ACLS/ Theraputic Hypothermia presentation
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ACLS/ Theraputic Hypothermia presentation

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Power point on the basics of CPR and Hypothermia post ROSC

Power point on the basics of CPR and Hypothermia post ROSC

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  • 1. CPR and Therapeutic Hypothermia
  • 2.
    • Do NOT stop chest compressions.
    • No more than five seconds hands off time.
    • Compress during defib charge time.
    • Do NOT check pulse after defib. Continue compressions for 2 minutes.
    • Do not stop compressions for intubation attempts. Either intubate during compressions or use the king airway.
    • The Mnemonic for a patient in cardiac arrest is now C-A-B. Not A-B-C.
    • It takes more than 1 min of good chest compressions to return CPP to pre pause levels. 1
    • The AHA has set forth new guidelines for the BLS field termination of CPR. 2
    • NEVER hyperventilate your patient. 6-8 BPM
  • 3. How the damage is done
    • It was thought that hypoxia causes the damage, this is somewhat indirect.
    • Free radicals, generated when the cells are flooded with O2, are the actual culprit.
  • 4.
    • Free radicals basically tear off an electron from part of the cell. Most critical damage occurs in the Mitochondria.
    Free radicals cause Oxidation--- Think rust-- This is the basic theory Hypothermia decreases the oxygen demand and production of free radicals
  • 5.  
  • 6. Therapeutic Hypothermia
    • Studied since the 1900s (1905).
    • Known to be beneficial since the 1950s
    • Slow to be accepted.
    • Wake County EMS studied and implemented the first widely known EMS Therapeutic hypothermia protocol in 2006
    • Many agencies already doing this have tripled or more their survival to discharge .
    • Number to treat is 8 or less.
  • 7. Percentage of All Attempted Resuscitations Neuro Intact 7.8% 6.2% 4.4% 1.9% P <0.05 * Wake County NC * When compared with baseline
  • 8. Neurologically intact – VF/VT 28% 20% 17% 10% Wake County NC
  • 9. We can achieve the same
    • You must achieve ROSC. Vasopressor for SBP less than 90.
    • Measure their temperature using the NG inserted temp probe. If you are unable to measure temp due to lack of supplies Initiate Hypothermia anyway!
    • If more than 34 C begin pressure infusing “iced” NS. Cool to 32°C to 34°C (89.6°F to 93.2°F)for 12 to 24 hours(Class I, LOE B)
    • Achieve ROSC.
    • Secure airway place Capnography and Temp probe.
    • Infuse 2 L NS or LR. (Up to 30ml/kg safely)
  • 10.
    • Expose pt and place ice packs.
    • Groin Bilaterally
    • Axilla Bilaterally
    • Carotid Bilaterally
    External Elements of Cooling
    • For every Degree cooled the pts cerebral O2 demand decreases by about 8%.
    • At our target hypothermia temperatures the O2 demand is cut in half! 3
  • 11. Exclusions -- Contraindications
    • Traumatic arrest Do not confuse this with asphyxia arrest (hanging ect.)
    • Actual or suspected uncontrollable bleeding internal bleeding
    • Pregnancy obvious or known
    • Cardiac Instability Recurring refractory arrhythmias. Somewhat common
    • Uncontrollable Hypotension MAP <70 despite the use of Vasopressor
    • Frank Pulmonary Edema
    • Pre-existing Environmental Hypothermia
  • 12. Inclusion Criteria
    • Patients in V-fib and non V-fib arrest
    • Pts received chest compressions Defibrillation(s) Even by FD or bystander prior your arrival.
    • Patient has achieved ROSC
    • Age >18 yrs We are not including pediatrics at this time.
    • Pt not following commands or GCS less than 8.
    • Transport patients to hypothermia capable facilities ONLY. Please keep yourself up to date on who this is.
  • 13. Side effects to know
    • A number of potential complications are associated with cooling, including coagulopathy, arrhythmias, and hyperglycemia, particularly with an unintended drop below target temperature. 4
    • The likelihood of pneumonia and sepsis may also increase.
    • Hyper thermia is common after resuscitation, temperature elevation above normal can impair brain recovery. The etiology of fever after cardiac arrest may be related to activation of inflammatory cytokines in a pattern similar to that observed in sepsis .
  • 14. Looking to the Future
    • Many different devices are being tested and many are approved and being used.
  • 15. More uses for hypothermia
    • CVA?
    • Closed head injury?
    • Spinal cord injury?
    • MI?
    • Trauma?
    • … ..?
  • 16. The future of CPR
    • Several devices are available and show great promise. A few are AHA recommended .
    Autopulse Lucas Device
  • 17. Summary
    • Therapeutic hypothermia is cheap and easy.
    • The science supporting this therapy is vast and growing.
    • The risk to the patient is negligible.
    • There is NO REASON to not provide this therapy.
  • 18. References
    • 1 Steen S, Liao Q Pierre L, et al: “The critical importance of minimal delay between chest compressions and subsequent defibrillation.” Resuscitation. 2003;58(3):249-258
    • 2 2010 AHA Guidelines
    • 3 Thorac Cardiovasc Surg 2006;132:153-154
    • 4 Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, Valsson F, Wanscher M, Friberg H. Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand . 2009;53:926 –934.