why was atropine removed from acls?

[Paramagic]

No epi, atropine or amiodarone looks like acls is becoming less "a" and more just "cls"

Just means we need to make sure that as stuff is removed we push to get what's added in its place, or even a larger/full level of acls meds

No, what we need to push for is a more evidence based approach to pre-hospital medicine, not getting more stuff to put in our bags to prop up our fragile egos.

Which, funnily enough, is what the removal of atropine represents.

[runswithneedles]

No epi, atropine or amiodarone looks like acls is becoming less "a" and more cls

They are always removing drugs, but will their be a time where they might be adding more?

No epi, atropine or amiodarone looks like acls is becoming less "a" and more cls

They are always removing drugs, but will their be a time where they might be adding more?

[paramedicmike]

I imagine they'll add drugs if and when the science shows that there will be a benefit in patient outcome for having done so.

Anecdotal evidence doesn't get anyone anywhere anymore. If there's no science to support it one doesn't have much of a leg on which to stand.

[croaker260]

Saddly, no one is actually looking at the "evidence" before responding.

For the record, the AHA ACLS textbook is pretty much the "ACLS graphic novel" for the masses. If you want to begin to get into serious ACLS/paramedicine, you START (but not end) here:

http://circ.ahajourn.../18_suppl_3.toc

The answer to your specific question on Atropine is here:

http://circ.ahajourn...ppl_3/S729.full

The specific text is HERE:

"Drug Therapy for PEA/Asystole

A vasopressor can be given as soon as feasible with the primary goal of increasing myocardial and cerebral blood flow during CPR and achieving ROSC (see “Vasopressors” below for dosing) (Class IIb, LOE A). Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb, LOE ) . For this reason atropine has been removed from the cardiac arrest algorithm."

Also please not the definition of CLass II recommendations:

The exact description of CLASS II A/B evidence is :

" For Class IIa recommendations, the weight of available evidence supports the action or therapy, and the therapy is considered reasonable and generally useful.

Recommendations were generally labeled Class IIb when the evidence documented only short-term benefits from the therapy or weakly positive or mixed results. Class IIb recommendations are identified by terms such as “can be considered” or “may be useful” or “usefulness/effectiveness is unknown or unclear or not well established.”

NOTE: It did not say it was BAD, just that it was removed because it was a class IIb, not IIa recomendation, and that ROUTINE use is not recommended.

Your exact defiinitin of "routine use" may vary. Here is mine (feel free to disagree):

Atropine may still be considered in specific situations. If I have a patient with a PEA that is a SLOW PEA (i.e. a bradycardic PEA) refractory to other interventions (i.e. H/T evaluation and vasopresors, and good CPR) then that is not routine use, It is patient specific use.

BTW, I also discussed this with our local cardiologists as well with good results.

So, you may or may not agree with me (and that is fine) , but put a little thought into the disagreement. Review the literature.

Regardless, Let me clearly state this for all to hear, because it is a HUGE soap box for me.

Any discussion of ANY AHA ACLS/PALS recommendation, one should review the science documents first. It will often answer any questions you may have and help you undrstand them better.

Thank you for your time.

Croaker

Edited February 14, 2012 by croaker260

[chbare]

Right, atropine has been removed from the algorithm. Never said it was harmful. I would expect people to use good clinical judgement and use it in certain situations where it may be helpful. Nerve agent exposure and PEA/asystole arrest during a colonoscopy for example. With that, I see no need to use it "routinely."

[systemet]

Right, atropine has been removed from the algorithm. Never said it was harmful. I would expect people to use good clinical judgement and use it in certain situations where it may be helpful. Nerve agent exposure and PEA/asystole arrest during a colonoscopy for example. With that, I see no need to use it "routinely."

Might be a reasonable idea in a hanging, or someone found on the floor by the toilet, as well. Can't see it making a huge difference, but I think it would be justified.

They are always removing drugs, but will their be a time where they might be adding more?

Not important. Too many people in EMS view what we do as a scope of practice or a drug list. That's not what's important. What's important is doing the best for the patient.

Looking at my old service over the last five years:

Drugs removed:

thiamine, droperidol, lidocaine, diazepam, meperidine, lidospray

Drugs added:

amiodarone, succinylcholine, IV nitroglycerin, metoprolol, prednisone, dexamethasone, ketamine, haloperidol, tetracaine, metoclopramide, rocuronium, ondansetron, ketorolac, nitropatch.

Looks like it was a net gain for them.

[Kiwiology]

In the last decade we've removed 50% dextrose, stesolid, lidocaine, metaclopramide, promethazine and frusemide (I suspect also nubain and/or foratol may have been lurking in one or two places i.e. ex DHB (hospital based) services)

In the last decade we've added 10% glucose, paracetamol, methoxyflurane*, ipatropium, ondansetron, fentanyl, ketamine, ceftriaxone, amiodarone, adenosine, suxamethonium, vecuronium and loratadine as completely new medicines

Also since 2002 GTN, glucagon, ipatropium, ondansetron, methoxyflurane* and loratadine have become Technician (EMT) medicines, Paramedics have gotten adrenaline, morphine, fentanyl, midazolam, ceftriaxone, amiodarone and 10% glucose; Intensive Care Paramedics have been upskilled with all other medicines not already listed at Technician or Paramedic level plus ketamine, adenosine and paralytics.

I strongly suspect the removal of adrenaline from cardiac arrest guidelines here come 2015 should there be no additional evidence of benefit between now and then

* methoxyflurane is carried by staff working in limited space (Motorcycle Response Unit and Rapid Response Unit) where entonox is not practical or in very rural areas where resupply of entonox is problematic

[runswithneedles]

Do pardon my double post. Would admin mind removing one of them.

So just to clarify. Although atropine has been removed from ACLS with the exception of some bradycardiac rhythms. Its been left in as a beneficial drug so long as the medic uses good clinical judgement.

[systemet]

So just to clarify. Although atropine has been removed from ACLS with the exception of some bradycardiac rhythms. Its been left in as a beneficial drug so long as the medic uses good clinical judgement.

It's been removed from the PEA / asystole algorithm.

It's still in the bradycardia algorithm. This is probably more based on past usage and expert opinion than any high quality epidemological research, but seems reasonable. It's still used as an adjunctive medication in intubating peds (somewhat controversial), and with ketamine (also somewhat controversial). It's also indicated as a treatment for OP / nerve agent poisoning.

The "beneficial, so long as the medic uses good clinical judgment" could probably apply to a lot of things. Most things are not beneficial if the medic is using poor clinical judgment.

[croaker260]

Do pardon my double post. Would admin mind removing one of them.

So just to clarify. Although atropine has been removed from ACLS with the exception of some bradycardiac rhythms. Its been left in as a beneficial drug so long as the medic uses good clinical judgement.

To be clear, it has not been removed from ACLS but simply from one of the protocols. There are a lot of drugs in that are not in that protocol that in the science documents are still permissible. Again...graphic novel version of ACLS vs. the unabridged Book version of ACLS.

Well, let your freedom of practice and your paycheck be your guide. Here where I work I my docs will listen to me when I point out this stuff and usually we agree. If you work somewhere else where the ..ahem ...lines of communication are more one sided.....well your results may vary.

But yes, in theory you are correct. But before I made my stand on this or any ground I would READ the documents and the supporting research, and be intimately familiar with the clinical science....not just simply regurgitate what some crazy old beat up crack-pot medic said on an internet forum.

Edited February 16, 2012 by croaker260