This document discusses therapeutic hypothermia after cardiac arrest and suggests starting it in the emergency department. It defines therapeutic hypothermia and reviews studies showing improved neurological outcomes when mild hypothermia is induced after cardiac arrest. The benefits of therapeutic hypothermia are explained. Methods for inducing hypothermia in the emergency department are presented, including cold intravenous fluids and surface cooling techniques. The document recommends inducing therapeutic hypothermia for comatose cardiac arrest patients with initial rhythms of ventricular fibrillation or pulseless ventricular tachycardia.

1. THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST: SHOULD WE START AT THE EMERGENCY DEPARTMENT
นพ.วินชนะ ศรีวิไลทนต์
ภาควิชาเวชศาสตร์ฉุกเฉิน
คณะแพทยศาสตร์ มหาวิทยาลัยธรรมศาสตร์

2. OBJECTIVE
Definition of Therapeutic hypothermia after cardiac arrest
Benefits of Therapeutic hypothermia
Apply into your emergency department

3. DISCLOSURE
No disclosures related to this presentation

4. WHAT IS THERAPEUTIC HYPOTHERMIA?

5. OUTCOME OF OHCA
ROSC
Survival to D/C
THAI
22.5 – 39.2 %
0 – 5.6 %
USA
26.3 %
8.5 – 11.2 %
Europe
33.5 %
10.7 %
Japan
20 – 33.1 %
12 %

6. CHAIN OF SURVIVAL : AHA 2010
•Immediate recognition and activated EMS (1669)
•Early CPR
•Rapid defibrillation
•Effective ALS
•Integrated Post-Cardiac Arrest Care

7. MANAGEMENT OF THE PATIENT AFTER CARDIAC ARREST
Airway and Breathing
Circulation
Neurological
Metabolic

8. POST-CARDIAC ARREST SYNDROME
Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome. Resuscitation. 2008;79(3):350-79. Epub 2008/10/31.

9. •Induce mild therapeutic hypothermia post cardiac arrest patient that not response to verbal command with
–Initial EKG was VF arrest
(Class I LOE B)
–Initial EKG was PEA or asystole
(Class IIb LOE B)
Peberdy M, Callaway C, Neumar R, et al. Part 9: Post–Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 suppl 3):768-86

10. BENEFITS OF THERAPEUTIC HYPOTHERMIA?

11. CEREBRAL PERFORMANCE CATEGORY SCALE (CPC)

13. Induce mild therapeutic hypothermia
“solitary treatment that prove to increase neurological outcome”

14. RCT 273 patients : 136 in Hypothermia,
137 in Normothermia
Post VF or pulseless VT

15. MILD THERAPEUTIC HYPOTHERMIA TO IMPROVE THE NEUROLOGIC OUTCOME AFTER CARDIAC ARREST

16. RCT 77 patients : 43 in Hypothermia,
34 in Normothermia
Post VF or pulseless VT

17. TREATMENT OF COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST WITH INDUCED HYPOTHERMIA

18. Good neurological outcome (normal or with minimal or moderate disability)
Hypothermia VS Normothermia
= 49% VS 26% (95%CI 13 to 43,P=0.046)
TREATMENT OF COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST WITH INDUCED HYPOTHERMIA

22. EFFECT OF THERAPEUTIC HYPOTHERMIA ON PATIENTS AFTER CARDIAC ARREST ASSOCIATED WITH NON-SHOCKABLE RHYTHMS
Eugene A. Hessel. Therapeutic Hypothermia After In-Hospital Cardiac Arrest: A Critique. Journal of Cardiothoracic and Vascular Anesthesia 2014;28(3):789–99.

23. HOW TO APPLY INTO YOUR EMERGENCY DEPARTMENT?

24. PHASE OF INDUCE MILD THERAPEUTIC HYPOTHERMIA
TEMP
TIME
GOAL
Keep core temperature 32-34C for 12-24 hr.

25. PHASE OF INDUCE MILD THERAPEUTIC HYPOTHERMIA
ผศ.นพ.สมบัติ มุ่งทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. Integrated Post Cardiac Arrest Care.สานักพิมพ์มหาวิทยาลัยธรรมศาสตร์ 2013:63-76

26. TIMING TO START THERAPEUTIC HYPOTHERMIA

31. Increase short term survival (ROSC)
Not difference in long term

32. THERAPEUTIC HYPOTHERMIA IN EMERGENCY DEPARTMENT

38. TEMPERATURE ON HOSPITAL ADMISSION

39. SURVIVAL OUTCOME

40. PHASE OF INDUCE MILD THERAPEUTIC HYPOTHERMIA
ผศ.นพ.สมบัติ มุ่งทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. Integrated Post Cardiac Arrest Care.สานักพิมพ์มหาวิทยาลัยธรรมศาสตร์ 2013:63-76

41. IMPLEMENTATION OF MILD THERAPEUTIC HYPOTHERMIA
Requires a multidisciplinary approach
Include prehospital personnel, emergency physicians and staff
Intensivists and ICU staff
Specialists in neurology and cardiology

42. Invasive techniques
Non-invasive techniques
- Infusion of cold intravenous fluid
- Heat exchange catheter
- Extracorporeal circulating cooled blood
- Intraventricular cerebral hypothermia
- Peritoneal lavage with cool exchanges
- Retrograde jugular vein flush
- Nasal, nasogastric and rectal lavage
- Nasopharyngeal balloon catheters
- Caps or helmets
- Cooling blankets
- Hydrogel-coated cooling pads
- Ice packs
- Immersion in cold water
METHODS TO INDUCE HYPOTHERMIA

43. COLD INTRAVENOUS FLUID

44. HEAT EXCHANGE CATHETER

45. COOLING CAPS

46. COOLING BLANKETS

47. ICE PACKS

48. ICE PACKS

49. HYDROGEL-COATED COOLING PADS

50. SURFACE COOLING
Simple to implement
Usually take 2-8 hr to achieving goal temperature
Often combined with additional cooling method

51. SURFACE COOLING
Hydrogel-coated cooling pads with devices control temperature through feedback mechanism
More expensive
Mean rate temperature reduction 1.4C/hr
Median time to goal temperature 137 min.

52. COLD INTRAVENOUS FLUID
Effective in emergency and prehospital setting
4C Ringer’s lactate solution or normal saline solution
30 ml/kg or 2,000 ml within 20-30 min

53. RCT : +4 degrees C Ringer's lactate solution or conventional fluid therapy
19 in the treatment group and 18 in the control group
At the time of hospital admission
core temperature was lower in hypothermia group
34.1+/-0.9 degrees C vs. 35.2+/-0.8 degrees C, P<0.001

54. CLINICAL TRIALS ON COOLING
Farid Sadaka. Prehospital Therapeutic Hypothermia for Cardiac Arrest. Mercy Hospital St Louis/St Louis University

55. REFERENCES
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Eugene A. Hessel. Therapeutic Hypothermia After In-Hospital Cardiac Arrest: A Critique. Journal of Cardiothoracic and Vascular Anesthesia 2014;28(3):789–99.
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Varon J, Acosta P. Therapeutic hypothermia: past, present, and future. Chest 2008;133:1267-74.
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ผศ.นพ.สมบัติ มุ่งทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. In:วินชนะ ศรีวิไลทนต์, บรรณาธิการ. Integrated Post Cardiac Arrest Care.สานักพิมพ์ มหาวิทยาลัยธรรมศาสตร์ 2013:63-76.

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59. THANK YOU