Skinny, Cold and Coded

[ERDoc]

Wow. At my community shop, I cannot get an EEG. Sometimes I can beg for an emergent MRI between 10am and 3pm. Same for VQ scans, but not on Sat and Sun. I guess each hospital has it's niche. As you know from dealing with the system I am in, anything out of the ordinary gets shipped to the big house.

[Just Plain Ruff]

Yeah like I said, it seems like a great thing having an EEG tech in house, but I can count on one hand the number of EEG's we've actually gotten when requested versus being able to count on my entire ER/EMS staff's hands and feet the number of EEG's that we've requested (even with the tech on duty).

Usually the issue isn't the tech but the doctor reading the EEG and that's done by some group in Pakistan or one of the STans. The time it takes for us to get an EEG results far outlasts the time it would take for use to get the patient to definitive care.

[chbare]

I don't know. I'd agree in a little different situation but I'm not so sure here. If there was some type of anoxic injury to the brain (or other type of insult to the brain) the hypothermia would probably be beneficial, but I'd still be hesitant here. This is pretty unstable patient with an unknown problem; there is the possibility that she has in issue that will be made worse by cooling. I don't think that the hypothermia is going to help with her management as it is either, just make it more difficult. As it stands she has only been cooled to 35.5C; letting her rewarm from that won't be an issue. Could even avoid the warmed fluids if concerned.

Out of curiosity, for the situation (a fixed-wing transfer from low care to high care) would you really ask (if it was even available, which I doubt) for an EEG prior to leaving?

If available, yes. EEG monitoring post arrest with ROSC in unresponsive patients is a class I intervention (*However, it is supported by class C evidence), therefore, if available, I would absolutely use it. (Emphasis on "if" however.)

Judgement call on the hypothermia, but unless compelling evidence is discovered, I am not keen to deviate significantly, particularly when seizures are not an uncommon occurrence post arrest.

[DartmouthDave]

I don't know. I'd agree in a little different situation but I'm not so sure here. If there was some type of anoxic injury to the brain (or other type of insult to the brain) the hypothermia would probably be beneficial, but I'd still be hesitant here. This is pretty unstable patient with an unknown problem; there is the possibility that she has in issue that will be made worse by cooling. I don't think that the hypothermia is going to help with her management as it is either, just make it more difficult. As it stands she has only been cooled to 35.5C; letting her rewarm from that won't be an issue. Could even avoid the warmed fluids if concerned.

Out of curiosity, for the situation (a fixed-wing transfer from low care to high care) would you really ask (if it was even available, which I doubt) for an EEG prior to leaving?

Hello,

From my expereince I would say 'no'. Sure, you may get it done but getting it 'offically' read is the problem.

I know that some larger centres in the US use bedside continuous EEG. But, I don't know too much about that.

I don't know. I'd agree in a little different situation but I'm not so sure here. If there was some type of anoxic injury to the brain (or other type of insult to the brain) the hypothermia would probably be beneficial, but I'd still be hesitant here. This is pretty unstable patient with an unknown problem; there is the possibility that she has in issue that will be made worse by cooling. I don't think that the hypothermia is going to help with her management as it is either, just make it more difficult. As it stands she has only been cooled to 35.5C; letting her rewarm from that won't be an issue. Could even avoid the warmed fluids if concerned.

Out of curiosity, for the situation (a fixed-wing transfer from low care to high care) would you really ask (if it was even available, which I doubt) for an EEG prior to leaving?

Now, this is common problem. Getting agreement between the receiving service, the sending Physician, and you own oncall Physician.

The patient that I based this case coded due to an electrolytes imbalance. She was cooled and had a full neurological recovery. But, there were issues. An issue that could be worsened by cooling if one is not careful.

This months Air Medical Journal has two slightly related case studies. Plus, what effect could hypothermia have on the K? Muscle weakness followed flaccidity?

Cheers

PS: I hope my post isn't too fragments. I am getting done on the waning hours of a night shift.

Edited August 11, 2013 by DartmouthDave

[triemal04]

If available, yes. EEG monitoring post arrest with ROSC in unresponsive patients is a class I intervention (*However, it is supported by class C evidence), therefore, if available, I would absolutely use it. (Emphasis on "if" however.)

Judgement call on the hypothermia, but unless compelling evidence is discovered, I am not keen to deviate significantly, particularly when seizures are not an uncommon occurrence post arrest.

It is. It might be worth a discussion with the receiving doctor either way; if you have the ability to communicate while in flight then there is plenty of time. If not, then yeah, judgement call. But either way, if the patient becomes even more unstable, I know what the first thing I'm stopping will be...

With the EEG what I'm getting at isn't that it wouldn't at some point be beneficial, but how beneficial would it be RIGHT NOW, and do you think it would a- be worth waiting for it to be performed and read, and b- can you interpret it yourself? I know I can't. Which rules out continous monitoring for me, which I don't think would work so well in a moving vehicle or plane anyway.

[Eydawn]

Doesn't it have to do with mobilization of K+ across the cell membrane post hypothermia with active warming? Something is tickling me about our hypothermic SAR patients and caution with rewarming without knowing labs... I also want to say profound hypoglycemia is a risk for some reason with associated seizures. Trying mightily not to google!

Wendy

CO EMT-B

RN ADN

[Just Plain Ruff]

With the EEG what I'm getting at isn't that it wouldn't at some point be beneficial, but how beneficial would it be RIGHT NOW, and do you think it would a- be worth waiting for it to be performed and read, and b- can you interpret it yourself? I know I can't. Which rules out continous monitoring for me, which I don't think would work so well in a moving vehicle or plane anyway.

But shouldn't any ER doc worth his salt be able to at least initially be able to interpret a EEG to determine if the EEG is a good EEG or a BAAAAAAAAAAAAD one? I mean flat line EEG or one with spikes that is a viable EEG for a patient.

I would sure hate to get an EEG done in a small town ER and then have the ER doc look at the EEG and have it have no spikes or whatever they have on them and there be no electrical activity - and that doc still send the patient on to the receiving center. That would look REALLY REALLY Bad on that doc wouldn't it?

[chbare]

Regarding EEG monitoring, it's a crap shoot as to who may have it and you can find literature that shows people who do not receive good education and do not routinely use the modality have much higher rates of misinterpretation. With that, I am not necessarily talking about the typical EEG recording, but rather continuous bedside monitoring using something like a four channel setup for seizure identification. Therefore, we are not talking about taking a snapshot and having a physician read it, but rather continuous monitoring looking for seizures. As stated, this likely limits the availability of this modality, particularly during transport.

Just to be clear, I see no clear role for traditional EEG monitoring as part of brain death determination in the immediate post arrest interval and I am talking about using the technology for a very specific post arrest issue. This is not an issue of viability at this point but rather an issue of identifying seizure activity.

[iStater]

But shouldn't any ER doc worth his salt be able to at least initially be able to interpret a EEG to determine if the EEG is a good EEG or a BAAAAAAAAAAAAD one? I mean flat line EEG or one with spikes that is a viable EEG for a patient.

I would sure hate to get an EEG done in a small town ER and then have the ER doc look at the EEG and have it have no spikes or whatever they have on them and there be no electrical activity - and that doc still send the patient on to the receiving center. That would look REALLY REALLY Bad on that doc wouldn't it?

The departments which manage the EEG technology have very strict standards they must adhere to especially when it comes to interpretations. Their medical director who is responsible for overseeing the skill of the technologists and the interpretations must be a board certified neurologist and certified in multichannel EEGs.

A single channel EEG would also be a waste of resources unless it was solely for the purpose of monitoring a known epileptic. At minimum 8 channels would be utilized. Some want 64 channels and some may run 128 depending on the goal of the testing. Few if any ED physicians are up to that challenge. Even those for sleep medicine are out of the range of their education.

EEG monitoring in the ICU would also be continuous. But, it is difficult to get a perfect EEG tracing with a patient on a hypothermia protocol. Even without obvious shivering, some artifact will be present on the tracing.

For brain death there are other criteria to be met. It would be very rare to interrupt a hypothermia protocol and warm up a patient to do a complete brain death challenge. EEGs are used for prognostic predictions in teaching hospitals but it is more for academic and research purposes rather than sharing with the family immediately especially if the patient is getting the hypothermia protocol. You don't initiate a very expensive treatment which is publicly presented as giving hope and also say it is futile at the same time. Most physicians will wait until the patient has been warmed and medications weaned or sedation vacations initiated before making any withdrawal of support determinations. Most organ procurement programs which take donors with or without brain death may want the patient to be off hypothermia before preceding with their discussions with the family although some are called early.

[Just Plain Ruff]

Aha!!! I just learned something today. thanks guys.