Hospital Induced Hyporthermia

[crotchitymedic1986]

Anyone doing this or heard anything about it:

http://soundmedicine.iu.edu/segment.php4?seg=1936

http://en.wikipedia.org/wiki/Induced_hypothermia

http://circ.ahajournals.org/cgi/content/full/108/1/118

http://www.childrenshospital.org/views/feb...ypothermia.html

[VentMedic]

Hypothermia has been used for specific purposes especially in the pedicatric world for many years.

It was also trialed in the 1980s in prehospital but cooling the patient was primative.

Hospitals started using hypothermia in larger numbers and different populations over at least the past decade and it is now being used prehospital in a few areas.

The stats on it are still questionable as some patients still die and occasionally you have someone who has no deficit post cardiac arrest. However, we have had patients with few or no deficits without the hypothermia. I believe the determining factors are still weighing more heavily on witnesses arrests and CPR initiated immediately.

Quote from your AHA Circulation Journal article:

Additional criteria for entry into the European study were witnessed cardiac arrest, an estimated interval of 5 to 15 minutes from patient collapse to first resuscitation

There is a very strict criteria as to which patients will be selected for the studies and usually they are the ones who would also have the best chance for survival without neuro deficits also.

Some patients may also not be counted in the stats if they were rewarmed early from complications during the hypothermia. Those that die during the protocol may not be counted. Some researchers are looking purely at the outcomes of a patient that survives through the entire course and their neurological deficits. But this is not unlike any other medical study which is why I tell people to pull up the original article to read the methology of the research rather than a fluff story in the newspaper or JEMS.

Edited July 21, 2009 by VentMedic

[Richard B the EMT]

There is currently a pilot program underway in New York City for hypothermic treatment of post cardiac arrest patients.

Sorry, but I just don't recall specifics at this time.

[scott33]

Wake County EMS (NC) have been doing it for a while. Plenty of articles about it, and their hypothermia protocol is here.

http://www.wakeems.com/ICE/ihv11.13.pdf

[FL_Medic]

Wake EMS was the third prehospital agency to start using induced hypothermia but has certainly been the leading agency to collect evidence. I saw Dr. Myers speak in Orlando in 2007 and was thoroughly impressed. I have written about hypothermia recently in my blog. Here is a link:

http://paramedicine101.blogspot.com/2009/0...mia-part-i.html

We are currently using our hypothermia protocol for post v-fib/v-tach arrest with ROSC.

[HERBIE1]

Been used for years in cardiac surgery and transplants, but obviously that is a controlled setting and very different circumstances. I understand the rationale behind the concept, and it makes sense, but as was mentioned, I think this needs to be more thoroughly studied. I can see it being useful for example when someone may have a refractory electrical problem that needs to be corrected and you need to buy some time. Problem is, too many of our arrests are unwitnessed and the down time is unknown. I see potential, but more data needs to be generated.

[Spock]

We started a hypothermia protocol a few months ago. If we get pulses back we infuse two liters of cold saline as fast as possible and support the BP with dopamine. Valium is given for shivering. We have used it twice now but both patients still died at the hospital some time later. We keep the saline in a cooler with freeze packs which are rotated every 12 hours. The City of Pittsburgh started this long before we did and they put small refrigerators in their trucks.

The recommendations for hypothermia were initially made in the ACLS update in 2000 and was given greater emphasis in the 2005 update because of the good results in the hospital setting. Taking it prehospital seems to make sense but I agree more data is needed.

Live long and prosper.

Spock

[OVeractiveBrain]

AHA Currents had an article about induced hypothermia for improvement of post arrest cerebral function. Then, there were several articles published in Australia and Europe touting its success. Essentially, regardless of the arrest condition, induction of hypothermia improved patient outcome; people who would have died lived and people who would have lost significant function retained it. People walked out of the hospital. They werent wheeled by the new BLS crew to a nursing home, they walked out on their own two feet.

The exact protocol used has yet to be identified. Many hospitals have initiated hypothermia protocols for inhospital arrests. Prehospital arrests (unfortunately for paramedics) show the smallest uses. This is mainly because medic trucks lack (1) an ability to adequately monitor core temperature (trans-esophageal or rectal monitoring), (2) specific equipment to induce hypothermia (refrigerated saline, circulation blankets, sometimes air conditioning all together), and (3) necessary pharmacologic intervention to prevent shivering (i.e. paralytics).

The only identifiable benefit prehospital providers can provide is in the very beggining of initiating hypothermia. Ice packs on the neck groin and axilla can start the process, but it requires a hospital to manage them appropriately. Medics should NOT be inducing hypothermia unless there is an established hypothermia protocol at their destination hospital. IF A MEDIC STARTS COOLING THEN THE COOLING IS TERMINATED PRIOR TO TARGET TEMPERATURE OR TARGET 48 HR RANGE, THE PROGNOSIS IS POORER THAN WITHOUT HYPOTHERMIA

In Hospital

* Paralytics to prevent shivering

* Water Circulating blankets, refrigerated saline, controlled air temperature

* Core body temperature monitoring

* Prophylactic antibiotics for infection prevention (increased risk when cold)

* Control temperature for 24-48 hours at 28-32 C

Results

* Improved cardiac survival

* Improved quality of life at discharge and at 5 years

* reduced mortality in survivors at 1 year

Prehospital

* Lack equipment to adequately induce

* Benefit of hospital hypothermia seen in patients without prehospital induction

Protocol is great for patients, sucks for medics, and the EMS community will likely be the absolute last to have access to any of the useful protocols.

[Mateo_1387]

The exact protocol used has yet to be identified. Many hospitals have initiated hypothermia protocols for inhospital arrests. Prehospital arrests (unfortunately for paramedics) show the smallest uses. This is mainly because medic trucks lack (1) an ability to adequately monitor core temperature (trans-esophageal or rectal monitoring), (2) specific equipment to induce hypothermia (refrigerated saline, circulation blankets, sometimes air conditioning all together), and (3) necessary pharmacologic intervention to prevent shivering (i.e. paralytics).

This really depends on your system. Inducing hypothermia in the field can be done effectively.

The only identifiable benefit prehospital providers can provide is in the very beggining of initiating hypothermia. Ice packs on the neck groin and axilla can start the process, but it requires a hospital to manage them appropriately. Medics should NOT be inducing hypothermia unless there is an established hypothermia protocol at their destination hospital. IF A MEDIC STARTS COOLING THEN THE COOLING IS TERMINATED PRIOR TO TARGET TEMPERATURE OR TARGET 48 HR RANGE, THE PROGNOSIS IS POORER THAN WITHOUT HYPOTHERMIA

EMS induction of hypothermia is a neat thing. It is one intervention where paramedic treatment influences the care the patient receives in the hospital environment. Also, in regards to your first sentence, our actions are to start cooling by applying the ice packs/infusing cold saline, the patient's benefit of such action is a better chance to recover neurologically intact. Delays in inducing hypothermia show to increase the incidence of neurological deficit.