Therepeutic Hypothermia post Cardiac Arrest

[sspruch]

Hi Everyone,

I am a paramedic from South Africa, working for a small private service striving to be the best in South Africa.

Noone in South Africa currently does therapeutic Hypothermia post Cardiac Arrest. Not even any of our hospitals. We are looking at trying to get up to a level where we can establish Post cardiac arrest induced hypothermia. Is there a device out there that we can use to induce hypothermia prehospital, and then hand over the patient in hospital with the machine and leave it there until the patient is back to normal temperature and then we can collect the machine.

Does anyone out there know of such a device? Or is anyone out there doing prehospital therapeutic hypothermia?

Let me know.

thanks
Shaun

 

[Flyhi]

HypoT treatment post ROSC

HI Shaun,

I know in Ireland the paramedics use 4 ice bags, 1 under each armpit and 1 in each groin. The Advanced Paramedics here are looking into chilled IV fluids but nothing solid on that yet. I know Miami FD have run a number of HyptoT IV treatments with great sucess. AS for a machine I dont know if I know of one you can put the Pt on and hand it over to the ED staff as part of the Pt care?? I know in Ireland they would not take it as its EMS equipment and the fact that they are not trained in its use. Unless the HypoT treatment includes pre and post hospital protocols then I think you will be beating your head against a brick wall.

Try this post in the international section and see what comes back. I am NREMT P qualified working here in Ireland but looking to move on. Do you have any info on direct access for overseas trained paramedics in South Africa. Worked there in Kimberly for a few months in a past life but did not get to see the nice spots :lol:

 

[bigbaldguy]

If I'm reading what you're asking correctly I think the answer is no. Putting someone into hypothermia post arrest is fairly simple the tricky part is at the hospital. Hospitals have to have special training, equipment, protocols Ect. There really aren't that many hospitals here in the US that do it, although that does seem to be changing.

 

[DrankTheKoolaid]

Check out EMCRIT podcasts. He touches on both the prehospital side of it along with indepth review of inhospital logistics. There should also be a link on his blog page to some protocols you can show your receiving facility to get them started

 

[FLdoc2011]

Yea, the main management comes on the inpatient side of things when we're pretty much dedicating 1-2 nurses to be bedside for the next 24hrs constantly checking labs, charting temps, etc... Just handing over a cooled pt and a machine to a hospital without them having the protocol, experience and equipment in place just isn't going to happen. Where I'm at it took at least a year to iron out all our inpatient protocols, I could only imagine the roadblocks and hassle of getting that going over there.

 

[Brandon O]

Yea, the main management comes on the inpatient side of things when we're pretty much dedicating 1-2 nurses to be bedside for the next 24hrs constantly checking labs, charting temps, etc... Just handing over a cooled pt and a machine to a hospital without them having the protocol, experience and equipment in place just isn't going to happen. Where I'm at it took at least a year to iron out all our inpatient protocols, I could only imagine the roadblocks and hassle of getting that going over there.

Well put. Prehospital and the ED are the easy part.

With that said, around here chilled saline or ice-packs are the treatment prehospitally (not that you necessarily need to start cooling in the field, depending on transport times and your philosophy). And in the ED I know that at least one facility likes the Arctic Sun. I don't think it's necessary to have direct interoperability between your field and hospital systems except perhaps for interfacility transfers...

But there should be something in place. In my opinion this is clear standard of care at this point, and any facility that for some reason can't do it should be transferring the patient somewhere that can (or if possible, EMS shouldn't be bringing them there to begin with). But that's just me.

 

[FLdoc2011]

Yea, pretty much is standard of care and we're already seeing some hospitals being bypassed that don't offer it.

As far as equipment, we're using a bolus of chilled saline and then external vests around trunk and legs that have cold water circulated through. Machine brand/name is Gaymar. It's basically just a pump and hooks to either a bladder or esophageal temp probe to adjust temperature.

When it goes smooth it can be smooth and uneventful. But we've had our share of trainwrecks where you just end up bedside for most of the night dealing with arrhythmias, hypotension, or bleeding where you may have to abandon hypothermia all together.

 

[Handsome Robb]

The hospital needs to keep the treatment going. It does nothing if you initiate it in the field then they don't continue the treatment. Like others said unless you are a hospital base service they wont use your equipment to care for someone in the hospital. Heck most if not all hospital remove all prehospital IVs within 24 hours of the arrival of the patient.

Generally chilled saline infusion + ice packs are used. Our TC does hypothermia but the other hospitals in the area do not so we don't start it in the field.

 

[Brandon O]

As far as equipment, we're using a bolus of chilled saline and then external vests around trunk and legs that have cold water circulated through. Machine brand/name is Gaymar. It's basically just a pump and hooks to either a bladder or esophageal temp probe to adjust temperature.

When it goes smooth it can be smooth and uneventful. But we've had our share of trainwrecks where you just end up bedside for most of the night dealing with arrhythmias, hypotension, or bleeding where you may have to abandon hypothermia all together.

I find that interesting as the locals claim very low rates of complication -- coagulopathies rare and generally minor, and hemodynamic compromise generally rare unless the patient shouldn't have gone under to begin with (i.e. already substantial bradycardia/hypotension -- they don't consider even multiple pressors to be a contraindication, but if pressure is uncontrolled even with pharmacological aid they won't cool). I do wonder how much inter-facility variation there is here, and how much is linked to the specific protocols in place and how much experience the center has. We're at a stage where the exact implementation of these methods is still mostly do-what-makes-sense -- comparative evidence isn't really in yet. So nobody knows.

By the way, at least one of the local EMS services does drop an esophageal temp probe after ROSC and titrate cold saline to target temp. That's a bit abnormal though.

I'm not necessarily sold on the need for prehospital cooling, but as NVRob alluded to, starting it in the field can be a way to make sure it gets continued at the hospital -- a grassroots way to push the plow of progress.

 

[Handsome Robb]

By the way, at least one of the local EMS services does drop an esophageal temp probe after ROSC and titrate cold saline to target temp. That's a bit abnormal though..

Our HEMS service uses rectal or esophageal temp probes from prehospital therapeutic hypothermia.

We've been trying to get the other hospitals on board with it so we can implement a prehospital protocol for hypothermia for ground units but I haven't heard anything past "it will happen eventually".

 

[sspruch]

I hear that you use rectal and esophageal probes to monitor the temperature, but what do you use to actually cool the patient and maintain the decreased body temperature?

I have seen there are Cooling blankets and cooling caps available, but these don't seem to be that reliable and effective. I see there is the transvenous option which seems to work, but I cannot find a portable machine that can do this?

Any ideas?

 

[sspruch]

I Understand that it is something that the hospital needs to form as a protocol, logistics training etc.

Currently, there is no hospitals in South Africa doing it. What we want to do is arrange for one of the hospitals in our area to start doing it. We will purchase the equipment, and we will train their staff, and assist in them creating their protocols, so we are looking at initiating pre hospital, then transferring them to the hospital that is trained in it, and does have policies and procedures for it, and handing over there where they will continue the care for 24-48 hours.

We just need to know what equipment to implement and use both pre hospital and in hospital.

Ideally we would like a portable machine that we can start prehospital, and then hand it over in hospital to trained staff who will manage it for the 24-48 hours, and then we can collect it again after that.

We are looking at implementing a total system / solution in our are partnering with the hospital.

Are any of you doing this out there?

 

[Brandon O]

I understand what you're describing here, but I think you'll find that options for that type of system are fairly limited.

Certainly, there's no theoretical reason why you couldn't try to implement one of the in-hospital devices used for temperature regulation (presumably either an external-type device, such as the Arctic Sun I mentioned, or a fluid-based recirculation system) in the prehospital setting... but they're usually large, cumbersome, and not really field-grade equipment. On the flip side, in most cases you probably don't need that level of fine control for the relatively short prehospital transport times. The only situations I could imagine this really being necessary are for very long transport times (probably well over one hour), or possibly to maintain temp for a long interfacility transfer after initial induction.

Mostly, the popular approach in the field seems to be cooling via gross measures such as icepacks or chilled saline, either making rough temperature measurements or just doing it blindly on the assumption that you're not going to overcool them with those methods in the brief EMS period. Then, upon arrival at the ED, a more comprehensive system with more exact temperature endpoints can be adopted.

Remember that the ambulance is always going to be a rough-and-tumble environment where simple, cheap, tough methods rule (and even coolers full of saline is too logistically difficult for some services). Trying to bring ICU-level control to that setting is often both difficult and unnecessary.

 

[zmedic]

I'd point out that many of the trans-venous systems use a large, central line, usually in the femoral. So if you are going to have people put those in they need to have the ability to do central lines.

 

[Christopher]

I know in Ireland the paramedics use 4 ice bags, 1 under each armpit and 1 in each groin. The Advanced Paramedics here are looking into chilled IV fluids but nothing solid on that yet.

Our interventional cardiologists asked us not to place ice packs on the right groin due to the apparently problematic level of vasoconstriction it causes. I've never found our ice packs to be terribly effective, but we try and keep the docs happy.

Intraarrest therapeutic hypothermia is cheap once you amortize the cost of the electric coolers (or if you are lucky your ambulance came stock with a cooler). If you have a ready supply of ice, a 5 gallon (~20 litres for the rest of y'all) cooler is fine. You can do Post-ROSC cooling and only put coolers on supervisor vehicles, but this has a higher incidence of shivering.

But I'll reiterate what the others have said, without buy-in from the hospital you cannot get this off the ground.

 

[Brandon O]

You can do Post-ROSC cooling and only put coolers on supervisor vehicles, but this has a higher incidence of shivering.

Not sure what you mean here?

 

[Christopher]

Not sure what you mean here?

Post-ROSC cooling has more shivering than intraarrest cooling. Supervisor vehicle has nothing to do with shivering Just a place to put less coolers for money reasons.

 

[Brandon O]

Ah, I dig. Intraarrest cooling is pretty close to the bleeding edge here, and I'm not sure I'd feel the need to commit the additional resources to make it possible (eg. as you suggest ice on every ambulance vs. ice on supervisor vehicles, in systems where that would be appropriate), unless we've already optimized our post-ROSC cooling so much that we're looking for new stuff to try. Significant added benefit just hasn't really been shown IMO.

 

[Christopher]

Ah, I dig. Intraarrest cooling is pretty close to the bleeding edge here, and I'm not sure I'd feel the need to commit the additional resources to make it possible (eg. as you suggest ice on every ambulance vs. ice on supervisor vehicles, in systems where that would be appropriate), unless we've already optimized our post-ROSC cooling so much that we're looking for new stuff to try. Significant added benefit just hasn't really been shown IMO.

Well, with less shivering you're giving less benzos, narcotics, and most importantly less paralytics as new research is showing the less paralytics you give the better their course is through the ICU.

Dr. Meyers from Wake County NC noted that sometimes EMS has to take charge to make TH happen: delivering patients cold and paralyzed only to hospitals which take TH patients and will keep them cold. He said by forcing their hand initially they got buy-in out of necessity in places which wouldn't acquiesce.

If you frame the debate as a money question--i.e. if you don't do TH, you don't get post-arrest--hospitals will take notice

 

[Brandon O]

I definitely agree. In fact, the committee folks around here are using that as a potential stick in trying to get all the area hospitals on board with hypothermia protocols: "if you don't, we may institute an EMS point-of-entry protocol requiring that they bypass you." Likewise, for those facilities that have the capability but aren't necessarily applying it universally, for us to bring someone in who's already cooled is a very different matter from bringing in an arbitrary arrest and hoping they dig out the laminated card.

Less shivering from intraarrest cooling is new to me, however. Any references?