CPR and Therapeutic Hypothermia

Do NOT stop chest compressions. No more than five seconds hands off time.Compress during defib charge time.Do NOT check pulse after defib. Continue compressions for 2 minutes.Do not stop compressions for intubation attempts. Either intubate during compressions or use the king airway.

The Mnemonic for a patient in cardiac arrest is now C-A-B. Not A-B-C.

It takes more than 1 min of good chest compressions to return CPP to pre pause levels. 1

The AHA has set forth new guidelines for the BLS field termination of CPR. 2

NEVER hyperventilate your patient. 6-8 BPM

How the damage is done• It was thought that hypoxia causes the damage,

this is somewhat indirect.• Free radicals, generated when the cells are

flooded with O2, are the actual culprit.

Free radicals basically tear off an electron from part of the cell. Most critical damage occurs in the Mitochondria.

Free radicals cause Oxidation--- Think rust--

This is the basic theory

Hypothermia decreases the oxygen demand and production of free radicals

Therapeutic Hypothermia

Studied since the 1900s (1905). Known to be beneficial since the 1950s Slow to be accepted. Wake County EMS studied and implemented the first widely known EMS Therapeutic hypothermia protocol in 2006Many agencies already doing this have tripled or more their survival to discharge .Number to treat is 8 or less.

Percentage of All Attempted Resuscitations Neuro Intact

0

1

2

3

4

5

6

7

8

NeuroIntact

Baseline New CPR ITD Hypo

Treatment Period

0

1

2

3

4

5

6

7

8

NeuroIntact

Baseline New CPR ITD Hypo

Treatment Period

7.8%

6.2%

4.4%

1.9%

P <0.05*

Wake County NC* When compared with baseline

0

5

10

15

20

25

30

35

NeuroIntact

Baseline New CPR ITD Hypo

Treatment Period

0

5

10

15

20

25

30

35

NeuroIntact

Baseline New CPR ITD Hypo

Treatment Period

Neurologically intact – VF/VTNeurologically intact – VF/VT

28%

20%

17%

10%

Wake County NC

We can achieve the same

You must achieve ROSC. Vasopressor for SBP less than 90.

Measure their temperature using the NG inserted temp probe. If you are unable to measure temp due to lack of supplies Initiate Hypothermia anyway!

If more than 34 C begin pressure infusing “iced” NS. Cool to 32°C to 34°C (89.6°F to 93.2°F)for 12 to 24 hours(Class I, LOE B)

Achieve ROSC.

Secure airway place Capnography and Temp probe.

Infuse 2 L NS or LR. (Up to 30ml/kg safely)

Expose pt and place ice packs.Groin BilaterallyAxilla BilaterallyCarotid Bilaterally

External Elements of Cooling

For every Degree cooled the pts cerebral O2 demand decreases by about 8%. At our target hypothermia temperatures the O2 demand is cut in half! 3

Exclusions -- Contraindications

Traumatic arrest Do not confuse this with asphyxia arrest (hanging ect.)

Actual or suspected uncontrollable bleeding internal bleeding

Pregnancy obvious or known

Cardiac Instability Recurring refractory arrhythmias. Somewhat common

Uncontrollable Hypotension MAP <70 despite the use of Vasopressor

Frank Pulmonary Edema

Pre-existing Environmental Hypothermia

Inclusion Criteria

Patients in V-fib and non V-fib arrestPts received chest compressions Defibrillation(s) Even by FD or bystander prior your arrival.

Patient has achieved ROSCAge >18 yrs We are not including pediatrics at this time.

Pt not following commands or GCS less than 8.Transport patients to hypothermia capable facilities ONLY. Please keep yourself up to date on who this is.

Side effects to know

A number of potential complications are associated with cooling, including coagulopathy, arrhythmias, and hyperglycemia, particularly with an unintended drop below target temperature. 4

The likelihood of pneumonia and sepsis may also increase.

Hyperthermia is common after resuscitation, temperature elevation above normal can impair brain recovery. The etiology of fever after cardiac arrest may be related to activation of inflammatory cytokines in a pattern similar to that observed in sepsis.

Looking to the Future

• Many different devices are being tested and many are approved and being used.

More uses for hypothermiaCVA?Closed head injury?Spinal cord injury?MI?Trauma?…..?

The future of CPR

Several devices are available and show great promise. A few are AHA recommended.

Autopulse Lucas Device

Summary

• Therapeutic hypothermia is cheap and easy.• The science supporting this therapy is vast and growing.• The risk to the patient is negligible.• There is NO REASON to not provide this therapy.

References• 1 Steen S, Liao Q Pierre L, et al: “The critical importance of minimal delay

between chest compressions and subsequent defibrillation.” Resuscitation. 2003;58(3):249-258

• 2 2010 AHA Guidelines

• 3 Thorac Cardiovasc Surg 2006;132:153-154

• 4 Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, Valsson F, Wanscher M, Friberg H. Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2009;53:926 –934.