Shocking asystole

[nova]

Even within a hospotal setting, is there no effective way to restart a heart in asystole?

[dare]

How do they restart a heart after a heart transplant?

[A-Stark]

They warm it up and as it becomes perfused it starts beating irregularly, at which point cardioversion is applied to convert to sinus rhythm.

[KennethToronto]

This may be a little stupid, but what's the point of doing chest compressions if there is no way of restarting the patient's heart? I thought that chest compression were jsut a way of buying time until you could permanently fix the problem.

 

So you can keep perfusion going while figuring out wtf is wrong, in theory at least.

 

From my own experience, it's 0%.

[__bdas51]

Is there harm associated with shocking the heart in asystole?

 

(sorry if this was discussed above, I didn't read the full thread thoroughly)

 

As a CC3 I recently experienced a code where the cardiac post-op patient was thought to be in asystole but really was in VFib.

 

CPR was started, the chest was opened and the heart manually squeezed until they got back into the OR where they set up the bypass, shocked the patient cause they went into VFib etc ...

 

From the code being called to getting back into the OR and getting the bypass machine set up it was probably around 20-30 minutes or so.

 

In retrospect, the surgeon was thinking perhaps the patient was actually in VFib but the fib waves were really small and people thought it was asystole, so really they should have shocked earlier

 

So my question is... is there harm to shocking in asystole, and then start compressions just in case the patient is actually in Vfib?

 

The surgeon spoke with the team and from what I gathered, the patient may have fared better if that was done

 

This is my first code, and I've only seen Vfib on the ECG a handful of times so I'm not sure if there's much variation in the waveforms on ECG or what

 

thoughts?

[rogerroger]

I have seen a small handful of PEAs resuscitated. As said previously, CPR buys you time by circulating blood and getting some meagre oxygenation to the brain and myocardium. ACLS algorithms are all about buying time. A true "resusitologist" uses this time to figure out why the patient has unstable/absent vitals in the first place and how the etiological mechanism could be rapidly corrected. This is the cerebral part of any resuscitation.

 

In all most all the cases of successful PEA resus it was secondary to either hyperkalemia, hypovolemia from penetrating trauma, obstructive shock, or hypothermia. These are all conditions we can rapidly identify (hopefully) and reverse. However, it takes a short amount of time to figure this out and treat it. In these cases CPR was life saving as it bought that needed time.

 

More often than not PEA = dead. Besides reversing the reversible causes there is not much you do. Even the evidence behind meds in these cases is weak. Atropine is no longer recommended and no benefit has been proven from using epi despite it still being recommended. You can have a good talk with some ACLS instructors about meds. This is a topic which is often under debate within the field.

 

Much of the research behind all the ACLS stuff is not ideal. Because of the obvious ethical issues with doing a good RCT. Almost everything we know from the use of meds etc is mostly from animal modelling. Also remember if you unsync shock something that is not VF/VT you are at risk of CAUSING VF. The animal modelling also supports not shocking PEA.

 

Overall ACLS is better than nothing and its cool when you do bring someone back to life. Unfortunately, for the PEA algorithm it usually ends without regaining cardiac activity. The reason for this being that the mechanism is unreversible or the patient has been hypoxic for too long prior to being found to be in PEA.

[leviathan]

All the above is true but he was asking about shocking asystole. You can technically do so but then you would cause an unnecessary interruption in chest compressions, which is very detrimental to coronary perfusion pressure and could lower chances of survival. The most important part of resuscitation is maintaining high quality chest compressions and providing minimal ventilations while you attempt to correct the underlying cause.

[rogerroger]

All the above is true but he was asking about shocking asystole. You can technically do so but then you would cause an unnecessary interruption in chest compressions, which is very detrimental to coronary perfusion pressure and could lower chances of survival. The most important part of resuscitation is maintaining high quality chest compressions and providing minimal ventilations while you attempt to correct the underlying cause.

 

Sure, same algorithm. The difference between asystole vs PEA is purely academic from the ACLS stand point. High quality chest compressions are key. However, there are more reasons beyond this why it is not useful to shock a PEA/asystole. It all boils down to the myocardial pathophysiology behind a PEA/asystolic arrest.

[leviathan]

Sure, same algorithm. The difference between asystole vs PEA is purely academic from the ACLS stand point. High quality chest compressions are key. However, there are more reasons beyond this why it is not useful to shock a PEA/asystole. It all boils down to the myocardial pathophysiology behind a PEA/asystolic arrest.

The etiologies are often very different for PEA and asystole, although they do overlap. In a lot of your "Hs and Ts" the pathophysiology doesn't relate to the myocardium, but I know what you're getting at. What the other guy/girl was saying was that sometimes you might have a very fine vfib that gets misinterpteted as asystole, but it's not worth interrupting compressions to shock a rhythm like that, which itself probably has a similar prognosis, etiology, and responsiveness to defibrillation as asystole would.

[nosuperman]

Side point - its very non-evidence-based at this point but a few sites have tried /are studying "hands-on" CPR, meaning people continue compressions through the shock. If found to be safe and effective it would conveniently avoid the whole maintenance vs. resuscitation dynamic.