ACTEP2014: Therapeutic hypothermia for ACTEP 2014
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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.
ACTEP2014: Therapeutic hypothermia for ACTEP 2014
- 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
- 45. COOLING CAPS
- 46. COOLING BLANKETS
- 47. ICE PACKS
- 48. ICE PACKS
- 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
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- 59. THANK YOU