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Management of a patient in cardiac arrest with asystole follows the same pathway as management of PEA. The top priorities stay the same: Following the steps in the ACLS Pulseless Arrest Algorithm and identifying and correcting any treatable, underlying causes for the asystole. The algorithm assumes that scene safety has been assured, personal protective equipment is being used, and no signs of obvious death are present.

Begin with the primary survey to assess the patient's condition:

1. Tap the patient on the shoulder and ask, "Are you all right?"
2. If the patient does not respond, call for help.
3. Give 2 minutes (5 cycles) of CPR before leaving patient to call for help.
4. Open airway.
5. Listen, check for breathing. Give 2 breaths that make the chest rise.
6. Check for a pulse.
7. If the patient does not have a pulse or any other signs of life, begin CPR, 30 compressions to 2 respirations. (Push hard and fast--100/minute. Release chest completely.)
8. Start an IV.
9. Begin oxygen.
10. Attach a monitor.

Follow the ACLS Pulseless Arrest Algorithm for asystole:

1. Check the patient's rhythm, taking less than 10 seconds to assess.
2. You see that the rhythm is not shockable.
3. Resume CPR (5 cycles). Rotate team members every 2 minutes with rhythm breaks to help maintain high quality CPR.
4. As soon as IV or IO access is available, administer epinephrine or vasopressin during CPR cycle. Do not stop CPR to administer drugs.
5. Consider administering atropine. (See qualifying note in Drug Therapies section.)
6. During CPR, search for and treat possible contributing causes (H's and T's in Figure 1).
7. Check rhythm.
a. If no electrical activity is present (patient is in asystole), resume CPR.
b. If electrical activity is present, see if the patient has a pulse.
c. If the patient does not have a pulse or there is some doubt about the pulse, resume CPR.
d. If a good pulse is present and the rhythm is organized, begin post-resuscitative care.

IV/IO access is a priority over advanced airway management. If an advanced airway is placed, change to continuous chest compressions without pauses for breaths. Give 8 to 10 breaths per minute and check rhythm every 2 minutes.

Without a pulse or electrical activity on the ECG for the patient, the emergency care team needs to decide when resuscitation efforts should stop. The patient's wishes and the family's concerns need to be considered, particularly if the patient has a Do Not Attempt Resuscitation Order in effect.