Iced Saline In The Field Prehospital Therapeutic Induced Hypothermia

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A presentation for EMS personnel about prehospital cooling of patients with return of spontaneous circulation in the field post cardiac arrest; research and application

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  • Iced Saline In The Field Prehospital Therapeutic Induced Hypothermia

    1. 1. Iced Saline in the Field – Induced Hypothermia for EMS MAST of 2009, or here to stay? Paul Davidson, M.D. Porter, Littleton and Parker Adventist Hospitals Emergency Medical Services
    2. 2. Concepts you will hear about <ul><li>1. Hypothermia has been proven to improve neurologic outcome in cardiac arrest survivors who remain comatose after ROSC. </li></ul><ul><li>2. Results from animal studies suggest that further improvements in neurologic outcome may be possible if hypothermia is induced earlier after ROSC. </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    3. 3. Concepts you will hear about <ul><li>3. Delayed induction of mild hypothermia results in less favorable outcomes. </li></ul><ul><li>4. Hypothermia by iced saline or other methods during arrest can improve outcome compared to delayed cooling or normothermia. </li></ul><ul><li>5. Iced saline can be cost-effective; it is feasible to give and it works </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    4. 4. Concepts you will hear about <ul><li>6. Iced saline, ITD and new 2005 CPR guidelines are saving lives in Wake County, NC. </li></ul><ul><li>7. Iced saline does not harm humans. </li></ul><ul><li>8. Who, what, why, how, when, where of iced saline in your EMS organization. </li></ul><ul><ul><li>ITD=IMPEDANCE THRESHOLD DEVICE, i.e. RES-Q-POD </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    5. 5. Standard of Care, 2005 <ul><li>Hypothermia for comatose cardiac arrest survivors is the standard of care </li></ul><ul><li>American Heart Association position statement </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    6. 6. Colorado Rule 500 update *Effective 4/30/09 Porter, Littleton and Parker EMS 303-765-6EMS
    7. 7. In case you missed it… Porter, Littleton and Parker EMS 303-765-6EMS
    8. 8. In case you missed it….. <ul><li>Moderate hypothermia has been proven to improve neurologic outcome in cardiac arrest patients who remain comatose after ROSC </li></ul><ul><li>26% neuro intact vs. 49% with 12 hours of lower body temp to 33 C </li></ul><ul><li>American Heart 2A recommendation </li></ul><ul><li>ILCOR recommendation </li></ul><ul><ul><li>ILCOR=INTERNATIONAL LIAISON COMMITTEE ON RESUSCITATION </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    9. 9. Why dead dogs say it works <ul><li>Dog studies have shown that in dogs, after the initiation of CPR, blood flow to the brain DECREASES as the time of the no-flow state INCREASES </li></ul><ul><li>Pre-treatment with moderate levels of hypothermia eliminates this effect, which in part explains how it works. </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    10. 10. Newsweek, July 2007 Porter, Littleton and Parker EMS 303-765-6EMS
    11. 11. European Study, 2002 Porter, Littleton and Parker EMS 303-765-6EMS
    12. 12. Neurological outcome/mortality at 6 months--Europe Porter, Littleton and Parker EMS 303-765-6EMS 56/137(41%) 76/138(55%) Death 75/136(55%) 54/137(39%) Favorable neurologic outcome HYPOTHERMIA NORMOTHERMIA OUTCOME
    13. 13. Australia Study, 2002 Porter, Littleton and Parker EMS 303-765-6EMS
    14. 14. Concept #2 Is faster better when it comes to cooling? <ul><li>Results from animal studies suggest that further improvements in neurologic outcome may be possible if hypothermia is induced during CPR and before ROSC </li></ul><ul><li>Sterz study - 30 dogs in VF x 10 min. </li></ul><ul><li>3 groups— </li></ul><ul><ul><li>control, </li></ul></ul><ul><ul><li>cool during CPR </li></ul></ul><ul><ul><li>cool after ROSC </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    15. 15. Sterz, 1991 results Porter, Littleton and Parker EMS 303-765-6EMS
    16. 16. Conclusions - Sterz <ul><li>Mild hypothermia started during or immediately after CPR improves neurologic recovery </li></ul><ul><li>Brain histology and outcome data were not significantly different between the 2 cooled groups </li></ul><ul><li>That is—can probably wait until ROSC to start cooling </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    17. 17. Concept #3 Delayed cooling leads to less favorable outcome <ul><li>Can cooling wait 15 minutes until the patient gets to the ED? </li></ul><ul><li>18 dogs in 3 groups-control, instant cooling to 34 C and delayed cooling for 15 minutes </li></ul><ul><li>VF x 5 minutes; animals revived with cardiopulmonary bypass and defib </li></ul><ul><li>Kuboyama </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    18. 18. Kuboyama - data Porter, Littleton and Parker EMS 303-765-6EMS
    19. 19. Kuboyama - conclusions <ul><li>Mild resuscitative cerebral hypothermia induced immediately with reperfusion after arrest improves cerebral function </li></ul><ul><li>Delay of 15 minutes in starting cooling may not improve functional outcome over the normothermic controls </li></ul><ul><li>That is, don’t wait till the ED </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    20. 20. More delayed cooling… <ul><li>17 dogs, VF x 3 min, 7 min of CPR </li></ul><ul><ul><li>Group 1(n=9) cooled to 34 C at 10 minutes </li></ul></ul><ul><ul><li>Group 2(n=8) cooled to 34 C at 20 min </li></ul></ul><ul><li>Outcome measurements were: </li></ul><ul><ul><li>Outcome performance category; OPC 1 is normal, OPC 4 is coma, OPC 5 is dead </li></ul></ul><ul><li>Nozari, 2006 </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    21. 21. Nozari, data Porter, Littleton and Parker EMS 303-765-6EMS
    22. 22. Nozari, conclusions <ul><li>Early application of mild hypothermia with cold saline during prolonged CPR enables intact survival </li></ul><ul><li>Delay in cooling markedly reduces its efficacy </li></ul><ul><li>That is, don’t wait until the ED </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    23. 23. Iced saline before/during CPR defibrillation? <ul><li>Researchers are looking at getting animal colder sooner and looking at impact on resuscitation </li></ul><ul><li>Boddicker, (2005) - 32 pigs </li></ul><ul><li>Abella, (2004) - 30 mice </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    24. 24. Abella, 2004 <ul><li>VF x 8 minutes for all 30 mice </li></ul><ul><li>CPR plus fluids: </li></ul><ul><ul><li>Group 1(n=10) Intra-arrest cooling to 30 C with ice water blanket </li></ul></ul><ul><ul><li>Group 2(n=10) Post-ROSC to 30 C, 20 minute delay in starting </li></ul></ul><ul><ul><li>Group 3(n=10) control at 37 C </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    25. 25. Abella, 2004 Porter, Littleton and Parker EMS 303-765-6EMS
    26. 26. Abella, 2004 Porter, Littleton and Parker EMS 303-765-6EMS
    27. 27. Abella, conclusions <ul><li>Induction of intra-arrest cooling with a cold blanket reduces mortality rates after cardiac arrest compared with either normothermic resuscitation or delayed hypothermic conditions. </li></ul><ul><li>In other words, start it during CPR </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    28. 28. Boddicker, 2005 <ul><li>4 groups of 8 pigs put into VF x 8 minutes </li></ul><ul><li>Normothermic </li></ul><ul><li>Mild hypothermia 35 C </li></ul><ul><li>Moderate hypothermia 33 C </li></ul><ul><li>Severe hypothermia 30 C </li></ul><ul><li>Endpoints-success of 1 st shock, total # of shocks, # achieving ROSC </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    29. 29. Boddicker, 2005 Porter, Littleton and Parker EMS 303-765-6EMS
    30. 30. Boddicker 2005 Porter, Littleton and Parker EMS 303-765-6EMS
    31. 31. Boddicker, 2005 Porter, Littleton and Parker EMS 303-765-6EMS
    32. 32. Boddicker, conclusions <ul><li>Moderate (33 C) or severe (30 C) hypothermia allows better defibrillation success and resuscitation outcome </li></ul><ul><li>In other words, </li></ul><ul><li>get them cool </li></ul><ul><li>as fast as possible </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    33. 33. Concept #5 <ul><li>Iced saline administration </li></ul><ul><li>in the field can be cheap </li></ul><ul><li>Iced saline is effective </li></ul><ul><li>at lowering temperatures </li></ul><ul><li>Iced saline is feasible </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    34. 34. 38 Bucks at Target Porter, Littleton and Parker EMS 303-765-6EMS
    35. 35. 20 Bucks at Target Porter, Littleton and Parker EMS 303-765-6EMS
    36. 36. About $3 Online Porter, Littleton and Parker EMS 303-765-6EMS
    37. 37. Cooler Experiment Porter, Littleton and Parker EMS 303-765-6EMS
    38. 38. Cooler Experiment Porter, Littleton and Parker EMS 303-765-6EMS
    39. 39. Bernard’s Iced Saline Study, 2002 <ul><li>22 cardiac arrest patients with ROSC </li></ul><ul><li>Given 30cc/kg of 4 degree C LR over 30 minutes once they got to ED </li></ul><ul><li>Median temp dropped from 35.5 to 33.8 C(1.7 degrees C) </li></ul><ul><li>Improved mean BP, no CHF seen </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    40. 40. Kim, Seattle, 2007 <ul><li>Studied the feasibility, efficacy & safety of 2 liters of 4 degree C saline </li></ul><ul><li>63 patients cooled, 62 control pts. </li></ul><ul><li>Given saline in field post ROSC </li></ul><ul><li>Findings—it was feasible to get at least 500cc—2 liters in before arrival to ED </li></ul><ul><li>with a pressure bag in 78% of the patients </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    41. 41. Kim, Seattle, 2007 <ul><li>It was effective at lowering temp 1.2 plus/minus 1 degree C </li></ul><ul><li>Average hospital arrival temp 34.7 </li></ul><ul><li>Safety-cooled group had higher blood pressures, slight drop in pH(0.1) no CHF </li></ul><ul><li>Nonsignificant trend toward survival to hospital discharge when presenting rhythm was VF </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    42. 42. Concept #6 <ul><li>So who is giving iced saline in the field and is publishing positive results? </li></ul><ul><li>Wake County, NC </li></ul><ul><li>1200 patients studied as sequential 2005 guidelines, ITD, iced saline were added </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    43. 43. Wake County EMS data Porter, Littleton and Parker EMS 303-765-6EMS
    44. 44. Survival – All Rhythms 4.6% 7.3% 8.2% 11.6% * when compared with baseline P<0.05* Porter, Littleton and Parker EMS 303-765-6EMS
    45. 45. Comparison of Outcomes Hypothermia vs. Baseline * P <0.05 when compared with baseline * * * * Porter, Littleton and Parker EMS 303-765-6EMS
    46. 46. Concept #7 – Do no harm <ul><li>Harm can occur if you drop below core temp of 32 C (arrhythmia) </li></ul><ul><li>No more time spent in field </li></ul><ul><li>ACLS drugs work fine at 32-34 C </li></ul><ul><li>No CHF seen—no pulmonary edema or drop in left ventricle ejection fraction in Kim’s or Bernard’s studies </li></ul><ul><li>MAP improved 20 mm Hg </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    47. 47. Discussion - who, what, why, etc.. <ul><li>Who gets chilled and who doesn’t? </li></ul><ul><li>What will protocol look like? </li></ul><ul><li>Where is destination after ROSC? </li></ul><ul><li>When do we start it - during CPR or after ROSC? </li></ul><ul><li>Why can’t we wait till the ED to cool? </li></ul><ul><li>How do we store & deliver iced saline, take temp, stop shivering? </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    48. 48. Who gets cooled? <ul><li>Inclusion criteria: </li></ul><ul><ul><li>ROSC after cardiac arrest, remains in a coma, temp>34, SBP>90 with/without pressors </li></ul></ul><ul><li>Exclusion criteria: </li></ul><ul><ul><li>Active bleeding, recent major surgery, severe infection, traumatic arrest, obviously pregnant, age<18, DNR </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    49. 49. What does protocol look like? <ul><li>Miami </li></ul><ul><li>Wake County </li></ul><ul><li>Columbus </li></ul><ul><li>Colorado Springs </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    50. 50. Porter, Littleton and Parker EMS 303-765-6EMS
    51. 51. Where is the destination? <ul><li>New York City, January 1, 2009 </li></ul><ul><li>Destination = hospital with a cooling program </li></ul><ul><li>Other cities have already done this-Seattle, Miami, Boston, Vienna, London </li></ul><ul><li>Denver-see Rule 500 </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    52. 52. Colorado Rule 500 update *Effective 4/30/09 Porter, Littleton and Parker EMS 303-765-6EMS
    53. 53. Destination <ul><li>Ideal destination hospital would be one with a cardiac cath lab and a therapeutic hypothermia program </li></ul><ul><li>Minnesota data - </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    54. 54. When to start iced saline? <ul><li>During CPR or after ROSC? </li></ul><ul><li>Evidence suggests earlier is better </li></ul><ul><li>No consensus yet; lack big human studies, animal data is compelling </li></ul><ul><li>Likely after ROSC to start with until more data is in </li></ul><ul><li>Studies going on in Seattle, Australia right now re: optimal timing </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    55. 55. Why not? Reasons cited for EMS not doing it <ul><li>Burdened with other tasks(62%) </li></ul><ul><li>Short transport times(61%) </li></ul><ul><li>Lack of fridge equipment(60%) </li></ul><ul><li>Receiving hospital doesn’t chill(57%) </li></ul><ul><li>Lack of prehospital guidelines(62%) </li></ul><ul><li>Suffoletto, 2007 </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    56. 56. How? <ul><li>How do we store iced saline? </li></ul><ul><li>How do we take the temperature? </li></ul><ul><li>How do we control shivering? </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    57. 57. Kim’s fridge, Seattle 2007 Porter, Littleton and Parker EMS 303-765-6EMS
    58. 58. Engel Model 15 <ul><li>0 degrees F to 40 F </li></ul><ul><li>$400 </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    59. 59. Refrigeration Devices <ul><li>Engel model 15 portable freezer </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    60. 60. Fridge in Supervisor’s SUV Porter, Littleton and Parker EMS 303-765-6EMS
    61. 61. Blue ice/ice - 28-30F for 30 hours Porter, Littleton and Parker EMS 303-765-6EMS
    62. 62. <ul><li>Prime IV set. </li></ul><ul><li>Press button to activate. </li></ul><ul><li>Cools in less than 60 seconds. </li></ul><ul><li>Cools 2 liters to average 4 - 6˚C. </li></ul>Set up and use Porter, Littleton and Parker EMS 303-765-6EMS
    63. 63. <ul><li>Single-use, sterile disposable. </li></ul><ul><li>Room temperature storage. </li></ul><ul><li>Requires no power. </li></ul><ul><li>No hazardous chemicals. </li></ul><ul><li>Portable - 1.8kg </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    64. 64. Arctic Blast update <ul><li>As of April 2009, the project is currently on hold per Medivance </li></ul><ul><li>Device has been FDA approved </li></ul><ul><li>May be available on a trial basis or for sale later in year </li></ul><ul><li>Price point-about $250 </li></ul><ul><li>? billable to patient, 2 year shelf life </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    65. 65. Colorado Springs <ul><li>Plug-in pelican box </li></ul><ul><li>Rewire ambulance, $500 each for Springs, $799 in ad </li></ul><ul><li>Carries 2 liters of NS </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    66. 66. Colorado Springs Porter, Littleton and Parker EMS 303-765-6EMS
    67. 67. Temperature Probes in the Field <ul><li>Tympanic </li></ul><ul><li>Esophageal </li></ul><ul><li>Rectum (damned near killed him!) </li></ul><ul><li>“ You will not get the medics near the patient’s rectum. Ever.”— Gene Eby, MD </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    68. 68. Esophageal Probes $10 each disposable, or $60 reusable, cidex Porter, Littleton and Parker EMS 303-765-6EMS
    69. 69. Esophageal Thermometer $130 Porter, Littleton and Parker EMS 303-765-6EMS
    70. 70. 38 Bucks at Target <ul><li>Wake County protocol—start saline if tympanic is >34 </li></ul><ul><li>Do no harm- tympanics are less reliable than esophageal but are quicker, less invasive and we just don’t want to get patient below 32 C </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    71. 71. Shivering Control - Paralytics <ul><li>Vecuronium- up to 10mg dose, will paralyze patient for 45 minutes </li></ul><ul><li>Doesn’t allow clinician to do neuro exam, may mask status epilepticus and insufficient sedation </li></ul><ul><li>Not necessary for short transports when shivering may not develop </li></ul><ul><li>Not likely to be approved </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    72. 72. Shivering Control <ul><li>Opiates - fentanyl, morphine, Demerol work well. Fentanyl and morphine already on the rigs. Reversible if BP drops. </li></ul><ul><li>Benzos - Versed, Valium </li></ul><ul><ul><li>work much less well but some agencies use </li></ul></ul><ul><li>Propofol - brief, has anti-convulsant properties, can drop BP </li></ul><ul><li>Etomidate - stable BP, lasts 45 minutes not likely to be approved for shivering </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    73. 73. Closing thoughts <ul><li>HACA saves brains/lives </li></ul><ul><li>Delaying HACA ruins brains/lives </li></ul><ul><li>Starting HACA sooner saves animal brains and maybe humans-data is pending </li></ul><ul><li>You will not do harm if protocol followed; State EMS says OK to do </li></ul><ul><li>Porter / Littleton / Parker EMS is here to help </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    74. 74. What agencies need to do <ul><li>Fund cooling equipment </li></ul><ul><li>Fund temperature equipment </li></ul><ul><li>Develop protocol </li></ul><ul><li>Train staff </li></ul><ul><li>Call base station to coordinate Arctic Sun and alert cardiac cath lab </li></ul><ul><li>Follow outcomes </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
    75. 75. Thank you <ul><li>Dr. Paul Davidson, EMS and ED MD </li></ul><ul><li>Porter, Littleton and Parker Adventist Hospitals, Emergency Medical Services </li></ul><ul><li>[email_address] </li></ul><ul><li>303-765-6EMS </li></ul>

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