I’m surprised this hasn't been done sooner, but I'm going to use this POTD to quickly delve into some of the important changes in the new 2023 AHA ACLS guidelines. Some of these are pretty surprising, some of them - not so much. But remember that these updates are crucial for ensuring our patients best outcome.
Calcium: Not the Hero We Thought
Recent Insights: Class 3 Recommendation (No Benefit)
These new guidelines mark a pivotal shift in our understanding of calcium's role in cardiac arrest management. While it remains critical in cases of hyperkalemia and calcium channel blocker overdose, recent studies have shown that its routine use in other scenarios may be associated with potential harm. This revelation underscores the importance of context-specific interventions in cardiac emergencies.
Magnesium: The Unfilled Promise
Evidence from Randomized Controlled Trials: Class 3 Recommendation (No Benefit)
Magnesium, once hypothesized to enhance outcomes in cardiac arrest, has been scrutinized in recent randomized controlled trials. Contrary to previous assumptions, these studies reveal no significant improvement in Return of Spontaneous Circulation (ROSC), survival rates, or neurological outcomes, irrespective of the initial rhythm. This finding challenges existing protocols and emphasizes the need for evidence-based practices.
ECPR: A Selective Savior
Updated Guidelines: Class 2a Recommendation (Moderate)
The guidelines now advocate for the judicious use of Extracorporeal CPR (ECPR) in specific scenarios of ACLS refractory cardiac arrests. This recommendation is based on the premise that ECPR, when utilized within a well-equipped and trained healthcare system, can offer a lifeline in otherwise dire circumstances. It highlights evolving resuscitation science and the importance of tailored emergency response.
Coronary Angiography: Choose Wisely
Strategic Approaches Recommended: Class 3 Recommendation (No Benefit)
A significant update pertains to the use of emergent coronary angiography. The guidelines now recommend a more cautious approach, favoring a delayed or selective strategy in patients without ST-segment elevation, absent indications like shock or significant myocardial damage. This nuanced stance reflects a growing appreciation for patient-specific strategies in post-cardiac arrest care.
Temperature Management: Chill Out Bro, But Not Too Much
New Standard of Care: Class 1 Recommendation (Strong)
Post-ROSC temperature control has been underscored as a vital aspect of patient management. The guidelines recommend maintaining a constant temperature between 32-37.5°C for all adults unable to follow commands post-ROSC. This approach, supported by robust evidence, marks a significant step forward in neuroprotective strategies following cardiac arrest.
TL;DR:
Calcium use is now limited to hyperkalemia and calcium channel blocker overdose.
Magnesium doesn't improve outcomes in cardiac arrest, regardless of rhythm.
Extracorporeal CPR (ECPR) is recommended in select, refractory cardiac arrests within equipped systems.
Emergent coronary angiography post-cardiac arrest is advised only with specific indications.
Strict temperature control (32-37.5°C) post-ROSC is emphasized for all adults unable to follow commands.
References for In-Depth Exploration
American Heart Association. 2023 ACLS Guidelines
Hsu CH, Couper K, Nix T, Drennan I, Reynolds J, Kleinman M, Berg KM; Advanced Life Support and Paediatric Life Support Task Forces at the International Liaison Committee on Resuscitation (ILCOR). Calcium during cardiac arrest: A systematic review. Resusc Plus. 2023 Mar 27;14:100379. doi: 10.1016/j.resplu.2023.100379. PMID: 37025978; PMCID: PMC10070937.
Reis AG, Ferreira de Paiva E, Schvartsman C, Zaritsky AL. Magnesium in cardiopulmonary resuscitation: critical review. Resuscitation. 2008 Apr;77(1):21-5. doi: 10.1016/j.resuscitation.2007.10.001. Epub 2007 Nov 26. PMID: 18037222.
Wongtanasarasin W, Krintratun S, Techasatian W, Nishijima DK. How effective is extracorporeal life support for patients with out-of-hospital cardiac arrest initiated at the emergency department? A systematic review and meta-analysis. PLoS One. 2023 Nov 7;18(11):e0289054. doi: 10.1371/journal.pone.0289054. PMID: 37934739; PMCID: PMC10629644.