Hypothermia Slidessaem

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Hypothermia Slidessaem

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  • Out-of-Hospital Cardiac Arrest Survival after the Sequential Implementation of 2005 AHA Guidelines for Compressions, Ventilations, and Induced HypothermiaJ. Brent Myers, MD MPHMedical DirectorWake County EMS System

  • AuthorsPaul Hinchey, MD MBA, WakeMed/Wake EMSBrent Myers, MD MPH, Wake EMS/WakeMedRyan Lewis, EMT-P, Wake EMSValerie De Maio, MD MSc, WakeMedEric Reyer, RN, WakeMedGraham Synder, MD, WakeMedGerald Maccioli, MD, Rex HealthcareDaniel Licastese, RN, Rex HealthcareRobert Lee, MS MA, WakeMed

  • DisclosurePaul Hinchey, Eric Reyer, and Brent Myers serve on the speakers bureau for Alsius Corporation

  • Capital County Research ConsortiumCommunity-based research group representing Rex Healthcare, Wake County EMS System, and WakeMed Health and Hospitals

    Includes nurses, physicians, paramedics, and research support

  • Community Wide ProjectMulti-phase before and after clinical trial

    All out-of-hospital cardiac arrests (OOH-CA) on a community wide basis were eligible for inclusion

  • Protocol Revision TimelineBaseline [Jan 2004-Apr 2005]: Traditional CPR, focus on airwayNew CPR [Apr 2005-Apr 2006]: Continuous compressions, delayed intubation for VF/VTImpedance Threshold Device (ITD) [Apr 2006-Oct 2006]Induced Hypothermia [Oct 2006-Oct 2007]

  • MethodsAll EMS records are maintained in an electronic databaseRecords with any of the following characteristics are reviewed to determine if cardiac arrest occurred:EMS Patient Disposition = cardiac arrestCPR procedure is recordedDefibrillation is recorded

  • Age less than 16Obvious traumatic origin of arrestEMS witnessed arrestArrest not in EMS controlPrison facilitiesOut-of-system interceptArrests under direction of non-EMS physician

    Cases Excluded from Review

  • MethodsData were analyzed using logistic regression Covariates offered for the regression:AgeGenderResponse time for the first defibrillatorWitnessed statusLocation

  • MethodsPrimary outcome was the proportion of OOH-CA patients for whom resuscitation was attempted that survived to discharge in baseline vs. hypothermia phasesSecondary outcomes include (by phase):Pulse at emergency department, survival to admission, neurological intact survival to dischargeAdditionally, results were stratified by initial rhythm

  • MethodsNeurologically intact survival was defined as CPC 1 or 2 at time of hospital discharge or discharge from rehabilitation if transferred directly from hospital2 blinded physician reviewers from each hospital independently assigned CPC scores based on patient records

  • Results3124 OOH-CA occurred during the study period1442 obvious deaths (no resuscitation attempted)1682 attempted resuscitations484 of 1682 were excluded due to:119 not under EMS control/not a code109 obvious traumatic origin 70 under the age of 16206 EMS witnessed1198 met inclusion criteria

  • Results

    Total OOH-CAN= 1198Baseline N = 372New CPRN= 319ITDN= 148HypothermiaN= 359

  • NOTE: no statistically significant difference between study periods

    Mean Age65Percent male58%Private Residence81%Witnessed Status36%Bystander CPR 36%Mean Defibrillator Response5.3 6.1 minsInitially VF/VT26%

  • Survival All Rhythms4.6%7.3%8.2%11.6%* when compared with baselineP
  • Survival VF/VT12%22%29%37%* When compared with baselineP
  • Percentage of All Attempted Resuscitations Neuro Intact1.9%4.4%6.2%7.8%* When compared with baselineP
  • Neurologically intact VF/VT10%17%20%28%* When compared with baselineP
  • Comparison of Outcomes Hypothermia vs. Baseline* P
  • Multivariate Odds of Survival

    FactorOdds95% CIAge0.970.96-0.98Residence0.500.31-0.82Bystander CPR2.181.34-3.54New CPR2.371.10-4.96ITD2.991.29-6.95Hypothermia3.671.86-7.26

  • DiscussionConfoundersRemoval of stacked defibrillationsProtocol-driven pre- and post-resuscitation cardiac arrest careImprovement with procedures due to repetitionHawthorne effectIntention-to-treat analysis

  • ConclusionThe sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia lead to significant improvements in neurologically intact survival for cardiac arrest in this urban/suburban community.

  • www.wakeems.com/saem

  • Criteria for Induced HypothermiaROSC after cardiac arrest not related to trauma or hemorrhageAge 16 years or greaterFemale without obviously gravid uterusInitial temperature >34 CPatient is intubated (no RSI)Patient remains comatose without purposeful response to pain

  • Multivariate Odds of Neuro Intact Survival

    FactorOdds95% CIAge0.970.96-0.98Bystander CPR2.651.49-4.71New CPR3.191.10-9.26ITD4.951.61-15.21Hypothermia6.212.35-16.41

  • Sample Database Entry

  • BackgroundWake County/Raleigh, NC:Single, 3rd service EMS System with 65,000 calls/yearReliable firefighter first responseResident population of ~825,000 (add 100 per day)Post-resuscitation patients are selectively transported to one of 2 high volume PCI centers

  • Cardiac Arrest ResponseAll calls receive EMD from a single, high-volume centerFire first response with AED and compressionsParamedic response with transport ambulancesSupervisory response at paramedic level

    *C=0.74