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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Asystole is a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow. Asystole is one of the conditions required for a medical practitioner to certify death.

In asystole, the heart will not respond to defibrillation because it is already depolarized, however some emergency physicians advocate a trial of defibrillation in case the rhythm is actually fine ventricular fibrillation, although little evidence exists to support the practice. Asystole is usually a confirmation of death as opposed to a heart rhythm to be treated, although a small minority of patients are successfully resuscitated, if the underlying cause is identified and treated immediately.


Common Causes

Possible underlying causes include the Hs and Ts.[1][2][3]

Causes by Organ System

Cardiovascular Cardiogenic shock, Degeneration of the sinoatrial or atrioventricular nodes, Ischemic stroke, Myocardial infarction, Pacemaker failure, Pulmonary embolism, Thrombosis
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine Hypoglycemia
Environmental Hypothermia, Lightning strike
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic Hypovolemia, Hypoxia
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal/Orthopedic No underlying causes
Neurologic No underlying causes
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic No underlying causes
Overdose/Toxicity Drug overdose
Psychiatric No underlying causes
Pulmonary Drowning, Pulmonary embolism, Tension pneumothorax
Renal/Electrolyte Hyperkalemia, hypokalemia
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma Trauma
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order



Shown below are EKGs depicting asystole.


Medical Therapy

It is important to exclude fine ventricular fibrillation in the patient presumed to have asystole. If VF is present, then cardioversion should be performed.

While the heart is asystolic, there is no blood flow to the brain unless CPR or internal cardiac massage (when the chest is opened and the heart is manually compressed) is performed, and even then, it is still a small amount. After many emergency treatments have been applied but the heart is still unresponsive, it is time to consider pronouncing the patient dead. Even in the rare case that a rhythm should reappear, if asystole has persisted for fifteen minutes or more the brain will have been deprived of oxygen long enough to cause brain death.

Related Chapters


  1. ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
  2. ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003. ISBN 0-87493-424-9.
  3. "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." Circulation 2005; 112: IV-58 - IV-66.

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