Induced Hypothermia for Heart Attacks

[MMiz]

I've been reading about Induced Hypothermia for Heart Attacks, and looked at the Wake County's impressive results. Their data is showing that the new treatment leads to a four-fold increase in the survival rate for cardiac arrest patients.

Has anyone else heard about this? Does anyone work for a service with a similar program? This sounds very progressive, especially for EMS.

 

[KEVD18]

heart attack/myocardial infarction-the loss of living heart muscle as a result of coronary artery occlusion. *still alive. in some trouble, but alive*

cardiac arrest- sudden cessation of functional circualtion. *dead*

sort of an important distinction

the use of induced hypothermia in cardiac arrest patients is showing some good results. im sure R/r will be along shortly with the book stats.

 

[Ridryder911]

Just attended a conference last Friday & Saturday. The facts are not in yet. Still VERY controversial and at this time, it does not appear to conclusive if there is really that much of a difference (dependent on what study you read).

I doubt we see an immediate change in EMS care, (yes there are several pilot studies performing field studies) but unless there is a receiving ED with ready available cath and continuous induction of hypothermia (immediately available) it is worthless.

I am sure the next few months there will be a statistical war from the studies to attempt to claim victory over each other.

Of course the bottom line will be if the costs is worth the change in the outcome. I really do not see a change occurring unless there is a significant change in outcomes.

R/r 911

 

[mikeylikesit]

well it is good in the sense that atleast if the patient does die their organs will still be usable for a while longer.

 

[VentMedic]

well it is good in the sense that atleast if the patient does die their organs will still be usable for a while longer.

Not necessarily. To keep a patient alive even for the 24 hours while on the hypothermia protocol in the hospital is challenging with profound fluctuations in BP and arrhythmia. It can be a very ugly death for the family to watch during that time. The organs may or may not be donor quality depending on whether there was aspiration during intubation, damage to the organs during the period of oxygen deprivation/resuscitation, how septic the patient can still become during that time and how well the kidneys can still function.

The rewarming phase can be even more difficult. Then, only after the patient is rewarmed, which is a slow process, can the procedures start to determine brain death for organ procurement which can take several more hours. The whole process to actual OR time can be up to 72 hours after the rewarming phase is complete.

While the initial cooling in the field may be helpful, that is only one step to a very long process and recovery. It is when you are sure the patient has not suffered any serious neuro deficits can you declare success. Often we still bring back someone who will be in a nursing home for the remainder of their lives. Usually, people only hear the great success stories that may or may not have occurred anyway with or without hypothermia.

Hypothermia is not new and has be done in pediatrics for at least 20 years. It was also tried in adults, including on the ambulances, in the 1980s. However, the methods for cooling adults back then were crude.

 

[mikeylikesit]

While the initial cooling in the field may be helpful, that is only one step to a very long process and recovery. It is when you are sure the patient has not suffered any serious neuro deficits can you declare success. Often we still bring back someone who will be in a nursing home for the remainder of their lives. Usually, people only hear the great success stories that may or may not have occurred anyway with or without hypothermia.

Hypothermia is not new and has be done in pediatrics for at least 20 years. It was also tried in adults, including on the ambulances, in the 1980s. However, the methods for cooling adults back then were crude.

So do they have something like a DNH(do no Hypothermiate)?

 

[jedirye]

Rid, you in Florida and were you talking about ClinCon?

Regardless, my service just started using induced hypothermia for cardiac arrest patients who have a ROSC but are still unconcscious.

An article about it's success:

Nature Coast EMS Staff Speak at National Conference on “ICE” Induced Cooling by EMS.
July 22, 2008

ICE (Induced Cooling by EMS) Therapy Results Astounds Physicians and EMS (Emergency Medical Service) Professionals at National EMS Clinical Conference in Orlando, Florida



Orlando, FL- - Speaking at the 34th Annual ClinCon Conference at The Rosen Centre Hotel in Orlando, Fl, on Friday, July 11, Florida-based EMS Medical Director Dr. Mary Ann Kolar astounded physicians and EMS professionals with a presentation on the impressive results of the Induced Hypothermia treatment protocol of post cardiac arrest patients in Citrus County, Florida. The presentation by Dr Mary Ann Kolar and Chief Training Officer, Jane Bedford, RN, CCP included a report on Nature Coast EMS’s treatment results citing the National average of out-of-hospital cardiac arrest patients that regain a pulse is 6.4% as reported by the American Heart Association, in Citrus County, 27% of cardiac arrest patients regain a pulse in the care of Nature Coast EMS. A patient experiencing a cardiac arrest in Citrus County has a 4 times greater chance of surviving than a patient experiencing a cardiac arrest somewhere else. For the patients that remained in coma after experiencing an out-of-hospital cardiac arrest that met the guidelines for induced hypothermia, 100% of these patient have walked out of the hospital, neurologically intact.



This simple treatment is able to bring a patient from a virtually unrecoverable condition of coma after an out-of-hospital cardiac arrest to waking up and going home. Richard Greenman and Paul Russell, two survivors, spoke to the group in an effort to encourage the physicians and EMS professionals to bring this life-saving treatment to their local EMS services and hospitals. “I just want to say ‘Thank You’ for what you do”, said survivor Paul Russell. Mr Russell is now back at work at Publix after experiencing a cardiac arrest at home in March. Both men shared their experiences and said they only have short term memory loss related to the day of their cardiac arrests.



Nature Coast EMS was the first EMS service in Florida to offer the ICE protocol in partnership with Citrus Memorial Hospital, the first rural hospital in the Nation to offer induced hypothermia for post cardiac arrest patients.



The ClinCon Conference is designed to create an educational experience that will help EMS Personnel provide the highest quality prehospital care to their patients.



Nature Coast EMS is the sole provider of advanced life support in Citrus County, located north of Tampa on Florida’s nature coast.


It doesn't go into too much detail to be honest, but as mentioned, they had two of our patients at the conference. One had been clinically dead for six minutes and the other for about nine minutes and both have no neurologic deficits. Quite amazing.

-rye

 

[VentMedic]

It doesn't go into too much detail to be honest, but as mentioned, they had two of our patients at the conference. One had been clinically dead for six minutes and the other for about nine minutes and both have no neurologic deficits. Quite amazing.

-rye

Since you are in Florida, you can easily access the many studies (both "miraculous and not") from University of Florida, USF, and University of Miami that have been done over the past several years. This is not new and had to have a significant trial period before being introduced. The results are very mixed as Rid stated.

There are a lot of factors that don't always get mentioned in the studies that also deserve some credit.

Was it a witnessed arrest?

Was CPR started immediately?

Other medical conditions?

How many other patients also rec'd hypothermia treatment prehospital and inhospital?

How many that died or had neuro deficits didn't make the study due to "technicalities" that excluded them from the study? Statistics can sometimes be presented for the benefit of those doing the study.

This is big business now and our ICUs have invested several hundred thousand dollars for equipment that might be obsolete in a few years. That is why the research is expanding into other areas such as stroke.

Right now this area has a large amount of grant money available to it so there will be a lot of both pro and con from the medical groups to form their research statements. A lot of researchers depend on this to keep their employment and status within a hospital/university environment.

Our survival and good outcome numbers look good but then our physicians are selective about who is going to be put on hypothermia protocol. Of course, those that don't get put on hypothermia protocol in the hospital and die won't count for the EMS study even though hypothermia was initiated in the field. So, it is actually difficult to know the overall stats.

 

[jedirye]

Vent, I guess I am failing to see the point of your post, no offense:

This is not new and had to have a significant trial period before being introduced.

Nope, sure isn't and I bet it did; did I say otherwise?


There are a lot of factors that don't always get mentioned in the studies that also deserve some credit.

Agree.

Etc. etc. I am merely mentioning that our service just started inacting this "Ice Alert" and we have had several good outcomes. For those of you that are interested, here is an article from one of the local newspapers about the man who was dead for a little while: http://www.lcni5.com/cgi-bin/storyviewxarchive.cgi?071+2008314-4539-071-071017.archive+NewsLocal

I've read that human brain death occurs in the four to six minute time frame (under warm circumstances, of course.) To have a man that was clinically dead for nine minutes and have been brought back essentially to how he was before without any deficits, to me, is amazing. I'm not saying it is a miracle, but I think the possibilities with this are certainly there with more research and unbiased statistical data.

-rye

 

[VentMedic]

Orlando, FL- - Speaking at the 34th Annual ClinCon Conference at The Rosen Centre Hotel in Orlando, Fl, on Friday, July 11, Florida-based EMS Medical Director Dr. Mary Ann Kolar astounded physicians and EMS professionals with a presentation on the impressive results of the Induced Hypothermia treatment protocol of post cardiac arrest patients in Citrus County, Florida. The presentation by Dr Mary Ann Kolar and Chief Training Officer, Jane Bedford, RN, CCP included a report on Nature Coast EMS’s treatment results citing the National average of out-of-hospital cardiac arrest patients that regain a pulse is 6.4% as reported by the American Heart Association, in Citrus County, 27% of cardiac arrest patients regain a pulse in the care of Nature Coast EMS. A patient experiencing a cardiac arrest in Citrus County has a 4 times greater chance of surviving than a patient experiencing a cardiac arrest somewhere else. For the patients that remained in coma after experiencing an out-of-hospital cardiac arrest that met the guidelines for induced hypothermia, 100% of these patient have walked out of the hospital, neurologically intact.

From the news paper link:

one of the five people in the area who have undergone ICE treatment.

This news clip reads just like many others "introducing the latest and greatest" article. Several other EMS agencies have published similar PR releases but what is really needed to make these news stories credible is a link to their published data and methology of collection.

While that is a great feel good news story you just linked to, it also proves my point from the previous post. The man was young (51) and since he had a previous MI, was probably taking meds that may have prevented more severe damage and exercising as well as having collateral circulation established.

I'm not arguing for or against it but I encourage people to read the scientific medical journals and not just the local newspapers or JEMS. At least look at the references in the JEMS' articles to find the articles in the medical journals to see if anything was lost in the translation. We do alot of hypothermia protocol patients for our research each week. While there is hope and benefit, other factors must still be considered to adequately do an objective study of the results.

 

[Flight-LP]

I am interested in knowing why everyone "oohs and ahhs" over every new study that pops up about cardiac arrests. Hypothermia isn't new as Vent pointed out, it actually has been utilized since the 50's. The stats that come out with these studies need to be heavily scrutinized, if given any attention at all. Wake County's for instance shows a 40 % survival rate. But what it doesn't overly emphasize is that all of those patients met the Upstein criteria which groups together the best circumstances for outcome. That percentage doesn't include the unwinessed arrests, the PEA's and Asystolic patients, nor does it include trauma. So in reality, their TRUE survival, meaning discharged neurologically intact, is still in the 10-20% range. The public, being the ignorant beings they are, just sees that 40%. Its deceitful, plain and simple. The sad part is that we are only hurting ourselves when we inflate or twist our numbers. Studies should be published for the betterment of mankind, not to stroke one's egos....................

 

[boingo]

I think if you read the recent literature again you'll see they are talking about improved outcomes in Utstein arrests. Never mind trauma, unwitnessed, asystole, etc. They have show a significant improvement in neurological outcomes in patients meeting Utstein criteria tx with TH post ROSC than those that don't recieve it. It is statistically significant. This is the group of patients with the highest likelyhood of surviving an arrest and are the ones who are most likely to benefit from the neuroprotective benefit of TH.

 

[karaya]

I am interested in knowing why everyone "oohs and ahhs" over every new study that pops up about cardiac arrests. Hypothermia isn't new as Vent pointed out, it actually has been utilized since the 50's................

It's new in the pre-hospital environment.

 

[VentMedic]

It's new in the pre-hospital environment.

It's new "again". It has already been attempted at other times in the field with different methods for various patient populations. Pediatric "near"-drowning patients are one example from the 1980s.

It's like the drugs in ACLS, Amiodarone and Vasopressin. Or CPAP which has be around for more than 50 years and even utilized in transport.

What was tried or used once before can always be born again for a different use. Some aspects of medicine recycles itself every 20 years as new technology or a different understanding emerges.

 

[karaya]

What was tried or used once before can always be born again for a different use. Some aspects of medicine recycles itself every 20 years as new technology or a different understanding emerges.

And that is a good thing, right?

 

[Ridryder911]

What is interesting for us that are old enough to remember when... is that there maybe a tiny tweak of the treatment or a little change and that is all. I have recently read where PASG is actually being reconsidered because of some new developments....

Again, medicine is alike life an ever revolving cycle....

R/r 911

 

[VentMedic]

And that is a good thing, right?

That depends. Amiodarone and Vasopressin both have mixed reviews. For CPAP, the technology has improved. Hypothermia has evolved but the data still has many variables. If you read articles from Resuscitation and other research based Emergency journals (not JEMS unless it is for the references), you will find mixed reviews on various protocols for cold water or environment resuscitation when it comes to rewarming or continuing to cool. Many medical reviews have been done for cases involving both scenarios.

Resuscitation Journal
http://www.resuscitationjournal.com/

Critical Care and Resuscitation
http://www.anzca.edu.au/jficm/resources/ccr/

Respiratory and Critical Care Medicine
http://ajrccm.atsjournals.org/

Journal of Emergency Medicine
http://www.elsevier.com/wps/find/journaldescription.cws_home/525473/description#description