Resuscitation Science tips: The NYC Project Hypothermia
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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.
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Resuscitation Science tips: The NYC Project Hypothermia
- 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.