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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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    Refresher    hypothermia tx Refresher hypothermia tx Presentation Transcript

    • Hypothermia in Cardiac Arrest
      By Jon Willoughby
    • 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
    • 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
    • Post Resuscitative Care
      You got them back!
      Now What???????
    • 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)
    • 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
    • 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
    • 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
    • Therapeutic Hypothermia to Improve Neurologic Outcome After Cardiac Arrest
      Hypothermia
      after Cardiac
      Arrest Study
      Group, NEJM
      2002;346(8): 549
    • Post-Resuscitation TherapeuticHypothermia
      [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
    • Neurological Outcome and Survival at 6 months
      NEJM 2002, 346:549
    • 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).
    • 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)
    • 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)
    • 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
    • Speeds of Cooling
      Plattner O et al,
      “Efficacy of
      Intraoperative
      Cooling Methods”,
      Anesthesiology:
      Volume 87(5)
      November 1997 pp
      1089-1095
    • 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.
    • 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/
    • 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/
    • 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/
    • 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/
    • Questions?