New cardiovascular guidelines are here: You’ll be amazed at the options
Guidelines give you exciting approaches, drugs, and techniques
The next time a patient with a life-threatening cardiovascular condition comes to your ED, you should use new approaches, drugs, and techniques to care for them. New guidelines are going to revamp the way you care for patients in the ED, predicts Mary Fran Hazinski, RN, MSN, FAAN, senior science editor for the American Heart Association’s (AHA) emergency cardiovascular care programs and clinical specialist in the division of trauma in the departments of surgery and pediatrics at Vanderbilt University Medical Center in Nashville, TN.
For the first time since 1992, the Dallas-based AHA has published a major revision to the guidelines for resuscitative and emergency cardiovascular care that are used throughout the world.1
All of the algorithms for advanced cardiovascular life support (ACLS), pediatric advanced life support, and basic life support have been revised, as well as the treatment guidelines for patients with acute coronary syndromes and stroke, Hazinski reports. You’ll need to review the guidelines and apply them immediately. "Most EDs will adopt them without much change."
These guidelines are particularly noteworthy because they are the first international guidelines, Hazinski underscores.
"As a result, they reflect science from all over the world," she says. "We are getting a lot more information about resuscitation. The more evidence we get, the better recommendations we can make."
From this point on, AHA will meet with international resuscitation experts for an evidence evaluator conference every five years, so the guidelines will be updated on a more predictable basis, Hazinski reports. "This will help instructors to better plan courses and renewals."
The new guidelines address pharmacology of resuscitation, ventilation, defibrillation, public access defibrillation programs, acute coronary syndromes, stroke, post-resuscitation care, and toxicology.
The guidelines give you many more options, says Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency/trauma services at UCI Medical Center at University of California-Irvine.
"The age limit has been lifted for use of interosseous access, which were formerly not used for children over 6 years of age," she notes.
There are more choices for drug therapies, Bradley reports. "There are also more considerations to prevent the arrest condition such as drug overdoses, electrolyte imbalances, and hypothermia," she says. "We are given a greater variety of interventions to help us care for our patients better," she says.
Here are some of the key changes in the guidelines:
• Algorithms have been significantly revised.
The guidelines contain an new international algorithm, significant expansion of tachycardia algorithms, revisions in the acute coronary syndromes algorithms, and the addition of vasopressin to the ventricular fibrillation/pulseless ventricular tachycardia algorithm, says Hazinski.
The algorithms pertaining to acute coronary syndromes and stroke have expanded even more, says Rebecca L. Stark-Johnson, CRNA, APNP, anesthesia manager at Fort Atkinson (WI) Memorial Health Services, and a regional faculty instructor for the AHA’s ACLS Program. "The text discussion pertaining to this is very good, and explores reperfusion to a large extent."
• There is a new focus on prevention.
ACLS still has as a teaching goal the mastery of resuscitation of the patient in witnessed ventricular fibrillation arrest, notes John M. Field, MD, FACC, FACEP, associate professor of medicine and surgery at Pennsylvania State University College of Medicine in Hershey, and ACLS science editor at the AHA.
"However, it is now realized that many arrests have prodromal periods when an intervention can prevent an arrest," he says. "This is emphasized in the areas of acute coronary syndromes and reperfusion, as well as the new ACLS-EP [experienced provider] course."
• There is a new range for tidal volumes.
The guidelines recommend that a tidal volume for patients receiving supplementary oxygen be approximately one half of the tidal volume previously recommended, says Stark-Johnson. "Now, the tidal volume delivered should approximate 6-7 mL/kg, if you are administering supplementary oxygen."
Higher volumes tend to increase the risk of gastric inflation, says Stark-Johnson. "Resuscitation professionals can use the chest rise’ as a rough indication of ventilation tidal volumes that are in that range."
Provide supplemental oxygen adjusted based on oximetry readings, if the victim has a perfusing rhythm, recommends Stark-Johnson.
Smaller tidal volumes are recommended only in the presence of oxygen administration, and are not recommended for patients who don’t have cardiovascular collapse, Hazinski underscores.
• Post-resuscitation care requires new approaches.
According to the guidelines, you should not actively rewarm patients who are mildly hypothermic following cardiac arrest, advises Stark-Johnson. "Treat febrile patients to achieve normothermia."
Ventilatory values in patients who require mechanical ventilation should be maintained within the normal range after cardiac arrest, the guidelines recommend. "Hyperventilation may be harmful," Stark-Johnson says. "An exception is the use of hyperventilation in patients who have signs of cerebral herniation."
• Ethical issues are addressed.
The new guidelines include more specific information about "do not attempt resuscitation" orders in the prehospital setting, indications for cessation of ACLS in the field, and family presence during resuscitation in the hospital, says Hazinski.
The resuscitation scene needs to be surveyed for a living will, advance directive, or no-CPR bracelet, notes Stark-Johnson. "The 911 call may not mean that the patient or family has changed their mind, but rather that they are uncomfortable with death at home."
There are specific criteria now listed in the algorithm for withholding or stopping resuscitation efforts, Stark-Johnson adds. "The criteria direct the team to consider the quality of resuscitation," she says. "There are now protocols for leaving the body at the scene."
• There are new recommendations for treatment of patients with drug overdoses.
Beta blockers can be harmful to patients with cocaine-associated acute coronary syndromes, says Stark-Johnson. "This has caused coronary vasoconstriction and should be avoided. Nitrates and benzodiazepines should be first-line therapy."
Alpha blockers might induce tachycardia and hypotension, she notes. "These should be reserved for patients who do not respond to nitrates and benzodiazepines."
Hypotension and ventricular arrhythmias occur with tricyclic overdoses, says Stark-Johnson. "The induction of systemic alkalosis [pH 7.5-7.55] is therapy of choice."
Acute respiratory failure (hypoxemia and respiratory alkalosis) may occur with opiate overdoses, says Stark-Johnson. "Reverse these abnormalities with mechanical ventilation before naloxone administration," she advises. "This will reduce the incidence of pulmonary edema and serious arrhythmias associated with abrupt catecholamine elevation."
• The section on tachycardias has been expanded.
The section on tachycardias now covers narrow-QRS complex tachycardias, wide-QRS complex tachycardias, and pre-excited tachycardias, reports Stark-Johnson.
For tachycardic patients not requiring immediate cardioversion, the guidelines recommend two things, says Stark-Johnson. "You need to make a specific rhythm diagnosis. You also have to recognize tachycardic patients who have significantly impaired cardiac function." Those patients have ejection fraction < 40% and overt heart failure.
Reference
1. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2000; 102:suppl 1.
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