Advanced cardiac life support update: the new ILCOR cardiovascular resuscitation guidelines. International Liaison Committee on Resuscitation

Pharmacotherapy considerations in advanced cardiac life support

Cardiac arrest and sudden cardiac death remain major causes of mortality. Early intervention has been facilitated by emergency medical response systems and the development of training programs in basic life support and advanced cardiac life support (ACLS). Despite the implementation of these programs, the likelihood of a meaningful outcome in many life-threatening situations remains poor. Pharmacotherapy plays a role in the management of patients with cardiac arrest, with new guidelines for ACLS available in 2005 providing recommendations for the role of specific drug therapies. Epinephrine continues as a recommended means to facilitate defibrillation in patients with pulseless ventricular tachycardia or ventricular fibrillation; vasopressin is an alternative. Amiodarone is the primary antiarrhythmic drug that has been shown to be effective for facilitation of defibrillation in patients with pulseless ventricular tachycardia or fibrillation and is also used for the management of atrial fibrillation and hemodynamically stable ventricular tachycardia. Epinephrine and atropine are the primary agents used for the management of asystole and pulseless electrical activity. Treatment of electrolyte abnormalities, severe hypotension, pulmonary embolism, acute ischemic stroke, and toxicologic emergencies are important components of ACLS management. Selection of the appropriate drug, dose, and timing and route of administration are among the many challenges faced in this setting. Pharmacists who are properly educated and trained regarding the use of pharmacotherapy for patients requiring ACLS can help maximize the likelihood of positive patient outcomes.

[Therapeutic hypothermia]

The benefit of therapeutic hypothermia after severe head injury is highly controversial. However, hypothermia is still used and studied in this context for multiple reasons. Efficacy of hypothermia is demonstrated after cerebral ischemia in numerous animal studies and after cardiac arrest in human studies. Hyperthermia is a major independent factor of outcome after cerebral ischemic or traumatic brain injury. Moreover, ICP is related to core temperature, and hypothermia may be used to decrease intracranial hypertension. However, many questions are still unresolved and can explain discrepancies between clinical studies: direct measurement of cerebral temperature, relationship between ICP, temperature and PaCO(2), level and duration of hypothermia and precise methods for cooling and particularly for rewarming.

Stepwise airway management in the trauma patient

The importance of establishing and maintaining a patent airway is a well-recognized principle in the resuscitation of all trauma victims. Many currently available guidelines for airway management in trauma patients have been aimed largely at anaesthetists or those with anaesthetic training. Typically they concen trate on either those patients who require intubation, with techniques to use when this fails, or those in whom little intervention beyond facemask oxygen is required. In reality, clinicians with varying degrees of skill will be faced with managing the trauma patient’s airway and many will not be able to safely attempt tracheal intubation. A pragmatic approach to airway assessment and management is presented that recognizes the variation in skills between clinicians. We also suggest that the role of supraglottic airway devices should now be recognized by all clinicians involved with airway management, particularly those not skilled in tracheal intubation and they should become an integral part of airway management.