A precordial thump may be useful in asystole as long as there has not already been a prolonged period of basic life support ( Fig 1). Recovery from asystole is unlikely unless there is either a trifasicular block (P waves should be seen on the electrocardiogram), the rhythm has evolved from an extreme bradycacrdia, or asystole is a transient sequel to defibrillation. The possibility of a mistaken diagnosis of asystole must also be remembered. Ventricular fibrillation may be mistaken for asystole if there is equipment failure, excess artefact, uncontrollable movement (e.g. in a moving ambulance or aircraft), or incorrect gain setting on the electrocardiogram. Thus, because ventricular fibrillation is much more likely to have a successful outcome, if it is suspected, it should be treated by an attempt at defibrillation first. If the waveform is asystole or very fine ventricular fibrillation, an automated defibrillator will not allow shocks to be given and time should not be wasted in persevering in these attempts. After excluding ventricular fibrillation, the patient's airway should be secured and intravenous access should be established. Intravenous epinephrine 1 mg should be given to enhance basic life support. Intravenous atropine 3 mg will completely block the vagus and is given once and once only to counter any excess vagal tone, although no proven benefit has been found in clinical studies. Undue delay in performing basic life support must be avoided. If there has been any recent electrical activity on the electrocardiogram, intravenous or transcutaneous pacing may be considered. In the absence of any electrical activity, further loops should be considered. High-dose (5 mg) intravenous epinephrine may be considered if there is no electrical activity after three loops. Recovery rarely occurs after 15 min of asystole.

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