Frank Guyette, MD, MS, MPH Jon Rittenberger, MD, MSc Cliff Callaway, MD, PhD University of Pittsburgh Department of Emergency Medicine

Frank Guyette, MD, MS, MPH Jon Rittenberger, MD, MSc Cliff Callaway, MD, PhD University of Pittsburgh Department of Emergency Medicine

Disclosures Philips Healthcare: Faculty

Learning Objectives Upon completion of this presentation the participants will be able to explain: How to initiate therapeutic hypothermia in EMS. How to protect the brain from injury after cardiac arrest. How to select the most appropriate level of care for the post arrest patient.

Mortality is about 95%. Good EMS systems can get ROSC in 40% of cases. Despite improvements in care, no significant improvement in survival. Resource and emotionally intensive.

Provide coronary perfusion pressure (CPP) Pressure must be greater then > 15 mmhg Increase CPP by doing deep, fast compressions without interruption. Stop fibrillating hearts Deliver oxygen to the tissues Brain Heart

Survival in 1960: 5% Survival in 2009: 4 8% We now know how to treat the first 30 minutes of this disease What is next?

Brain Injury after Cardiac Arrest Brain Dead Severity of Injury Normal If you have acute, severe cerebral edema, no therapy will help Duration of Ischemia

Saving Lives! HCASG, 2002 Bernard, 2002 55% Good Outcome 49% Good Outcome? Outcome

Implementation of a standard postresuscitation protocol: Sunde (2006) Protocol includes therapeutic hypothermia

What Can EMS Do? Good CPR Early Defibrillation in VF/VT Pre hospital Hypothermia Post Arrest Care Transport to the appropriate facility

Ischemic injury occurs in the brain within minutes. Reperfusion injury may begin within minutes. Reperfusion Injury is caused by chemicals released when blood rushes back into the ischemic brain Reperfusion injury can last for up to 12 hours. Hypothermia reduces the brain s need for oxygen and decreases reperfusion injury makes sense.

Is Early Better? Animal data suggest early induction of hypothermia improves outcome. Stertz et al. (1991) Crit Care Med Kuboyama et al. (1993) Crit Care Med HACA patients required 4 16 hours to reach target temperature and still demonstrated benefit.

Is Early Better? Hypothermia is only used in 2 5 % of hospitals nationwide. Pre hospital hypothermia may convince some hospitals to continue the treatment. Paramedics may help improve in hospital care.

Can we do Hypothermia? Australians began cooling in the field using only ice packs and wet cloth. Early is feasible. Kamarainen 5 patients treated with 4 degree saline. Kim 63 patients with cold saline.

What is the Best Method of Pre hospital Cooling?

Kliegel et al., 2005; Resuscitation 64: 347 351. (N= 26: 35.6ºC > 33.8ºC) ~2 liters cold saline Virkkunen et al., 2004; Resuscitation 62: 99 302. (N=13; 35.8ºC > 34.0 ºC) Bernard et al., 2003; Resuscitation 56: 9 13. (N=22: 35.5ºC > 33.8ºC)

A combination of exposure and cold saline (20 cc/kg FAST) is effective and practical for prehospital providers. Patients cooled by EMS in Western PA reach goal temperature 3 Hours faster than patients cooled in the Emergency Department.

Is Hypothermia Safe for Prehospital Providers? Mild hypothermia (32 34 degrees C) has not been associated with increased incidence of sepsis and bleeding. Hovdenes included patients who were hemodynamically unstable (patients on pressers and balloon pumps). Davis et al. recently suggested that diversion to Cardiac Arrest centers may be feasible as there was no relationship between survival and transport time.

Is Hypothermia Safe for Pre hospital Providers? Inclusion Criteria ROSC Age >18 GCS <8 or unable to follow verbal commands

Is Hypothermia Safe for Prehospital Providers? Exclusion Criteria Pregnant Environmental Hypothermia Traumatic Arrest Active Uncontrolled Bleeding Cardiac Instability Refractory or recurrent dysrhythmia Inability to maintain MAP>70 despite use of a vasopressor

High Tech Equipment $12.99 cooler $2.00 for saline (Free at ED) Cold Saline

What Adjuncts are Useful for Cooling? Keep the patient from shivering! It uses up energy that the patient may need. Shivering makes it harder to cool patients. Sedatives (Versed, Ativan, MS, Fentanyl) Fentanyl is least likely to lower blood pressure Versed is a good sedative and short acting. Paralytics May be required to prevent shivering

It is possible to dramatically increase survival in a given system (31% to 56% of admitted patients surviving to one year) Unlikely that it is one particular intervention. More likely, it is the whole package of proactive critical care delivered with a sense of urgency. Sunde (2007) Resuscitation 73: 29 39

Watch Out for the CRUMP! Patients who survive cardiac arrest often become hypotensive after ROSC. Blood pressure drops when all the epinephrine wears off. Be prepared to start an Epinephrine or Dopamine drip.

After more than a few minutes of circulatory arrest, ROSC is followed by CRUMP You better be mixing up pressors here dopamine CPR Drug ROSC Shock CRUMP Menegazzi, 2008

Watch Out for the Crump! Patients with injured brains may need higher blood pressures to keep blood flowing to the brain. Check the blood pressure every 5 minutes. Maintain SBP>110 or MAP>80.

Control the Airway Secure an Airway Comatose patients can not protect their airway. Intubate if possible. Consider a superglottic airway if intubation is difficult. Keep saturations above 92% Hypoxia is bad! Hyperoxia is also bad, so turn the oxygen down.

Control the Airway Hyperventilation is BAD! Fast ventilation reduces CO 2. Low CO 2 tightens blood vessels to the brain. Monitor Ventilation Bag slowly (10 12 BPM) Keep end tidal CO 2 between 40 45 mm/hg

100% 80% 60% 40% 20% 0% 1 2 3 4 5 6 7 8 9 10 Hospital

Think ACS! Up to 80% have MI as etiology for CA 2 Recent Consults: 33 M with 99% LAD and 70% Circumflex 35 F with 100% RC 12 lead ASAP Not IF they need a cath, WHEN!

Good outcome for 52 / 96 (54%) cases with CATH versus 36 / 145 (28%) of cases with no CATH CATH has 2.16 [1.12, 4.19] odds ratio of good outcome (after adjusting for Coma, Hypothermia, STEMI,Age, Sex, In hospital or Out of Hospital and Initial Rhythm)

Good Alive Outcome Bernard Hypo 49% 49%* HACA Hypo 59% 55%* Sunde After 56% 56% UPMC Presby 52% 45% *selective inclusion criteria Trend continues in 2008

Center for Post CPR Care 1. Written Protocols 2. Multiple Specialties 3. QI Programs 4. Research 5. Education EMS Emergency Medicine Physical / Occupational Therapy Cardiology Critical Care Medicine Neurology Neurophysiology Renal Medicine PM&R Internal Medicine Palliative Care Type 1 Type 2 Type 4 Type 3 1. Hypothermia 2. Cerebral Blood Flow 3. Use Local Data to Prognosticate 4. Early Cardiac Intervention 5. Systematic Rehabilitation Surgery Toxicology Adequate Case Volume Seen by Specialist

Common Pitfalls Failure to pressure infuse Most transports only infuse ~ 500 ml Cardiac Arrest is like trauma, just sicker Inadequate sedation Shivering will warm quickly Transfer to hospital that does not provide postarrest care. Certainly no benefit to cool and rapidly rewarm May be harmful

PA DOH Protocol

Hypothermia is part of a care package Prehospital hypothermia will not improve survival UNLESS Hospitals continue therapy Patients receive rehab and secondary prevention Transport to closest appropriate facility Feedback to EMS as part of CQI

Acknowledgements Jon Rittenberger, MD, MS Clif Callaway, MD, PhD Rene Alvarez, MD Michael DeVita, MD Samuel Tisherman, MD Margo Holm, PhD Dave Hostler, PhD James Menegazzi, PhD Ron Roth, MD John Cole, MD Mark Pinchalk, EMT P, MS Michael Turturro, MD Curt Niel, EMT P Mitch Kampmeyer, BS Advanced Cooling System

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