Induced Hypoterhmia for ROSC

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Omnimedic

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The newest post on this topic I can find is dated almost three years ago which leads me to believe not many places are doing it. If I am incorrect, or if there is a more current post that I missed, please forgive me.

One of the things that is quickly coming down the pipe for CPR in my area (South Texas) is induced hypothermia for patients who experience a spontaneous return of spontaneous circulation (ROSC).

I know trends vary aross the country (and even within states, as some of my colleagues in other parts of my own state haven't heard of it yet.) So, my question is this: I'd like to see a geographical representation from around the country (and world) of who currently has a protocol or is actively involved in a field trial involving induced hypothermia for ROSC. Please identify where you are from if it's not obvious in your signature/info, which of the two you fall into, how long the protocol has been in effect, if you have used it, and if so, with what kind of results.

If you're not familiar with it, here's the down and dirty of it:

If the patients gets a pulse back, the room temperature NS IV bags used during resusciation are changed out for bags carried in a DC-powered cooler in the units, with the goal to get the patient's temperature down to 33*C (91.4*F) as quickly as possible, (with paralysis if needed to prevent shivering as the body attempts to raise its temperature). Once delivered to the ED, the patient is brought down to the target temp, maintained in the ICU for 24 hours, then slowly brought back up to a normothermic level. The kicker of it is that the patient must be transported to a receiving facility that can maitnain the continuum of care of the specialized protocol.

The theory behind it is that the hypothermia provides a protective mechanism from anoxic brain injury during reperfusion of the brain. Just like like we are all taught from day 1 in EMT class: "They're not dead until they're warm and dead."

Thanks for the feedback,
OmniMedic
 
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My agency has a hypothermia protocol for ROSC patients, it's been active for about a year now. There is inclusion/exclusion criteria that needs to be considered prior to initiating therapeutic hypothermia, including:

Inclusion criteria:
GCS <8
Pt age: > Puberty

Our protocols exclude:
Pregnant or suspected pregnant Pts
Trauma Pts
Suspected sepsis
Recent major surgery

That's just some of the criteria off the top of my head. I haven't had the opportunity to use the TH protocol yet myself, but I hear it has excellent results if utilized appropriately.
 
We do it abit different, most people wait until they regain pulses to start Cool Saline. We Get an IV/IO and immediately attached a chilled liter bag of Saline, so that we begin the process at the begining of the call. And we don't wait until ROSC has already begun.
 
.I've read that starting cooling before rosc was not good. Where I work we start cooling the pt as best we can with ice packs and saline.
 
First thing I do everyday once I check out my truck is grab a "hypo kit"........I have never seen it used. IF someone gets ROSC, they never remember to use the hypo kit.

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rmabrey said:
First thing I do everyday once I check out my truck is grab a "hypo kit"........I have never seen it used. IF someone gets ROSC, they never remember to use the hypo kit.

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Click to expand...

That's sad. In our system, your chart would be QI reviewed and you'd get dinged for not meeting the standard of care. We chill down every ROSC here.
 
There is no reason to be doing a "study" or a "pilot" of therapeutic hypothermia at this point in time. The evidence is extremely robust. If you're going to do it make it the standard of care. It is absolutely untrue that it's "not good" to begin cooling prior to ROSC. In fact there's a slight trend toward patients being easier to resuscitate. Just verify they are not already hypothermic at baseline.

Tom
Hilton Head Island Fire & Rescue
(Implemented "Code ICE" protocol in 2011 with iced saline and external cooling)
 
There are MANY south Tx agencies doing it (all of the big ones that I know of). Two of the agencies I work for have been doing it for a couple years; my FT has just switched from doing it post-ROSC to intra-arrest induction. All of the hospitals down here are on board with it as well.
 
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We had a hospital that was not onboard with it, so it was explained to them that if they were not going to continue a measure that we started in the field then we will not be bringing them our STEMIs our any Post arrest patients. They started doing induce hypothermia soon after...
 
I know the Houston area is in on it.... Thats the closest major metro area to me.

@TomB:Agreed, there is no reason to be doing a study or pilot.... It should be the standard, or at least moving toward it, but alas, some agencies are so far behind the curve that they are just now getting therapies that were "cutting edge" ten years ago (some of which are falling out of favor)

@n7lxi and Fish: Where is "here? I'm trying to get a trend of "where" it has become the standard of care

@fish: funny how facilities change their tune when they may lose those patients that will receive a bill of $150K+ isn't it?
 
Our medical director wants it but he is still dealing with the hospitals in the area. None use it.
 
The one county I am is using it in the hospital, but not the field yet.

The other county is absolutely against it. But they're screwed up anyway
 
Its a standard here for ROSC.

We did a trial of prehospital cooling vs waiting to ED. From memory there was no significant difference found, but we're keeping at it anyway for various reasons. I'm no expert, I am but a lowly ALS paramedic and a graduate at that, but I'll chat to some intensive care medics at work, are you interested in anything in particular?

- Pt intubated (so RSI, if not tubed during the arrest)
- Collapse to ROSC > 10/60
- Normal functional status
- Temp. > 34.5 C
- No pulmonary oedema evident
- Cardiac arrest not due to haemorrhage

http://www.ambulance.vic.gov.au/Media/docs/Adults2-7914fa4e-3ede-4329-9acf-c2adcc77a5be-0.pdf (these ones are a little old now, and just the briefest of overviews from the guidelines, but you get the picture).


We use up to 2L of cold saline kept in insulated bags changed over at the start of every shift. Some of the fancy city MICA types might have fridges, I'm not sure.

More exciting is the recent initiation of the POLAR trial. Using roughly the same cooling procedure for TBI pts. Just read the pre-hospital manual today.
Very excited to see how it works out.

http://www.anzicrc.monash.org/polar-rct.html
 
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It's in our protocols here (Houston area).

It will also be a topic of discussion 1/24/2012 at a STEMI conference held down here at Methodist Hospital, so I'll have more to add to this conversation then.
 
Omnimedic said:
I know the Houston area is in on it.... Thats the closest major metro area to me.

@TomB:Agreed, there is no reason to be doing a study or pilot.... It should be the standard, or at least moving toward it, but alas, some agencies are so far behind the curve that they are just now getting therapies that were "cutting edge" ten years ago (some of which are falling out of favor)
Click to expand...

I disagree. Whilst it is true that induced therapeutic hypothermia post ROSC (at least for VF/VT arrests) is standard of care, with an NNT of about 7 for benefit, there is no evidence that doing it in the field is of any benefit. The only decent study that looked at it came out of Australia a few years back and found no difference between paramedic cooling and hospital cooling. There is (as Melclin has pointed out) now a trial underway to determine whether earlier (i.e. pre-ROSC) cooling will show benefit, as this has not yet been determined either.

So an organisation electing not to carry out an unproven intervention can hardly be accused of not being current.
 
Just had my second opportunity to use field initiated hypothermia over the weekend. Optimistic due to the first time initiating the protocol resulting in the patient walking out of the hospital with no neuro deficits. Whether our field care helped or not I'll probably never know, but so far so good.
 
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