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?

[Altra, BSN, RN]

" ... One hundred and thirty-four patients who required CPR were studied prospectively. ... Our rates of immediate survival, survival at 24 h and survival to discharge 49.3%, 28.5% and 13.4%, respectively."

Seems like this study noted survival rates similar to what several of us have posted here.

[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 did assist with a code where the woman was pronounced, family came in and all of us were still in the room (3 nurses, 1 aide) to remove lines, et tube when she spontaneously started breathing and had a pulse (this was 20 minutes later!!!!!!) it was the strangest thing. the family was dumbfounded, to be called back after they saw her and being pronounced. um.... there's a pulse and she's breathing..... she lasted for 4 hours, i believe... though it was amazing, i still don't believe that is successful - that was not because of us coding her, that was her own heart that did that. miracle for a short period, whatever you want to call it. she did move her head to her family, but no other response.

as far as success, i mean walking out of the hospital once they were coded in the er. none of this coding in the icu, cath lab, or, where the environment can be anticipated and the person starts out with a pulse. this topic is taking a new path, now...

[MassED, BSN, RN]

Seems like this study noted survival rates similar to what several of us have posted here.

it does - though it does point out that the statistics for survival vary, and that study included other areas of a hospital (ICU for instance). That, like my last post, is a controlled environment, which will significantly improve outcome after arrest. I would like to see statistics for ER specific.

[hypocaffeinemia, BSN, RN]

Just to add yet another example: One of our ICU patients today coded twice in the ER last night and then coded once right before I came in for shift change. This patient's 24 hour survival is not looking very probable, but technically that's 3 successful codes right there.

This scenario is incredibly common at my facility.

[MassED, BSN, RN]

Seems like this study noted survival rates similar to what several of us have posted here.

this is just so interesting, the more I look, there's quite a bit of info out there on this topic:

http://www.rwjf.org/pr/product.jsp?id=21335

"CPR has a small chance of working for people who are seriously ill or dying. One study shows that individuals with overwhelming infection have less than a 3 percent chance of being discharged from a hospital after CPR"

"According to the medical literature, the chance of surviving CPR is, at best, 18 percent."

"A survey that included health care workers found that those who were over 65 years old predicted a 59 percent survival rate for a person treated with CPR. People under 30 were even more optimistic, predicting a 75 percent survival rate." (It's good that we're optimistic, though...)

[MassED, BSN, RN]

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.

that is wonderful to have a successful peds code.

the peds codes i have worked have been sids and one horrific three year old drowning....

ok, gotta get to work on that note - have to put that out of my mind before work.

[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)

was that cardizem at the end of a code???

[MassED, BSN, RN]

Just to add yet another example: One of our ICU patients today coded twice in the ER last night and then coded once right before I came in for shift change. This patient's 24 hour survival is not looking very probable, but technically that's 3 successful codes right there.

This scenario is incredibly common at my facility.

and that is an ICU admission, not the kind of patient I am referring to (and we don't keep our ICU admissions in the ER.. uh uh, no no) Though that this patient was successful three times is fantastic!!!

[hypocaffeinemia, BSN, RN]

Was that Cardizem at the end of a code???

Cardene isn't the same as Cardizem.

They're both calcium channel blockers, sure, but Cardene doesn't have the antiarrythmic properties Cardizem has- in fact it doesn't affect the heart much at all. It's selective for cerebral vessels although it does have systemic effects.

[CritterLover, BSN, RN]

was that cardizem at the end of a code???

no, it was an anti-hypertensive of some sort. i think it was cardene, but it may have been labatelol.

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....

i'm sorry; i wasn't trying to be a smart--- here, i was referring to your statement:

experience more than one, well, maybe i need to question where i'm working and the docs running the codes

yep, of course guidelines are modified based on research.

again, not trying to be a smart---; the point i was trying to make (and making it poorly) is that the latest research is showing that simpler things work (cpr over advanced techniques; amiodarone over a complicated lidocaine --> bertrylium -->?? sequence) causing acls to seem dumber, when maybe it isn't a deliberate attempt to make it easier -- it's just working out that way.

[CritterLover, BSN, RN]

another thought, massed.

i'm wondering what you are considering to be a "successful code."

i'm defining a "successful code" (in this instance) to be one where the patient is able to be resuscitated to the point where they are able to leave the er and make it to icu. they may die there (even shortly after they get there), they may be extremely critical, but they do leave the er with a pulse, bp, and respirations (even if those respirations are assisted with a vent and the bp is augmented with pressors).

i think you need to be careful when you look into the literature, because most of the literature out there deals with survival in terms of time -- 24 hrs, 72 hrs, 30 days, 1 year -- rather than er disposition. (i see quite a bit of literature surrounding the 24hr, 30 day, 90 day, and 1 yr points).

so, if we are defining "successful code" in the same terms, and you are looking at er codes in general -- not just "came in dead/stayed that way," then i stand by what i wrote earlier: if you haven't seen any successful codes in your six years in the er, something is wrong.

(wow -- i realize that sounds kind of harsh, and i apologize for that, but i do stand behind it)

[GilaRRT]

another thought, massed.

i'm wondering what you are considering to be a "successful code."

i'm defining a "successful code" (in this instance) to be one where the patient is able to be resuscitated to the point where they are able to leave the er and make it to icu. they may die there (even shortly after they get there), they may be extremely critical, but they do leave the er with a pulse, bp, and respirations (even if those respirations are assisted with a vent and the bp is augmented with pressors).

i think you need to be careful when you look into the literature, because most of the literature out there deals with survival in terms of time -- 24 hrs, 72 hrs, 30 days, 1 year -- rather than er disposition. (i see quite a bit of literature surrounding the 24hr, 30 day, 90 day, and 1 yr points).

so, if we are defining "successful code" in the same terms, and you are looking at er codes in general -- not just "came in dead/stayed that way," then i stand by what i wrote earlier: if you haven't seen any successful codes in your six years in the er, something is wrong.

(wow -- i realize that sounds kind of harsh, and i apologize for that, but i do stand behind it)

allow me to take issue with you? stats is a pretty neat concept and may help us understand things a little bit better. you seem to be calling solid cow waste on the claim of not having a successful code in six years?

lets go to gilarn's lab and do some mad scientist stuff?

i am going to define a successful code as somebody who can see wombies in green shorts. in our hospital we have a pretty good success with our codes. our success rate is 25%.

so, here we have bubba bob thorton jr. the 4th twice removed frame shift mutation of the throne. bubba just started working in the er. bubba is a lucky dude and experiences a code a day. what are bubba's chances of having a successful code on day one? 25%. what about day two? 25%. what about every other day? yep, 25%. so, is it possible bubba could go six years and not have a successful code? yep, sure is.

it is quite possible to go six years and not have a successful outcome. with the low rates of success (depending on how you define success), and some areas where ems can call in the field, it is possible that you may not even have a code in 6 years.