r/emergencymedicine • u/Fit-Survey-6678 EMT and ER tech • 2d ago
Discussion 2025 AHA ACLS guidelines? The fuck?
Fuck you mean IV calcium effectiveness has not been well established for hyperkalemia? No fucking way?
I'm going through my ACLS course rn since my EM job requires it, but I know I'll be in for a huge shock if and when I actually start practicing as a physician.
Me reading the slide: https://youtu.be/61_f_zTBC8w?si=29eLFimwo59m1QJH
(not a rickroll, I swear on the uncrustables in the EMS room)
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u/CaelidHashRosin Pharmacist 2d ago
You’re in for a treat as you progress through the evidence. Pretty much nothing has good evidence except high quality CPR in cardiac arrest, despite what we do.
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u/Moshtarak 2d ago
The guidelines don’t say not to give calcium for suspected hyperkalemia. They just say don’t routinely give Ca. People throw everything at most arrest patients - calcium, bicarb, fluids, D50. Waste of time and resources.
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u/PerrinAyybara 911 Paramedic - CQI Narc 2d ago
The bicarb is what sends me to the moon
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u/Moshtarak 2d ago
What’s crazy to me is it’s been recommended against for yearssssssssss on a routine basis but everyone seems to still love it.
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u/PerrinAyybara 911 Paramedic - CQI Narc 2d ago edited 2d ago
I have suffered moral injury when I call for termination and the doc wants me to bush bicarb and transport.
I CQI calls and often have to ask why they used bicarb in witnessed arrests that have a capno of 25-30 due to great compressions why they are giving it.
I've done entire classes on why bicarb actually harms our patients.
People love watching the capno numbers spike and keep doing it.
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u/Moshtarak 2d ago
Well nothing you can do if some dodo on the other line won’t allow you to terminate efforts. It’s def a med that has not shown any benefit (outside of your possible toxic poisoning) and possible neurological harm if ROSC is obtained. For me, if no proven benefit and possible harm, I won’t give it.
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u/but-I-play-one-on-TV ED Attending 2d ago
As long as high quality compressions are being performed, I just kinda shrug and let the medics give what they think is appropriate when I take medical control calls. Beyond compressions and appropriate defibrillation it's all voodoo anyway.
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u/Ben__Diesel Paramedic 1d ago
Ive been meaning to look up the pathophysiology that bicarb effects (not just decreasing acidity) and why exactly hypertonic bicarb is considered harmful as opposed to isotonic bicarb which is beneficial in HyperK. But since youve brought it up... would you care to elaborate on your thoughts?
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u/PerrinAyybara 911 Paramedic - CQI Narc 1d ago
Sure thing. Some of my favorite educators in the world have already done some great work on this so I'm going to get you some links.
Start here if you need an acid/base refresher:
https://www.foamfrat.com/post/2018/09/17/quantitative-acid-base-practical-application-case-study
Then go to these:
https://www.foamfrat.com/post/2018/08/28/the-capped-bicarbonate-volcanohttps://foamfrat.libsyn.com/podcast-74-bicarb-or-bye-carb
For nerding out in chronological order with a variety of learning and teaching styles included. EM, and pharm style.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4780490/
https://www.nuemblog.com/blog/bicarb-arrest
Then for a cherry on top, some discussion of various specialties and why they keep doing it or not.
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u/Dangerous_Strength77 Paramedic 2d ago
I've actually been yelled at by an ED Physician, in an ED, for not giving bicarbonate to a patient with similar presentation.
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u/Fit-Survey-6678 EMT and ER tech 2d ago
I'm more surprised that it's purported to not be as effective lol
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u/Moshtarak 2d ago
Yea that’s fair. Though they’re just saying there isn’t any good studies show definitive benefit in the arrested patient. We all know D50 helps hypoglycemia but there is a reason hypoglycemia keeps getting removed and readded as a cause of arrest. Cardiac arrest stinks - in the end I’m convinced other than a few doses of epi and good CPR, nothing i’ll do matters lol
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u/extracorporeal_ Resident 2d ago
The calcium trial was actually stopped earlier due to concerns for harm across all end points from it. Was ultimately statistically non significant and there are some other issues with the design, but the trend was sus
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u/Ben__Diesel Paramedic 1d ago
A theory provided in some of the literature Ive recently read is that rates of positive outcomes may be negatively effected by providers who frequently use Ca as last ditch efforts in a "throw everything at the wall to see what sticks" method.
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u/Playful_Technician32 2d ago
This recommendation is coming from the COCA trial:
https://pmc.ncbi.nlm.nih.gov/articles/PMC8634154/
Danish study, randomized calcium to placebo, worse ROSC incidence with calcium group (27% versus 19%, p of 0.09), study was actually stopped early due to concern of harm in calcium group.
So give calcium if you suspect hyperkalemia as etiology of arrest or a calcium channel blocker overdose. Otherwise don’t give routinely. That’s how I practice now.
And for those of you who do not know the evidence behind double sequential defib, look up DOSE-VF study, lead author Cheskes. We routinely perform DSED where I work, including pre hospital environment.
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u/Dr_HypocaffeinemicMD 2d ago
Don’t forget to slam epi into the veins of your refractory VF arrest though
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u/Resussy-Bussy 2d ago
Surprised they also don’t recommend dual sequential defib and say there’s no evidence essentially?
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u/Quiet_Ganache_2298 2d ago
It will also void your warranty. That may go into their decision making
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u/Drew_Manatee ED Resident 2d ago
For the defibrillators? If ACLS recommended dual sequential, manufacturers would start making defibrillators with plugins for 2 sets of pads overnight.
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u/theskirata 2d ago
It’s not meant to be the same device with two pads to my knowledge? The whole idea is to have it be slightly delayed apart, separate shocks from different devices.
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u/Drew_Manatee ED Resident 2d ago
Because there isn’t a machine that’s made that can do both shocks. Yet.
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u/Available-Bedroom312 2d ago
Get going Lifepak, I wanna be able to defib at 720J
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u/Fit-Survey-6678 EMT and ER tech 2d ago edited 2d ago
you see this has utility in trauma settings, you'll set the patient on fire and fire cauterizes bleeds /j
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u/YoungSerious ED Attending 2d ago
In theory, it shouldn't be very difficult to have a setting that delivered two shocks in short sequence (the way sequential is supposed to be delivered).
If they can program the machine to recognize and time shocks with sync to wave morphology, they can definitely time it to deliver 2 in sequence to 2 separate pads. That's light work for an engineer.
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u/PerrinAyybara 911 Paramedic - CQI Narc 2d ago
So it would require a second giant capacitor which is an entirely different hardware setup. It's not a software issue.
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u/YoungSerious ED Attending 2d ago
You are sort of missing the point. The point is that making a machine that can do it is not that hard. The person I was replying to was saying you needed a second machine, and the point all along was fundamentally you don't, you just have to put together a machine that will do it. It isn't complicated tech.
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u/PerrinAyybara 911 Paramedic - CQI Narc 2d ago
You DO need a second machine right now. As someone who is very familiar with how these machines are built and has spent a ton of time with servicing them it's far more complicated than you are thinking. There are strict requirements they have to follow for size and weight to get contracts with DOD stuff and helo ops. They are literally given a box and told everything has to fit inside of it.
The capacitor for the defib is one of the largest internal parts and duplicating it causes space and other problems, it has a significant inrush current as well that doubling it will also cause a significant board change. Board changes are capped at a percentage before they have to go through the entire FDA approval again which is something they avoid doing.
Even if the AHA agreed with DSED it's still a significant lift to make it happen. One that is such a rare use case doesn't make great sense, vector change also has a similar efficacy and would be far easier for them to recommend. The cost for doing so simply isn't worth it.
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u/ellihunden 2d ago
That’s way the word sequential is there. Cambridge had a OOH arrest where they ended up doing a triple sequence defibrillation
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u/insertkarma2theleft Paramedic 2d ago
Cambridge who, England?
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u/ellihunden 2d ago
Yes Cambridge university. 24 y/o had CPR preform immediatly in an OOH arrest. total down time 82min before ROSC. Look it up interesting read
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u/theskirata 2d ago
Depends on the manufacturer. Corpuls have stated it’s fine with their machines, not sure about others. It’s what we use here, hence I know for them.
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u/PerrinAyybara 911 Paramedic - CQI Narc 2d ago
Only if it's a v4+ and a v4+. They have weaker capacitors but ultimately it won't do anything to them as long as its sequential. We've been doing it over 15 years with every version of the lp15.
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u/LunarSoul ED Attending (not that ED) 2d ago
What evidence there is, is really poor and driven by bias. No one's gonna write up a case where DSED failed etc. They really want to minimize any stopping compressions. I don't really bother with DSD either. I'd rather do a stellate ganglion block in those cases.
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u/r4b1d0tt3r 2d ago
I would not say a positive rct is poor in the cardiac arrest space. Stuff with shittier evidence gets in there glances side eye at epi.
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u/eIpoIIoguapo 2d ago
Not sure why you’re being downvoted; it’s a lot easier to do a stellate ganglion block while compressions are ongoing than it is to apply a second set of pads. And a lot of smaller shops either only have one defibrillator or are prohibited by policy from doing DSD because it voids the warranty (this is the case at my community site).
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u/PerrinAyybara 911 Paramedic - CQI Narc 2d ago
It doesn't violate the warranty, they will only refuse to replace the single board that would get damaged IF you do it at the same time instead of you know sequentially. It's a less than $5k fix and there's only been a single documented instance of that occurring on a LP15.
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u/LunarSoul ED Attending (not that ED) 2d ago
Because people like to hear their own opinions supported and can't handle opinions to the contrary unfortunately.
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u/PerrinAyybara 911 Paramedic - CQI Narc 2d ago
The AHA is not the defining guidelines for someone versed in resus. It's the algorithm for podiatrist and others that don't run them constantly. It also has a love affair with epi and hates POCUS.
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u/Aspirin_Dispenser 2d ago
I’ve always described ACLS as being a decent framework for how to approach an entirely undifferentiated cardiac arrest. If you have no idea as to why the patient is dead, it’s a good place to start. But the moment you know why a patient is in arrest, most of it should be thrown out of the window in lieu of a more tailored approach.
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u/adoradear 2d ago
I know. It weirds me out too. The # of patients I’ve had in periarrest with almost sinusoidal EKGs who normalize the second I slam the calcium…..I’ll be continuing to give calcium if there’s a chance it could be due to hyperK (esp if in PEA) unless/until they show harm.
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u/theoneandonlycage 2d ago
Make sure you cardiovert if your VT patient has a pulse but defibrilate if they don’t have a pulse.
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u/SpudTryingToMakeIt ED Attending 2d ago
EMRAP did a great piece on this. blew my mind the research doesn't back up what I feel like I have seen
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u/thruthelurkingglass ED Attending 2d ago
They’re not wrong, it’s not really been established as beneficial in rigorous studies of cardiac arrest patients. That said, if someone is known to be be hyperkalemic and then has cardiac arrest, I think most of us are gonna at least try it…but yeah if you’re that far gone it’s probably not gonna help more than just your typical ACLS algorithm.