What to do if a patient with an epicardial (Electrode on the outer layer of the heart) pacemaker goes into asystole (flatline, no heart rhythm)?

Management of Asystole in a Patient with an Epicardial Pacemaker

For a patient with an epicardial pacemaker who goes into asystole, immediate initiation of high-quality CPR with minimal interruptions is required, while simultaneously activating the pacemaker function if available. 1

Initial Management

• Begin high-quality CPR immediately with chest compressions at a rate of at least 100 per minute and minimal interruptions 1
• Attempt to activate the epicardial pacemaker function if accessible, as pacing may generate cardiac output when myocardial contractility is not critically compromised 1
• Secure advanced airway management and ventilation while continuing compressions 1
• Establish intravenous access for medication administration 1

Medication Administration

• Administer epinephrine 1 mg IV every 3-5 minutes 1
• Give atropine 3 mg IV once (single dose) for asystole 1, 2
  • Atropine prevents or abolishes bradycardia or asystole produced by vagal activity 2

Rhythm Assessment and Further Management

• Reassess rhythm after 2 minutes of CPR 1, 3
• If VF/VT develops, switch to the VF/VT algorithm and deliver immediate defibrillation 1, 3
• If asystole persists, continue CPR and search for potentially reversible causes 1

Special Considerations for Epicardial Pacemakers

• Check for pacemaker malfunction, which may be the cause of asystole 1
• Assess for potential electromagnetic interference that could be affecting pacemaker function 1
• Position defibrillation paddles/pads at least 8 cm from the pacemaker generator if defibrillation becomes necessary 1
• Consider the possibility of pacemaker wire issues, as complications with epicardial pacing wires can occur 4

Reversible Causes to Consider

• Evaluate for the "5 H's and 4 T's" - particularly focusing on: 1
  • Hypoxia
  • Hypovolemia
  • Hydrogen ion (acidosis)
  • Hypo/hyperkalemia
  • Hypothermia
  • Tension pneumothorax
  • Tamponade (cardiac)
  • Thrombosis (coronary or pulmonary)
  • Toxins

Percussion Pacing

• If there is a delay in activating the epicardial pacemaker, consider percussion pacing (fist pacing) 1
• Perform percussion pacing with blows at a rate of 100/minute over the heart (not the sternum) 1
• This technique may be effective in producing cardiac output, particularly when myocardial contractility is not critically compromised 1

Important Caveats

• Routine electrical pacing is not effective as a treatment for asystolic cardiac arrest in general, but may be beneficial in this specific scenario with an epicardial pacemaker already in place 1
• Electrical countershock may be more effective than medications in cases where asystole appears later in resuscitation, as it may actually be fine VF misdiagnosed as asystole 5
• After any defibrillation attempts, immediately resume chest compressions without checking for pulse, as the majority of patients remain pulseless for over 2 minutes after shock delivery 6
• Be aware that electromagnetic interference can affect pacemaker function and potentially cause asystole in pacemaker-dependent patients 7

When to Consider Termination of Resuscitation

• Resuscitation should generally continue for at least 20-30 minutes from the time of collapse unless there are overwhelming reasons to believe that resuscitation is likely to be futile 1
• Continue to reassess for potentially reversible causes throughout the resuscitation 1