Management of cardiac arrest

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Editor, – I refer to the article 'Current concepts in the management of cardiac arrest' by John L. Holmes (Aust Prescr 1997;20:41-5).

Dr Holmes appears to have taken official recommendations for cardiopulmonary resuscitation and mixed them with personal preferences.

The algorithm given for advanced cardiac life support (ACLS) does not concur with the Australian Resuscitation Council ACLS guidelines or the American Heart Association ACLS guidelines. Deviation occurs on a number of points, but of particular concern is the recommended list of drugs for ventricular fibrillation.

Fig. 1 (the resuscitation algorithm) should be kept simple. Blind defibrillation is usually reserved for cases where monitoring is difficult. Fig. 1 implies 3 x defibrillation then another 3 x defibrillation in the case of ventricular fibrillation.

The Australian Resuscitation Council has produced an ACLS flowchart which has removed many of the drugs referred to in Fig. 1. What level of evidence supports their retention here? Sotalol, procainamide and potassium cannot be routinely recommended and are potentially detrimental; bicarbonate should be given earlier than 20 minutes when hyperkalaemia is suspected.

Basic life support, defibrillation and intubation/hyperventilation are the only 3 manoeuvres supported as effective steps in the ALS algorithm. Adrenaline is still the main drug of ACLS (in addition to oxygen!).

Theresa Jacques
Intensive Care Unit
St George Hospital
Kogarah, N.S.W.

Dr J.L. Holmes, the author of the article, comments:
Far from being my personal preferences, this article reflects the views of several experts who regularly treat cardiac arrest, as well as drawing on current resuscitation literature.

As in any medical emergency, the management of cardiac arrest requires judgement and expertise, and doctors should not be restricted to inflexible algorithms. The flowchart in my article proposes a simple, logical approach to cardiac arrest, emphasising the important core management (namely, ongoing CPR, intubation, hyperventilation, fluid loading and adrenaline) and outlining additional interventions which may be considered for asystole, ventricular fibrillation (VF) and electromechanical dissociation.

I agree with Dr Jacques that bicarbonate may be used early in resuscitation if there is pre-existing hyperkalaemia. It is important, however, to interpret the flowchart in the context of the article which already addresses most of the other issues she raises.

The drugs listed for the management of VF are not 'routinely recommended'. The article clearly states that drug therapy in VF is of secondary importance to electrical defibrillation. Lignocaine is often used routinely, but the other drugs listed should only be considered in refractory VF which has not responded to repeated DC shocks. In such circumstances, most experienced practitioners will try any additional intervention which may help. It is specious to suggest that drugs such as sotalol should not be tried because they are 'potentially detrimental' when the patient is virtually already dead!

Even though positive outcomes arising from the use of such interventions must remain anecdotal, positive outcomes are at least occasionally reported.