1. ACLS: Apocryphal Conclusions Lacking Substantiation
Good morning, everyone. My name is Michael Ehmann. I am an Assistant Professor at Hopkins and it is an honor to talk with you all today.
One of the real perks of working at Hopkins is getting to be in a place where there is a rich historical medical tradition. So, we are going to start off with a few cases involving emergency care for cardiac arrest that are taken from the historical annals at Hopkins.
Michael Ehmann, MD MPH MS
Johns Hopkins Department of Emergency Medicine
Maryland ACEP – March 14, 2019

2. Disclosures
None
But before we get to those cases, I have no conflicts of interest to disclose

3. Case one: johns Hopkins hospital august 20, 1957
Our first case comes from 1957

4. And was published the following year in the Annals of Surgery
Ann Surg. 1958;148(3):462-8

5. August 20, JHH
It describes

6. August 20, JHH
nine-year-old female
A 9 year old girl

7. severe bronchial asthma
August 20, JHH
severe bronchial asthma
With a history of bad asthma

8. August 20, JHH
brought to the hospital 30 minutes after the onset
of substernal pain and cough
Who is brought in for chest pain and cough

9. August 20, JHH
walked into the Emergency Department and collapsed
But upon entering the ED she collapses

10. pulseless and cyanotic
August 20, JHH
pulseless and cyanotic
Is pulseless and cyanotic

11. intubation was quickly done
August 20, JHH
intubation was quickly done
So was intubated and cardiac massage was initiated
and cardiac massage begun

12. The heart beat was easily restored August 20, 1957 JHH 56-79-82
She quickly achieved ROSC but, oh by the way,
easily restored

13. the thoracotomy wound was closed
August 20, JHH
the thoracotomy wound was closed
the team had to close the patient’s thoracotomy incision because they had performed open cardiac massage for a non-traumatic pediatric hypoxic arrest

14. unconscious and unresponsive, with dilated, fixed pupils…
August 20, JHH
unconscious and unresponsive, with dilated, fixed pupils…
Hypothermia was begun and the temperature kept at 30o to 33o C
Thankfully, for the patient’s sake, she remained unresponsive. They did some targeted temperature management and kept her at degrees for the next 24 hours

15. August 20, JHH
Forty-eight hours after arrest the patient was conscious and responsive
And 2 days later, she was awake

16. No abnormalities were found
August 20, JHH
And by 2 months post arrest, back to baseline. A great save, but a bit more invasive than perhaps we’d prefer or are now used to.
No abnormalities were found
on examination two months later.

17. Case Two: Johns Hopkins Bayview March 1, 2015
Our second case comes just over a half century later, and is one of mine from residency. It will, I’m sure, look familiar to just about everyone in the room.

18. March 1, 2015 BV
67F w/ h/o CAD s/p CABG & PCI BIBA c/o SSCP x 30 min. EMS EKG w/ STE I & aVL & reciprocal depressions. Given ASA 324 mg PTA.
A 67 year old woman with significant cardiac history presented via EMS with chest pain and STEMI on her pre-hospital EKG

19. March 1, 2015 BV00508196 T 35C BP 91/48 HR 91 RR 30 SpO2 91%
She was hypotensive, tachypneic and mildly hypoxic on ED arrival

20. March 1, 2015 BV00508196 (-) rales (-) murmur (+) diaphoresis
(+) pallor
And didn’t look too well

21. Case Three: March 1, BV
This was her ED EKG with ST elevations in leads I and aVL and reciprocal depressions

22. March 1, 2015 BV00508196 A/P: Known CAD p/w STEMI & cardiogenic shock.
ASA given PTA. Plan Plavix, heparin, dopamine gtt for BP, cath lab.
So our treatment plan was what we would all recognize as standard therapy for ACS and cardiogenic shock

23. March 1, 2015 BV
PRIOR TO GROIN ACCESS, the patient developed ventricular fibrillation requiring at least 4 DCCV countershocks with restoration of sinus rhythm…the patient regained consciousness and was able to breathe spontaneously. IV Amiodarone was administered.
But as the patient was en route to the cath lab, she decompensated and degenerated into Vfib, requiring 4 shocks to regain a perfusing rhythm before being given a bolus of amio

24. Successful PCI of the proximal LAD into the second diagonal branch
March 1, 2015 BV
Successful PCI of the proximal LAD into the second diagonal branch
The patient was awake, fully communicative, and verbalized a resolution of her chest pain symptoms
Once defibrillated, the cardiology team was able to perform successful PCI and she made a full recovery

25. How Did We Get Here?
So how did we get here? This is random, I know. But, this morning, we are going to walk through the history of ACLS. While we’re doing so, I’ll show clips of concert films or musical documentaries released simultaneously with that year’s ACLS protocol so that you are in the right frame of mind for what it was like to be practicing then.
Now, if you don’t recognize this GIF or lyric: it’s from ”Once in a Lifetime” by the Talking Heads seen here performing in Jonathan Demme’s Stop Making Sense, filmed in LA in This is the second greatest concert film ever made. If you haven’t seen it, leave this talk and log onto Netflix right now.
I'm just kidding. Please keep paying attention up here because I want you to understand how from the 1950s and open cardiac massage, to the first ACLS guidelines published in 1966, to the most recent update to the ACLS guidelines in 2018, what has changed to cardiac arrest care. What have we learned in the last half century? What is left to do?

26. After this presentation, you will be able to:
Learning Outcomes
After this presentation, you will be able to:
Place the current ACLS protocol in historical context
Describe the evidence behind ACLS recommendations
Recognize that standard of care does not necessarily mean evidence-based
That is what we are going to spend the next 20 minutes discussing.
Here are our learning objectives for the day.

27. ACLS: History
In 1966, the first standardized guidelines for management of cardiopulmonary arrest were published in JAMA by the National Academy of Sciences. Updates have been published in each of the subsequent years listed here and since 2017, recommendations have been updated continuously and published both online and in Circulation.
As you’ll see, however, these recommendations were made without a lot of evidentiary support. In fact, for a long time, the pattern was to publish recommendations and only then once they were out there, study the specifics to see if the recommendations actually worked.
It’s an interesting approach that really turns the whole concept of evidence-based practice on its head.

28. ACLS: History So let’s get started. First up is 1966.
You’ll recognize this artwork from Yellow Submarine by the Beatles, which was a film whose soundtrack was released as a freestanding album.
If you’ve never seen it before, you should check it out. It’s very 60s and very groovy and anything goes – kind of like the first CPR guidelines.

29. ACLS: 1966 Airway: Head-tilt/neck-lift; intubation ASAP
Breathing: 12 BPM
Circulation: 1.5 – 2” every second
2 rescuers 5:1
1 rescuer 15:2
Check pulses “periodically”
Drugs/Electricity: None
These are the recommendations from that first JAMA paper. They’re almost comically lacking evidence. There are 2 references provided. Both are editorials without any authors listed – one from 1962 and the other from 1965.
The guidelines recommend early intubation but mouth to mouth-or-mouth-to-nose is “unequivocally superior to all manual methods,” and a compression rate of 60 is preferred.
There are no recommendations regarding medications or defibrillation and interestingly, this paper explicitly says that CPR should NOT be taught to the general public, though we now teach that early CPR & defibrillation are best practice.
JAMA, 1966

30. ACLS: 1966
This image from the 1966 JAMA paper should look familiar to us and shows the classic ABC approach to CPR including the “unequivocally superior” method of delivering rescue breaths.
So this is it!
This is the foundation upon which modern ACLS is built: a seven page consensus statement without any authors listed who refer to two expert opinion pieces to support their recommendations.
Let's see if things get any better.

31. ACLS: History
The next two ACLS guidelines were released in 1974 & I grouped these together for reasons we will discuss in a moment, so we are splitting the musical difference with the greatest music documentary ever made: The Last Waltz filmed by Martin Scorcese in Released in 1978, it was the final show of The Band’s farewell tour where they brought out multiple guest stars, including Van Morrison who you see here wearing a purple velvet sequined jumpsuit and performing leg kicks while singing Caravan with Rick Danko, Robbie Robertson and Levon Helm.
The Band is the greatest rock band of all time. Period. No references needed.

32. ACLS: 1974 – 1980 ABCs unchanged Drugs Electricity: 200 – 300J
ACEP adopts BLS/ACLS certification
Hands off time < 30 seconds
Drugs
Lidocaine, procainamide, bretylium, propranolol, atropine, isoproterenol, epinephrine, norepinephrine, dopamine, dobutamine, metaraminol, calcium, digitalis, nitroprusside, nitroglycerin, sodium bicarb
Diuretics & steroids for cerebral edema
Electricity: 200 – 300J
So, 8 & 14 years after the initial ACLS recommendations were released, the 1974 & 1980 updates include references for the first time but without reporting the strength of these recommendations. As this was the case for both updates, I have grouped them together here.
The basics of CPR are largely unchanged from 1966 but the big change is that ACLS interventions are now much more advanced than the simple ABCs and include medications (CLICK) and defibrillation (CLICK).
From here on out, simply because of time, we are going to focus on the C, D & E aspects of ACLS care but the A & B interventions will remain on the slides, grayed out (CLICK), so you can reference them later if you wish.
But, importantly, the 74 and 80 guidelines are especially notable for explicitly recommending for the first time epinephrine in cardiac arrest (CLICK).
JAMA, 1974; JAMA, 1980

33. ACLS: 1974 – 1980 ABCs unchanged Drugs Electricity: 200 – 300J
ACEP adopts BLS/ACLS certification
Hands off time < 30 seconds
Drugs
Lidocaine, procainamide, bretylium, propranolol, atropine, isoproterenol, norepinephrine, dopamine, dobutamine, metaraminol, calcium, digitalis, nitroprusside, nitroglycerin, sodium bicarb
Diuretics & steroids for cerebral edema
Electricity: 200 – 300J
epinephrine
As we all know, epi has become a mainstay pharmacotherapy for ACLS but, in these guidelines, the only reference for the use of epi is a 1968 study performed by Joseph Redding at Baltimore City Hospital - now called Johns Hopkins Bayview.
Let’s talk about what Dr. Redding did to change the face of ACLS care for the next 50 years
Similarly, The recommendation for shock strength is based on two reviews from One author writes, “The appropriate electrical shock strength for trans-chest defibrillation is controversial. As in most controversies, there are data to support both positions, but there are not enough data to resolve the issue. Studies to determine the best shock strength are in progress, and may settle this issue later. Meanwhile, practicing physicians need guidelines for using defibrillators now." This goes to show that these guidelines were not only NOT evidence-based; they were KNOWINGLY not evidence-based. It's really kind of amazing.
JAMA, 1974; JAMA, 1980

34. Epinephrine – 1968
He divided 105 dogs into 7 groups of 15 each. All were then subjected to V fib arrest.

35. HCO3 EPI EPI + LIDO EPI + HCO3
Epinephrine – 1968
HCO3
PHENYL
METHOXAMINE
EPI
After 10 minutes of down time & just before beginning CPR, each group was given a different drug: epi (CLICK), bicarb (CLIKC), phenylephrine (CLICK), methoxamine (CLICK), epi + lidocaine (CLICK), epi + bicarb (CLICK) or nothing at all (CLICK).
EPI + LIDO
EPI + HCO3

36. HCO3 EPI EPI + LIDO EPI + HCO3
Epinephrine – 1968
HCO3
PHENYL
METHOXAMINE
EPI
After 4 minutes of CPR, the dogs were defibrillated & observed.
EPI + LIDO
EPI + HCO3

37. Epinephrine – 1968
Of the 15 dogs in the epi alone group, 5 were defibrillated with 1 shock (CLICK). 2 were defibrillated with 2 shocks (CLICK). 8 were unable to be defibrillated.

38. Epinephrine – 1968
After 24 hours, of the 7 dogs in sinus rhythm after treatment with epi and 1 or 2 shocks, 2 dogs were awake (CLICK), 3 were semiconscious (CLICK) & 2 were dead (CLICK) in addition to the 8 that could not be defibrillated.
To be clear, what I have just told you is that the original ACLS recommendation for using epinephrine in cardiac arrest was based on the outcome of an experiment with 15 dogs, 87% of whom were dead or comatose after treatment with epi.
The ACLS recommendation for epinephrine in cardiac arrest, based on this experiment, established epi as the standard of care for half a century.

39. ACLS: History
Moving right along to the 80s. This is Freddie Mercury performing with Queen at Wembley in London in The concert footage was released on VHS in I’ve heard some people advocate for using this song, Another One Bites the Dust, instead of the BeeGee’s Staying Alive to keep time during chest compressions…I won’t say if I think that’s a good idea or not.

40. ACLS: 1986 A: Head-tilt/chin-lift B: 2 rescue breaths immediately
Mouth to stoma added
B: 2 rescue breaths immediately
C: Pulse check after 2 breaths
Increase compression rate to /min
Check pulses “every few minutes”
Hands off time < 7 seconds
D: Epi 1mg q5 minutes
E: 3 stacked shocks, starting at 200J
The classic teaching of 2 rescue breaths before pulse check has no references given but lasts for two decades until 2010.
The compression rate has increased from 60 to per minute based on 4 studies. 2 on the cardiac pump theory from 1984 & 1985 with 24 dogs & 4 humans; and 2 on the thoracic pump mechanism in 1979 & 1980 in 15 dogs. That's right, a total of 39 canine & 4 human subjects determined the optimal compression rate for CPR in 1986.
The dosing of epi, explicitly stated for the first time in the 1986 guidelines has no references provided.
Focusing on electricity, though there was no evidence published to support the 3 stacked shocks recommendation, the initial defibrillation charge recommendation was changed from a range to 200J after – for the first time – a well-designed prospective randomized trial for ACLS care. Dr. Weaver in Seattle published a study in NEJM of 249 patients with VF who were shocked with 320J on even days of the week & 175J on odd days. They were tracked for number of shocks needed to defibrillate, post-shock rhythm & overall survival. There was no difference in outcomes so the recommendation was for the lower strength.
JAMA, 1986

41. ACLS: 1986
These 3 algorithms may be familiar to some in the room who might have used them early in their careers was the first year in which the recommendations were presented in this algorithmic way - a format with which we all are now familiar.
On the left, you see VFib & pulseless Vtach.
In the upper right is the PEA algorithm which, at the time, was referred to as electromechanical dissociation
The lower right shows the asystole algorithm
JAMA, 1986

42. ACLS: History
In 1992, Nevermind by Nirvana went to #1 on the Billboard charts, was certified gold & platinum and ultimately sold over 1 million copies by the end of the 90s. Kurt Cobain died 2 years later after committing suicide at age 27. In 2015, a biopic about Cobain was released called Montage of Heck – the first film about Cobain to be made with cooperation from his family, including Courtney Love. Though it was controversial, it was met with pretty widespread acclaim.

43. ACLS: 1992 Classes Level of Evidence
I: Benefit >>> Risk. Strong. Should be done
IIa: Benefit >> Risk. Moderate. Is reasonable
IIb: Benefit ≥ Risk. Weak. May be reasonable
III: Benefit = Risk or Risk > Benefit. No benefit/harm
Level of Evidence
A: RCTs or meta-analyses w/ multiple populations
B: 1 RCT or nonrandomized w/ limited population
C: Case reports or opinion w/ very limited population
I know you all are familiar with the strength of evidence and recommendation grading system so I include the specifics here merely as a reminder. We won’t see any levels of evidence reported in the ACLS guidelines until 2010, but beginning in 1992, the recommendations are graded for the first time.

44. ACLS: 1992 A: Exhaled-air ventilation before ETI (Class I)
End-tidal CO2 recommended for ETT placement
B: Look, listen, feel
C: No major changes
“No…guidelines…to assess…efficacy of CPR”
Drugs:
Epi 1mg q 3-5 minutes (ungraded)
Epi 5mg or 0.1 mg/kg (Class IIb if 1mg fails)
Electricity added to BLS
Let’s again focus on epi in For the first time, we have references for dose recommendations. The 1992 authors cite 3 papers from 1923, 1949 and 1962 that reported INTRACARDIAC epi during INTRAOPERATIVE arrest to support their 1mg IV recommendation. They acknowledge that it was “assumed that 1mg of IV epinephrine would work the same as 1mg of intracardiac epinephrine.”
The authors also include 2 references in support of the 5mg dosing recommendation – one is an abstract from Ian Stiell & the other is a paper by Paradis published in JAMA in Interestingly, the 1990 Paradis paper is a study of coronary perfusion pressure during CPR and does not mention any medications. It is NOT a study of epi during CPR. I honestly think the ACLS authors cited the wrong reference & meant to include a 1991 paper from the same group that actually did look at standard vs high dose epi, but I can’t be sure. Nevertheless, if we assume that they meant to cite the 1991 paper which actually addressed the clinical question of standard vs high dose epi, the evidence to support high dose epi is STILL questionable since the study studied only epi and coronary perfusion pressure but did not measure any patient centered outcomes such as survival or neurologic outcome.
Finally, the ubiquity of AEDs allowed for early defibrillation to be added to the BLS algorithm. 2 studies by Eisenberg in 1980 & Stults in 1984 showed that survival to discharge in patients suffering OHCA increased about six-fold if defibrillated. This leads to the guidelines stating, “rapid defibrillation is the major determinant of survival in cardiac arrest due to VF."
JAMA, 1992

45. ACLS: 1992
Here is the 1992 VF & pulseless VT algorithm. We’ve already discussed the lack of data to support any dosing of epinephrine, let alone the higher dosing
JAMA, 1992

46. ACLS: 1992
Similarly, we've discussed that there are no references provided for delivering 3 sequential shocks though the initial Joules still come from the Seattle study.
JAMA, 1992

47. ACLS: History
This is 8 mile. The Marshall Mathers LP was released in There were no good music documentaries about the year I’m not even going to play a clip here. Sorry, millennials.

48. ACLS: 2000 A & B: No changes Circulation: Drugs
15:2 ratio for 1 or 2 rescuer CPR (IIb)
Rate of 100 BPM (IIb)
Drugs
Epi 5mg vs 1mg (Class IIb)
Vasopressin vs epi (IIb)
Amiodarone vs lidocaine (IIb)
Electricity: Non-escalating shocks (IIb)
But to the AHA's credit, in 2000, each of their recommendations were graded
Since 1992, there had been multiple studies on epinephrine dosing. The 2000 guidelines say, “Although epinephrine has been used universally in resuscitation, there is a paucity of evidence to show that it improves survival in humans.” They continue “8 randomized clinical studies involving more than 9000 cardiac arrest patients have found no improvement in survival to hospital discharge or neurological outcome…for high dose compared with standard doses…Therefore, high-dose epi is not recommended for ROUTINE USE but can be considered if 1-mg doses fail.” With this class IIb recommendation, the intervention is deemed acceptable.
Vasopressin was added after being shown to increase coronary perfusion pressure in pigs & 240 human patients in 2 studies. Both showed no difference in hospital survival for patients treated with vasopressin or epi, so vaso was similarly added as a class IIB recommendation.
Based on the ARREST & GUSTO 1 trials in the 1990s - which raised concern about lidocaine resulting in post-MI fatal arrhythmias - amio supplanted lidocaine as the preferred option for shock-refractory pulseless VT & VF.
Finally, though still recommending stacked shocks, now the guidelines recommended non-escalating dosing and just staying at 200J.
Circulation, 2000

49. Here is the combined arrest algorithm from the 2000 recommendations with the addition of vasopressin, though unlike the 1992 algorithm, 5mg epi does not appear on the algorithm.
Circulation, 2000

50. ACLS: History
This is Green Day’s Billie Joe Armstrong singing American Idiot, from the rock opera of the same name which went to #1 on the charts, sold over 6 million copies, won the best rock album Grammy and then was made it to Broadway and was nominated for the best musical Tony. A film adaptation is reportedly in the works and Green Day holds a special place in my heart because Dookie was the very first CD I ever bought when I was in third grade.

51. ACLS: 2005 A & B: No changes Circulation:
30:2 ratio (all adults; 1-rescuer child) (IIa)
15:2 ratio (2-rescuer child; all infants) (IIb)
Compress at 100 BPM (IIa)
Pulse checks q2 min (IIa); none for lay rescuers
Drugs: Amio 300mg  150mg (IIb)
Electricity: Single shock  CPR (IIa)
But, more importantly, we are now reaching the recent practice guidelines that many here will remember well.
In 2005, the evidence for a compression rate of 100 was upgraded from grade IIb to IIa based on 1 study of 20 pigs & 2 studies of 32 humans.
Use of amio in the 2002 ALIVE study in NEJM showed increased survival to hospitalization for OHCA VF treated with amio compared to lidocaine so amio continued to be preferred as first line treatment of shock-resistant VF/pVT.
The probably-erroneous 1990 reference for epi dosing that we first saw in 1992 & again in 2000 is now no longer present.
This year, many of you will remember, stacked shocks were removed from the recommendations after multiple studies demonstrated delays between shock delivery and starting compressions and since newer AEDs reported a first-shock success rate >90%, avoiding shocks at the expense of compressions was thought to be reasonable.
Circulation, 2005

52. The 2005 algorithm is now looking very familiar to us with the updates that we just discussed highlighted
Circulation, 2005

53. ACLS: History
It Might Get Loud was released in 2010, and traces the early development & playing styles of 3 amazing lead guitarists: Jimmy Page, The Edge, & Jack White. The highlight of the film is when all 3 sit down together in a room & just start playing & everybody’s faces melt.

54. ACLS: 2010 BLS: ABC  CAB Circulation: Airway: Breathing: No change
Hands-only CPR for public
Depth: ≥2 inches (IIa,B)
Rate: ≥100 BPM (IIa,B)
Airway:
Waveform ETCO2 (I,A)
Cricoid pressure no longer recommended (III)
Breathing: No change
Alright, we’re in the home stretch here! The 2010 guidelines give both level of evidence & recommendation class for the first time but the biggest change is the reordering of BLS care from ABC to CAB.
Compression depth was increased to at least 2" based on a prospective observational cohort study of 60 VF patients. A depth of 1.5-2" resulted in 88% success for first defibrillation shock compared to 100% success for compression depth greater than 2". The n for the group receiving compressions >2”? Five.
Compression rate of at least 100 (rather than rate = 100) is based on a prospective observational cohort study by Christenson of 506 patients that showed a survival to discharge odds ratio of 3 when chest compression fraction >60%.
Circulation, 2010

55. ACLS: 2010 Drugs: Electricity: Post-ROSC care
Routine thrombolysis, HCO3, Ca++ not recommended (III)
Atropine removed from PEA/asystole (IIb, B)
Electricity:
Shock at manufacturer dose (120 – 200J) (I, B)
Post-ROSC care
For drugs, the routine use of lytics, bicarb & calcium is no longer recommended.
Routine thrombolysis was shown in 2 NEJM studies – one from 2002 and the other from 2008 – to have no benefit & to increase the risk of ICH. Bicarb in the undifferentiated patient was shown in multiple studies to have either no benefit or harm due to worsening myocardial and cerebral intracellular acidosis. For calcium the authors simply state, "There is no benefit," but do not elaborate any further.
Additionally, the 2010 guidelines place a new focus on post-ROSC care, which we now recognize is pretty important.
Circulation, 2010

56. This is the 2010 algorithm with updates regarding the tenets of high quality CPR.
Circulation, 2010

57. ACLS: History
Coming up to the present day and the best musical documentary of 2015: What Happened, Miss Simone? This won the Academy Award for best documentary of the year and is a fascinating look at the troubled life of one of the most incredible musicians of the 20th century, Nina Simone.

58. ACLS: 2015 Circulation: Airway: Breathing:
Depth: 2–2.4 inches (I, C-LD)
Rate: 100–120 BPM (IIa, C-LD)
ETCO2 < 10 mmHg after 20 minutes CPR in intubated patients poor prognosis (IIb, C-LD)
Airway:
Ultrasound for ETT confirmation (IIa, C-LD)
Breathing:
10 BPM with advanced airway (IIb, C-LD)
Starting with C: a compression depth of at least 2" has been shown in multiple analyses to improve outcomes, hence the class I recommendation. The upper limit of 2.4" is derived from a 2013 observational study of 110 men & 60 women that showed iatrogenic injuries – though nonfatal – were more common in men when compression depth was >6cm.
The rate of comes from Idris’ 2015 registry analysis of 6,000 OHCA patients treated by EMS in the ROC Consortium that showed rates below 100 or greater than 120 had decreased survival to hospital discharge
There's also more of a focus on when to terminate resuscitation & a new recommendation that ETCO2 <10 should be considered as 1 component of a multimodal approach to ending resuscitation.
For airway & breathing, ultrasound gets some love & is added as a method for endotracheal tube confirmation when capnography is unavailable, & the recommended respiratory rate is set at 10 BPM rather than after the 2015 ILCOR systematic review found numerous animal studies & 1 human observational trial but no high quality evidence to show rates other than 10 improved survival or neurologic outcome.
Circulation, 2015

59. ACLS: 2015 Drugs: Electricity: No change Post-ROSC:
Standard dose epi (IIb, B-R)
High dose epi not recommended (IIINB, B-R)
Vasopressin offers no advantage (IIb, B-R)
Steroids of uncertain benefit (IIb, C-LD)
Electricity: No change
Post-ROSC:
TTM 32-36ᵒC (I, B-R)
Shockable OHCA (I, B-R)
Nonshockable and IHCA (I, C-EO)
And of course, back to epi: the level of evidence for standard dosing was strengthened by the PACA trial in Australia which studied 500 patients who received either 1mg epi or placebo. They found higher ROSC with epi but no difference in hospital survival or neurologic status. Interestingly, the study was stopped early because the authors couldn’t reach their target enrollment of It was supposed to be a 5 center study, but 4 backed out when the press & politicians in Australia began framing the study as unethical. This goes to show the Catch-22 of how recommendations that become "standard of care" even if unsubstantiated can hinder future study of these same interventions to test their efficacy. We’ll discuss the PARAMEDIC-2 trial in just a moment.
Interestingly, in 2015, routine use of high dose epi was changed from a Class IIb to a Class III recommendation – meaning should not do. This change, however, was not based on any new studies compared to the previous IIB or “consider as reasonable” recommendations in 2000, 2005 and The references cited for this change in 2015 were all published before 2000 so the reasoning behind this change is unclear to me.
Vasopressin was removed entirely for the sake of simplicity, not because of harm. Multiple studies, including 2 with 2400 patients each, and another with 300 patients comparing epi + vaso or vaso alone to epi alone found no difference in outcomes. Though I agree with the interpretation of the committee that there is no difference between the 2 drugs, what I find interesting is that – as we have all just learned – the data supporting epi is not really that strong so we are eliminating vaso because it is equivalent to epi, but neither has been shown to improve the outcomes that matter: long-term survival & functional neurologic status.
Finally, the recommendations for TTM are based on the Nielsen NEJM article from 2013 that compared post-ROSC temperatures of 33 & 36 degrees & found no difference in outcomes. This, of course, is a throwback to our opening case from 1958 in the Annals of Surgery.
Circulation, 2015

60. Here is the 2015 algorithm with the only significant change from 2010 here in the asystole pathway with the removal of vasopressin.
Circulation, 2015

61. ACLS: History
And, we’ve made it. It's been a long, strange trip but here we are at the current guidelines and the best musical documentary of 2018: Quincy. Made by his daughter, actress Rashida Jones, this is a biopic of musician and uber-producer Quincy Jones who worked with everyone from Frank Sinatra to Michael Jackson to Kendrick Lamar, seen here. Quincy Jones has had some recent controversies, but the documentary is really interesting and features Bruce Swedien, who was Jones’ go-to sound engineer and happens to be one of our resident’s uncle, which I think is pretty cool. Check it out.

62. ACLS: 2018 & Beyond Circulation: No change Airway: No change
Breathing: No Change
Drugs:
Amiodarone vs lidocaine (IIb, B-R)
Electricity: No change
In 2017, the ACC and AHA decided to no longer release updates every 5 years, but rather to continuously update their recommendations annually and post them online.
So here is our current algorithm, which is nearly identical to The only major change between 2015 and 2018 is that lidocaine was given a stronger recommendation for shock resistant Vfib. As you’ll remember, since 2000, amio had been preferred to lidocaine after the ARREST, GUSTO-1 and ALIVE trials, but with the 2018 guidelines the use of either agent is given a Class IIB LOE B recommendation for use in “VF/pVT that is unresponsive to defibrillation.” This was based on the 2016 ALPS study published in NEJM by the ROC Investigators (Resuscitation Outcomes Consortium) that showed in a placebo controlled RCT of 3026 patients suffering OHCA who remained in Vfib or pulseless VT after at least one shock, there was no difference between placebo, amiodarone and lidocaine.
Circulation, 2018

63. So…How Did We Get Here?
And that’s it…So, how did we get here?

64. Summary of 2015 Evidence Circulation, 2015
As we come to our conclusion, this table, provided by the ACC/AHA writing group, is the most telling. It summarizes all of the 314 recommendations made in the 2015 ACLS guidelines which are mostly still made in the current 2018 guidelines. They haven’t re-created this table for today, but how many of these recommendations from the last full recommendation are supported by high quality evidence?
Class I or benefit is significantly greater than risk and should be done? 25%.
Class IIa or benefit is greater than risk & is reasonable to do but additional studies with focused objectives are needed? 23.5%
Class IIb or benefit is greater than or equal to risk & may be considered but additional studies with broad objectives are needed? 44.5%
Class III showing no benefit? 1.5%
Class III showing harm & should not be done? 5%
LOE A for data derived from multiple randomized control trials or meta-analyses studying multiple populations? 0.6%
LOE B for limited populations studied with one RCT or multiple nonrandomized studies? 28%
LOE C for very limited populations evaluated with either limited data from case studies or expert opinion? The vast majority of recommendations at 70%
Only 2 interventions receive the strongest recommendation based on the best data, < 1% of all recommendations made and both of those are telling us what we shouldn’t do, but not what we should.
Circulation, 2015

65. What’s Next? PARAMEDIC2 ACLS continuous web updates
Double-blinded RCT epi vs placebo
8,014 adults with OHCA in the UK
Epi: Higher 30-day survival but…
More survivors with severe neurologic impairment
ACLS continuous web updates
ECCguidelines.heart.org
Clearly, there is still work to do. So what’s next?
We discussed how the PACA trial affected the ACLS recommendations in 2015, but as I’m sure many of you are aware, the results from the PARAMEDIC2 trial were published late last year in NEJM. This multi-site placebo-controlled double-blinded randomized control trial of standard-dose epinephrine in OHCA with a primary outcome of 30-day survival showed that though epi can favorably impact 30-day survival, it likely occurs at the expense of a favorable neurologic outcome. This raises big ethical questions that we will not delve into today but, for one, will look forward to seeing how the PARAMEDIC2 results are considered for the ACLS protocol by the writing group.
NEJM, 2018

66. After this presentation, you will be able to:
Learning Outcomes
After this presentation, you will be able to:
Place the current ACLS protocol in historical context
Describe the evidence behind ACLS recommendations
Recognize that standard of care does not necessarily mean evidence-based
So here, again, are our learning objectives. I hope you now have a keener understanding of the history of cardiac arrest care & how what we think of as settled core emergency medical knowledge is not necessarily supported by high quality evidence. We must continue to question why we do things the way that we do and to always wonder if there is a better way.

67. References
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Here are my references, any of which I am happy to share with you if you get in touch with me

68. Shock delivered… resume CPR
And finally, this is my dog, Fess, being resuscitated by his buddies Leonard & Henry. Thankfully, he made a full recovery without epi because God knows he’s hyper enough.
Thanks again for your attention.