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Clinical Pearls

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Significant Changes=20 to ACLS

The new ACLS 2000 guidelines were = recently=20 released and may be found in Circulation, 2000; 102 = (suppl=20 I). Here is a summary of the most significant = changes that=20 impact our practice immediately.

1) = Amiodarone.=20 This anti-arrhythmic can be found throughout the new = guidelines,=20 having been placed in several of the=20 = algorithms.

        = ;        =20 VF/pulseless VT: now considered the first-tier = agent for=20 shock-refractory VF/pulseless VT, relegating lidocaine to = second=20 tier=20 = status

         &n= bsp;      =20 wide-complex tachycardia of unknown type: = can be=20 used as the drug of first=20 = choice

         &n= bsp;      =20 stable narrow complex SVT: one of several=20 available treatment=20 = choices

         &= nbsp;      =20 stable V. Tach: May be used as the initial agent = in=20 stable monomorphic V. Tach and polymorphic V. Tach with a = normal QT=20 = interval.

         = ;       =20 A fib/Flutter: may be used in all three = defined=20 patient populations (normal cardiac function, impaired = function =E2=80=93 EF=20 < 40%, and WPW)

2) Vasopressin, 40 u = IV, may be=20 used as an alternative to epinephrine in the treatment of=20 VF/pulseless VT after three shocks are administered. = Actually=20 vasopressin, a powerful vasoconstrictor, is considered a = class IIb=20 intervention (acceptable, possibly helpful) whereas = epinephrine is=20 class indeterminate. Vasopressin is given only once, unlike = the=20 standard epi every 3 =E2=80=93 5 minutes.

3) = Bretylium has been=20 removed from the algorithms. Interestingly, this is in part = a result=20 of the shortage of the world's natural sources of bretylium, = as=20 supplies appear to be nearly exhausted.

4) Lidocaine = has been=20 significantly de-emphasized. As noted in the guidelines, the = evidence supporting its efficacy in VF/VT is poor and=20 methodologically weak. Lidocaine may still be found in the = stable VT=20 algorithm, but is considered a lesser alternative to other=20 = drugs:

        =20 Monomorphic VT:=20 =

           = ;   =20 normal cardiac function - procainamide or = sotalol are=20 the top agents (class IIa =E2=80=93 acceptable, probably = helpful) with=20 lidocaine and amiodarone considered=20 = IIb.

          &= nbsp;   =20 poor EF - amiodarone or lidocaine

Lidocaine = has been=20 removed from the stable wide complex tachycardia=20 algorithm.

5) Recognizing the proarrhythmic effects = of=20 antiarrhythmic agents, the tachycardia algorithms recommend = one and=20 only one agent per patient. For example, previously the = approach to=20 stable VT was lidocaine, followed by procainamide, followed = by=20 bretylium. Now, the physician is asked to choose a single = agent from=20 a list of acceptable treatments. For example, amiodarone = 150mg every=20 10 to 15 minutes as needed.

6) Adenosine has been = used=20 previously as the initial agent for stable wide complex = tachycardia.=20 The thinking was that it would be effective if the rhythm = was=20 supraventricular, and would not do any harm if, in fact, the = patient=20 was in VT. However, concerned about the overuse of adenosine = for=20 diagnostic purposes given that most such patients are in VT, = the=20 guidelines now ask the clinician to devote more attention to = making=20 a specific rhythm diagnosis. Therefore, adenosine has been = removed=20 from the wide complex tachycardia algorithm. It remains as = the first=20 line agent for narrow complex tachycardias.

7) High = dose=20 epinephrine is no longer recommended. This is in response to = the=20 lack of convincing efficacy and some evidence indicating = that=20 cardiac arrest survivors who received high dose epinephrine = have=20 more postresuscitation complications than survivors who = received the=20 standard dose.

8) Clinicians must now confirm = endotracheal=20 tube position by using nonphysical examination techniques = such as=20 end-tidal CO2 detectors and esophageal detector devices. In = cardiac=20 arrest and conditions of low pulmonary flow, the potential = for false=20 negative readings leading to the possible removal of a = properly=20 placed tube is acknowledged.

9) A rather provocative=20 statement: The prehospital EKG is useful and effective in=20 prehospital urban/suburban EMS systems and should become = standard=20 equipment on all ACLS units that handle acute coronary = syndrome=20 patients.

10) Isoproterenol has been removed from = the=20 bradycardia algorithm.

11) The wide complex = tachycardia of=20 unknown type algorithm has undergone the most dramatic = change.=20 Previously, recall that the sequence was lidocaine, = adenosine,=20 procainamide, bretylium. Now, the algorithm divides into = patients=20 with preserved cardiac function (cardioversion or = procainamide or=20 amiodarone) or with EF < 40%/CHF (cardioversion or = amiodarone).=20

12) One criticism of the old PEA algorithm is that = it did=20 not allow for the differentiation of a markedly hypotensive = state in=20 which the systolic function of the heart is unable to = generate a=20 palpable pulse, versus conditions of true EMD, in which = there is no=20 contraction of the heart. The new PEA algorithm asks for = immediate=20 assessment of blood flow with a doppler.

13) = Clinicians may=20 now elect to treat stable VT with immediate cardioversion.=20

14) A detailed approach to atrial = fibrillation/flutter is=20 now presented with attention to stability, ejection = fraction, and=20 duration of the arrhythmia. Treatment is based upon the sum = of these=20 factors.

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