ACLS/ Theraputic Hypothermia presentation

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Power point on the basics of CPR and Hypothermia post ROSC

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ACLS/ Theraputic Hypothermia presentation

  1. 1. CPR and Therapeutic Hypothermia
  2. 2. <ul><li>Do NOT stop chest compressions. </li></ul><ul><li>No more than five seconds hands off time. </li></ul><ul><li>Compress during defib charge time. </li></ul><ul><li>Do NOT check pulse after defib. Continue compressions for 2 minutes. </li></ul><ul><li>Do not stop compressions for intubation attempts. Either intubate during compressions or use the king airway. </li></ul><ul><li>The Mnemonic for a patient in cardiac arrest is now C-A-B. Not A-B-C. </li></ul><ul><li>It takes more than 1 min of good chest compressions to return CPP to pre pause levels. 1 </li></ul><ul><li>The AHA has set forth new guidelines for the BLS field termination of CPR. 2 </li></ul><ul><li>NEVER hyperventilate your patient. 6-8 BPM </li></ul>
  3. 3. How the damage is done <ul><li>It was thought that hypoxia causes the damage, this is somewhat indirect. </li></ul><ul><li>Free radicals, generated when the cells are flooded with O2, are the actual culprit. </li></ul>
  4. 4. <ul><li>Free radicals basically tear off an electron from part of the cell. Most critical damage occurs in the Mitochondria. </li></ul>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 <ul><li>Studied since the 1900s (1905). </li></ul><ul><li>Known to be beneficial since the 1950s </li></ul><ul><li>Slow to be accepted. </li></ul><ul><li>Wake County EMS studied and implemented the first widely known EMS Therapeutic hypothermia protocol in 2006 </li></ul><ul><li>Many agencies already doing this have tripled or more their survival to discharge . </li></ul><ul><li>Number to treat is 8 or less. </li></ul>
  6. 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
  7. 8. Neurologically intact – VF/VT 28% 20% 17% 10% Wake County NC
  8. 9. We can achieve the same <ul><li>You must achieve ROSC. Vasopressor for SBP less than 90. </li></ul><ul><li>Measure their temperature using the NG inserted temp probe. If you are unable to measure temp due to lack of supplies Initiate Hypothermia anyway! </li></ul><ul><li>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) </li></ul><ul><li>Achieve ROSC. </li></ul><ul><li>Secure airway place Capnography and Temp probe. </li></ul><ul><li>Infuse 2 L NS or LR. (Up to 30ml/kg safely) </li></ul>
  9. 10. <ul><li>Expose pt and place ice packs. </li></ul><ul><li>Groin Bilaterally </li></ul><ul><li>Axilla Bilaterally </li></ul><ul><li>Carotid Bilaterally </li></ul>External Elements of Cooling <ul><li>For every Degree cooled the pts cerebral O2 demand decreases by about 8%. </li></ul><ul><li>At our target hypothermia temperatures the O2 demand is cut in half! 3 </li></ul>
  10. 11. Exclusions -- Contraindications <ul><li>Traumatic arrest Do not confuse this with asphyxia arrest (hanging ect.) </li></ul><ul><li>Actual or suspected uncontrollable bleeding internal bleeding </li></ul><ul><li>Pregnancy obvious or known </li></ul><ul><li>Cardiac Instability Recurring refractory arrhythmias. Somewhat common </li></ul><ul><li>Uncontrollable Hypotension MAP <70 despite the use of Vasopressor </li></ul><ul><li>Frank Pulmonary Edema </li></ul><ul><li>Pre-existing Environmental Hypothermia </li></ul>
  11. 12. Inclusion Criteria <ul><li>Patients in V-fib and non V-fib arrest </li></ul><ul><li>Pts received chest compressions Defibrillation(s) Even by FD or bystander prior your arrival. </li></ul><ul><li>Patient has achieved ROSC </li></ul><ul><li>Age >18 yrs We are not including pediatrics at this time. </li></ul><ul><li>Pt not following commands or GCS less than 8. </li></ul><ul><li>Transport patients to hypothermia capable facilities ONLY. Please keep yourself up to date on who this is. </li></ul>
  12. 13. Side effects to know <ul><li>A number of potential complications are associated with cooling, including coagulopathy, arrhythmias, and hyperglycemia, particularly with an unintended drop below target temperature. 4 </li></ul><ul><li>The likelihood of pneumonia and sepsis may also increase. </li></ul><ul><li>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 . </li></ul>
  13. 14. Looking to the Future <ul><li>Many different devices are being tested and many are approved and being used. </li></ul>
  14. 15. More uses for hypothermia <ul><li>CVA? </li></ul><ul><li>Closed head injury? </li></ul><ul><li>Spinal cord injury? </li></ul><ul><li>MI? </li></ul><ul><li>Trauma? </li></ul><ul><li>… ..? </li></ul>
  15. 16. The future of CPR <ul><li>Several devices are available and show great promise. A few are AHA recommended . </li></ul>Autopulse Lucas Device
  16. 17. Summary <ul><li>Therapeutic hypothermia is cheap and easy. </li></ul><ul><li>The science supporting this therapy is vast and growing. </li></ul><ul><li>The risk to the patient is negligible. </li></ul><ul><li>There is NO REASON to not provide this therapy. </li></ul>
  17. 18. References <ul><li>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 </li></ul><ul><li>2 2010 AHA Guidelines </li></ul><ul><li>3 Thorac Cardiovasc Surg 2006;132:153-154 </li></ul><ul><li>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. </li></ul>

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