American Heart Association

If you are reading this, you likely had no choice whether or not to read the ACLS manual.

Regarding content: I first took it back in 2015, and a lot has changed since then. I'm reasonably sure the stroke section wasn't so large, nor the discussion on primary and secondary assessments. AHA should stick to ACLS and let the separate modules for stroke be, particularly as there is a stroke certification that is essentially another four-hour class. It makes for too much preparation for what is a show more traditionally two-day course. The primary and secondary assessments were oddly presented, and done much better in your average EMT or Paramedic book. Note terminology in those resources uses 'general' and 'focused' assessment. This echoes nursing practice as well.

Regarding format: The book itself follows that annoying bullet point, ADHD learning style where it interrupts itself to highlight critical points or point the way to online resources (again, how much prep can one do for a two-day course?) It's also strangely divided, with one section about the coronary and stroke issue, and the other about 'high functioning teams' that have the ACLS algorithms hidden in it. I appreciate the team concept, I really do, but better organization would help.

Regarding the material: what is most useful here is the sections on tachycardia and acute coronary syndrome. I appreciate the flow within each section, although I'll note cardioversion is not the actual first option for unstable patients with wide QRS in practice, if you define 'unstable' as low blood pressure. Still, the information was useful.

What drives me absolutely bonkers is the AHA saying that we can 'do better' with resuscitation. I'm not sure if you are aware of this, but we are mortal. So many of the deaths that happen are people that are in an appropriate time of life (ie, past average lifespan) that are essentially dying of natural causes, but for whatever reason, someone calls 9-1-1. Panic, usually.

Regarding CPR effectiveness:

The claim usually involves lots of drilling down into what 'saved' means. Note that some studies call 'saved' the 'return of spontaneous circulation after CPR' but does not include endpoints such as 'leaving the hospital alive' or 'walking after CPR,' which we could agree means a widely-hoped-for endpoint.

Historically, Seattle/the Pacific Northwest has a strong bystander CPR tradition, as well as cardiovascular tradition (it's where the MD that primarily was responsible for EKGs and developing our understanding of them worked). Nobody has 70% actual survival rates, so I'm not sure where that number comes from. I think in their pre-Covid heyday, they as high as 50% survival. Interestingly, the strongest connection between survival and CPR is tied to BYSTANDER CPR, which is one of the ironic things about this science. DON'T WAIT FOR EXPERTS.

However, when it comes to the science of resuscitation, I invite you to peruse the International Liaison Committee on Resuscitation, the international committee that makes the recommendations surrounding CPR. They read all the studies, conduct a mega-analysis, and make recommendations based on quality of evidence. 2020 was a big release for updates, but they've done it almost annually since. If you drill down into each section, you'll see a lot of this:

"The BLS Task Force chose to make a discordant recommendation (a strong recommendation despite very low-certainty evidence)" (I'd cite, but you know GR. From 2020 Recommendations).
Science? Iffy. Based on psychology of groups/individuals and public policy.

and this for Narcan for ODs:
"A recent SysRev identified 22 observational studies evaluating the effect of overdose education and naloxone distribution and found an association between implementation of these programs and decreased mortality rates. On the basis of expert opinion..."
Observational studies and expert opinion. Science? Iffy.

Or, using feedback devices in hospital, which we now use:

"The BLS Task Force agreed on a weak recommendation for healthcare systems to consider CPR feedback devices, given the evidence that they improve the quality of CPR and there was no signal of patient harm in the data reviewed."

Note: "No harm" but not they actually improved outcome. A weak association because 'quality CPR' is thought to improve survival, but they can't tie that to out-of-hospital survival.

Regarding backboards:

"The treatment recommendations have been updated from 2010; they are all weak recommendations based on very low-certainty evidence. The BLS Task Force suggests performing manual chest compressions on a firm surface when possible; this includes activation of a bed’s CPR mode if it has this feature. During in-hospital cardiac arrest, the task force suggests against moving a patient from a bed to the floor to improve chest compression depth. The task force was unable to make a recommendation about the use of backboards because the confidence in effect estimates was so low."

You get the idea; when it comes to actual science of survival, the data is actually weak on what works and doesn't. These studies don't even talk about who is "supposed" to survive--in-hospital codes are called for people that are actually dying, but family is unable to accept this process as well as the people who have 'unplanned codes.' Because these studies usually include both categories of people (as well as the large grey area between the two extremes), you just aren't going to get definitive evidence on what 'saves' people, except for very small, case-report style studies. The science has had to rely on a lot of animal studies, which are highly problematic.

Trigger warnings for animals and death:

I'm not sure if you are aware of this, but some of their 'do better' goals are based on pig studies. Oh yeah: they kill pigs and then try to revive them. Needless to say, your average pig doesn't have the cholesterol build-up of your average 70 year old American. And by all means, let's talk quality of life. When we 'save' these pigs, are they capable of going back to the farm and fathering little baby pigs? I'm thinking no one ever tests that. What I'm saying, in other words, is take their assertations with a grain of salt. I worry about healthcare provider expectations and burnout, fearing that they might be setting themselves up for failure. show less

I wished it didn't abuse acronyms so much. Sometimes makes it harder to know what the chapter is about. The vasopressor dosages are real nice, but I would find it to be a lot more helpful if they showed an image on how an adrenaline infusion is prepared. I don't know if since this is a book aimed at American health personnel that are too cushy having technical assistants doing everything, but as an anesthesiologist in a developing country, these kinds of situations can and do happen in an OR show more setting and showing images on how to start intraooseus lines and preparing all of the vasopressor infusions would come in handy. I also felt let down the manual skips the dosage pf morphine for heart attack pain which is another situation I can face in my job without warning. The manual doesn't mention fentanyl as a suitable alternative and due to the peculiarities of the socialized system I work for, we don't get a crash course using moephine for situations that aren't as pain coadyuvants during routine surgery. Seems like the manual has a complimentary online course you have to complete in order fpr you to get the acls diploma during the hands on course, hopefully these specific complaints are handled there.

Otherwise, I enjoyed this manual as a nice complement to the Raul Esper book on asystole in the OR which says some of the same stuff but in less detail and more aimed for ER docs. show less

Good Spanish language translation, nicely organized. I like it how the 2020 manual now has a section for ECMO even though it now cuts back on the EKGs. Sadly had to give it 4 stars because it doesn't include one single Covid CPR protocol even though the book was published in 2021 and there is still no mentioning of using the Salad technique during crash intubations even though it has been highly publicized since 2018.

Still, it's otherwise a great manual.

Good Spanish language translation, nicely organized. I like it how the 2020 manual now has a section for ECMO even though it now cuts back on the EKGs. Sadly had to give it 4 stars because it doesn't include one single Covid CPR protocol even though the book was published in 2021 and there is still no mentioning of using the Salad technique during crash intubations even though it has been highly publicized since 2018.

Still, it's otherwise a great manual.