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Asystole
Calvin Vonn

v.1.0 - Last updated 24 Feb 2020

Overview

SIMULATION TYPE SIMULATION TIME PATIENT AGE GROUP

Simulator based 10 - 20 minutes Adult

DEBRIEFING TIME TARGET GROUPS

20 - 40 minutes Physicians, paramedics, nurses, and others
managing cardiac arrests.

Why use this scenario?

This patient case has been developed for the Laerdal SimMan advanced simulators to address major learning objectives with an emphasis on cardiac arrests and
respiratory emergencies. Simulation of the patient case promotes, patient assessment and management, critical thinking skills, team interaction and communication,
debrie ng, student re ection, and remediation.
Summary
This case presents a patient in witnessed cardiac arrest. The participant is expected to call for help, initiate CPR, and recognize asystole on the monitor. The participant
should also recognize that this patient has poor outcome potential due to severe congestive heart failure prior to this incident and the presence of asystole. A decision
on when to stop resuscitation efforts should be considered by the participant. It will not be possible to resuscitate the patient unless the optional progression feature of
ventricular brillation is used.

Optional Progression
The addition of a DNAR (do not attempt resuscitation) bracelet to the patient allows the instructor in this case to discuss when resuscitative efforts should not be
initiated. Alternatively, the ventricular brillation button can be activated to convert the rhythm into ventricular brillation, which will require de brillation and make
successful resuscitation possible.
Scenario Learning Objectives

General Management
Applies the Adult BLS Healthcare Providers Algorithm
Demonstrates effective chest compressions (CPR)
Demonstrates basic airway maneuvers
Demonstrates effective bag-mask ventilations

Case-speci c
Applies the treatment from the Adult Cardiac Arrest Algorithm
Recalls general indications, contraindications, and dosages of drugs relevant to treatment of cardiac arrest
Demonstrates correct administration of relevant drugs
States possible causes of asystole cardiac arrest
Discusses when to stop resuscitation efforts

Optional
Recognizes DNAR bracelet
Recognizes ventricular brillation
Explains why early de brillation is essential in management of VF/pulseless VT
Applies local protocols for VF/pulseless VT

Team Dynamics
Demonstrates effective teamwork (see form)

0
Prepare

Location
The patient case is designed to operate in a variety of patient settings in which emergencies occur
Equipment List
The equipment list covers medical supplies, drugs, and uids that are speci cally needed for the case. However, it is recommended that protocols and equipment re ect
the local resources of the setting. Additional drugs, including drugs that would commonly be given in error, could also be available to promote consideration of
indications and contraindications for each drug.

Equipment
Universal precautions equipment
Airway adjuncts (OPAs, NPAs)
Oxygen supply source
Oxygen delivery devices (nasal cannula and/or non-rebreathing mask)
De brillator or AED
ECG electrode cables
Suction device and suction catheter (tonsil tip and exible)
Stethoscope
CPR backboard
Infusion pump
Pulse oximeter probe
Advanced airway equipment (optional)
Continuous waveform capnography

Drugs and Fluids

Epinephrine
Epinephrine infusion
Vasopressin
Amiodarone
Lidocaine
Magnesium sulfate
Dopamine infusion
Atropine
Glucose
Saline
Adenosine
Sotalol
Procainamide
Preparation and Setup
Dress the simulator in typical male clothing for the patient’s age
Place on a stretcher/gurney
Optional: Place a DNAR bracelet

Note: If the simulator supports fluids, the fluid system should always be filled prior to simulation unless otherwise specified above.
Use this scenario with

SimMan 3G Adult

SimMan 3G Trauma Adult

SimMan Essential Adult

SimMan Essential Bleeding Adult

SimMan 3G PLUS Simulator

Additional Simulation Equipment

Patient Monitor

SpO2 Probe

Simulation Devices

LLEAP - Laerdal Learning Application

Simulation Modes

Automatic Mode - Physiological Patient Case

Simulate

Learner Brief
Calvin Vonn is an 83-year-old male known to have severe congestive heart failure. Today he has not been feeling well and calls his daughter for help. When she comes to
see him, he complains of chest pain and shortness of breath, so she drives him to the emergency department. Upon entry into the ED he collapses and a paramedic who
is passing by calls for help and starts CPR. Mr. Vonn is quickly placed on a gurney and brought to the resuscitation area.

Patient Overview

Calvin Vonn
AGE WEIGHT GENDER

83 years 80 kg Male

HEIGHT

180 cm

Initial Vital Signs

TEMPERATURE HEART RATE RESPIRATION RATE

98.6 °F 0 bpm 0 rpm

BLOOD PRESSURE SPO2 HEART RHYTHM

-/- mmHg No signal Asystole

Medical History

Prior Medical History

Mr. Vonn has a history of severe congestive heart failure due to arterial hypertension (EF 15-20%) Currently this is being treated with ACE inhibitor,
diuretics, beta blocker, and digoxin. He’s living alone but his daughter who lives nearby regularly comes to see him.

Recent Medical History

Calvin Vonn was admitted 2 weeks ago because of volume overload and arrhythmia. Two days later he was discharged after adjustment of his medication.

Clinical Findings

Lifeless
Cyanotic

Expected Interventions
Start CPR immediately upon recognition of arrest
Administer a vasopressor (either epinephrine or vasopressin)
Consider possible reversible causes
Optional: if patient has a DNAR bracelet, stop resuscitation efforts
Assessment Instruments

Team Dynamics

The Elements of Team Dynamics form may be used for assessing effective teamwork during simulation.

Separate attachment to download and print: View Team Dynamics Assessment Form

Operator Information
Debrief

Case Considerations
The term asystole de nes an absence of electrical activity in the heart. Asystole typically progresses from a slowing bradycardia, various degrees of atrioventricular
block, or PEA. Patients in cardiac arrest with asystole generally have a poor prognosis.

Once asystole has been con rmed, the major goal of management is to identify and treat a reversible cause of the arrest. Whenever asystole is seen on the monitor, the
rhythm must be con rmed in a second ECG lead.

This is done to establish that the rhythm is not ne VF and to ensure that there has been no operator error in setting up the monitor.

All patients in asystole should receive CPR immediately. When performing CPR, rescuers should remember to push hard and fast (at least 100 compressions per
minute), allow complete chest recoil, minimize interruptions, and avoid excessive ventilation. If multiple rescuers are available, they should rotate the task of
compressions every 2 minutes to avoid fatigue.

Next, all asystole patients should receive a vasopressor agent - either epinephrine or vasopressin - as a rst-line medication.

Critical to all asystole cases is consideration of a probable cause and identi cation and treatment of a reversible cause for the arrest.

When reviewing possible causes of asystole, remember the H’s and T’s:

Hypoxia Toxins
Hypovolemia Tamponade (cardiac)
Hydrogen ion Tension pneumothorax
Hypo/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary

A valid “do not resuscitate” (DNR) or “do not attempt resuscitation” (DNAR) order should be identi ed quickly and respected. Termination of efforts should be
considered after assessment of responsiveness, pulse check, and con rmation by stethoscope and ECG.

Ethical considerations regarding when to start and stop resuscitation efforts are always important. Depending on the cultural situation, allowing or even encouraging
presence of family and/or close relatives during termination of ACLS efforts may be an important step in obtaining closure on the death of a loved one.
Publication Details
Scenario Information

Version
1.0

Publication Date
2020-02-24

Release Notes

Version 1.0

This scenario has previously been published on www.mysimcenter.com, 2011.

Credits

Elizabeth A. Hunt, MD, MPH, PhD

Assistant Professor of Anesthesiology and Critical Care Medicine
Assistant Professor of Pediatrics
The Johns Hopkins Medicine Simulation Center
The Drs. David S. and Marilyn M. Zamierowski Director
Baltimore, Maryland

Frederick Korley, MD
The Robert E. Meyerhoff Professor
Assistant Professor
Department of Emergency Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland

Eric Niegelberg, MS, NREMT-P

Assistant Professor of Emergency Medicine
Administrative Director for Emergency Services
Department of Emergency Medicine
School of Medicine
Stony Brook University
Stony Brook, New York

Charles N. Pozner, MD
Medical Director, STRATUS Center for Medical Simulation
Brigham and Women’s Hospital
Assistant Professor of Medicine (Emergency Medicine)
Harvard Medical School
Boston, Massachusetts

Edward R. Stapleton, AAS, EMT-P

Associate Professor of Emergency Medicine
Director of Prehospital Education
Department of Emergency Medicine
School of Medicine
Stony Brook University
Stony Brook, New York

Laerdal acknowledges the contributions of staff of the Johns Hopkins Hospital, a Laerdal customer, to the development of the Emergency: Respiratory & Cardiac
Patient Cases.

Laerdal thanks staff at the Danish Institute for Medical Simulation, Herlev Hospital, Denmark, for participating in the validation of the Emergency: Respiratory &
Cardiac Patient Cases.