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Refresher hypothermia tx

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Induced Mild Hypothermia in Cardiac Arrest

Induced Mild Hypothermia in Cardiac Arrest

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  • 1. By Jon Willoughby
  • 2. Resuscitation After Cardiac Arrest: A 3 Phase Time Sensitive Model  The Electrical Phase: 0 to 4 minutes post VF onset  If defibrillation is achieved, excellent outcome  Little need for ventilation or drugs  The Circulatory Phase: 4 to 10minutes post VF onset  Cardiac and CNS hypoxia  Poor organ function even if defibrillation is achieved  Provide circulation to ‘prime the pump’  Re-fibrillation common – consider anti-arrhythmics  The Metabolic Phase: >10 minutes post VF onset  Consider hypothermia  Is epinephrine harmful? Weisfeld et al, JAMA 2002;288:23
  • 3. Improving ACLS  Delaying defibrillation (CPR first)  Improving CPR- better thoracic vacuum during decompression  Mono vs. biphasic defibrillation  Constant vs. incrementing energy defibrillation  Vasopressors  Epinephrine  Vasopressin – only shown to be better in Asystole  Antiarrhythmic drugs
  • 4. Post Resuscitative Care  You got them back!  Now What???????
  • 5. Why do we need to improve post resuscitative care?  The median incidence of EMS-treated cardiac arrest across sites was 52.1 per 100 000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4%.  Median ventricular fibrillation incidence was 12.6 per 100 000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% with significant differences across sites for incidence and survival  When polled people believe that there is a 65% survivability of cardiac arrest vs. the actual 8.4% Graham Nichol; Elizabeth Thomas; Clifton W. Callaway; et al. JAMA. 2008;300(12):1423-1431 (doi:10.1001/jama.300.12.1423)
  • 6. Why should we????  Only 10% of cardiac arrests that arrive at hospital alive survive to go home !  About 60% of cardiac arrest survivors regain consciousness  1/3 experience irreversible cognitive disabilities …this is where therapeutic hypothermia has its effect
  • 7. Therapeutic Hypothermia  The goal of therapy =  initiate within 2-4 hours of return of spontaneous circulation  target core temperature of 32-34°C reached within 6 hours after initiation of treatment.  Theory is based in its ability to prevent the cascade of events following a cardiac arrest which inhibit neurologic functioning
  • 8. How it is thought to work  Slows ongoing hypoxic neurologic damage following cardiac arrest  Several mechanisms:  Reduces cerebral metabolic rate  Suppresses free radical production  Suppresses excitatory amino acid release  Suppresses calcium shifts  Effects recognized since the 1950’s
  • 9. Therapeutic Hypothermia to Improve Neurologic Outcome After Cardiac Arrest Hypothermia after Cardiac Arrest Study Group, NEJM 2002;346(8): 549
  • 10. Post-Resuscitation Therapeutic Hypothermia 0% 10% 20% 30% 40% 50% 60% 70% Holzer et al [1] Bernard et al [2] Survival with Normothermic recovery Survival with Hypothermic recovery [1] Holzer et al, NEJM 2002; 0.3C/hr cooling with cold air and ice packs [2] Bernard et al, NEJM 2002; 0.9C/hr cooling with ice packs
  • 11. Neurological Outcome and Survival at 6 months 0% 10% 20% 30% 40% 50% 60% Favorable Death Normothermia Hypothermia NEJM 2002, 346:549
  • 12. Standard of Care AHA Guidelines Nov 2005  Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to:  32°C to 34°C  for 12 to 24 hours when the initial rhythm was ventricular fibrillation (VF).  Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrest. (Level of Evidence: IIb) CIRCULATION AHA :105, 166560 V1 (1).
  • 13. Who should get cooled?  Greater than 18 years of age  Non-traumatic cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia  return of spontaneous circulation without full neurological recovery (i.e. comatose)
  • 14. Who should not get cooled  Pregnancy  Severe cardiogenic shock  Primary coagulopathies  DNR status  Coma unrelated to cardiac arrest  Received CPR greater than 45 minutes  Suffered a cardiac arrest that is not due to primary VF or Vtach (e.g. PEA, asystole, non-cardiac, etc)
  • 15. Various cooling methods  They differ greatly by time to cool and cost:  Ice bags at axillae & groin  Rapid infusion of cold saline  Cooling Blanket  ThermoSuit  Ice Bath (Artic Sun)  Neural Cooling device
  • 16. Speeds of Cooling Plattner O et al, “Efficacy of Intraoperative Cooling Methods”, Anesthesiology: Volume 87(5) November 1997 pp 1089-1095
  • 17. What does the treatment involve?  Temperature goal 32° - 34° C. within 2-6 hours.  Monitor temperature with esophageal probe Q1h  MAP goal 60-80 mm/Hg  Maintain HOB at 30 ° C elevation.  No heated humidification on the ventilator  Maintain PO2 90 – 100 mmHg  Maintain pH within normal range  Begin enteric feeding as soon as practical.  Passively re-warm (no heating blanket) after 24 hours of cooling has been completed.
  • 18. Pre-Hospital Cooling Richmond Ambulance Authority  The VCU and RAA initiative, known as the Advanced Resuscitation Cooling Therapeutics and Intensive Care Center (ARCTIC)return of spontaneous circulation, from 25 percent in 2001 using conventional treatments to 46 percent in 2008. "Resuscitation and Survival Rates". Published by the Richmond Ambulance Authority, November 16, 2009. retrieved 10-16-10 http://www.raaems.org/content/view/95/2/
  • 19. Pre-Hospital Cooling Richmond Ambulance Authority  In turn, the survival rate to hospital discharge improved from 9.7 percent in 2003 to 17.9 percent at the end of 2008. The national average is less than 7 percent. "Resuscitation and Survival Rates". Published by the Richmond Ambulance Authority, November 16, 2009. retrieved 10-16-10 http://www.raaems.org/content/view/95/2/
  • 20. Pre-Hospital Cooling Richmond Ambulance Authority  ARCTIC has two goals: to restart the heart as quickly as possible following onset of cardiac arrest, and to protect the brain by starting cooling as early as possible and bringing resuscitated patients to a single specialized post-resuscitation facility. "Resuscitation and Survival Rates". Published by the Richmond Ambulance Authority, November 16, 2009. retrieved 10-16-10 http://www.raaems.org/content/view/95/2/
  • 21. Pre-Hospital Cooling Richmond Ambulance Authority  Between 2001 and 2008, the team evaluated 1,598 cases of adult, out-of-hospital cardiac arrest events in Richmond, Va., and concluded that a building block strategy comprised of a unique combination of mechanical chest compressions, airway management, drugs that restart the heart, and cold saline given during resuscitation prior to the return of spontaneous circulation, sequentially improved patient outcomes. "Resuscitation and Survival Rates". Published by the Richmond Ambulance Authority, November 16, 2009. retrieved 10-16-10 http://www.raaems.org/content/view/95/2/
  • 22. Questions?