Reflections on ACLS

Commentary

CJEM 2005;7(6):415-416

This month the International Liaison Committee on Resuscitation (ILCOR) will release its "Consensus on Science and Treatment Recommendations" in the journals Circulation and Resuscitation. The 2005 Emergency Cardiac Care (ECC) guidelines, which are based closely on this, will be released in Circulation in December. These guidelines include basic, advanced, pediatric and neonatal life support and are arguably the most comprehensive and widely circulated evidence-based publication in the history of medicine. Why then, do many emergency physicians view advanced cardiac life support (ACLS) negatively? The reasons likely arise from the way ACLS guidelines evolved, the realities of cardiac arrest resuscitation and, to some extent, our own resulting biases and misconceptions.

In 1966 the National Academy of Sciences and the National Research Council co-sponsored the first conference on cardiopulmonary resuscitation (CPR). This resulted in the introduction of cardiovascular resuscitation guidelines to help health care providers make optimal decisions during the stress and chaos of a cardiac arrest resuscitation. The American Heart Association subsequently took the lead on guideline revisions and courses such as ACLS, and in 1993 ILCOR was formed to coordinate the efforts of resuscitation organizations throughout the world. Although early guidelines were based predominately on expert opinion extrapolated from scant evidence, they were enthusiastically received. I distinctly recall taking my first ACLS course as a medical student in the early 1980s, and the sense of relief and confidence I felt after developing an organized approach to any cardiac arrest scenario. Years later, as an ACLS instructor, I saw these same emotions on the faces of physicians, nurses, medical students and paramedics who took ACLS courses.

But not everyone was happy. Some physicians with resuscitation expertise felt that the ACLS guidelines were too formulaic and were particularly inappropriate for special scenarios such as overdoses or hypothermia. Others, aware of the literature, felt that since compelling evidence of benefit only existed for CPR and defibrillation, all other interventions should be deemed optional. In response, the scope of ACLS was broadened in 1992, and in 2000 a grading system was introduced to differentiate between what was known to be beneficial, what might be beneficial, what was known to harm, and what was indeterminate. However, these solutions resulted in a longer ACLS manual and more complicated treatment algorithms — both potentially frustrating and intimidating for less experienced providers.

During the past decade ACLS was open to contradictory criticism by those with vastly different perspectives. It was deemed too simplistic by some, and too complex by others. Concerns were also raised about whether the guidelines had become de facto standards.

So what is the context for applying ACLS? Overall survival rates after CPR remain dismal, in large part because insufficient patient information necessitates the application of ACLS on many people who turn out, with the clarity of hindsight, to have irreversible pathology. Despite increasing evidence of high survival rates with good neurologic outcome when CPR, defibrillation availability, and post-resuscitation care are optimized, our generally negative personal experiences applying ACLS result in fertile ground for nihilism and the erroneous belief that "nothing works." Such a perspective can be reinforced by the fact that previous ACLS guidelines have, not surprisingly, endorsed some interventions that were subsequently proven to be ineffective, such as high-dose epinephrine.

In recent years commercial interests have presented another challenge to the mission of ACLS. Some aspects of resuscitation have become big business, and how the guidelines address such things as public-access defibrillation, biphasic defibrillation, thrombolytics for stroke, and amiodarone for ventricular fibrillation has financial implications, both for those who pay for health care and for those who profit from it. Despite hard work and altruism, the 2000 guidelines were tainted by charges of scientific and financial conflict of interest. Regardless of whether these charges were justified, the unfortunate result was that the concerns raised in a few specific areas became, for some, the basis for skepticism of the entire ECC guidelines process and even the motivations of the American Heart Association. Such skepticism seems particularly rampant in the North American emergency medicine community, in part fuelled by the strong opinions of a few high-profile individuals involved in emergency medicine education.

As we await the publication of the 2005 ECC guidelines, I think there are many reasons to be upbeat and optimistic. The new guidelines are more evidence-based than ever before. The Consensus on Science and Treatment Recommendations were developed by ILCOR over a 5-year process to examine 276 topics related to CPR and ECC. Hundreds of content experts and researchers systematically reviewed the literature and completed 403 worksheets, which are freely available on the Internet (see www.c2005.org). Potential conflicts of interest, whether scientific or financial, were addressed by an unprecedented approach that was both rigorous and transparent. In January 2005, 380 individuals from around the world met in Dallas to review this material and reach consensus. Canadian research and the Canadian emergency medicine community were well represented at this conference.

Resuscitation research is notoriously difficult, as is evaluating the evidence to determine when the endorsement of a potentially effective change in practice is warranted. The 2005 ECC guidelines contain major changes that will generate spirited discussion. As emergency medicine providers, we have a responsibility to carefully review the new ECC guidelines. Given the transparent and publicly available approach applied to their development, it will be easy for individuals to delve further into intriguing or controversial topics to reach their own conclusions. I believe these guidelines will provide both a clear template to facilitate optimal care by less experienced providers and a rigorous systematic evaluation of the literature for those with more interest and expertise — thus allowing tailored leading-edge care based on local factors, interpretation and experience.

Let's take a positive approach to the 2005 ECC guidelines. They are the result of a colossal amount of unpaid work by hundreds of individuals. We owe these people our thanks for their efforts to help us interpret and apply a complex and ever-increasing body of literature, as do our patients for helping them avoid untimely sudden death.