Flatline!

May 5th, 2005

Filed under: Comics, Medicine, TV

One of the biggest and most common medical mistakes in comic books (as well as television and the movies) is the treatment of asystole — more commonly called a flatline.

scene from Action Comics #817We’ve all seen the scenario: a patient’s heart stops beating and the cardiac monitor gives off an unrelenting “beep” while a flat neon line traces a path across the screen. The doctor grabs the defibrillator paddles aand places them on the patient’s chest. He yells, “Clear!” and then shocks the patient. Again and again.

This scenario is not only wrong, but may actually work against the patient.

The most common cause of a “flatline” is an accidentally disconnected monitor lead, so it’s best to quickly make certain the patient’s heart has actually stopped before beginning treatment.

If there is a known cause (for example drug overdose, low potassium or low temperature) it is best to treat this abnormality as well as treating the asystole.

The recommended treatment of asystole is IV medication: epinephrine and/or atropine. There has also been some success reported in using vasopressin combined with epinephrine.

scene from Superman #175Transcutaneous pacing can work in certain situations if performed early.

Electrical defibrillation is not recommended for the treatment of asystole and is not part of the standard ACLS treatment algorithm. There are some clinicians who feel that defibrillating asystole leads to worse outcomes, but there is a difference of opinions among experts about this. (I was taught that “you might as well try it, it can’t do any harm” – but I will defer to the physicians who deal with it on a routine basis.)

Key points:

  • Asystole is a very, very bad thing. The vast majority of these patients never survive long enough to be discharged from the hospital.
  • Defibrillation may have some use in the treatment of asystole, but is not routinely recommended (and actively discouraged by some experts). It certainly should not be the knee-jerk response to a flatline.

5 Responses to “ Flatline! ”

  1. David Oakes
    May 6th, 2005 at 12:10 am

    Of course, as a Director/Artist, would you rather have Black LIghtning shotting of five gajillion volts while Superman bounces around like a mackerel (sorry, McEr-L, the Scottsman of Krypton) in heat, or have the intern pass Dr. Bob four mikes of atropine and then sit and wait? (Especially when Dr. Bob might then be obliged to pronounce/spell works like “parasympathomimetic”.)

    Of course, Tarantino was able to milk it for all it was worth and then some. I am surprised we don’t see more injections post-Fiction. (My guess is that machines that go Zap! are easier to rent than trick needles.)

  2. Aine
    May 6th, 2005 at 12:25 pm

    This is one thing that has always confused me. I understand why zapping a guy won’t restart the heart, but don’t you also need to do chest compressions? Adrenaline will get your heart beating faster or more likely to keep on beating once you get it started but what gets the the signal center thingy in the heart (the name escapes me, as always) which triggers your heartbeat to start up again? Because that has obviously switched off if you’re flatlining. Or can adrenaline do that as well? (Medicine isn’t my strong point. I studied itty bittier things.)

  3. Your Obedient Serpent
    May 7th, 2005 at 9:29 am

    Okay, two questions from someone whose big medical experience was an undergrad physiology course and a few years of pushing gurneys:

    1) Does a “flatline” actually indicate that the patient’s heart has, in fact, stopped beating?

    2) If 1) is correct, and there’s no blood circulation, how can IV medication get to the heart?

  4. Woody!
    May 10th, 2005 at 8:56 pm

    So, Jack Bauer actually did something wrong the other night on 24? Man, my whole world no longer makes sense.

  5. Scott
    May 17th, 2005 at 10:30 pm
    Official Comment

    Chest compressions are key to a good resuscitation and allow some blood (delivering oxygen — and maybe medications, and removing waste products) to circulate.

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