Koolaid for ROSC

[FL_Medic]

Have you stayed around to see what the core temp is on arrival with just the cooled NaCl?

At least that is easier and can be discontinued discretely once inside the ER if the discision is made not to continue the protocol.

But, how would you feel if you knew the hospital wasn't carrying on with something you thought worth while to start?

That's most of our population.

I'm not using the protocol, so no. But the key is to keep the pt at 32-34 C watching their temperature while en route. Once at the hospital they keep them cool for 24 hours.

[Just Plain Ruff]

the exclusion criteria you listed for age is greater than 16 shouldn't that be reversed?

[VentMedic]

FL_Medic

Why don't you go to the local hospitals that already have established hypothermia protocols. Observe a few patients on the protocol. Talk to the ICU nurses. See if they have seen a lot of success stories. Like I mentioned before, we do this in our ICUs occasionally. It can be a long 24 hours for the bedside staff. But, get some up close information for yourself.

We had our best success with peds. So what is the age range again for your potential protocols?

[OVeractiveBrain]

Fiznat and I did our capstone project on this very subject. There is no doubt in any of the papers we read that suggests that induced hypothermia upon return of spontaneous circulation in a patient that remains comotose is not a good idea.

If you get them back, make them cold. S I can post our abbreviated bibliography if youd like. Most were obtained through Ovid via Yale University, so access may be limited unless you work / know of a place that has fairly loose wallets for subscriptions.

Basically, if their dead, you get them back, but they wont wake up, make them cold. I think the best review is in the AHA magazine "Currents" I think it was summer of 06? I cant quite remember which it was, but it was a good review.

Since then, talk of inducing hypothermia during the code have arisen. For prehospial providers inducing hypothermia would be ineffective. If we rapidly cooled some body they would shiver, thus increasing metabolic demand and defeating the purpose. To fix that, we would have to RSI them, a technique that most services are not liberal about handing out. Paralysis must be initiated in order to stop shivering. Then there is monitoring for hemmorrhage and seizures. Fully inducing some one on the street or in an ambulance i dont think we will ever see.

However, for prehospital providers I like the idea of initating hypothermia. Apply ice packs to central regions (groin, neck, axilla) to start the process. That makes induction by rapid infusion that much easier. Then, if you want to discontinue (which is not recommended because it nearly gaurentees death) you just remove them. The problem is of course when the crews start it, and the hospital doenst follow it up.

U Chicago i think was the first to do it here in the states. Hartford hospital on connecticut is utilizing the technique for in-house codes. I think in the next year or two, we are going to see the technique used much more often.

This idea comes from the use of hypothermia in other scenarios (such as neurosurgery and some older surgeries in russia). Make the body cold, less bad things happen.

So you dont have to read all teh abstracts yourself:

Neurologic outcome improves for patients induced to ~90 F for 24 hours and slowly rewarmed. Human study in Melbourne Australia and in Multi-center, multi-nation Europe.

It doesnt matter how fast you cool them (sooner the better) but cooling them after too long a time (12 hours) does do any good, and you have to slowly rewarm them.

Animal models show this works for trauma, and can be initiated while CPR is in progress (medical and trauma)

Risks include bleeding, seizure, vifb (watch for those osborne waves),

1 - Bernard et al, Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia, New England Journal of Medicine. 346(8):557-63, 2002 Feb 21

2 - Bernard, Stephen. Buist, Michael. Monteiro, Orlando. Smith, Karen. Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest Resuscitation. 56(1):9-13, 2003 Jan.

3 - Bernard, SA, Outcome from prehospital cardiac arrest in Melbourne Australia; Emergency Medicine 1998; 10:25-9

4 - Bigelow WG, Lindsay WK, Greenwood WF: Hypothermia; its possible role in cardiac surgery: An investigation of factors governing survival in dogs at low body temperatures. Ann Surg 1950; 132:849–866

5 - Hachimi-Idrissi, S. Corne, L. Huyghens, L. The effect of mild hypothermia and induced hypertension on long term survival rate and neurological outcome after asphyxial cardiac arrest in rats. Resuscitation. 49(1):73-82, 2001 Apr.

6 - Holzer, Michael. Efficacy and safety of endovascular cooling after cardiac arrest: cohort study and Bayesian approach. Stroke. 37(7):1792-7, 2006 Jul

7 - Hypothermia after Cardiac Arrest Study Group, Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. New England Journal of Medicine. 346(8):549-56, 2002 Feb 21.

8 - Nordmark, Johanna. Rubertsson, Sten; Induction of mild hypothermia with infusion of cold (4 degrees C) fluid during ongoing experimental CPR. Resuscitation. 66(3):357-65, 2005 Sep

9 - Nozari, et al. Critical time window for intra-arrest cooling with cold saline flush in a dog model of Cardiopulmonary resuscitation, Circulation. 113(23):2690-6, 2006 Jun 13

10 - Vanden Hoek, Terry L. Critical Care Preconditioning and postresuscitation injury. Medicine. 30(4 Suppl):S172-5, 2002 Apr.

11 - de Vreede-Swagemakers, J J. Out-of-hospital cardiac arrest in the 1990's: a population-based study in the Maastricht area on incidence, characteristics and survival. Journal of the American College of Cardiology. 30(6):15

12 - Wu, Xianren. Et al. Induction of profound hypothermia for emergency preservation and resuscitation allows intact survival after cardiac arrest resulting from prolonged lethal hemorrhage and trauma in dogs. Circulation. 113(16):1974-82, 2006 Apr 25.

13 - Zweifler, et al. Rectal temperature reflects tympanic temperature during mild induced hypothermia in nonintubated subjects. Journal of Neurosurgical Anesthesiology. 16(3):232-5, 2004 Jul.

[FL_Medic]

the exclusion criteria you listed for age is greater than 16 shouldn't that be reversed?

Sorry, all of those are reversed, they must meet that criteria

[FL_Medic]

Since then, talk of inducing hypothermia during the code have arisen. For prehospial providers inducing hypothermia would be ineffective. If we rapidly cooled some body they would shiver, thus increasing metabolic demand and defeating the purpose. To fix that, we would have to RSI them, a technique that most services are not liberal about handing out. Paralysis must be initiated in order to stop shivering. Then there is monitoring for hemmorrhage and seizures. Fully inducing some one on the street or in an ambulance i dont think we will ever see.

It's being done with cool NS. They are getting them down and the hospitals are keeping them cold. Vecuronium is used for the shivering, not true RSI. As the research is being done the bennifit is greatly outweighing the risk. It is being studied in the Neuro patients as well and has shown to reduce morbidity in the presence of CVA, but I haven't read much of the research on this modality for CVA quite yet.

[OVeractiveBrain]

It doesnt matter how its done, NS or water cooling blanket. My point was that induction is not appropriate for field crews.

I meant simply as a practical standpoint. Most medical directors are not comfortable with handing out paralyzing medications to every rig. In fact, their misuse and failure of RSI in connecticut has caused some services to have that right pulled. Only small, highly trained and tightly regulated services are allowed to carry those drugs.

I agree that the therapy is amazing, but rapid induction with cold saline should be done in the hospitals, not the back of the bus. Ice packs initiate the induction and saline can finish it off.

Remember, we cannot cater general policies on the best medics. We have to cater to the mid-range or below. Im not saying that some couldnt handle vec or roc, just that it is not appropriate for the average population of paramedics.

On top of that, shivering is not the only complication. Dropping the temperature too low causes hazardous effects (resulting in the abandonment of the therapy in the early 80s). The most effective means of measurement are bladder or esophageal. Two methods medics dont have. To boot, most medics dont even have oral or tympanic thermometers (which are not reliable for the therapy anyway). When ice cold saline can induce some one in under 30 minutes, it is very possible that the medics, with limited assessment tools and manpower, can make something go wrong. I suppose you could argue that since we can intubate we could also place esophageal thermometers, and since monitors are so expensive they could install a temp reader, but to change the system so drastically with yet another severely invasive procedure is challenging. With that, why not teach medics to start central lines, or install transportable X-rays in the back of rigs? Im exaggerating on purpose; field personnel do not have the technique, equipment nor manpower to accurately produce this therapy.

Also note seizures, arrythmias, bleeding.

Instead, I would much rather see activation of a "code team" much like we have for Strokes, Traumas, and some cardiac issues. That being, there is a code with ROSC that remains comatose, the medics alert the facility so that when the crew arrives, the rapid infuser is set up, the saline is loaded, the ICU has been alerted, and the medications are drawn up. So, like an angiogram or CT scan, the hospital is able to throw in a central line (Which the patient will get anyway being in the ICU), rapidly infused, EEG and ECGs applied, with much better ability to control for bleeding.

In fact, Im joinging the "EM" club here at Tulane. I hope to meet some medical directors and give them the presentation fiznat and I gave to the CT North Central EMS. I dont know if we had anything to do with it, but not even a year later, Hartford hospital started using the therapy in house. I hope to get the New Orleans hospitals to start using the therapy (particularly important due to the number of younger codes / would-be codes, mostly from trauma)

I am an advocate of the therapy, just not for field personnel inducing in the field. Before we get to that point (if at all) the therapy needs to be applied in hospital with rigorous guidelines with significant manpower.

Overactive

[flight-lp]

Sorry my friend, but your opinion, although welcomed and respected, is way off base. I do concede that you are correct in the aspect of some medics not quite "up to par", but there are some really revolutionary services out there with well educated and top notch Paramedics. These are the services performing this procedure. Maybe this idea is not well taken in your area, but it is well supported in ours, only one hospital has not elected to continue this thereapy and we have elected to bypass that facility in the case of one of these presentations. We do have the needed manpower, diagnostic equipment (rectal is effective for this technique pre-hospital), and appropriate pharmacological interventions. Thus far, our results are outstanding, hopefully we will have something on paper by the end of the year. This is a wonderful treatment option, one that when combined with items such as the ITD, a CPR assist device such as the Lucas, and effective defibrillation, will show a dramatic increase in arrest survivability...................

[rock_shoes]

Sorry my friend, but your opinion, although welcomed and respected, is way off base. I do concede that you are correct in the aspect of some medics not quite "up to par", but there are some really revolutionary services out there with well educated and top notch Paramedics. These are the services performing this procedure. Maybe this idea is not well taken in your area, but it is well supported in ours, only one hospital has not elected to continue this thereapy and we have elected to bypass that facility in the case of one of these presentations. We do have the needed manpower, diagnostic equipment (rectal is effective for this technique pre-hospital), and appropriate pharmacological interventions. Thus far, our results are outstanding, hopefully we will have something on paper by the end of the year. This is a wonderful treatment option, one that when combined with items such as the ITD, a CPR assist device such as the Lucas, and effective defibrillation, will show a dramatic increase in arrest survivability...................

I say thank god for progressive services such as yours. Without services like this one willing to try things still deemed experimental we would be much deeper in the dark ages of EMS than we are. As for some medics not being up to the task I don't believe it will be a problem in these types of services. If a service is this progressive sub-par medics will not last more than a few weeks and most likely won't make it past the interview.

I look forward to seeing the published results when they are available. Please keep us posted.

[AnthonyM83]

I forget if I got this from the convo with ccmedic or his article or my prep class or other article, but it discussed the idea of how cells that are forced to revive but aren't functioning properly will initiate apoptosis in order to save the surrounding cells (by not taking up nutrients and energy).

Anyway, seems like steps in the right direction as far as revival medicine.