Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab

"I just received my new ACLS class materials, and I noticed that atropine is no longer used for cardiac arrest. How is that possible after it having been in the protocols for so many years?"  — Anonymous, via Facebook

I do have to admit that this was surprising, and it will be hard to let go of those old habits. However, understanding how the American Heart Association (AHA) develops their standards is important in accepting any of the changes that they have made, or will make in the future. We have talked about atropine in a past article (https://www.cathlabdigest.com/ articles/Ask-Clinical-Instructor-13, January 2009).

The 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science were published in November 2010, and are available online at https://circ.ahajournals.org/content/vol122/18_suppl_3/. Since then, there has been a flurry of activity to get educational materials changed and instructors updated. Many programs that provide advanced cardiac life support (ACLS) education began using these new standards in March and April of this year.

ACLS guidelines have developed from just what people “thought” might work, to a systematic, evidenced-based approach to what DOES (or doesn’t) work. The treatment protocols are then adjusted to support this evidenced-based medicine.

This can yield significant changes, as we have seen in the “compression only” approach to CPR, and in changing the mnemonic from “A-B-C” (airway, breathing, chest compressions) to “C-A-B” (chest compressions, airway, breathing). As someone who has used the “ABC’s” since the mid-70s or so, this is a big change in my mindset, and will take a little getting used to.

In the case of atropine, the evidence behind its effectiveness in cardiac arrest is not so positive. The AHA standards state, “Available evidence suggests that routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B). For this reason, atropine has been removed from the cardiac arrest protocol.”

That being said, there is still some uncertainty about atropine. Elsewhere in the standards it says, “Lower-level clinical studies provide conflicting evidence of the benefit of routine use of atropine in cardiac arrest.” Simply, the evidence that it provides benefit is not greater than it not providing benefit.

Now, the cardiac arrest algorithm is revised to be simpler (Figure 1).

It is important that all individuals who provide patient care, or are present during cardiac arrest situations, have completed an ACLS class. This will help with the standardized care to the patient when multiple individuals are involved.

If you have a question, email Todd at tginapp@rcisreview.com or visit the RCIS Review Facebook page at www.facebook.com/RCISReview.

Reference

1. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S639, doi:10.1161/CIR.0b013e3 181fdf7aa.