ACTEP2014: Therapeutic hypothermia for ACTEP 2014

Therapeutic hypothermia after cardiac arrest: Should we start at the ED - อ.นพ.วินชนะ ศรีวิไลทนต์, พญ.สมจินตนา เอี่ยมสรรพางค์

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.ส านักพิมพ์มหาวิทยาลัยธรรมศาสตร์ 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.ส านักพิมพ์มหาวิทยาลัยธรรมศาสตร์ 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
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.
Bryan G, Robert A, Joseph L, et al. Therapeutic Hypothermia for Acute Myocardial Infarction and Cardiac Arrest. The American Journal
of Cardiology 2012;03(048):461-66.
Eugene A. Hessel. Therapeutic Hypothermia After In-Hospital Cardiac Arrest: A Critique. Journal of Cardiothoracic and Vascular
Anesthesia 2014;28(3):789–99.
Joseph V, Paul E, Sharon E. Therapeutic hypothermia: a state-of-the-art emergency medicine perspective. American Journal of
Emergency Medicine 2012;30:800–10.
Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N
Engl J Med 2002;346:549 –56.
Bernard S, Gray T, Buist M, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J
Med 2002;346:557–63.
Nolan J, Morley P, Vanden T,et al. Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support
task force of the International Liaison Committee on Resuscitation. Circulation 2003;108:118–21.
Hachimi-Idrissi S, Corne L, Ebinger G, et al: Mild hypothermia induced by a helmet device: a clinical feasibility study. Resuscitation
2001;51:275-81.
Oddo M, Ribordy V, Feihl F, et al. Early predictors of outcome in comatose survivors of ventricular fibrillation and non-ventricular
fibrillation cardiac arrest treated with hypothermia: a prospective study. Crit Care Med 2008;36:2296-301.
Hay A, Swann D, Bell K, et al. Therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest. Anaesthesia 2008;63:
15-9.
Nielsen N, Hovdenes J, Nilsson F, et al. Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac
arrest. Acta Anaesthesiol Scand 2009;53:926-34.
Steiner T, Meisel F, Mayer S, et al. Therapeutic hypothermia. New York: Marcel Dekker; 2005.
Varon J, Acosta P. Therapeutic hypothermia: past, present, and future. Chest 2008;133:1267-74.
Nolan J, Morley P, Hoek T,et al. Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advancement Life Support
Task Force of the International Liaison committee on Resuscitation. Resuscitation 2003;57:231-5.
ผศ.นพ.สมบัติ มุ่งทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. In:วินชนะ ศรีวิไลทนต์, บรรณาธิการ. Integrated Post Cardiac Arrest Care.ส านักพิมพ์
มหาวิทยาลัยธรรมศาสตร์ 2013:63-76.

56. Bernard S, Buist M. Induced hypothermia in critical care medicine: a review. Crit Care Med 2003;31:2041-51.
Bloch J, Manax W, Eyal Z, et al. Heart preservation in vitro with hyperbaric oxygenation and hypothermia. J Thorac
Cardiovasc Surg 1964;48:969-83.
David S, Marcelo M, Ricardo T. Therapeutic hypothermia after return of spontaneous circulation: Should be offered to
all? Resuscitation 2012;83:671– 3.
Jon C, Francis X, Samuel A, et al. Outcomes of a hospital-wide plan to improve care of comatose survivors of cardiac
arrest. Resuscitation 2008 November;79(2):198–204.
Shashank P, Sadiq B, John M, et al. Therapeutic hypothermia for out-of-hospital cardiac arrest: implementation in a
district general hospital emergency department. Emerg Med J 2011;28:970-73.
Barnaby R, Mark D, Kathleen B, et al. Survey of the use of therapeutic hypothermia after cardiac arrest in UK paediatric
emergency departments. Emerg Med J 2013;30:24–7.
Galloway R, Sherren P. Therapeutic hypothermia following out-of-hospital cardiac arrest; does it start in the emergency
department? Emerg Med J 2010;27:948-49.
Christine E, Shannon C, Aaron A, et al. Therapeutic Hypothermia Protocol in a Community Emergency Department.
West J Emerg Med. 2010;11(4):367-72.
Silfvast T, Pettila V. Outcome from severe accidental hypothermia in Southern Finland—a 10-year review. Resuscitation
2003;59:285-90.
Silfvast T, Tiainen M, Poutiainen E, et al. Therapeutic hypothermia after prolonged cardiac arrest due to non-coronary
causes. Resuscitation 2003;57:109-12.
Alzaga A, Cerdan M, Varon J. Therapeutic hypothermia. Resuscitation 2006;70:369-80.
Dietrich C, Tobias J. Intraoperative administration of nitric oxide. J Intensive Care Med 2003;18:146-49.
Safar P. Resuscitation of the ischemic brain. In: Albin MS, editor. Textbook of neuroanesthesia with neurosurgical and
neuroscience perspectives. New York: McGraw-Hill, Health Professions Division;1997. p. 557-93.
นพ.วินชนะ ศรีวิไลทนต์. Overview of Post Cardiac Arrest Care and Regionalization of Resuscitation Centers. In:วินชนะ ศรีวิไลทนต์,
บรรณาธิการ. Integrated Post Cardiac Arrest Care.ส านักพิมพ์มหาวิทยาลัยธรรมศาสตร์ 2013:1-13.
Skulec R, Truhlar A, Seblova J,et al. Pre-hospital cooling of patients following cardiac arrest is effective using even low
volumes of cold saline. Crit Care. 2010; 14: R231.
REFERENCES

57. Bernard S, Smith K, Cameron P. et al. Induction of therapeutic hypothermia by paramedics after
resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized
controlled trial. Circulation.2010; 122: 737–42.
Bernard S, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia after
resuscitation from nonventricular fibrillation cardiac arrest. Crit Care Med. 2012; 40: 747–53.
Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on
survival and neurological status among adults with cardiac arrest. JAMA. 2013;(Nov 17 doi:
10.1001/jama.2013.282173).
Mengyuan D, Fenglou H, Jun G, et al. Prehospital therapeutic hypothermia after cardiac arrest:
A systematic review and meta-analysis of randomized controlled trials. Resuscitation
2013;84:1021–8.
Cabanas J, Brice J, De Maio V, et al. Field induced therapeutic hypothermia for neuroprotection
after out-of hospital cardiac arrest: a systematic review of the literature. J Emerg Med 2010.
Varon J. Therapeutic hypothermia and the need for defibrillation: wet or dry? Am J Emerg Med
2007;25:479-80.
Diringer M. Treatment of fever in the neurologic intensive care unit with a catheter-based heat
exchange system. Crit Care Med 2004;32:559-64.
Holzer M, Roine R. Hypothermia after cardiac arrest: a treatment that works. Curr Opin Crit
Care 2003;9:205-10.
O'Sullivan S, O'Shaughnessy M, O'Connor T. Baron Larrey and cold injury during the
campaigns of Napoleon. Ann Plast Surg 1995;34:446-9.
Bell D, Brindley P, Forrest D, et al. Management following resuscitation from cardiac arrest:
recommendations from the 2003 Rocky Mountain Critical Care Conference. Can J Anaesth
2005;52:309-22.
REFERENCES

58. Ryan M, Beattie T, Husselbee K, et al. Use of the infant transwarmer mattress as an external
warming modality in resuscitation from hypothermia. Emerg Med J 2003;20:487-8.
Varon J, Acosta P. Therapeutic hypothermia use among health care providers in 2 developing
countries. Am J Emerg Med 2008;26:244.
Al-Senani F, Graffagnino C, Grotta J, et al. A prospective, multicenter pilot study to evaluate the
feasibility and safety of using the CoolGard System and Icy catheter following cardiac arrest.
Resuscitation 2004;62:143-50.
Haugk M, Sterz F, Grassberger M, et al. Feasibility and efficacy of a new non-invasive surface
cooling device in post-resuscitation intensive care medicine. Resuscitation 2007;75:76-81.
Virkkunen I, Yli-Hankala A, Silfvast T. Induction of therapeutic hypothermia after cardiac arrest
in prehospital patients using ice-cold Ringer's solution: a pilot study. Resuscitation
2004;62:299-302.
Bernard S, Buist M, Monteiro O, et al. Induced hypothermia using large volume, ice-cold
intravenous fluid in comatose survivors of out-of hospital cardiac arrest: a preliminary report.
Resuscitation 2003;56:9-13.
Kim F, Olsufka M, Carlbom D, et al. Pilot study of rapid infusion of 2 L of 4 degrees C normal
saline for induction of mild hypothermia in hospitalized, comatose survivors of out-of-hospital
cardiac arrest. Circulation 2005;112:715-9.
Kamarainen A, Virkkunen I, Tenhunen J, et al. Prehospital therapeutic hypothermia for
comatose survivors of cardiac arrest: a randomized controlled trial. Acta Anaesthesiol Scand
2009;53:900-7.
Farid Sadaka. Prehospital Therapeutic Hypothermia for Cardiac Arrest. Therapeutic
Hypothermia in Brain Injury. Mercy Hospital St Louis/St Louis University 35-48.
REFERENCES

59. THANK YOU