wonder what the opinion is on the "new" ACLS guidelines

[MassED]

I just took my recert today for ACLS and found it to be incredibly dumbed-down. I am shocked the primary focus is on compressions, mainly. It is a lot easier than it was two years ago, but is this better for us, as nurses?

[hypocaffeinemia, BSN, RN]

well I guess you were in the right place at the right time. I still think that is quite unusual. To witness arrests and have that occur in the ER is quite fortunate for patients! To have that defibrillator would make their chances that much greater for survival. I'll probably get hit with something like this tomorrow at work.... :uhoh21:

The witnessed arrests were mostly those that came in barely alive and were actively crumping. Maybe our EMS service is a bit more proactive than shipping pre-deadended patients to us.

Although there was one guy that had a broken humerus which apparently disguised radiated shoulder pain associated with an MI and spontaneously went from A&O to pulseless on the ground in the span of mere seconds. That was lucky-- not the massive aMI he threw but the fact he decided to code right there.

[MassED, BSN, RN]

Define success.

From an ER standpoint a successful code is revival and stabilizing enough to transfer to ICU. I've seen hundreds of these.

If we are defining success as the patient returning to the same quality of life as prior to the arrest, of course the success rate will be

successful code: perfusing rhythm (and a pulse!). Survival.

Hundreds????

Here's an interesting link from the AHA - it notes there are no reliable national statistics on CPR..... http://216.185.112.5/presenter.jhtml?identifier=4483

[hypocaffeinemia, BSN, RN]

Also to add, much of the same goes on at my current hospital-- I'm just on the receiving end of it being in the ICU.

My facility is a moderate-sized community hospital without trauma (we're expanding shortly to become a decent sized regional med center, however). I'm in suburban Houston, and apparently our little ER sees more patients than Memorial Hermann (the level I) in the medical center (again, no trauma).

[MassED, BSN, RN]

The witnessed arrests were mostly those that came in barely alive and were actively crumping. Maybe our EMS service is a bit more proactive than shipping pre-deadended patients to us.

Although there was one guy that had a broken humerus which apparently disguised radiated shoulder pain associated with an MI and spontaneously went from A&O to pulseless on the ground in the span of mere seconds. That was lucky-- not the massive aMI he threw but the fact he decided to code right there.

I'm not talking about nearly coding....... like I say, they're fortunate to drop when they arrive... how nice of them to wait

[hypocaffeinemia, BSN, RN]

successful code: perfusing rhythm (and a pulse!). Survival.

Hundreds????

Survival at what time span? I know the statistics are poor for the first 48 hours, but if I recall correctly they approve afterward.

Using the definition of success as a perfusing rhythm and survival post 1 hour of arrest, I can attest I've seen hundreds.

Of that, only a rare few were stable and back to relative baseline hemodynamics and neuro, however-- mostly the reversible ODs and other respiratory arrests.

[XB9S, BSN, MSN, EdD, RN, APN]

WHen you talk about survivial post cardiac arrest this is measured in most hopsitals at different stages. (I assume that the US isn't going to be that different from the UK in this as many of the statistics are international)

Return of spontaneous circulation

12 hour survival

24 hour survival

survival to discharge

survival to 6 months

As far as survivial to discharge, I audited our cardiac arrest statistics and In hospital cardiac arrests survival to discharge sat at about 8%.

THe general feeling is that if you have a cardiac arrest in hospital then you are in a pretty poor condition to begin with, most of them are non shockable rhythms and as a result of sepsis, hypovolaemia, hypoxia.

[CritterLover, BSN, RN]

i wasn't referring to codes in other units, as i'm in the er - i'm sure there are statistics out there for those that are inpatient codes versus those that come into the er coding, those inpatients would likely have a better shot at survival. i'm puzzled - how many of you have had successful codes in the er? how many? once an individual is in the position of being coded, it's not a good situation, so i'm surprised anyone is surprised that i haven't witnessed a successful code. i'm baffled that anyone has witnessed any - even one would be amazing. to experience more than one, well, maybe i need to question where i'm working and the docs running the codes!

are you just talking about the "found down" people that come in with cpr in progress? in a sporadic 5 yrs in the er (most part-time/prn), i've seen at least a few of those survive (for a few days, anyway). one was particularly memorable -- what i think "saved" him was that his episode was caused by a brain bleed, rather than a cardiac event. it was the first (and only) time i've had to hang a cardene (i think) drip at the conclusion of a code.

so yeah -- unless you're in a rural/semirural area with long ems response times, i would probably question why you've never seen a prehospital code survive to make it to icu.

if you're including the people that get effective bystander response (cpr/aed), the people that code in the back of the ambulance, and people that code after being roomed in your er, then i really think someone needs to look in to the reason why you've never seen a code survive to the icu -- even if you are in a pretty rural area.

as for the "dumbing down" of acls, i was really surprised the emphasis that is placed on cpr right now. according to the little computer scenarios i did, the ambu bag is preferred over intubation so that cpr isn't interrupted, and that really surprised me.

but, the guidelines are based on the evidence that is out there. look at lidocaine -- how long did we use that first line for v-tach/v-fib, when there was very little evidence that it was effective?

the guidelines are bound to change as research evolves.

i think that part of the issue is the development of better drugs for ventricular arrythmias. it used to be epi, lidocaine, bertryllium (?) ... maybe some others that i never learned. now we have amiodarone -- one drug which actually works -- taking the place of at least two that don't really work all that well.

(i know that lidocaine is still on the algorithm, but it isn't on our crash cart anymore, and i can't remember the last time i used it)

[Altra, BSN, RN]

Several successful codes here.

I agree with CritterLover. I acknowledge the widsom of the old saying that "if they come in dead they usually stay dead" but if you've never had a successful code in more than a few years of practice ... it seems like a statistical anomaly, at the very least.

[sirI, MSN, APRN, NP]

More than several successful codes here and am in a very rural area.

[Altra, BSN, RN]

that is what I just posted about... how many successful codes have people actually witnessed, 1, 3, 5? In what time frame, working over a 10 year time frame, 20 years? This kindof points off topic, but hey, I'm interested to hear the answers!

After giving this some more thought ... I'll put the number of successful codes that I personally have participated in or witnessed in a little over 3.5 years of practice at about a dozen, including one memorable pedi code.

[MassED, BSN, RN]

are you just talking about the "found down" people that come in with cpr in progress? in a sporadic 5 yrs in the er (most part-time/prn), i've seen at least a few of those survive (for a few days, anyway). one was particularly memorable -- what i think "saved" him was that his episode was caused by a brain bleed, rather than a cardiac event. it was the first (and only) time i've had to hang a cardene (i think) drip at the conclusion of a code.

so yeah -- unless you're in a rural/semirural area with long ems response times, i would probably question why you've never seen a prehospital code survive to make it to icu.

if you're including the people that get effective bystander response (cpr/aed), the people that code in the back of the ambulance, and people that code after being roomed in your er, then i really think someone needs to look in to the reason why you've never seen a code survive to the icu -- even if you are in a pretty rural area.

as for the "dumbing down" of acls, i was really surprised the emphasis that is placed on cpr right now. according to the little computer scenarios i did, the ambu bag is preferred over intubation so that cpr isn't interrupted, and that really surprised me.

but, the guidelines are based on the evidence that is out there. look at lidocaine -- how long did we use that first line for v-tach/v-fib, when there was very little evidence that it was effective?

the guidelines are bound to change as research evolves.

i think that part of the issue is the development of better drugs for ventricular arrythmias. it used to be epi, lidocaine, bertryllium (?) ... maybe some others that i never learned. now we have amiodarone -- one drug which actually works -- taking the place of at least two that don't really work all that well.

(i know that lidocaine is still on the algorithm, but it isn't on our crash cart anymore, and i can't remember the last time i used it)

i was at a rural er in nc prior to coming to the second busiest hospital in massachusetts. in n.c., we were the only er to stabilize and send off to a level 1 in nearby va. or more inland in n.c. we were it, so we received everything unless they were pronounced on scene. i actually don't think it's all that common to have a successful code, so i'm more likely to believe that "most" er nurses have not, if ever, seen a successful code. there might be a few cases, like methylene's, but for the most part, successful codes are not the norm. "someone" needs to look into why i haven't witnessed a successful code?? ha ha!! that would be trying to control those variables that are not controllable: the patient, the circumstances, the doc prescribing the course of treatment, perhaps the level of care within an er - like a rural one with inexperience (but the two i have worked within are fantastic).... like i posted earlier, i would love to have codes with a positive outcome, but once you're in that position of being coded, you're stepping with both feet in the grave....

yep, of course guidelines are modified based on research.

[MassED, BSN, RN]

several successful codes here.

i agree with critterlover. i acknowledge the widsom of the old saying that "if they come in dead they usually stay dead" but if you've never had a successful code in more than a few years of practice ... it seems like a statistical anomaly, at the very least.

i might just have to do my own little poll at work, i'll get back to ya.... i still do believe that having successful codes are not the norm.... there are so many variables....

here's some info from nih: http://www.ncbi.nlm.nih.gov/pubmed/16439311

"the success rate of cardiopulmonary resuscitation (cpr) may differ from institution to institution, even within different sites in the same institution. a variety of factors may influence the outcome. in this study, we assessed the adequacy of cpr attempts guided by the current standards and aimed to define the factors influencing the outcome following in-hospital cardiac arrest. one hundred and thirty-four patients who required cpr were studied prospectively. different variables for the cpr performance were recorded using forms designed for this study in the light of the guidelines. in these cpr forms various data including the demographics, history, monitoring, number, composition and experience of the anaesthesiologists, the site of cpr, time of day, the delay before onset of cpr, tracheal intubation, duration of arrest, initial rhythm in ecg monitored patients, management of cpr, drug administration and reversible causes of cardiac arrest were recorded. our rates of immediate survival, survival at 24 h and survival to discharge 49.3%, 28.5% and 13.4%, respectively. the extent of monitoring prior to arrest, the attendance of one or more experienced anesthesiologists in the cpr team, cpr during office hours, cpr in icu or operating room, early initiation of cpr and tracheal intubation prior to arrest were found as the factors increasing discharge survival. we conclude that early initiation of cpr with an experienced team in a well-equipped hospital sites increases the discharge survival rate following cardiac arrest.

and here's a link for cpr statistics, which i've posted before....: http://www.towson.edu/wellness/documents/cardiopulmonaryresuscitationstatistics.pdf