Cooling cardiac patients

[DwayneEMTP]

(No link as it's from another site, credit to ncmedic309)

What do you all think? Do you see problems with the treatment or implementation pre-hospital?

Wake County NC paramedics use new 'cool aid' method

by

Starting today, cardiac arrest patients in Wake County will have an edge that improves their chances of leaving the hospital walking and talking.

Paramedics with Wake County Emergency Medical Services and the county's two 24-hour cardiac care hospitals, Rex Hospital and WakeMed, will begin using a novel therapy that protects patients' brains from damage by quickly dropping their body temperature.

Cooling the patient reduces the brain's need for oxygen, helping to minimize the damage that typically occurs after the heart stops and blood flow to the brain is interrupted.

Studies of the treatment, called therapeutic hypothermia, suggest it prevents brain death in one out of every six patients. That means a patient who would have been in a persistent vegetative state, and possibly removed from life support, instead might survive intact.

"We hope to see more people surviving in a meaningful way," said Dr. Brent Myers, a Raleigh emergency physician and medical director of Wake County EMS.

EMS responds to a cardiac arrest in Wake County roughly every 18 hours -- more than 600 last year alone, Myers said.

But the number of people who receive the cooling therapy will be relatively small. Some patients are beyond reviving when paramedics arrive. Others regain consciousness after a quick shock with a defibrillator and don't need the treatment.

Instead, the treatment is aimed at patients whose heartbeats are restored but remain unconscious. Myers estimates that EMS will use it on 80 to 100 people in the next year, based on the number of cardiac patients who would have met eligibility criteria for the therapy last year.

Paramedics will start cooling down the patients in the field with ice packs and infusions of ice cold saline solution, then transport them to Rex or WakeMed. Hospital staff will continue the cooling by hooking up patients to devices that gradually drop the patient's body temperature as low as 89 degrees Fahrenheit.

For optimal results, patients must be kept cool for between 12 and 24 hours, then gradually warmed up again, according to published research.

If Wake County's results are at least as good as those published in American and Australian studies, therapeutic hypothermia may result in an additional five to 15 patients a year making a successful recovery, Myers said. Success is defined as patients being sent home able to care for themselves and able to hold at least a part-time job.

Potential is great

That might not sound like much, but it would be a significant increase in the number of patients who make a good neurological recovery. Last year, Myers said, just 23 cardiac arrest patients who would have been candidates for the therapy went home with good brain function.

"Usually these patients don't survive," said Dr. Bob Denton, an emergency physician at Rex Hospital. "The benefit is potentially overwhelming."

Wake County is one of the first communities nationally to begin offering therapeutic hypothermia after cardiac arrest. Myers, the EMS medical director, said he is aware of only two other communities -- Seattle, Wash., and Pittsburgh, Pa. -- that offer the treatment or plan to begin it shortly.

Myers said that Wake EMS started looking into doing therapeutic hypothermia for cardiac arrest last year as a way to give patients every chance of surviving with a good quality of life. Patients in Wake County are successfully resuscitated -- that is, their hearts are restarted -- about 30 percent of the time, according to data kept by EMS.

But despite those results, which far exceed the national average of 5 percent to 7 percent, most patients were still suffering brain death, Myers said.

Dr. Paul Hinchey, a Raleigh emergency physician who was completing a fellowship with EMS at the time, suggested trying therapeutic hypothermia. When EMS asked the county's hospitals to discuss collaborating on the project, it took off. Rex, it turned out, was already considering starting the therapy for cardiac arrest patients transported to its emergency room. And after reviewing published studies, WakeMed was game to try it.

"It didn't make sense for EMS to start this if hospitals weren't going to continue it," Myers said.

Dwayne

[Ridryder 911]

I believe it has potential, now with that saying I would not want to be the hospital legal defense team for the ones that did not get informed consents etc.. on trial studies.

R/r 911

[paramedicmike]

... I would not want to be the hospital legal defense team for the ones that did not get informed consents etc.. on trial studies.

Oh come on Rid! They're dead! Who needs informed consent on a stiff?!

And before the rest of you get all uptight about this...I'm joking.

-be safe.

[AZCEP]

Active cooling has it's place, but I'm not sure it is prehospital.

The need to keep the temperature between 90 and 92 degrees Farenheit is troublesome at best, under closely monitored circumstances. In a moving ambulance, it will be next to impossible.

There was some discussion a few years ago that most resuscitations are mildly hypothermic through passive mechanisms, so the need to actively cool them wasn't being supported. Reducing the metabolic demand is a great idea, but doing it through cooling carries many questions on methodology.

Very interesting how the EMS system has influenced the hospitals to continue the treatment.

[JakeEMTP]

I have a friend of mine who works for Wake County EMS. I'll try and see if he has some info from the Medic's prospective.

[Spock]

The benefit of hypothermia for management of cardiac arrest survivors has been supported in the literature for a number of years but not widely implemented. The literature only supports hypothermia for patients with a blood pressure and who are admitted to the ICU. I am aware of no literature that supports hypothermia in the prehospital phase of treatment. If you are fortunate enough to get pulses back in the ambulance, I suspect the paramedic should focus on maintaining a BP, ensuring adequate oxygenation and ventilation, treating dysrhythmias and maybe looking for a cause.

Where is Wake County NC? I'm only asking because I'm thinking of moving to NC and was just looking for information.

Live long and prosper.

Spock

[JakeEMTP]

Spock,

Wake county is the Greater Raleigh area. Busy service with some excellent Hospitals.

[Timmy]

My organisation is currently doing research into this. The deal is we apply cold packs to a patient’s in VF, in an effort to reduce neurological damage and improve the patient’s chance of a full system recovery post arrest.

The research is being done as event first aid with out response times to an arrest being under 1-2 mins. It would be interesting to see if there’s much difference between event first response and front line paramedics with different time restraints.

[Dustdevil]

I think this is especially a good idea for systems that utilise basics. Since they want invasive skills so badly, I would be more than happy to let them handle the rectal intubation necessary to properly cool the core. Maybe then they can legitimately lay claim to occasionally saving lives. If not, well then at least it gives them something to do and gets them out of my hair. Kinda like sending the father-to-be to boil water.

[Asysin2leads]

For a while we thought the best thing for VF patients was to stop everything and immediately defibrillate them. Now they want 2 minutes of CPR prior to defibrillation. Next, apparently, its waiting for the body to cool before defibrillation. After we do all that, do you think that maybe, ummmmm, we could get around to, like, shocking them?