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Section 4 - CARDIAC


Asystole is a terminal condition identified by an absence of any cardiac electrical activity. It is important to CONFIRM true asystole early in the management of the case. Consider all possible reversible causes for Asystole utilizing a national recommended mnemonic of “H’s and T’s”:

H’s T’s
Hypovolemia Tension Pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen Ion (acidosis) Toxins or Tablets (overdose)
Hypo/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, cardiac

In addition, also consider the following:

Hypoglycemia Trauma

Check proper lead placement – confirm that a “flat line” is not an equipment or operator error BASED ON MEDICAL ETIOLOGY OF ASYSTOLE - REFER TO APPROPRIATE PRACTICE PARAMETER:

When the Patient found in True Asystole:

  • Initiate 5 cycles of high quality CPR (push hard/push fast)
    • Minimum of 100 compressions per minute, minimize interruptions
    • Compression rate of 30:2 for approximately 2 minutes
    • Depth of compression of at least 2 inches
    • Initiate the use of a mechanical compression device if available
  • Assist ventilations with OXYGEN @ 100% via BVM - DO NOT HYPERVENTILATE
  • Establish intravenous access via IV or IO
  • Reassess for circulation every two minutes
  • Consider advanced airway procedure using supraglottic airway (king tube) or endotracheal intubation
    • Do not interrupt compressions to place an advanced airway
    • Confirm tube placement with capnography (a range 5-20 mmHg is indicative of low cardiac output)

Pharmacologic Therapy:

The current national guidelines do not include ATROPINE for treatment of TRUE ASYSTOLE as there is no proof it has a therapeutic benefit.

Under the Seminole County Practice Parameters the use of ATROPINE SULFATE is indicated in cardiac arrest that may be caused by extreme bradycardia/hypotension.
The Paramedic may use ATROPINE SULFATE based on clinical impression where there is a possibility that its use will have a positive therapeutic benefit.
If ATROPINE SULFATE is used, the recommended dose is: ATROPINE SULFATE 1 mg rapid IVP or IO Repeat every 3 - 5 minutes up to a total of .04 mg/kg

Electrical Therapy/Pacing is no longer recommended

Check for pulse and rhythm change after all interventions.

If suspected DRUG OVERDOSE (5.05)

  • For calcium channel and beta-blockers
    • Administer GLUCAGON 2 mg IVP, IN or IO May repeat x 1
  • For calcium channel blockers
    • Administer CALCIUM CHLORIDE 1 gram IVP or IO
    • Avoid if patient is on digoxin or lanoxin
  • For tricyclic antidepressants (amitriptyline [Elavil], amoxapine, imipramine [Tofranil ], nortriptyline [Pamelor] and tetracyclic antidepressants (Remeron) OD, with wide QRS> 0.10 sec
  • For narcotic OD

For patients with HYPERKALEMIA:

Suspect hyperkalemia in patients with any of the following: Diagnosis of Renal Failure or any form of kidney insufficiency, widening QRS, increased K+ in diet (excessive consumption of cherries, bananas, melons or citrus), acidosis, or shock. Note last dialysis TX.

Termination of Resuscitation:

In Medical Related Cardiac Arrests, the paramedic may terminate resuscitative efforts in Non-Hypothermic Adults provided all of the following criteria have been provided and established:

  • Patient initially presents and maintains in True Asystole (verified in 2 leads)
  • Airway has been successfully controlled (not necessarily intubated)
  • EPINEPHRINE 1:10,000 (0.1 mg/ml) 1 mg IVP or IO has been administered & allowed time to circulate x1
  • EtCO2 is (less than) < 20 mm Hg
  • If clinically indicated - ATROPINE SULFATE 1.0 mg rapid IVP/ IO has been administered and allowed time to circulate x1.


  • After 15 minutes of ALS procedures without any response or return of spontaneous circulation


  • After the patient’s personal medical doctor agrees to sign the death certificate

Contact will be made in conjunction and compliance with Federal, State, Local, and Agency Laws and Policies regarding patient body care and removal.

A paramedic may decide to continue resuscitation efforts as outlined in these Practice Parameters. Reasons to continue may include scene safety, location, and input from present family members.

If patient combative post resuscitation, refer to ANALGESIA / SEDATION PARAMETER (2.04)