Update on ACLS drugs
There are several exciting new developments in advanced cardiac life support (ACLS), which will result in new guidelines being published next year.
"We are reviewing proposals for additions and changes to the guidelines," reports John Field, MD, FACC, FACEP, associate professor of medicine and surgery at Penn State University College of Medicine in Hershey, PA. "That review process will continue until next September, when an evidence evaluation conference will be held in Dallas."
Revised guidelines to be compiled
All of the clinical evidence will be evaluated at that meeting, says Field. "Medicine in general is turning to outcome, evidence-based guidelines, with a core of randomized, controlled, clinical trials to the degree they are available. The Guidelines 2000 conference will be held in February. At the end of this process, revised guidelines will be published in Circulation, the official publication of the AHA."
Here are some changes in ACLS to be aware of:
• Prevention and intervention. There is an increased focus on prevention and intervention. "The focus in ACLS has definitely changed," says Jean Proehl, RN, MN, CEN, CCRN, current president of the Emergency Nurses Association in Park Ridge, IL. "They are focusing on prevention, not just resuscitation. That’s a significant difference in the content of the class in the last 15 years."
Lectures now address stroke and acute coronary syndrome, says Proehl. "We have always talked about MIs but we’re now talking about them in a lot more detail than we previously shared in the ACLS class, and the stroke content is totally new. The diagnostic and intervention pieces are more elaborate than they used to be."
Identifying, helping at-risk patients important
Educational focus has expanded to include prevention, notes Field. "There are two new chapters in the ACLS textbook, published in 1998. One focuses on acute coronary syndromes and the prevention of complications of unstable angina, acute MIs, the use of thrombolytic drugs, and other reperfusion strategies such as angioplasty. Also, a new chapter was added that addresses reperfusion therapy in stroke patients who are eligible."
There will be increasing emphasis on the importance of identifying patients at risk for stroke and stroke in evolution, notes Field.
"All the educational materials will be revised at the end of the 2000 conference, and will encompass the text, slides, and guidelines," he says.
• Advanced ACLS course. A new ACLS-EP course for experienced providers is being pilot tested and developed, reports Field.
"The course will address questions such as, if you knew 10 minutes before the arrest that certain high-risk complications were present, what would you do to prevent the arrest?" he notes. "It will encompass various topics such as electrolyte abnormalities, hypothermia, and various types of toxicological problems." The other area under pilot testing and development is an introductory revision of the textbook, says Field. The first chapter of the textbook, ACLS for Providers, is being expanded specifically for the introductory provider. "These are in pilot testing and development and are not available yet."
The advanced ACLS course will be a potential option for advanced providers to recertify, says Joseph Ornato, MD, FACC, FACEP, professor and chairman of the department of emergency medicine at the Medical College of Virginia in Richmond.
"It addresses special situations and allows the providers to refresh their skills. It also allows them to extend their skills into case management where there are other issues to contend with, such as hypothermia or near-drowning resuscitation, or resuscitation and an overdose," he explains.
• High-dose epinephrine. High-dose epinephrine is clearly not showing a benefit, says Ornato. "In the last year or two, we have seen several trials indicating a lack of value in both the hospital and prehospital setting.1 One of the things we discussed at the conference is what change in recommendation should be made based on this [evidence]."
Trials with high-dose epinephrine have been discouraging, Field says. "The European epinephrine study group, published in the New England Journal of Medicine last year, showed that repeated doses of epinephrine were no better in terms of resuscitation than standard doses."
There is no literature showing improved long-term survival rates, says Proehl. "It has been demonstrated that you can resuscitate more people in an acute event, but there is nothing that shows this makes a huge difference in long-term survival."
• Vasopressin. "Because the high-dose epinephine trials were discouraging, the question comes up: Is there a better vasoconstrictor to use in resuscitation?" says Field. "There is some information available about vasopressin. This is one of the issues that is going to be discussed at the guidelines meeting."
Vasopressin has been studied in Europe and looks promising as a potential replacement for epinephrine, says Ornato. "This is a hot item for discussion," he adds. "However, for almost five years, there have been almost no successful clinical trials on resuscitation in the United States because of FDA regulations on performing such research. The rules are difficult and created a major problem. In effect, no clinical research is being done in this area."
• Amioderone for V-fib treatment. This treatment appears to be a very promising agent, says Ornato. "The arrest’ trial from Seattle (presented at the American College of Cardiology meeting held March 1999 in New Orleans) indicates it increased survival to hospital discharge by 30%, compared to standard ACLS," he notes. "We have routinely been using it in our paramedic system since last April, and it’s been on our code cart since it got FDA approval several years ago."
Lidocaine is currently the antiarrhythmia agent in the algorithm, notes Field. "[The] arrest trial is looking at amiodiorone, and there is interest in using it for refractory ventricular fibrillation. The arrest’ trial has shown an improved survival return of circulation to the hospital ED. The issue of the optimal antiarrhythmic and its position in the algorithm will also be discussed, with specific reference to amiodirone."
• Reperfusion. "New strategies are being developed, such as two recently completed trials with single bolus agents, similar to t-PA," says Field. "These are actually genetically derived mutants of t-PA; they are TNK and lanatoplase. Efficacy trials have shown that these agents are as effective as t-PA, but are not yet approved by the FDA and have to go through that process. "
The issue of single bolus agents and prehospital administration of thrombolytic therapy on selected patients will be addressed, Field notes.
"Specific treatment of patients with large infarcts and cardiogenic shock in the context of direct mechanical revascularization will be further considered," he adds. "There still will be a continuing emphasis on very early treatment of patients with reperfusion therapy to limit infarct size and prevent episodes of ventricular fibrillation."
Reference
1. Gueligniaud P, et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. N Engl J Med 1998; 339:1,595-1,601.
Sources
For more information about ACLS drugs, contact the following:
• John Field, MD, FACC, FACEP, Penn State University College of Medicine, Division of Cardiology, H047, Penn State University College of Medicine 500 University Drive, Hershey, PA 17033. E-mail: [email protected] or [email protected].
• Joseph Ornato, MD, FACC, FACEP, Medical College of Virginia, Department of Emergency Medicine, 401 N. 12th St., P.O. Box 980401, Richmond, VA 23298. E-mail: [email protected].
• Jean Proehl, RN, MN, CEN, CCRN, Dartmouth-Hitchcock Medical Center, RR#2, Box 340, Cornish, NH 03745. Telephone: (603) 650-6049. E-mail: [email protected].
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