ACLS: Asystole/PEA

1) Begin CPR

[follow BLS algorithm]

Info: use supplemental oxygen if available; attach cardiac monitor/defibrillator when available; do not delay CPR

2) Evaluate Rhythm

[confirm non-shockable asystole/PEA]

Info: ensure all leads/wires connected and ECG size not minimized

3) Resume CPR Immediately x2min

[start with compressions]

Info: use 30:2 ratio compressions to ventilations, each breath over 1sec with visible chest rise; consider advanced airway device if bag-valve-mask ventilations do not result in visible chest rise, confirm airway placement using 2 methods (consider waveform capnography) and secure, then ventilate 10 breaths/min (avoid hyperventilating), do not pause compressions for ventilations; establish IV/IO access ASAP; consider central access if IV/IO access unobtainable

4) Give Epinephrine During CPR

[epinephrine]

Dose: 1 mg (10 mL of 0.1 mg per mL solution) IV/IO q3-5min prn

5) Evaluate Rhythm

[confirm non-shockable asystole/PEA]

Info: assess AFTER 2min (5 cycles) of CPR; ensure all leads/wires connected and ECG size not minimized; if rhythm becomes shockable at any time, see ACLS: VF/Pulseless VT Table

6) Resume CPR Immediately x2min

[start with compressions]

Info: repeat 5 cycles (2min) CPR and q2min rhythm checks

7) Treat Reversible Causes

[5H's]

hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia

[5T's]

tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary), thrombosis (coronary)

8) Optimization and Prognostication

[optimization]

Info: if available, quantitative waveform capnography, arterial diastolic pressure, and central venous oxygen saturation may be used to optimize CPR efforts

[prognostication]

Info: if intubated patient unable to achieve ETCO2 >10 mm Hg via waveform capnography after CPR x20min, may be used in decision to terminate resuscitation, but should not be single deciding factor