ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA)
Inclusion Criteria: Apneic, pulseless patients not in ventricular fibrillation or ventricular tachycardia. These guidelines do not apply to patients for whom a resuscitation attempt is not indicated (refer to DETERMINATION OF DEATH IN THE FIELD Policy). If the patient's cardiac rhythm changes at any time during resuscitation, refer to the appropriate, specific guidelines.
NOTE: ALS units may discontinue resuscitation attempts in victims of blunt or penetrating traumatic cardiac arrest if no signs of life are present AND the patient remains in asystole.
- Assess and support vital functions including provision of immediate and consistent high-quality CPR. Chest compressions are the first priority, consistent with the AHA’s “C-A-B” resuscitation method. Apply ECG pads and ETCO2 monitors. Perform all resuscitation maneuvers with the monitor/defibrillator in manual mode and the PADDLES lead.
- Some agencies may use the manual monitor-defibrillator in AED mode for ADULTS only, depending on proper AED mode configuration, agency MOP, and specific authorization from EMS Medical Direction.
- Obtain vascular access as soon as possible, but access does NOT take priority over chest compressions or application of the defibrillator.
- Avoid over-ventilation!
- Do not attempt placement of an advanced airway (supraglottic or endotracheal) for at least 6 minutes – not until completing three 2-minute CPR cycles – unless necessary because of regurgitation. Advanced airway insertion MUST NOT interrupt chest compressions.
- Confirm asystole (if suspected) by checking for loose lead connections, monitor power, and signal gain. The AHA and the Medical Direction Team no longer recommend checking for asystole in multiple leads.
- Administer epinephrine 1:10,000:
- 1 mg IVP or IO every 3 to 5 minutes
- 0.01 mg/kg IVP or IO; every 3 to 5 minutes
- If any of the following causes of asystole and PEA is suspected, initiate standing order treatment ASAP:
- Hypoxia – Ventilate with 100% oxygen; confirm proper advanced airway position with continuous waveform capnography (ETCO2 monitoring).
- Hypothermia – Protect from further cooling; do not actively rewarm; administer only 1 round of resuscitation drugs.
- Overzealous ventilation – Provide only 8 to 10 breaths per minute over 1 second each, using a one-handed squeeze of the BVM. Low ETCO2 may indicate both overzealous ventilation and/or ineffective chest compressions.
- Hypovolemia - Infuse Normal Saline IV or IO:
- 20 mL/kg boluses, as needed (up to 1,000 mL total cumulative volume).
- 20 mL/kg bolus. May repeat twice, as needed, unless DKA or unless signs of volume overload develop (e.g. rales, JVD).
- Contact BioTel for additional boluses.
e. Hyperkalemia (renal failure or dialysis) or pre-existing acidosis (renal failure, dialysis, methanol ingestion, aspirin overdose) or tricyclic antidepressant overdose:
Adult and Pediatric
Sodium bicarbonate 1 mEq/kg IV Push or IO
f. Narcotic overdose:
- Naloxone 2 mg IV Push or IO.
- Naloxone 0.1 mg/kg IV Push or IO.
- Contact BioTel for repeat dosing.
g. Beta-blocker overdose:
- Glucagon 1 mg – 2 mg IV/IO/IM/IN.
- May repeat once after 20 minutes.
- Glucagon 0.5 mg (under age 1 yr) or 1 mg (at least one year of age) IV/IO, IM, or IN.
- May repeat once after 20 minutes.
h. Calcium channel blocker overdose:
- Calcium chloride (10%) solution: 10 mg/kg – 15 mg/kg IV Push or IO (0.1-0.15 mL/kg). (optional medication)
- Contact BioTel for authorization and dosing (risk of phlebitis). (optional medication)
i. Tension pneumothorax - Pneumothorax AND Hemodynamic Instability
- Perform needle thoracostomy.
- Contact BioTel as soon as possible.
- Refer to the NEEDLE THORACOSTOMY Special Procedure.
- If the resuscitation attempt is prolonged (greater than 15 minutes), consider:
- Sodium bicarbonate 1 mEq/kg slow IVP or IO; AND/OR
- Calcium chloride (10%) solution, 10 – 15 mg/kg (0.1 – 0.15 mL/kg) IV Push/IO. (optional medication)
- Sodium bicarbonate 1 mEq/kg slow IV Push or IO.
- Contact BioTel for additional recommendations.
- In the event of return of spontaneous circulation, refer to POST-CARDIAC ARREST CARE Guidelines.
- If there is no response to therapy and no evidence of reversible causes of asystole or PEA, consider terminating all resuscitation efforts in the field. Refer to the Termination of Resuscitative Efforts section of the DETERMINATION OF DEATH Policy.
- For additional patient care considerations not covered under standing orders, consult BioTel.