Kashish Sharma
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Written By: Kashish Sharma | Published : February 23, 2023 6:45 PM IST
Asystole is defined as a cardiac arrest rhythm in which there is no discernible electrical activity of the heart. Few patients are likely to have a positive clinical outcome in asystole as there are bleak chances of survival.
Everybody understands a flat line on an ECG monitor and what it means. Interestingly, the classic flat line is not as straightforward as they might show in movies. As per medical experts, human heart activity is not an on-off switch but it can stop and restart multiple times during a critical cardiac event like an arrest. Many times, patients are brought seemingly dead to emergency rooms. As the attending doctor tries to confirm the flat line on the monitor, they have to ensure that the rhythm they are getting on the monitor is not mimicking the 'flat line' or what is technically called asystole.
The human heart is a powerhouse. It runs on electricity. It is the minute current that forces your heart to pump blood throughout the body. The graph that flashes on an ECG monitor taps the electrical activity of the heart. An abnormal ECG means that something might not be right with your heart. Sometimes the fault might be with the electrical machinery of the heart, other times it could be the muscular body that might give up.
Asystole is defined as a cardiac arrest rhythm in which there is no discernible electrical activity of the heart. Few patients are likely to have a positive clinical outcome in asystole as there are bleak chances of survival. There are other problematic rhythms that might mirror asystole in some circumstances, hence the doctors don't give up on the patient as soon as the flat line flashes on the screen and might engage in CPR (cardiopulmonary resuscitation) or shock therapy which might be necessary for other abnormal rhythms that can be rectified.
The time how long a doctor has to wait after a 'flat-line' flashes on the monitor is a tricky span. It might not be an easy task to declare a person dead without ensuring that their heartbeat and circulation might not return. The situation remains to be a shaky path and can have ethical and legal consequences for the practitioners.
Dr Sarath Narayan, an emergency physician practising in Sarvodaya Hospital, Faridabad shared a similar account. A 57-year-old man was brought seemingly dead to the emergency room. The doctor informed that the man had no previously known comorbidities and his was a case of unnatural death.
Dr Narayan said: "I tried to revive the man by giving him CPR and I did that for half an hour. I was objected to by the patient's family for not declaring him dead instantly and unnecessarily buying time but this slope is a slippery one. When to stop is not an easy question to answer. Also, the fact is not widely known that a flat-line on an ECG monitor offers a bleak possibility of coming back. In situations like these, you are in a war between the urge to confirm your objective observation and the human instinct to try once more. I am sure many medical practitioners like me would often encounter such a tricky situation."
There are some causes of a flat line that might not be an asystole such as loose leads, loss of power to the ECG monitor or low signal gain.
A discussion paper published in a leading media journal talks about how the heart might continue to show electrical activity long after blood flow or pulse has stopped. The paper described the review of 480 flatlines out of which 67 showed on-off fluctuations. The longest that the heart stopped before restarting on its own was four minutes and 20 seconds. The longest time that heart activity continued after restarting was 27 minutes, but most restarts lasted just one to two seconds. However, most of the patients reviewed weren't able to make it back to life. This shows that intermittent signals on the bedside monitors might be natural during the dying process but can be an immense source of confusion for medical practitioners and loved ones who might see them as signs of revival.
As per experts, there is not just one abnormal heart rhythm during a cardiac arrest. In fact, there can be four kinds of it. Some are shockable and others are not. Rhythms like pulseless ventricular tachycardia (VT) and ventricular fibrillation (VF) are chaotic rhythms that are mostly due to the electrical machinery of the heart going haywire. These rhythms can be rectified using shock therapy. However, flat line or asystole is not an easily rectifiable condition as it means that heart muscles have become unresponsive to electrical machinery and shock therapy would make no difference to the situation. The only way forward to deal with a flattening line is to continue CPR and provide medication. The chances for survival are often bleak once there is a flat line on the monitor.
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