Hypothermia pre hospital

[rayzon20mg]

Hello getting people to talk about this topic is difficult what about the thought of pre hospital hypothermia induced for head injury, this decreases the risk of rised ricp and brain damage, here we are considiring it.

 

[Veneficus]

Not sure why it should be difficult to talk about.

More and more benefits are demonstrated as time goes on.

From the physiologic standpoint it is perhaps the only longterm treatment that reversibly lowers cell metabolism.

Of course it is not just a prehospital intervention. You must have a hospital that is willing to continue the therapy. (aka will spend money on it)

 

[firemedic0227]

During our medic class as a class we had to do a presentation and we decided to do it on Hypothermia treatment for Cardiac Related problems i.e. Heart attacks in the Prehospital setting. We came up with a lot of good stuff, it does a lot to help with Heart Attacks in the long run of things.

 

[DPM]

The new AHA guidelines include therapeutic hypothermia once ROSC is achieved. I've also read about the benefits in Spinal chord / Nero type injuries.

It all seems to make sense to me

 

[BayareaMedic]

It's apart of Alameda County protocol. Seems to be the best way to reduce the risk of getting ROSC back and having the pt's system begin working so hard to recover from the "event", that you turn around and loose the pt again. Its been proven that if you are able to slow the heart as well as the rest of the system down after ROSC , the chance of survival goes way up.it Also assists in the reperfusion process. All around therapeutic hypothermia is an awesome pre hospital and hospital treatment when you get those occasional viable patients.

 

[Handsome Robb]

The new AHA guidelines include therapeutic hypothermia once ROSC is achieved. I've also read about the benefits in Spinal chord / Nero type injuries.

It all seems to make sense to me

To add to this I have heard of agencies using it intrarrest rather than post arrest. Haven't seen a study on it though.

I agree with Vene, why is it a hard subject to talk about?

 

[Smash]

The OP's question was therapeutic hypothermia (TH) for head injury, which I presume means traumatic, rather than in the post arrest patient.

Nevertheless: TH for cardiac arrest is a definite benefit, NNT of about 6 I believe. However, there is no evidence that starting it post-ROSC in the field is of any added benefit to starting it in the ER. There is no evidence that starting it whilst working the code is of any benefit either, although that trial is currently being undertaken in Melbourne, Australia. I personally like the idea, but we will have to wait for the data.

Now, for traumatic brain injury, TH is not currently recommended. It has been played with a number of times in the past, and there is another trial underway, also in Melbourne (they are busy people) to see how it goes. Again, time will tell.

 

[Maine iac]

Smash, just curious but do you have a reference for your claim about TH not working for neuro?

The reason I ask is twofold, first in my favorite TV show, Trauma, my main man (the HEMS medic) chilled the kid with a cord injury and he ended up not being paralyzed. Second, in the recent large profiled ski accident of Sarah Burke, she was flown off the mountain and taken to Salt Lake City where she was cooled down. I have heard of other ICUs doing this as part of a stroke protocol, but to my knowledge it is not being done in a prehospital setting. Before it could be, I would think the medics would have to be comfortable with RSI and identifying appropriate head injuries to be included.


The local HEMS program here did a trial using manatol for head injuries. I believe in their study it was statistically significant for slowing damage with increased ICP. I could see one of these osmosis drugs being used before prehospital TH for head injuries.

 

[Handsome Robb]

First Trauma isn't a great reference... Also in that episode it was an SCI not a head injury. Don't ask me how I know h34r:

Mannitol and therapeutic hypothermia are two different things...

Also Sarah Burke died...so TH in that case did not prove to be effective. It was a terrible accident and a horrible loss for our skiing community, I feel for her family.

 

[Maine iac]

Haha I know Trauma isn't something to site unless it involves humor and special effects.

Sarah Burke's accident I think was just too severe and hypothermia or not probably would not have had any effect.

Here is a link to paper I found:
http://reference.medscape.com/medline/abstract/11014530

I think in many hospitals TH is something preformed for select neuro patients, and I think in some limited settings it could be a prehospital treatment, but it might be hard to identify those patients. Which is where I was saying the use of Mannitol might be something else to consider.

 

[Smash]

Smash, just curious but do you have a reference for your claim about TH not working for neuro?

Sydenham E, Roberts I, Alderson P. Hypothermia for traumatic head injury. Cochrane Database of Systematic Reviews 2009, Issue 2.

The local HEMS program here did a trial using manatol for head injuries. I believe in their study it was statistically significant for slowing damage with increased ICP. I could see one of these osmosis drugs being used before prehospital TH for head injuries.

I would be interested to see this, as to the best of my knowledge there has never been any strong evidence for benefit from mannitol in the acutely head injured patient. If it is used at all it is just as a single bolus in the patient who is herniating.

Wakai A, Roberts IG, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database of Systematic Reviews
2007, Issue 1

Mendelow AD, Teasdale GM, Russell T et al. Effect of mannitol on cerebral blood flow and cerebral perfusion pressure in human head injury. J Neurosurg 63:43-48, 1985

Muizelaar JP, Lutz HA, Becker DP et al. Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head injured patients. J Neurosurg 61:700-706, 1984

Rosner MJ, Coley I. Cerebral perfusion pressure: a hemodynamic mechanism of mannitol and the pre-mannitol hemogram. Neurosurg 21:147-156, 1987

Cruz J, Miner ME, Allen SJ et al. Continuous monitoring of cerebral oxygenation in acute brain injury: injection of mannitol during hyperventilation. J Neurosurg 73:725-730, 1990

Cold GE. Cerebral blood flow in acute head injury. Acta Neurochir S49:18-21, 1990

Kaufmann AM, Cardozo E. Aggravation of vasogenic cerebral edema by multiple dose mannitol. J Neurosurg 77:574-589, 1992

Schwartz ML, Tator CH, Rowed DW. The University of Toronto head injury treatment study: A prospective randomised comparison of pentobarbital and mannitol. Can J Neurol Sci 11:434-440, 1984

Smith HP, Kelly DL, McWhorter JM et al. Comparison of mannitol regimens in patients with severe head injury undergoing intracranial monitoring. J Neurosurg 65:820-824, 1986

 

[DPM]

Contrary to what I posted previously, I haven't found evidence showing benefit of pre-hospital hypothermia. Added to that, there is no way to effectively achieve that where I am. The protocols / equipment don't support that treatment, and short of banging some cold packs in the groin / armpits etc I don't really know how you would even do it.

 

[Maine iac]

Smash, two things for you....

First, I might very well be mistaken about that trial, it has been quite sometime since I read it.

Second, where are you getting all of your sources from? Are you with a university so you have access to some of those sites like Pubmed, or do you have another search function that you use. Or did you just Google it all? I'd love to know so that I can fairly quickly pull up papers to stat check against.

Thanks!


Edit: I read the blurbs about your TH link for traumatic neuro.... but what about hypothermia for stroke which is not a traumatic event (in the sense of trauma).

http://stroke.ahajournals.org/content/35/6/1482.short

Therapeutic hypothermia for acute stroke The Lancet Neurology - Volume 2, Issue 7 (July 2003

 

[Smash]

Smash, two things for you....

First, I might very well be mistaken about that trial, it has been quite sometime since I read it.

Second, where are you getting all of your sources from? Are you with a university so you have access to some of those sites like Pubmed, or do you have another search function that you use. Or did you just Google it all? I'd love to know so that I can fairly quickly pull up papers to stat check against.

Thanks!


Edit: I read the blurbs about your TH link for traumatic neuro.... but what about hypothermia for stroke which is not a traumatic event (in the sense of trauma).

http://stroke.ahajournals.org/content/35/6/1482.short

Therapeutic hypothermia for acute stroke The Lancet Neurology - Volume 2, Issue 7 (July 2003

I have access to some through my employer, some through state government, some a free online and some I subscribe to as an individual.

I can't admit to being up to date with much literature on hypothermia for stroke. It's a compelling idea (as with trauma and post/peri-arrest) but good ideas don't necessarily translate into real world data. I think the issue in the field would be determining the right patient to provide it to. I imagine that it would be a good idea for ischemic/thrombotic stroke, but given the effects of cold on clotting, less of a good idea for haemorrhagic. That's just me talking crap though, I don't really have anything to support that.

 

[KellyBracket]

Wake County EMS is leading the way in hypothermia for post-ROSC in cardiac arrest. In addition, my old service in New Hampshire (Frisbie) is carrying chilled saline

As for head injury and stroke, it continues to be (at best) not ready for roll-out.

How about this instead: "Neuroprotective Effect of Acute Ethanol Administration in a Rat With Transient Cerebral Ischemia "

 

[Brandon O]

How about this instead: "Neuroprotective Effect of Acute Ethanol Administration in a Rat With Transient Cerebral Ischemia "

I'll do you one better -- ethanol plus caffeine http://stroke.ahajournals.org/content/34/5/1246.full

Boston EMS uses this protocol: get ROSC, drop an esophageal temperature probe, infuse chilled saline down to I can't remember what, like 86 degrees maybe. No evidence AFAIK, especially with the very short transport times in Boston, just playing with the concept -- although it has been suggested that instituting these things in the field may be a driving force for their continuation in the hospital (different to discontinue an intervention than to fail to initiate it in the first place).

There's ongoing work with hypothermia for stroke (even conscious patients), head injury, etc. -- even hemorrhagic shock, which seems like madness due to the coagulopathy, but they're trying to "chill past" that dangerous point until the patient's a benign popsicle. Interesting stuff. Soon we'll be bringing big ice chests to toss all our sick patients in...

 

[epipusher]

Recently met up with my third ROSC field hypothermia save. This makes the third person in three years that I personally have seen leave the hospital with zero neuro. deficits.