POTD: 2023 AHA ACLS Updates

I’m surprised this hasn't been done sooner, but I'm going to use this POTD to quickly delve into some of  the important changes in the new 2023 AHA ACLS guidelines. Some of these are pretty surprising, some of them - not so much. But remember that these updates are crucial for ensuring our patients best outcome.

Calcium: Not the Hero We Thought

Recent Insights: Class 3 Recommendation (No Benefit)

These new guidelines mark a pivotal shift in our understanding of calcium's role in cardiac arrest management. While it remains critical in cases of hyperkalemia and calcium channel blocker overdose, recent studies have shown that its routine use in other scenarios may be associated with potential harm. This revelation underscores the importance of context-specific interventions in cardiac emergencies.

Magnesium: The Unfilled Promise

Evidence from Randomized Controlled Trials: Class 3 Recommendation (No Benefit) 

Magnesium, once hypothesized to enhance outcomes in cardiac arrest, has been scrutinized in recent randomized controlled trials. Contrary to previous assumptions, these studies reveal no significant improvement in Return of Spontaneous Circulation (ROSC), survival rates, or neurological outcomes, irrespective of the initial rhythm. This finding challenges existing protocols and emphasizes the need for evidence-based practices.

ECPR: A Selective Savior

Updated Guidelines: Class 2a Recommendation (Moderate)

The guidelines now advocate for the judicious use of Extracorporeal CPR (ECPR) in specific scenarios of ACLS refractory cardiac arrests. This recommendation is based on the premise that ECPR, when utilized within a well-equipped and trained healthcare system, can offer a lifeline in otherwise dire circumstances. It highlights evolving resuscitation science and the importance of tailored emergency response.

Coronary Angiography: Choose Wisely

Strategic Approaches Recommended: Class 3 Recommendation (No Benefit) 

A significant update pertains to the use of emergent coronary angiography. The guidelines now recommend a more cautious approach, favoring a delayed or selective strategy in patients without ST-segment elevation, absent indications like shock or significant myocardial damage. This nuanced stance reflects a growing appreciation for patient-specific strategies in post-cardiac arrest care.

Temperature Management: Chill Out Bro, But Not Too Much

New Standard of Care: Class 1 Recommendation (Strong) 

Post-ROSC temperature control has been underscored as a vital aspect of patient management. The guidelines recommend maintaining a constant temperature between 32-37.5°C for all adults unable to follow commands post-ROSC. This approach, supported by robust evidence, marks a significant step forward in neuroprotective strategies following cardiac arrest.

TL;DR:

• Calcium use is now limited to hyperkalemia and calcium channel blocker overdose.

• Magnesium doesn't improve outcomes in cardiac arrest, regardless of rhythm.

• Extracorporeal CPR (ECPR) is recommended in select, refractory cardiac arrests within equipped systems.

• Emergent coronary angiography post-cardiac arrest is advised only with specific indications.

• Strict temperature control (32-37.5°C) post-ROSC is emphasized for all adults unable to follow commands.

References for In-Depth Exploration

1. American Heart Association. 2023 ACLS Guidelines

2. Hsu CH, Couper K, Nix T, Drennan I, Reynolds J, Kleinman M, Berg KM; Advanced Life Support and Paediatric Life Support Task Forces at the International Liaison Committee on Resuscitation (ILCOR). Calcium during cardiac arrest: A systematic review. Resusc Plus. 2023 Mar 27;14:100379. doi: 10.1016/j.resplu.2023.100379. PMID: 37025978; PMCID: PMC10070937.

3. Reis AG, Ferreira de Paiva E, Schvartsman C, Zaritsky AL. Magnesium in cardiopulmonary resuscitation: critical review. Resuscitation. 2008 Apr;77(1):21-5. doi: 10.1016/j.resuscitation.2007.10.001. Epub 2007 Nov 26. PMID: 18037222.

4. Wongtanasarasin W, Krintratun S, Techasatian W, Nishijima DK. How effective is extracorporeal life support for patients with out-of-hospital cardiac arrest initiated at the emergency department? A systematic review and meta-analysis. PLoS One. 2023 Nov 7;18(11):e0289054. doi: 10.1371/journal.pone.0289054. PMID: 37934739; PMCID: PMC10629644.

POTD: Subcutaneous insulin in DKA management

Happy to start off this month of Admin Resident with a requested POTD, the SQuID trial (Subcutaneous Insulin in Diabetic Ketoacidosis).

Diabetic Ketoacidosis (DKA) management traditionally involves intensive treatments like fluid resuscitation, electrolyte replacement, and intravenous insulin infusions. This approach often necessitates ICU admissions, especially for mild to moderate DKA cases, due to hospital policies. However, the strain on ICU resources and the extended ED stays prompt the need for alternative treatments. A promising solution emerges with the use of Subcutaneous (SQ) insulin in mild to moderate DKA, potentially reducing ICU admissions and ED overcrowding.

Clinical Question:

Does the SQ insulin protocol reduce ED length of stay in adult patients with mild to moderate DKA compared to traditional IV infusion?

Methodology:

    • Approach: Implementation of the SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) protocol in an urban academic ED.

    • Study Design: Prospectively derived, quasi-experimental (pre-post) study, with retrospective data analysis.

    • Participants: Adult ED patients with mild to moderate DKA.

    • Exclusions: Severe DKA (HCO3 <10mmol/L, Arterial pH < 7.0), pregnancy, serious infections, and other critical conditions.

Outcomes Measured:

    • Fidelity: Frequency of required glucose checks every 2 hours.

    • Safety: Proportion of patients needing rescue dextrose for hypoglycemia.

    • Operational Impact: ED Length of Stay (LOS) and ICU Admission Rate.

Results:

    • ED LOS Reduction: The SQuID protocol showed a reduction in ED LOS compared to the traditional method.

    • ICU Admissions: Slight decrease, though not statistically significant.

    • Safety: Comparable between SQuID and traditional protocols.

Utility in the Emergency Department

The SQuID protocol's primary advantage in the ED is its potential to significantly reduce patient LOS. This efficiency can alleviate the overcrowding issues, allowing the ED to manage other emergent conditions more effectively. However, successful implementation requires careful planning and education, as it alters the conventional treatment approach for DKA.

Pitfalls to Consider

While promising, the SQuID protocol has several pitfalls:

    1. Increased Monitoring Requirement: The protocol demands more frequent glucose monitoring, which could strain ED resources.

    2. Misclassification Risk: Incorrect assessment of DKA severity could lead to inappropriate protocol application.

    3. Education and Training Needs: Extensive education for ED staff, hospitalists, and nurses is necessary for effective and safe implementation.

    4. Safety Concerns: The increased incidence of hypoglycemia events, compared to historical controls, necessitates vigilant monitoring.

Strengths and Limitations:

    • Strengths: Addresses a critical clinical question with a clearly defined protocol.

    • Limitations: Includes potential for increased glucose monitoring frequency, subjective decision-making affecting LOS and ICU admissions, and limited generalizability due to the single-center setup.

Discussion: Implications and Considerations

The SQuID protocol demonstrates a potential shift in DKA management. It not only reduced ED LOS but also showed equivalent safety compared to the traditional insulin infusion pathway. However, several challenges like the need for extensive hospital-wide education, potential misclassification of DKA severity, and concerns about hypoglycemia management necessitate cautious implementation.

Clinical Take Home Point

The SQuID protocol offers a promising alternative for managing mild to moderate DKA, potentially reducing ED LOS and ICU admissions. However, considerations regarding hospital-wide education, monitoring frequency, and safety concerns mean that it's not yet ready for widespread adoption.

References

    • Griffey RT et al. "The SQuID Protocol (Subcutaneous Insulin in Diabetic Ketoacidosis): Impacts on ED Operational Metrics." Acad Emerg Med 2023. PMID: 36775281

POTD: Medical Trivia Potpourri

Why is baby aspirin 81mg instead of 80mg?

This is a remnant of the medieval apothecary system. In the late 1700s, medication dosages in the apothecary system were based on the weight of a grain of barleycorn, with the unit of weight termed the grain (abbreviated gr)1. The standard dose of aspirin used back then was 5 gr, equivalent to 325mg. This is also why Tylenol tablets also comes in multiples of 325mg. Baby aspirin was one quarter of that, which is equivalent to 81mg.

Where does the term “mad as a hatter” come from?

Poisoning. This comes from mercury poisoning. In the 18th and 19th centuries, mercury nitrate was used in the process of turning animal fur into felt products. Many hatters developed tremors and neuropsychiatric symptoms during this period2.

How glucagon received its name.

Kimball and Murlin found that a substance secreted from the pancreas causes hyperglycemia when injected into rabbits and dogs. They decided to name this substance glucagon, short for “glucose agonist3.”

What animal venom contributed to research in GLPs?

Gila monster. In the 1990s, Dr. Eng was researching in how Gila monsters were able to maintain blood sugar despite long periods of not eating, and discovered a peptide called exendin-4 in its venom, this is structurally and functionally similar to GLP14.

Adrenaline vs epinephrine? Acetaminophen vs APAP?

It’s because the English language is derived from so many different roots. Adrenaline derives from Latin, “ad + renal”, or “on kidney”. Epinephrine derives from Greek, “epi + nephros”, which again translates to “on kidney.” The names from Tylenol comes from different abbreviations of its chemical structure.

• Acetaminophen = N-acetyl aminophenol.

• Paracetamol = N-acetyl-para-acetyl-amino-phenol.

• APAP = N-Acetyl-Para-Acetyl-Amino-Phenol.

You think you’ve got a lot of (laryngeal) nerve?

The recurrent laryngeal nerve branches from the vagus nerve (CN X) to innervate much of the larynx and control speech. Due to embryological development, the left and right laryngeal nerves wrap around the aortic arch and right subclavian vessels, respectively. As we develop, the heart grows further away from our throat, causing stretching of the “recurrent” nerve. This leads the nerve to make a 10cm U-turn in humans. In Giraffes, the recurrent laryngeal nerve approaches 5 meters. In dinosaurs, this is hypothesized to reach 28 meters5.

Was “War-farin” discovered during research as part of some war effort?

Close, but not quite. Actually, it's not really close either. Warfarin was discovered because of cows randomly bleeding to death. Cattle farmers invited researchers from the University of Wisconsin to figure out why. These researchers discovered that the cattle were eating moldy sweet clover hay, which was found to contain a substance called “coumarin” that anticoagulated the cows and caused them to hemorrhage. The patent rights for this discovery were given to the Wisconsin Alumni Research Foundation (WARF) which is where “WARFarin” originates from, as well as the generic name “Coumadin” from the substance coumarin6,7.

References

1.           Zupko RE. Medieval Apothecary Weights and Measures: The Principal Units of England and France. Pharm Hist. 1990;32(2):57-62.

2.           Where did the phrase “mad as a hatter” come from? HISTORY. Published May 8, 2023. Accessed January 1, 2024. https://www.history.com/news/where-did-the-phrase-mad-as-a-hatter-come-from

3.           Müller TD, Finan B, Bloom SR, et al. Glucagon-like peptide 1 (GLP-1). Mol Metab. 2019;30:72-130. doi:10.1016/j.molmet.2019.09.010

4.           Exendin-4: From lizard to laboratory...and beyond. National Institute on Aging. Published July 11, 2012. Accessed January 1, 2024. https://www.nia.nih.gov/news/exendin-4-lizard-laboratory-and-beyond

5.           The “Unintelligent Design” of the Recurrent Laryngeal Nerve. Office for Science and Society. Accessed January 1, 2024. https://www.mcgill.ca/oss/article/student-contributors-did-you-know-general-science/unintelligent-design-recurrent-laryngeal-nerve

6.           Warfarin Discovery | Wisconsin Alumni Association. Accessed January 1, 2024. https://www.uwalumni.com/news/warfarin/

7.           Ankit’s brain. Pharmacy Selective Rotation.