1. Asystole: a true
story.
Craig Hore

2. And I don’t mean this one…

3. Asystole is the end
 60 year old man ?previously well
 Presented to regional hospital ED with




syncope
Asystolic arrest soon after arrival
Intubated
CPR and adrenaline ~ 20 mins
Called for senior advice (no ED SS)

4. “Should we call it?”

5. “Let me have a quick look…”
 Patient is as described
 ECG rhythm strip:

6. “Surely we can call it now?”
What would you do?

7. Clinical examination
 Patient looks surprisingly pink for at least 20 mins
asystole
 Confirm no peripheral pulses but palpable
“pulses” with CPR
 “Gut feeling” is hmmmm…….
 What’s that rule about asystole?

8. Is it really asystole?
 Check other leads (I,III, V) – no obvious
difference
 Closer look at lead II – are those small bumps?
 Rhythm strip with increased amplitude:

9. “What now then?”
This calls for something completely different….

10. Wasn’t thinking of this. But…?

11. Transcutaneous pacing

12. Transcutaneous pacing
 “Older style” TCPM (Lifepak)
 Rate set at 70bpm
 Amplitude increased by 20 mA increments
 Capture at 120 mA
 Good pulses and SBP 130mmHg!

13. Rembrandt van Rijn “The Raising of Lazarus” Los
Angeles County Museum of Art, Los Angeles

14. (WTF!)V
Rembrandt van Rijn “The Raising of Lazarus” Los
Angeles County Museum of Art, Los Angeles

15. The Raising of Lazarus…..
 Patient started to move!.....
 …opened eyes!!......
 ..responded to simple instructions!!!
 Transcutaneous pacing did not appear to be
causing him to much discomfort
 What now?

16. Temporary pacing wire
 Insertion of temporary transvenous pacing wire
in ED (RIJV; balloon flotation)

17. Temporary transvenous
pacing
 How do I know it’s in the correct position?
 Length of insertion
 ECG electrode
 Ectopics
 CXR / bedside imaging

19. Temporary transvenous
pacing
 What settings?
- demand?
- rate?
- sensitivity?
- output?

20. Settings
 Capture threshold - the minimum electricity output
(mA) required to pace the heart (capture)
 Asynchronous – paces at a fixed rate, ignoring any
of the patient’s intrinsic activity
 Demand - paces only if the intrinsic heart rate gets
lower than the set rate. This is the usual setting.
 Sensitivity – the sensitivity of the pacemaker to the
patient’s intrinsic activity. When an intrinsic beat is
“sensed’ (sensing light), this “inhibits” the
pacemaker from firing

21. Settings
 Setting sensitivity – turn the output to 0 (prevent
discharge); set rate below intrinsic rate; reduce
sensitivity (increase amplitude) until no sensing
of intrinsic activity (sensing threshold); set at ~
half the amplitude of this threshold.
 Setting output – turn output to 0 and set rate at
10-15 bpm higher than intrinsic rate; increase
output until capture occurs (capture
threshold); set at 2-3 times higher than this
threshold.

22. Eventual outcome
 Extubated inED
 Admitted to CICU
 History of syncope over several months –
neurological work-up was normal!
 Probable sick sinus syndrome
 Referred to Metropolitan hospital for permanent
pacemaker
 Full neurological recovery and return to usual
independent activities

24. Summary
 Don’t ignore those gut instincts
 The old rule of thumb: a rhythm disturbance with
haemodynamic compromise needs electricity
 Temporary pacing can save lives
 Transcutaneous pacing is getting better and
easier
 Temporary transvenous pacemaker insertion is
getting better and easier

25. GiottoThe Arena Chapel Frescoes: The Raising of Lazarus

26. GiottoThe Arena Chapel Frescoes: The Raising of Lazarus
“It’s a
miracle!! The
Haematologist
was right!”