ACLS recertification

--- the other day came at somewhat of a bad time, as the 2005 guidelines are about to be updated. Publication is expected this fall. It got me thinking---what will the new guidelines look like? Our instructors had no inside information on the changes. As one who's tried to keep up with the field I thought now would be a fun time to offer some predictions. Now, I can only offer what changes I think the AHA should make. What they'll actually do is anybody's guess. In the past the guidelines have tended to be a few years behind where they need to be. So here goes (disclaimer---adult cardiac arrest only):

EMT providers who arrive at the scene of a cardiac arrest should start pumping immediately while one rescuer inserts an oral airway and provides oxygen via a nonrebreather mask. The victim should receive 200-300 compressions before rhythm analysis and defibrillation with the AED. Initial rescue breaths will be eliminated and intubation delayed. There will need to be some wiggle room for clinical judgment if collapse to arrival time is known to be less than 5 minutes, if good quality CPR is already in progress or if circumstances strongly indicate a respiratory arrest progressing to cardiac arrest. The recently announced ROC PRIMED trial caused public confusion on this issue and added little to our knowledge of appropriate timing of initial defibrillation.

Rescue breaths should be eliminated in witnessed arrest unless circumstances strongly indicate a primary respiratory etiology.

Resuscitation medications should remain in the algorithms but, in view of mounting studies which question the impact of drugs for cardiac arrest, the wording and class of recommendations may need to change.

The guidelines should incorporate the three phases of resuscitation---electrical, hemodynamic and metabolic---as a conceptual framework for discussion of assessment and intervention.

The guidelines will need to incorporate new evidence concerning post resuscitation care, particularly therapeutic hypothermia. Code teams will need to anticipate and prepare for post resuscitation care. In the new era of applied hypothermia neurologic assessment immediately following return of spontaneous circulation should be considered unreliable in planning subsequent care of comatose patients.

Background: the Resuscitation Outcomes Consortium, an updated repository of research in out of hospital cardiac arrest.