Have We Taken the 'Advanced' out of ACLS?

By Jim Upchurch

2009 has been an interesting year for prehospital cardiac resuscitation. Much evidence has been compiled that should change the way we approach the pulseless, breathless patient. From our EMS colleagues in Arizona, D.C., and British Columbia (and others from previous years), it is clear that anything interrupting properly performed chest compressions decreases the patient's chance of survival. And, oh my God, could tracheal intubation be BAD? Well, it is if it interferes with chest compressions or if we over-ventilate. What about not ventilating a witnessed cardiac arrest patient? Is it ok to just slap on a face mask and concentrate on chest compressions and defibrillation? Yep, at least initially.

Then there's the IV and the drugs. Even if you do initiate intravenous or intraosseous access and administer the drugs without compromising chest compressions, they may not work. "No way," you say. However, our EMS colleagues in Norway studied over 800 out-of-hospital cardiac arrest patients that were randomly divided into those who received the standard ACLS drugs (418) and those who did not (433), and the results showed "no statistically significant improvement in survival to hospital discharge."

So does this mean that we no longer 'pop the top' on the code drugs? That is not completely clear at this time, but it does point us right back to maintaining minimally interrupted chest compressions and providing early defibrillation as the foundation treatment with proven increased survival for the cardiac arrest victim.

So what is the future of ACLS? Since we tend to practice how we train, perhaps a better question is to ask what the next version of the ACLS course will look like. I can't tell you for sure, but I can offer my own version based on three assumptions. First, preventing a cardiac arrest is more effective than treating one; second, the patient in cardiac arrest fares better if we maintain chest compressions, defibrillate early, and don't over-ventilate; and third, discovery of a reversible cause for a patient's cardiac arrest increases successful return of spontaneous circulation. The American Heart Association already has a one-day course that addresses the first assumption above, ACLS for Experienced Providers. The heart of this course is the six hours spent on medical conditions that if treated in a timely manner may prevent cardiac arrest. Perhaps it is time to make this part of the standard ACLS course.

We could then continue to strengthen the training emphasis on minimal interruption of chest compressions and appropriate airway management, particularly with the research based 'less is sometimes more' approach to ventilation. And we could provide more detail on those 'reversible causes' for cardiac arrest. Finally, we should add a segment on post-resuscitation care. For instance, how do we keep patients alive with an intact brain once we bring them back from the dead? This could include topics such as hyperventilation prevention, therapeutic hypothermia, and the importance of obtaining an ECG once there is return of spontaneous circulation. Certainly it would be a busy two-day course.

So, are we really taking the 'Advanced' out of ACLS? I think not, just following the increasing trail of evidence.