Dr. Meredith Trubitt

Hey, before we get to the show, I wanted to remind you to check

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Dr. Meredith Trubitt

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Dr. Meredith Trubitt

so we're here in Nashville.

Dr. Mon Ami

We are.

Dr. Meredith Trubitt

Which is apparently a very music inclined city.

Dr. Mon Ami

Apparently.

Dr. Meredith Trubitt

Yeah. And we're actually going to be talking about something sort of not music related, but in some ways philosophically it is.

Dr. Mon Ami

I really have no idea where you're going with this.

Dr. Meredith Trubitt

We're going to be walking the flatline.

Dr. Jessica Nave

Oh gosh. Yeah.

Dr. Mon Ami

Okay.

Podcast Disclaimer Voice

The Curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions for the more that you statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash, like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework and let us know when we're working.

Dr. Mon Ami

And welcome back to the curbsiders. I'm Dr. Mon Ami and joined by my eternally efficiently, effervescently effervescent co host, Dr. Meredith Trubitt. On tonight's show, we discuss some of the updates from the 2025 ACLS guidelines with our wonderful guest, Dr. Jessica Nave. In just a minute, Meredith's going to tell you a little bit more about her and the topic. But before we do that, Meredith, will you please remind the good people in the audience what it is we do on this show.

Dr. Meredith Trubitt

Sure, Mooney. We are the Internal Medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. And today, tonight, this afternoon, what is time exactly? We have a fantastic guest, Dr. Jessica Nave. She's a hospitalist at Emory University Hospital and has served as the Medical Director of the Rapid Response Team, co director of the Resuscitation Simulation Program for the Emory Internal Medicine Residency Program, and also as co chair for both the EUH and EHC Resuscitation Committees. And she is here to teach us a little bit about the updates in the ACLS guidelines. And I'm pretty pumped for this talk because we're not going to really be going into the 700 details of it, really, just going into really what's changed since the last updates.

Dr. Mon Ami

So you're Saying I don't need to have the card in hand as I'm listening. I hope not, but never be too sure.

Dr. Meredith Trubitt

Yeah. All the power to you if that's your jam.

Dr. Mon Ami

Also, you said pumped. Feels like a bit of a pun.

Dr. Meredith Trubitt

Hey, way to go. You caught it.

Dr. Mon Ami

Hell, yeah. All right, and a reminder that this and most episodes will be available for CME credit for all healthcare professionals through VCU Health at curbsiders.vcuhealth.org all right, Jessica, we're so excited to have you on the show. We're gonna do a bit of a lightning round to get you to know you a little better outside the hospital. Start with a real softball. What is it that you would be doing if you were not a physician?

Dr. Jessica Nave

Ooh, I guess it's been long enough now that I can probably talk about this, but I got pretty far and was kind of at the end stages of actually starting a career with the CIA whenever I got my medical school acceptances, and I was like, you know, I should probably live a more normal life, but why? Yeah, I've gone back and forth wondering that since that time, but three little kids and a husband at home, I guess, does that to you. But never say never, you know, still could happen.

Dr. Meredith Trubitt

So you were applying to medical school and applying for a job at Langley. Yep. And those two things were on a similar trajectory for you?

Dr. Jessica Nave

Yep.

Dr. Meredith Trubitt

Tell me more.

Dr. Jessica Nave

I just had this weird childhood fascination with wanting to be a CIA agent and travel the world and do really cool things. But I also really liked medicine and science, and I don't really know what that means about me to connect the two, but it was a crossroads in my life, and I had to make a really hard choice.

Dr. Meredith Trubitt

I have to say. We've had several interviews, and no one has had such a good, fun fact.

Dr. Mon Ami

No, no. And frankly, it's the first time we've asked this question, so maybe that's just like, a current theme, a lesson that we need to ask new questions.

Dr. Meredith Trubitt

Yeah. So we'll go ahead and go to our next question. I think a lot of people kind of get into the resuscitation field, but I'm curious to know, kind of why is this one so meaningful to you?

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Yeah.

Dr. Jessica Nave

Well, it started more as I was voluntold to get into this, and there was a need by the program to run the simulation program for the residency. So I had been kind of a black cloud during residency and ran a lot of codes on my call nights, and I kind of was forced to get pretty good at this stuff. And I think that fear led into me saying, yes, I will help run this program because you never master a subject, I think personally, until you teach it, until you're capable of teaching it really well. So I got involved that way. It has become more personal since then because my older brother at the age of 39, had a cardiac arrest out of hospital. He survived it. And then a month and a half had his fourth cardiac arrest. Survived that as well. He's had two in hospital cardiac arrest, two out of hospital cardiac arrests. And even with this last one, even though he had an internal defibrillator, shocked him five times. It did not work. It actually took an AED and a very responsive policeman who actually brought the AED over and did two external shocks that was able to shock him out of it. So this is very personal to me. I want to make sure that I stay up to date as much as possible, but I also want to make sure that all of my colleagues stay up to D and help teach this. So, you know, in the service of my brother and patients like him, really

Dr. Mon Ami

appreciate you sharing that with us. You didn't have to. And it's just like I think we all get kind of down rabbit holes in medicine sometimes and we don't always know why. And to have such a clear why is like, I imagine it really keeps you motivated and helps you do as good a job at this as you possibly can.

Dr. Meredith Trubitt

Absolutely agree. No notes.

Dr. Mon Ami

We're gonna zag a little here. Meredith, picks of the week. You feeling it?

Dr. Meredith Trubitt

Yeah, I mean, I, as Moni already knows, I'm just in the throes of potty training the two year old. So all of my picks of the week are really the Amazon products to make potty training fun. Can throw some of that in the show notes for anyone who cares.

Dr. Mon Ami

I think our audience is wide ranging and it might actually speak to some people.

Dr. Meredith Trubitt

I just want everyone to know that the people in my life who told me it's a beautiful process, I personally am putting them in a category that do not ask them for advice in the future. And everyone who told me how terrible it is, I just. You're in my corner. I appreciate it.

Dr. Mon Ami

If you know, you know, what about you? Mine for this one. So you won't be listening to this. Well past March. But March Madness is always so much fun. And if you guys are longtime listeners, you may know that Meredith and I have differing allegiances for college sports. But we're both very fortunate because our respective women's basketball teams are actually going to be playing each other tomorrow night. So that's pretty exciting. So Michigan Lady Wolverines will be playing the Lady Horns for a spot in the Final Four. They both made the Elite 8 and that's pretty cool.

Dr. Meredith Trubitt

It is. And we will still be talking to each other.

Dr. Mon Ami

Hmm. Our friendship survived some bad football games, so I, I, I do think we're gonna survive it. But debatable. We do have to record the rest of these episodes and then maybe we can talk about our separation. Okay, before we get too sidetracked, because you and I could both talk about college sports all day. I think we should probably take it to our first case from Cash Lock. So I am going to take us there. Ms. A is a 72 year old female with known diabetes, hypertension and coronary disease with a CABG about seven years ago and COPD who came to me about 48 hours with sepsis from pneumonia. She's still having a cough, but overall getting better. After finishing up rounds, you hear a rapid and just immediately run up the stairs and the rapid team is there. Her vitals are notable for heart rate in the 130s to 140s with a blood pressure of 78 or 50, respirations of 23 and saturating 90% on 2 liters. She's connected to a monitor and noted to be an afib. So this is unstable. It's a narrow complex tachyarrhythmia. And I know I'm supposed to shock her, Jessica, but the nurse looks over and she asked me how many joules? And I'm looking at the algorithm and I'm thinking this looks different, but I can't remember what the changes are. So talk us through a little bit about what the changes are with the joules and like how much power to give.

Dr. Jessica Nave

Yeah, absolutely. So back in the last iterations of the 2020 guidelines, in the tachyarrhythmia algorithm, if you look at the joules for each thing, it's 50 to 100 joules. And when you're doing a synchronized cardioversion, except in the case of AFIB and flut, which they were recommending 120 Joules. The update this year though is that they have actually increased that joule for first dose shock for afib and flutter to 200 joules. Everything else, they've kind of increased it from that range of 50 to 100 to. Now the algorithm clearly states 100 joules. So it's basically increasing the joules for your shocks. For any narrow complex tachycardia, the Rationale behind that is that in the past we thought you kind of want the minimum dosage in order to get, you know, break the rhythm because there's this theoretical risk of myocardial injury and even potentially stunning the myocardium to where even if you did get them out of that rhythm, the myocardium wouldn't want to work very well to have the cardiac output that you want. But what they have found in these most recent studies is actually when they looked at that, when they measured things after the shock, such as your troponin elevations or did an echo to actually see if they were having any myocardial injury, they didn't see any. It was about the same. And additionally, the higher voltage initial shock actually got the patient out of it more often, higher success rate and required fewer overall shocks. So kind of the take home point is go high, shock at a shock at, you know, at a much higher joule than you originally would do with a cardioversion.

Dr. Mon Ami

Great. So go high, go big or go home for sure. And I think, you know, the thing that comes up a lot when you're a hospitalist is whether or not they should go to the unit or not, like the triage question. So I think just based on the initial vitals, I'd be like, oh, this probably goes to the unit. But it seems like there might be more that goes into that decision. And I was curious how you thought through that.

Dr. Jessica Nave

Yeah, so with these ones, it's never a right or wrong answer. I think it really has to do about the culture of your hospital and what you're capable of handling. For example, at my hospital, we don't have a step down unit or an intermediate unit. So it's ICU or not. And we have an incredibly sick patient population. So we really try to retain ICU beds and be very thoughtful about sending patients to the icu. Additionally, I'm very spoiled in that I have an entire rapid response team that are completely dedicated to this function in the hospital that can sit with that patient for two hours, you know, after a rapid response event and monitor their vitals every 15 minutes. So for that reason, I wouldn't send this patient to the icu if they're hemodynamically stable after cardioversion, I would just have them on, you know, essentially checking their vital signs more often and having somebody at bedside checking in or very close and checking in on them a lot. But it really just depends on the resources you have at your hospital and sort of the culture.

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Okay.

Dr. Meredith Trubitt

So I think That's a really good place to kind of stop that case. For now we've done an entire episode two on the narrow complex dachyarrhythmias which anyone who wants more on that can go back and listen to. But we'll go ahead and go to our next case. So as any first day on service in Black Cloudness, you are wrapping up with Miss A when you hear another page overhead about another one of your patients. Mr. B. He's an 82 year old man and he's admitted for possible pneumonia as and also for further cardiac workup for a mildly elevated troponin. And when you get to his room the nurse alerts you that telemetry called the rapid due to a wide complex QRS tachyarhythmia. He's connected to the monitor and you know vt, he's talking to you. He states he feels like a little bit funny but otherwise has not noticed any other new symptoms. His vitals are similar to arrival in the ER only now also with elevated heart rate. So we're going to start with kind of talking about this as stable vt. The guidelines seem to have had a notable change for medications to reach for. Previously I know it was sotalol, procainamide, amiodarone. I really only use amiodarone which we can talk about at a later point. But it seems like in the newer updates sotalol was removed. So I was hoping we could talk a little bit about the how and why of that decision.

Dr. Jessica Nave

Yeah, absolutely. So I think most of us think of sotalol and we think afib or flutter almost as like a second third line EP is usually doing that. We don't really have much to do with it. Don't typically think of it in acute cessation of stable V tach but it was in the guidelines and it was because it does have an indication for that. Additionally, when they've done studies in the past, I think there was one in 2015 that was doing a head to head trial of Soto versus Lidocaine and found that sotalol actually outperforms lidocaine. But we also know from every other trial that lidocaine is not good at doing cessation of a stable V tach. So for that reason when they've looked at the evidence for amio and procainamide those have much better outcomes. And even though they haven't done a clear head to head trial against sotalol, it's just looking at the evidence, it seems that there's more efficacy for those additionally Sotalol has a black box warning for prolongation of QT pretty significantly. So there's a thought that it's maybe even more pro arrhythmic. And so therefore I think they just simplified the algorithm and said let's just stick with amiodarone and procainamide and take sotalol off.

Dr. Meredith Trubitt

That actually seemed to be a theme kind of through the guidelines, which I appreciated as a hospitalist is like if no one's using it, if it's not like good, like let's not have it as an option even. We should not be messing around with having more options than we need.

Dr. Jessica Nave

Right Decision fatigue.

Dr. Meredith Trubitt

Exactly.

Dr. Mon Ami

My first thought when I saw that Sotolada was ever there, I was like, which crash carts had that anyway?

Dr. Meredith Trubitt

I've never even maybe it's because I just never even thought to look.

Dr. Mon Ami

But yeah, it might say more about

Dr. Jessica Nave

it's not on our crash carts.

Dr. Mon Ami

It may say more about me than the guidelines, but.

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Dr. Mon Ami

Foreign.

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Dr. Meredith Trubitt

So now talking about procainamide and amiodarone, if those are the only two options in the crash car that someone is debating in, let's maybe start with amio because I feel like I'll just be honest, that's my first choice. Can we talk about dosing for it in stable VT?

Dr. Jessica Nave

Yeah, absolutely. So the amiodarone dose is 150mg delivered over 10 minutes and you can repeat as needed if your V tach recurs. And then you put them on a maintenance infusion of 1 milligram per minute for the first six hours.

Dr. Meredith Trubitt

And then procainamide, which I don't use a lot, similar kind of long infusion

Dr. Jessica Nave

time it is, it's a longer infusion, it's 20 to 50 mgs per minute until the arrhythmia is suppressed or until the patient gets hypotensive because it is very much known to cause some hypotension and there's a maximum dose of 17 milligrams per kilogram given. Then you also put the patient on a maintenance infusion at 1 to 4 mgs per minute and for both of

Dr. Meredith Trubitt

those, because you're going to be like on the infusion and I think this makes sense to anyone going back to the ICU Triage question. These patients are going to be triaged into the unit because they're going to be continuously monitored, unlike our.

Dr. Jessica Nave

I'm a little more afraid, I think, of ventricular tachycardia than I am with the narrow complex and atrial rhythms in this patient. Especially, like, as you said, because they have an infusion. Plus, it's just a more high risk rhythm. This patient I would not keep on the floor, and I would use one of those highly needed ICU beds.

Dr. Mon Ami

And other than Meredith's comfort with amiodarone, is one recommended more than the other?

Dr. Jessica Nave

No, in the guidelines, they are equivocal.

Dr. Mon Ami

Got it. Okay. I think we can progress Mr. B's case a little bit. So he gets the MEO transferred to the unit like we talked about, and his VT technically improves overnight. And the thought at this point is it was sepsis, it was infection, and he's doing okay on the floor. So the nurse says a little bit after that that, oh, he's actually starting to feel similarly to right before his first episode. And then she comes back to check on him and he's actually unresponsive. And he's connected to a monitor and it shows like, that he's in V fib and a code is cold. So I think before we get into the nitty gritty of the code situation, kind of important to talk a little bit about the statistics of this, because I think as hospitalists, we think everything is terrible or everything is fine. And knowing the numbers is kind of helpful. I like to know objective data. So the first question sort of is, how often does in hospital arrest occur?

Dr. Jessica Nave

Yeah, so that one, this actually was in the preamble of the updated guideline. So all this evidence comes from the various registries that we have around the country. But the number that they published was a little surprising to me. It was one in 100.

Dr. Meredith Trubitt

Yeah, I mean, to me, that number blew my mind too, because it feels like almost probably, what, once, at least a quarter, you. You have taken, like, care of that number of patients, unique patients, that. That can happen to you.

Dr. Jessica Nave

Yeah. I think it's when you add in the ICU population that we don't hear the codes called overhead. Every time that it really changes those numbers. It's just harder to track as a hospitalist on the FL because most of those codes are not called.

Dr. Mon Ami

Yeah. And how often do we get rosc?

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Yeah.

Dr. Jessica Nave

So this has been increasing, thankfully, over the last decade. Not by much, but it is increasing. So at this time, we're about 72% of the time we can get return of spontaneous circulation.

Dr. Mon Ami

That's good.

Dr. Meredith Trubitt

In hospital.

Dr. Mon Ami

In the hospital. Yeah. And, and just for the listeners, we were very particular about making sure this was hospital specific updates to the guidelines. You can look at the guidelines yourself if you have questions about some of the out of hospital statistics. And I guess the other probably a little bit more pertinent for all of us is what's the survival rate to discharge for these folks?

Dr. Jessica Nave

Yeah, so it's great when you get rosc, but can they actually leave the hospital alive? That number does fall pretty precipitously from the 72% down to 24%.

Dr. Meredith Trubitt

So that to me says that there is something in that kind of post Ross time that's going to be important to be looking at for future research.

Dr. Jessica Nave

Absolutely. It's sort of the hot new area of research right now.

Dr. Mon Ami

So I think it's good to kind of focus on some of the more patient centered outcomes. So obviously survival rate's really important, but in addition to that, I'm curious about sort of the favorable neurologic prognosis question. So like what percentage of folks are discharged with that?

Dr. Jessica Nave

Yeah, so this is the gold standard in all of cardiac arrest. We want to make sure that we save patients lives, but more importantly that they have good neurological outcomes. Like what's the point of saving someone's life if they're neurologically devastated? So that number is really interesting because it was published of that 24% that are discharged alive from the hospital, 85% roughly have favorable neurological outcomes.

Dr. Meredith Trubitt

And can we define what is favorable neurologic outcomes?

Dr. Jessica Nave

Yeah, so there's a few, there's a few scoring systems that people use in the research. One of them is a cerebral performance category, a CPC score. A CPC score of 1 or 2, which is independently functioning with their ADL's is actually what they generally consider a favorable neurological outcome.

Dr. Meredith Trubitt

Okay, I'll leave it there.

Dr. Mon Ami

Yeah, just kind of reiterating. I think the reason that we want to talk about these kind of numbers is it's kind of like you're saying, Jessica, ROSC is great, but what are we really looking at in terms of discharge and then are people have a meaningful recovery? Because I think that's the language a lot of us try to have when we're talking with patients. So knowing the chances of what a meaningful recovery would be is probably good for us to have in the back of our minds as we navigate those patients and the conversations that we have with them.

Dr. Meredith Trubitt

So now that I think we have that framing out the rest of our case, we'll imagine that we are in this magical hospital called cash like gold standard.

Dr. Mon Ami

I love that coining of the term. Meredith, good work.

Dr. Meredith Trubitt

Yep. It's just things are perfect there. Everything runs on point. Code team is just. They wrote the algorithm. It looks like when they come in, they arrive quickly. All roles are clearly delineated. The pads are placed, CPR is started. Someone is already on airway. Their closed loop communication is pristine. And Mr. B is still there and he's in refractory VF. And after several rounds of shocks, we are kind of in the same predicament. So someone in the room is like, because we're at cash, like gold standard is like, what about vector change or double sequential defibrillation? And you're in the corner and you're like, I clearly shouldn't be at cash like gold standard because I don't know what these things are. So first let's. I know this was like a hot topic in the guideline updates, but maybe let's start with defining them.

Dr. Jessica Nave

Absolutely. So a vector change is when, typically whenever a patient goes into cardiac arrest. What's in the guidelines right now is anterior lateral placement of the pad. So one on the front right side of the chest and then the other one on the lateral side of the left part of the chest. With vector change, it's actually switching the pad position to an AP position. So one on the front right over the heart and then one on the back. So you're sandwiching the heart differently, changing the vector of travel from that biphasic shock.

Dr. Meredith Trubitt

What's the logic to that? Like, benefit to that?

Dr. Jessica Nave

Yeah. So there's actually an ongoing study actively right now. Hopefully that we'll see resulted in the next year or two that will probably inform the next guidelines in 2030. But we're really looking at pad placement. I have seen even in the case of my own brother, he had a subcutaneous ICD and it was not enough to actually break the shock and it took the external shock. And so the thought is the impedance of travel across the tissue dramatically changes how you respond to the shock. So the thought is with the vector change that you gave it a chance to go that direction, but perhaps the anterior posterior position is actually more effective because there's less impedance.

Dr. Mon Ami

That's a lot of physics.

Dr. Meredith Trubitt

It is, but the nerd brain in me makes you wonder, is it also kind of anatomy based? People's anatomy may dictate which one could be better.

Dr. Jessica Nave

Absolutely. They're even looking at that I think in the study right now, because in patients who are really barrel chested, have copd, that may not be as effective as a lateral shock versus a very obese or very muscular patient. It might be better. So, yeah, a lot more to come, but it's an interesting area of research right now.

Dr. Meredith Trubitt

Cool. And what is double sequential defibrillation?

Dr. Jessica Nave

So this one is fascinating to me. This is actually where you use two sets of pads, one in the anterior lateral position, one in the anterior posterior position, and two defibrillators. And you are rapidly delivering two shocks sequentially with the two different defibrillators.

Dr. Meredith Trubitt

And what's the logic to that one?

Dr. Jessica Nave

That one is. We know kind of what we talked about with the AFIB and the tachyarrhythmias for the supraventricular tachycardias. Go big or go home. This is a similar thought process. You want to shock that heart and have the best chance and you want to do it from every direction. So it's really just trying to blast the heart and get it to reset the conduction.

Dr. Meredith Trubitt

And so in that one, are they also actively studying that like with the vector change or is. They're not comparing those two.

Dr. Jessica Nave

They did a recent study called the Dose VF trial that was published in the New England Journal of Medicine. It was basically comparing standard defibrillation with this vector change defibrillation and the double sequential defibrillation. And what they found was in survival to hospital discharge, the standard defibrillation that we currently do had a survival of 13.3%, the VECT 21.7% and the double sequential defibrillation had 30.4%, with 27% of them having good neurological outcome. So there was quite a difference and improvement in both hospital discharge, but with neurological outcome.

Dr. Meredith Trubitt

Okay. And the guidelines, though, at least the 20, 25 ones, it. It labels this as a 2B recommendation. So can we talk a little bit about why, if this study was that promising, why it's only 2B?

Dr. Jessica Nave

Absolutely. There's some drama surrounding this. This actually was my. I was most excited about this guideline. How would they take this trial into account and what would they do with that in the updated guidelines? When you actually look at how they grade evidence for guidelines, it's based on the class of evidence. So they take every study, they assign it a class, and then they assign a recommendation based on that. They did assign this recommendation as a 2B, which is weak, meaning the benefit might outweigh the risk, or they could be EQUIVOCAL within that to be. You can say three different things. You can say it may be reasonable, it may be considered or usefulness or effectiveness is unknown or uncertain. And they have a choice of which of those to say. The American Heart association chose to say the last one, that it is, you know, its usefulness is unclear or uncertain. So they're not actively recommending it.

Dr. Meredith Trubitt

But.

Dr. Jessica Nave

But ilcor, which is the International Liaison Committee on Resuscitation, which is where. Aha. And you know, the European guidelines, where all of the different countries around the world come together in a consortium and talk about it, they gave the same level of evidence assignment, but they went with might be reasonable. So it's kind of created a little bit of drama in the United States because we are very, very focused on guideline language. And to us, to an end user, saying something may be considered or maybe reasonable is different than saying it's uncertain or the usefulness is unknown.

Dr. Meredith Trubitt

So you, as being expert in this, in your practice, you have the person who is in refractory vf. Does that mean that you would go ahead and try, like some vector change or double sequential?

Dr. Jessica Nave

Absolutely. I have not had a chance to do it yet since these guidelines came out. I haven't had a case that was a refractory vf. But absolutely, if you see VF and, you know, you just want to keep shocking and shocking and you shock over and over again, at some point you need to try something else. And so I will absolutely be calling for a second defibrillator, even on the floor and trying this. I know that logistically it's a lot harder on the floor than in a ICU setting where the team is more used to this. Things are right there. I'm sure I will be questioned when this day comes, but absolutely, yeah.

Dr. Meredith Trubitt

To me, it's a funny question how the language, I agree, really is going to probably dictate how comfortable people are with it, but in the practicality of the situation, the person's, you know, functionally dead. So I feel like there's no harm in trying is like the. Where my head would go, I think, in the moment. And at least the vector change option doesn't necessarily require extra equipment at the time. Like to at least be trying something if that is a limitation. It just seems like this is not guidelines around antibiotics.

Dr. Jessica Nave

Yeah, yeah, exactly. You have a little more freedom to try things because like you said, the alternative is that the patient is dead. So, like on a patient with my brother, if he was on the floor of a hospital and he is young, he is 43. And that VF is not breaking. Absolutely. If I'm the crazy doctor sister sitting at the bedside, I'm going to be asking, please, please bring in another defibrillator. Let's double shock him.

Dr. Meredith Trubitt

Yeah.

Dr. Mon Ami

Speaking of things like doing no harm or what's the harm in doing it, one of the things that was definitely not a thing when I first learned ACLS 15 years ago was pocus. So we're going to zag again. Espen is my M.O. because I think we covered that last part really well. So inevitably encodes you have like 150 people in the room and in the tail end, the pocus team shows up and they're like, do you need a central line or anything else? And I guess I'm curious what your thoughts are and what the guidelines say about the use of pocus in. In one of these emergent situations.

Dr. Jessica Nave

Yeah, absolutely. I also was not trained on pocus very much other than doing procedures. Since that time, I've had more hands on practice, but I don't trust that I can find lung sliding in the middle of a code. So it's very, very hard. The guidelines sort of reflect my approach, which is it may be considered, but absolutely do not interrupt CPR for this. Don't let it get in the way of anything. And it has to be done by somebody who knows what they're doing and knows what to do with the information.

Dr. Mon Ami

Yeah, really Just for high yield information too. Right. So H's and T's related information and pretty much nothing else.

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Dr. Mon Ami

So I think the pocus stuff kind of lends itself naturally to talking a little bit about IV access because they always show up or they might not always show up asking about central lines. So central lines, IV access, IO. Let's talk about that.

Dr. Jessica Nave

Absolutely. So in residency many years ago now, you had to, to basically physically block the surgical residents from coming in and throwing in a surgical central line, a dirty line in the middle of a code. I don't see that as much anymore. So I think it's pretty accepted that this, you know, the guidelines actually saturated and got through that IV access and IO access are both very much preferred over a central line. Now that being said, unfortunately, because as someone who really likes to place iOS during codes, the 2023 updates came out and said that IV was preferable to IO. Whenever they looked back at studies that weren't actually looking at that question specifically, but the studies that they looked at, the outcomes were better in patients that had the medications delivered IV. They have since for the 2025 updates, done randomized control trials looking at this question and IV outperforms IO. So it is very clear in the guidelines this year, IV over IO with a very distant central line.

Dr. Mon Ami

It's kind of like, I think we talked about this, we trained around the same time. So the change in the last decade or so is pretty impressive. For similarly surgical residents were showing up to all the things for when I was, you know, that's just like really cool to see that change over time and like in real time adjusting to the data, which I really like.

Dr. Meredith Trubitt

And then I think we were curious if there's a number of IV attempts someone should try given kind of that superiority to the IO access.

Dr. Jessica Nave

Yeah, I think the Recommendations right now are three. So try it three times and go for IO.

Dr. Meredith Trubitt

And then presumably once you get the IO access, kind of keep trying to get an IV thereafter to switch over. Yep, cool.

Dr. Jessica Nave

So it is still a useful skill, everyone.

Dr. Meredith Trubitt

So now let's kind of advance Mr. B a little bit. Maureen plays case out, I think in both directions for the sake of kind of this conversation. But let's keep it positive, keep us on a high. Let's assume Mr. B got ROSC. Let's talk a little bit about what maybe some of the overarching themes are to post arrest care, especially since that seems to be important to getting him to discharge and how have kind of the guidelines changed here for 2025.

Dr. Jessica Nave

Yeah, so the last guideline update and the 2025 update have both really focused on this post cardiac arrest care. It's used to be, you know, you really focused on actually running the code and then the second you got rosc, it's like, okay, we're done. I think there's more and more recognition that, nope, that patient is far from being done. And there's an entire algorithm that is dedicated to the post arrest care. The new things for the 2025 updates, when we're comparing it to the 2020 updates, are in targeted temperature management. So the 2020 updates were 32 to 36 degrees. Now they've sort of liberated that a little bit. 32 to 37.5 degrees, really the emphasis is just avoiding fever. So we're not cooling people as actively as we used to. In fact, that number's gone down dramatically, much to the chagrin of a lot of the vendors that came up with really cool, you know, mechanisms for in the ICU cooling patients. Additionally, the in neuro prognostication, it's very set that you wait 72 hours, whereas before there wasn't a clear timeline of when you actually do neuro prognostication testing. Additionally, with hemodynamics, there was a thought back in 2020 that you just wanted to avoid hypotension. Now we're very much focusing on the mean arterial pressure, trying to target that a little bit more. In addition, with oxygenation, as you all probably know, you just throw people on high flow oxygen and move along. But there is thought that hyperoxygenation is actually bad. And so there's an explicit range in the 2025 updates of trying to maintain an O2 sat of 90 to 98%. So don't try to get them to that hundred.

Dr. Meredith Trubitt

So I think that's the Way I read a lot of it is that they're trying to really like more clearly define what those goals are. And it sounds like then from the hypotension to like MAP goals, they're just trying to define like, it's like avoiding hypotension. Like you said, depending on the hospital you're in, hypotension can mean kind of different things. Giving you the MAP goals will give you clear kind of guidance as to like, hey, this is what we're aiming for in this time. And all of that goal is that 72 hours until you make that prognostication. Okay. And then that's also when can liberate like you're not going to be in that cooling phase or anything like that.

Dr. Jessica Nave

Correct.

Dr. Meredith Trubitt

Okay. Yeah.

Dr. Jessica Nave

I think it's the thought process was that we were doing a lot of that too early after cardiac arrest. And there's a lot of healing and different mechanics happening to the body during that time. So they're trying to give a longer but more defined period of time to do a lot of that work.

Dr. Meredith Trubitt

And that prognostication should come like from neurology or testing or. That part's not as well defined yet.

Dr. Jessica Nave

Yeah, unfortunately, because guidelines have to be accessible to almost every hospital, no matter what your resources are. That part is not quite as defined in places that have it. Neurology consultation is absolutely warranted and most of the time they're the ones leading that piece.

Dr. Meredith Trubitt

Got it. Okay, so let's go back to Mr. B. Say that, you know, he's still in refractory VF. We've tried all the things and we're not getting ROSC for him. I think the other big kind of question that comes up is kind of how do you think through termination of resuscitation? And what are some of the recommendations around determining that?

Dr. Jessica Nave

Yeah, this is still a very hard question and one that the guidelines haven't fully given us an answer to. There's no algorithm or anything that exists that clearly tell you how long you should perform acls on a patient or when you should call the code. The only thing we have is some objective markers. So an end tidal CO2, if you're able to have that during, you know, kind of throughout the code, if you are not consistently seeing an end tidal CO2 above 10, then that is a very good sign that at the 20 minute mark from the time of the code, that that patient's chance of survival is so low that you can use that as an objective marker to call the code. But outside of that, it's really, it comes down to the clinical scenario. For me personally, I take into account the actual patient, you know, how old are they, how healthy are they, what's happening to them clinically. Another big thing that I always want to make sure is that you're involving the opinion of everybody in the room because some people may feel very differently, they may be more connected to that patient or understand that patient's functioning more than you do as somebody who's just randomly walking in and responding to a code. So I use the end tidal CO2. If we're able to have that, if the patient was intubated and we have that as a marker, I ask the opinion of everybody in the room and I take into account what's happening with the patient, what was their rhythm? We know from all of the studies that V tach and V fib, our shockable rhythms have a higher chance of survival than our non shockable rhythms, especially asystole. So yeah, until we kind of come up with something that gives us very, very clear guidance, it's a clinical decision that I think should be made with the entire team in the room.

Dr. Meredith Trubitt

Do you talk a little bit too about, you know, I think in real time when this is happening? Oftentimes family is called. How do you incorporate sometimes a very challenging, high stress situation that has like such a time limited and resource limited kind of decision that has to be made?

Dr. Jessica Nave

Yeah, that's always a good question. This this year was interesting with the updated guidelines because they actually mentioned in the guidelines to involve the family in the decision, which I thought was really interesting. And me myself, when I've run codes in the hospital, I've actually had patients, families in the room at the time of the code. I feel like most of the time they are ushered out and kind of kept out in the hall or taken to another area where the chaplain is sitting with them. So if they're in the hospital, having them actually witness what is happening, especially if you've been having those goals of care conversations and that patient probably is not someone who you or I would ever consider a resuscitation candidate. But you know, they are actually now wanting patients families to be involved and witness the cardiac arrest or at least see what's happening, it helps, helps with their closure, it helps with the decision itself. And a lot of times those patients families will say, okay, we're done, like let's call the code.

Dr. Meredith Trubitt

I think it's interesting that they added it to the guidelines. And I agree. Like, I feel like in My training, it's usher out. But then I have noticed like in conversations thereafter, there's a lot of questions as to like, like, you know, what does it mean that you did everything? And I think that to be able to see what everything looks like during a code is one of the times in medicine where seeing is going to be better than when it. Whatever you say. Yeah, absolutely. That was like also a really mind blowing moment in these guidelines. Okay, well, Moni, any other questions? Hot takes for Jess.

Dr. Mon Ami

No hot takes, but curious if you have any take home points for our listeners.

Dr. Jessica Nave

Yeah, I think in the world of resuscitation, you know, there are things that we do when everybody says you throw the kitchen sink at a patient when they're in this scenario because otherwise the alternate is death. I do believe in that to some degree. You want to be very thoughtful about what you're doing and the medications that you're giving. But some of these things that are being shown as promising in the literature that aren't quite guideline based. I am very much a proactive, like let's try it sort of mentality because it takes a lot of studies to be able to get something into the guidelines and in cardiac arrest research itself because the prevalence is so small of how we can actually do the studies. It's not like you can enroll patients in a study way ahead of time and have a research coordinator 247 sitting in the hospital. Hospital. This event is often unpredictable and so for that reason it's hard to study. But I would say stay up to date. You know, these things that are showing promise, be liberal about using them in the hospital and just try, especially for those young patients like my brother, you know, please try.

Dr. Mon Ami

And then anything you'd like to plug the 2025 guidelines. And also if you're at SHM or I guess you'll be hearing this after, definitely hit up Dr. Jessica Nave to give this talk to your group. She did it for our grand rounds at where we work and it was a really great talk. So that's my plug because you don't have one for yourself.

Dr. Jessica Nave

Well, thank you.

Dr. Meredith Trubitt

So this has been another episode of the Curbsiders bringing you a little knowledge knowledge food for your brain hole.

Dr. Mon Ami

Yummy.

Dr. Meredith Trubitt

Still hungry for more?

Dr. Mon Ami

Yep.

Dr. Meredith Trubitt

Join our Patreon and get all episodes ad free twice monthly bonus episodes@patreon.com curbsiders. You can find show notes@thecurbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. Including our Curbsiders Digest, recapping the latest practice, changing articles, guidelines and news and internal medicine.

Dr. Mon Ami

And here at the Curbsiders, we're committed to high value practice changing knowledge. And to do that we need your feedback. So please email us@askcurbsiders gmail.com it also helps a lot when you subscribe. Subscribe, rate and review the show on YouTube, Spotify or Apple Podcasts. A reminder that this and most episodes are available for CME credit for all healthcare professionals through VCU Health at curbsiders.vcuhealth.org A special thanks to our US for writing this episode. Dr. Caroline Coleman who's with us here at SHM and to the whole Curbsiders team Team Our technical production is done by the team at Podpaste. Elizabeth Proto does our social media, Jen Watto runs our Patreon, Chris the Chew Manchu moderates our Discord and Stuart Brigham compose the theme music. With all that, until next Time Tomorrow, I am Tony Amin and as always,

Dr. Meredith Trubitt

I'm still Meredith Trubitt. Thank you and good night.

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