Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

2015 ACLS Cardiac Arrest Algorithm

Yesterday, Dr. Bryan Bledsoe posted this on FaceBook with the caption –

The future of ACLS. I’ll bet I’m much more right than wrong!


FaceBook page for original.

Where are the drugs?!?!?

All of the drugs that work are right there.

We just pretend that the drugs work, even though there is no evidence that they improve the important stuff – neurologically intact survival to discharge.

There may be some reasons for this not to happen.

1. The traditionalists on the ACLS committees do not die off retire in large enough numbers.

2. Miraculously, some well done research is published that demonstrates that epinephrine improves neurologically survival to hospital discharge.

3. The critics were right all along and Dr. Bledsoe does not know what he is doing.

Have the critics been right?

Almost everyone acknowledges that Dr. Bledsoe has been right about the abuse of helicopter EMS. His only critics appear to be those who depend on helicopter EMS for paychecks and those who have their hands in their pants on helicopter landing zones. Unfortunately the EMS agencies have not done a great job of controlling the behavior of the whackers.

Imagine giving medicine that is appropriate for the patient, rather than treating all change in mental status with one shotgun approach. That used to be a fantasy, but now there are much fewer protocols that require indiscriminate administration of a coma cocktail. There is still a cult of thoughtless naloxone (Narcan) pushers, but that will also change.

SSM (System Status Management) continues to burn out crews and vehicles, but some administrators continue to believe. Since they administrate in back offices, we do not know where their hands are. Improved response times? The difference in response times is insignificant and response times have never been shown to be important outside of cardiac arrest.

Too much oxygen is a bad thing. While this has been hard for a lot of people to accept, the evidence continues to show that we should treat the drug oxygen as a drug. We should adjust the dose to the patient’s response.

How much will the 2015 ACLS Cardiac Arrest Algorithm look like this?

Probably a lot. I will also bet that Dr. Bledsoe is much more right than wrong.

.

Comments

  1. Couldn’t agree with this more!

  2. Since you mention the drug oxygen… if the evidence shows that too much oxygen is bad for patients that we think even need it (ACS, ischemic stroke, etc), then why are we giving it routinely to patients that we know probably don’t even need it? I don’t think of any “routine” use for it anymore, but i can tell you that many providers desperately want to give it routinely.

    • David B,

      Since you mention the drug oxygen… if the evidence shows that too much oxygen is bad for patients that we think even need it (ACS, ischemic stroke, etc), then why are we giving it routinely to patients that we know probably don’t even need it?

      That depends on where we are.

      My protocols in Pennsylvania state to only give oxygen to maintain a sat of ≥94%.

      I don’t think of any “routine” use for it anymore, but i can tell you that many providers desperately want to give it routinely.

      Acutely short of breath patients may be the only ones who should receive supplemental oxygen in the emergency setting.

      .

  3. “1. The traditionalists on the ACLS committees do not die off retire in large enough numbers.
    2. Miraculously, some well done research is published that demonstrates that epinephrine improves neurologically survival to hospital discharge.
    3. The critics were right all along and Dr. Bledsoe does not know what he is doing.”

    Rogue, let me propose a fourth possibility:

    4. Advanced post-resuscitation care, such as hypothermia, catheterization, bypass, or other therapies may be combined with existing drugs that improve survival to hospital admission, together producing greater survival to discharge.

    Thoughts?

  4. Response times are insignificant outside of cardiac? I am sorry but i very much disagree, if i have a pt who is having a cardiac problem (usually just ‘my chest hurts’, not usually a full blown AMI) it makes not a whole lot of difference if you get there in 10 minutes or 30, they make it to the hospital none the less, there is no field tested proof that a petal to the metal fast response increases chance of survival. However, what about trauma? How could you in good medical reason tell us that there is no difference if response times are fast or slow in trauma? The first thing they hammer into your head in training as EMS and Doctors alike, is the Golden Hour for treatment and the Platinum 10 minutes for EMS transport, it’s there for a reason.

  5. First remove oxygen from the QA slips, why do people believe 25 lpm is required on cardiac arrest, if we are going to used evidence based (fine by me) then the updates need to be done and the QA forms updated just as timely.
    Posted in a truck has proven nothing in my opinion other than causing backaches. Why are EMS quarters if we have them always after thoughts in DPW garages and other industrial parks hidden away from the public and the filthiest places possible? Where do you see any other healthcare professional taking out their own trash, shoveling their sidewalk to get in to work?

  6. Preety god that algoritm. I work in work safety field in my country and is true.
    Thank you.

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