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8.3 Asystole & PEA

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AHA PALS Provider Pediatric Advanced Life Support

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1 Chapter 1: Course Overview & Exam Logistics

1.1 Current Exam Facts 1.2 Audience, Prerequisites & Study Plan

2 Chapter 2: Systematic Pediatric Assessment

2.1 Pediatric Assessment Triangle (PAT) 2.2 Evaluate–Identify–Intervene Sequence 2.3 Primary Assessment: ABCDE 2.4 Secondary Assessment, SAMPLE & Vitals by Age

3 Chapter 3: Respiratory Distress & Failure

3.1 Respiratory Distress vs Failure 3.2 Recognition & Immediate Intervention Priorities 3.3 Oxygen Delivery & Basic Airway Support

4 Chapter 4: Airway Problems & Ventilation Strategies

4.1 Upper Airway Obstruction 4.2 Lower Airway, Lung Tissue Disease & Disordered Control 4.3 Bag-Mask Ventilation & Advanced Airways During CPR

5 Chapter 5: Shock Fundamentals & Hypovolemia

5.1 Compensated vs Hypotensive (Decompensated) Shock 5.2 Hypovolemic Shock 5.3 Isotonic Fluid Bolus 10–20 mL/kg & Reassessment

6 Chapter 6: Distributive, Cardiogenic & Obstructive Shock

6.1 Distributive & Septic Shock Pathway 6.2 Cardiogenic Shock 6.3 Obstructive Shock

7 Chapter 7: Pediatric BLS & High-Quality CPR

7.1 High-Quality CPR Metrics 7.2 Compression-Ventilation Ratios 7.3 CPR Quality Monitoring: ETCO2 & Diastolic BP

8 Chapter 8: Pediatric Cardiac Arrest Algorithm

8.1 Arrest Recognition & Systematic Approach 8.2 VF/pVT & Defibrillation Energy 8.3 Asystole & PEA 8.4 Epinephrine in Arrest: Dose & Timing

9 Chapter 9: Bradycardia & Narrow-Complex Tachycardia

9.1 Bradycardia with Poor Perfusion 9.2 Sinus Tachycardia vs SVT 9.3 Stable SVT: Vagal Maneuvers & Adenosine

10 Chapter 10: Unstable Tachycardia & Wide-Complex Rhythms

10.1 Unstable Tachycardia & Synchronized Cardioversion 10.2 Wide-Complex Tachycardia & VT with Pulse 10.3 Antiarrhythmics for Tachycardia with Pulse

11 Chapter 11: Reversible Causes & Special Circumstances

11.1 Reversible Causes: The H's and T's 11.2 Special Circumstances at Exam Level 11.3 Extracorporeal CPR (ECPR) Overview

12 Chapter 12: Post–Cardiac Arrest Care

12.1 Post-ROSC Oxygenation & Ventilation 12.2 Post-Arrest Hemodynamic Support 12.3 Temperature Control & Glucose 12.4 Neuroprognostication & Transport

13 Chapter 13: Vascular Access & Core Pharmacology

13.1 IV and Intraosseous Access 13.2 Epinephrine Dosing in Depth 13.3 Amiodarone, Lidocaine & Adenosine 13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely

14 Chapter 14: Team Dynamics & Megacode Readiness

14.1 High-Performance Team Roles 14.2 Closed-Loop Communication 14.3 Constructive Intervention, Debriefing & Exam Integration

8.3 Asystole & PEA

Key Takeaways Explain This Topic AI

Asystole and PEA are nonshockable rhythms—do not defibrillate them.

Management pillars: continuous high-quality CPR, epinephrine as soon as possible, airway/ventilation support, and aggressive treatment of reversible causes (H’s and T’s).

Early epinephrine in initial nonshockable rhythms is associated with better outcomes—do not wait multiple cycles if access can be obtained.

Confirm asystole carefully: check leads/connections, consider gain, and verify in at least one additional lead (or more) so fine VF is not missed.

Hypoxia is a dominant reversible cause in pediatric PEA/asystole—optimize oxygenation and ventilation while you treat other H’s/T’s.

Last updated: August 2026

Nonshockable Arrest: Asystole and PEA

When the rhythm is asystole or pulseless electrical activity (PEA) , electricity will not restart effective output. Defibrillation of true asystole/PEA wastes time, interrupts CPR, and does not improve outcome. The nonshockable pathway is built on CPR + early epinephrine + airway/ventilation + reversible causes .

Definitions

Rhythm What it is Shock?

  • Asystole No ventricular electrical activity (“flatline”) No
  • PEA Organized (or semi-organized) electrical activity without a palpable pulse / effective perfusion No
  • Fine VF Very low-amplitude VF that can look almost flat Yes — treat as VF

PEA is a clinical diagnosis: the monitor shows electrical activity that might even resemble a “normal” rate/complexes, but the child has no pulse . Common PEA-associated contexts in pediatrics include severe hypoxia, hypovolemia, tension pneumothorax, tamponade, toxin effects, and severe metabolic derangements.

Confirming asystole (do not miss fine VF)

Before locking into a pure asystole mindset:

Confirm pad/lead connections and power.

Check that the gain/amplitude is adequate so fine VF is not hidden.

Confirm the flatline in at least one other lead (preferably more) when multi-lead monitoring is available.

If the rhythm is actually fine VF , the correct path is defibrillation—not endless epinephrine-only asystole care. Conversely, do not “try a shock just in case” for clearly confirmed asystole/PEA as a routine.

  • Management Priorities for Asystole/PEA
  • 1. High-quality CPR without unnecessary pauses

Compressions are the only artificial cardiac output. Keep rate, depth, recoil, and compression fraction high. Pause only briefly (~2-minute cycles) for rhythm/pulse checks. If still nonshockable and pulseless, resume CPR immediately .

2. Epinephrine as soon as possible

For initial nonshockable rhythms, give epinephrine early —as soon as IV/IO access is available during CPR. Early epinephrine in nonshockable arrest is associated with better outcomes (higher ROSC/survival signals in resuscitation science teaching). Dose and interval are detailed in Section 8.4: 0.01 mg/kg IV/IO every 3–5 minutes .

Do not withhold epinephrine until after multiple fruitless cycles if access can be obtained now. Do not prioritize endotracheal drug delivery over getting IV/IO.

3. Airway and ventilation—especially hypoxia

Because pediatric arrest is so often secondary to respiratory failure , the nonshockable pathway is inseparable from airway management:

  • Open the airway; provide effective bag-mask ventilation with oxygen
  • Ensure chest rise; rule out obstruction
  • Avoid hyperventilation
  • Advance the airway if needed without prolonged CPR interruptions
  • Treat the underlying respiratory disease process when identified

Hypoxia sits at the top of the reversible-cause list in many pediatric PEA/asystole cases. Fixing oxygenation/ventilation is not optional “extra credit”—it is core therapy.

4. Search and treat H’s and T’s aggressively

While CPR and epinephrine run, the team leader assigns someone to hunt reversible causes:

H’s (high-yield pediatric framing)

  • Cause Pediatric clues Immediate actions
  • Hypovolemia Fluid losses, sepsis capillary leak, hemorrhage Isotonic fluid boluses; blood if hemorrhage
  • Hypoxia Respiratory failure, drowning, obstruction Airway, O₂, ventilation

Hydrogen ion (acidosis) Prolonged arrest, toxic alcohols, metabolic disease Support ventilation/perfusion; specific therapy per cause

  • Hypo-/hyperkalemia Renal disease, DKA shifts, suctioned/ileostomy losses Electrolyte-directed therapy
  • Hypothermia Environmental exposure, drowning Rewarming per protocol
  • Hypoglycemia Infants, liver failure, sepsis Check glucose; treat documented hypoglycemia
  • T’s
  • Cause Pediatric clues Immediate actions
  • Tension pneumothorax Trauma, positive-pressure ventilation, unequal BS Needle decompression
  • Tamponade Trauma, post-op cardiac Fluids bridge; drainage when indicated
  • Toxins Overdose, medication error Antidotes/supportive care
  • Thrombosis (pulmonary/coronary) Selected high-risk settings Expert reperfusion pathways
  • Trauma Multisystem injury Hemorrhage control + cause-specific obstruction relief
  • (Chapter 11 expands reversible causes and special circumstances.)

Loading diagram... Pediatric Asystole/PEA Pathway

Rhythm Changes and Common Exam Traps

Arrest rhythms can change. A child may start in PEA, convert to VF after CPR/epinephrine, or develop organized rhythm with ROSC. Reassess every cycle and switch pathways when the rhythm branch changes.

Trap list

  • Trap Why it is wrong
  • Defibrillating confirmed asystole “just in case” Not indicated; delays CPR/cause treatment
  • Treating PEA with synchronized cardioversion PEA is pulseless arrest, not unstable tachycardia with a pulse

Delaying epinephrine for prolonged intubation attempts Early epi matters on the nonshockable path; airway support can start with bag-mask

  • Ignoring hypoxia while cycling drugs Respiratory failure is a leading pediatric driver
  • Declaring asystole from a single unconfirmed flat lead May miss fine VF or loose leads
  • Clinical scenario

A 9-month-old with bronchiolitis becomes apneic and pulseless. Monitor: asystole after lead confirmation. Actions: CPR, bag-mask with oxygen, IO access within seconds, epinephrine 0.01 mg/kg , suction/airway positioning, prepare for advanced airway if bag-mask fails— no shock . If later rhythm is VF, immediately pivot to defibrillation at 2 J/kg .

Bottom line for 8.3: Asystole/PEA → do not defibrillate → CPR + early epinephrine + airway/ventilation + H’s/T’s , with hypoxia front-of-mind, and confirm asystole so fine VF is not missed.