing or asystole The treatment for pacing-induced asystole (absence of cardiac rhythm) is atropine.
- Atropine counteracts reflex vagal cardiac slowing or asystole. 2
From the Research
Treatment for Pacing-Induced Asystole
The treatment for pacing-induced asystole involves various interventions, including:
- Immediate countershock treatment, which has shown some promise in restoring normal cardiac activity, although the results are not statistically significant 3
- Transcutaneous pacing, which can be of value in treating profound bradycardia, but is unlikely to be effective in complete asystole 4
- Advanced life support and resuscitation techniques, such as early defibrillation, cardiopulmonary resuscitation, and vasopressin administration, which may improve survival rates in patients with asystole 5
- Percussion pacing, a little-known procedure that can be used as a temporary emergency cardiac pacing method in haemodynamically unstable bradycardias, including bradycardic pulseless electrical activity and complete heart block with ventricular asystole 6
- The use of point-of-care ultrasound (PoCUS) to guide resuscitation management, as ECG rhythm alone is not an accurate predictor of cardiac activity 7
Key Findings
- The effectiveness of these treatments varies, and some may not be suitable for all patients with pacing-induced asystole
- The use of multiple interventions, such as a combination of advanced life support and resuscitation techniques, may be necessary to improve survival rates
- Further research is needed to determine the most effective treatment strategies for pacing-induced asystole, and to improve patient outcomes 3, 4, 5, 6, 7