This document summarizes a study conducted by the NYC Project Hypothermia Working Group to evaluate the effects of intra-arrest induction of therapeutic hypothermia via large-volume ice-cold saline infusion on survival outcomes for out-of-hospital cardiac arrest. The study found that administering large volumes of ice-cold saline during cardiac arrest resuscitation efforts improved rates of return of spontaneous circulation and survival to hospital discharge when compared to a control period without this intervention. Further research is still needed to evaluate the long-term effects and most appropriate patient populations.

1. NYC Project Hypothermia Working Group*
represented by
John Freese, M.D.
Chief Medical Director
Fire Department of New York
and
Principal Investigator
NYC Project Hypothermia

2. Timeline
2003-2008: Fire Department of New York (FDNY)and
New York City Regional Emergency
Medical Advisory Committee (REMAC)
work to optimize prehospital resuscitation
protocols
2008: FDNY, REMAC, Greater New York
Hospital Association, Health and Hospitals
Corporation, New York City Department of
Health and Mental Hygiene, and New York
State Department of Health develop NYC
Project Hypothermia

3. Jan 5, 2009: NYC Project Hypothermia – Phase I
initiated (selective transport of successfully
resuscitated cardiac arrest patients to
hospitals providing therapeutic
hypothermia)

4. Aug 1, 2010: NYC Project Hypothermia – Phase II
initiated (intra-arrest induction of
therapeutic hypothermia via large-
volume, ice-cold saline infusion)

5. We sought to assess the effects of intra-arrest
induction of therapeutic hypothermia via
large-volume, ice-cold saline (LVICS)
infusion on immediate survival end-points
for out-of-hospital cardiac arrest (OOHCA).

6. Data was gathered from the FDNY’s Cardiac
Arrest Registry for the periods in question
with data derived from:
- automated Computer Aided Dispatch
entries
- post-resuscitation phone interview with
paramedics
- prehospital medical record reviews
- ECG data review
- mandatory hospital data reporting

7. Control Period = August 1, 2009 – May 31, 2010
Study Period = August 1, 2010 – May 31, 2011

8. Control Period = August 1, 2009 – May 31, 2010
Advanced Cardiac Life Support-style protocol
- CPR (including delayed defibrillation for non-EMS
witnessed arrests)
- initial defibrillation attempts
- airway management (including intubation)
- consider treatments for reversible causes of
bradyasystolic arrests
- vasopressin
- epinephrine
- atropine
- amiodarone
- additional treatments after consultation with medical
control physicians

9. Study Period = August 1, 2010 – May 31, 2011
Advanced Cardiac Life Support-style protocol
- CPR (including delayed defibrillation for non-EMS
witnessed arrests)
- initial defibrillation attempts
- airway management (including intubation)
- consider treatments for reversible causes of
bradyasystolic arrests
- intra-arrest initiation of therapeutic hypothermia
- vasopressin
- epinephrine
- atropine
- amiodarone
- additional treatments after consultation with medical
control physicians

10. Intra-arrest initiation of therapeutic hypothermia
- large-bore (>18g or greater) IV or IO access
- ice-cold saline (stored at 2.5oC, infusion ~4oC)
- large-volume (30cc/kg, maximum 2 liters)
- pressure infusion sleeve
Exclusions
- pulmonary edema
- neurologically intact following initial resuscitation
- loss of or inability to maintain IV/IO access
- ice-cold saline not available at the time of
resuscitaiton

11. Neither group included traumatic arrests or those of
hemorrhagic etiology.
All other arrests were included regardless of
presenting rhythm, etiology, or arrest
characteristics.
Standard Utstein definitions were utilized.
Chi-square analyses without Yates’ correction were
utilized (p<0.05 = significant).

12. Control Period = 5,738 resuscitations
Study Period = 5,856 resuscitations
with LVICS 4,571**
** Due to the lack of required equipment among
some advanced life support ambulances in the
New York City 911 system during the study
period.

13. Control Period Study Period (with LVICS) p
N 5,738 4,571 0.821
Male gender 3,008 (52.4%) 2,386 (52.2%) 0.837
Age < 80 3,777 (65.8%) 2,938 (64.3%) 0.105
Race (black) 1,644 (28.7%) 1,338 (29.3%) 0.504
EMS < 5 min 3,819 (66.6%) 3,124 (68.3%) 0.057
Cardiac Etiology 4,447 (77.5%) 3,578 (78.3%) 0.359
Bystander Witnessed 1,731 (30.2%) 1,444 (31.6%) 0.125
EMS Witnessed 516 (8.9%) 364 (8.0%) 0.068
Bystander CPR 1,853 (32.3%) 1,509 (33.0%) 0.769

14. Average infusion volume: 1260ml (range 100-2000)
On-scene termination of resuscitation: 1,866 (40.8%)
End-tidal CO2 values
No difference in the percentage of patients
receiving ALS medications during the
resuscitation (89.1% vs 94.2%, p=0.096).
Initial CO2 (mean) Ten Minute CO2 (mean)
Control 21.4mmHg 21.7mmHg
Study Period 21.8mmHg 22.8mmHg

15. P<0.001
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Control Period Study Period (LVICS)
27.90%
32.57%
ROSC

16. P<0.001
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Control Period Study Period (LVICS)
21.05%
24.75%
SROSC

17. 0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Control Period Study Period (LVICS) Study Period (>150cc)
27.90%
32.57%
38.04%
ROSC
P<0.001
P<0.001
P<0.001
Control Period Study Period (LVICS) Study Period
(>1,500 ml LVICS)

18. 0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Control Period Study Period (LVICS) Study Period (>150cc)
21.05%
24.75%
26.76%
SROSC
P<0.001
P<0.001
P=0.094
Control Period Study Period (LVICS) Study Period
(>1,500 ml LVICS)

19. The administration of large-volume, ice-cold
saline for the intra-arrest initiation of
therapeutic hypothermia improves immediate
survival for out-of-hospital cardiac arrest.
Further work is required to assess the impact of
this effect on long-term, neurologically intact
survival and specific patient populations for
which this therapy may be of greatest benefit.

20. Co-Investigators
Stephan Mayer, MD
Scott Weingart, MD
David Prezant, MD
Greater New York Hosp ital Association
Zeynep Sumer
New York Downtown Hospital
Alexander Slotwiner, MD
Bellevue Hospital Center
Norma Keller, MD
Priscilla Legette, RN
Robert Roswell, MD
Beth Israel Medical Center – Petrie Division
Pierre Daniel Kory, MD
Harlem Hospital Center
Reynold Trowers, MD
Lenox Hill Hospital
Bushra Mina, MD
Metropolitan Hospital Center
Elliott Perla, MD
Mount Sinai Medical Center
Jennifer Frontera
New York Presbyterian Hospital – Cornell
Maureen McCauley, RN
Oren Friedman, MD
New York University Medical Center – Tisch
Margaret Myburgh
New York Presbyterian Hospital – Columbia
Stephan Mayer, MD
Hector Lantigua
St. Luke’s – Roosevelt Hospital
Dan Wiener, MD
Montefiore Medical Center
Robert Forman, MD
Angela Toro
Laura Gallo
Bronx Lebanon Hospital – Concourse
Charles Martinez, MD
Stacy Nunberg
John Coffey, MD
Jacobi Medical Center
Alex Cohen, MD
Lincoln Medical and Mental Health Center
Raghu Loganathan, MD
Rafalena Estrella
Montefiore Medical Center
Mank Menegus, MD
Elmhurst Hospital Center
Scott Weingart, MD
Flushing Medical Center
Wei Chen, MD
Jamaica Hospital
Geoffrey Doughlin, MD
North Shore – Long Island Jewish Medical Center
Paul Mayo, MD
Peninsula Hospital Center
Phyllis Prawzinsky, RN
Queens Hospital Center
Ricardo Lopez
St. John’s Episcopal Hospital
Eric Nazziola, MD
Brookdale University Hospital
Lewis Marshall, MD
Coney Island Hospital
Edmund Giegrich, MD
David Neckritz
Svetlana Makhover
Alisa Milevich
Marie Longo
Woodhull Medical and Mental Health Center
Samuel Agyare, MD
Tahira Chaudhry, MD
Kingsbrook Jewish Medical Center
Phillip Hew, MD
Kings County Hospital Center
Robert Kurtz, MD
Long Island College Hospital
Joshua Rosenberg, MD
Lutheran Medical Center
Beth Raucher, MD
Mary Margaret Heaney, RN
Gloria Tsan, MD
Maimonides Medical Center
Sheila Namm
New York Methodist Hospital
Josef Schenker, MD
Jessica Van Voorhees, MD
Interfaith Medical Center
Russell Robinson
Staten Island University
Theodore Maniatis, MD
Richmond University Medical Center
Jay Nfonoyim, MD
Mount Sinai Hospital of Queens
Yi-An Lee, MD
Arunakumari Timmireddy
North Shore University Hospital
Todd Slesinger, MD
St. Barnabas Hospital
Ernest Patti, MD
NY Westchester Square Medical Center
Jasminder Luthra, MD
NY Community Hospital of Brooklyn
Una Morrissey, RN
Beth Israel Medical Center – Kings Highway
Susanne Stefko
Ann O’Neill
Kimberly Henderson
Ramy Yakobi
Brooklyn Hospital Center
Sylvie DeSauza, MD
NYC Regional Emergency Medical Advisory
Committee
Joe Bove, MD
NYC Department of Health and Mental
Hygiene
Olivette Burton (IRB Chair)
NYS Department of Health
Lee Burns
Mark Henry, MD

21. All of the Certified First Responders, Emergency
Medical Technicians, and Paramedics of the
FDNY and the New York City 9-1-1 System.