Post-Cardiac Arrest Hypothermia Protocols

[drdique]

Hello all you ALS guru's

I work up in Alberta, Canada and just recently transported a post-cardiac arrest resuc.. Curious what others are doing with regards to inducing hypothermia of 32-34 degrees Celcius with these patients. Comments?

 

[rmellish]

I wish we were doing that where I work...

 

[Epi-do]

We have a protocol for induced hypothermia post cardiac arrest, but our transport times are so short I have only heard of it being used a handful of times in the couple years we have had it.

 

[daedalus]

We are doing it in South Santa Barbara county as part of a study. I think it is exciting, but I think we will have to wait for more definitive answers before rolling it out everywhere.

As an aside, my county is going to do away with ACLS and PALS within a few years! Our medical director (Ventura and SBC) thinks ACLS is crap.

 

[Melbourne MICA]

Posr resus

Hello all you ALS guru's

I work up in Alberta, Canada and just recently transported a post-cardiac arrest resuc.. Curious what others are doing with regards to inducing hypothermia of 32-34 degrees Celcius with these patients. Comments?

On Melbourne MICA we now have a complex post ROSC management plan that overall has three components. Haemodilution, hypothermia and hypertension.

Haemodilution and Hypthermia are achieved through fluid challenge with cold NaCl and paralysis with Pancuronium

Hypertension is achieved through inotropes specifically Epinephrine in bolus doses immediately post (and during) resus continued with Epi infusion at high rates typically 20-50mcg/min.

The desired numbers are a temp of 33 degC and a MAP of 160/90 with ongoing arrhythmia and general management.

Our evidence based theoretical basis for this approach has established that these three elements reduce both secondary neurological injury from hypoxia and secondary reperfusion injury after ROSC.

In essence then the resus has now been divided into two sections. The primary cardiac resus component and once ROSC has been achieved a neurological resus designed to limit secondary brain injury so neuro outcomes are improved.

I can go into the pathophysiology of this approach in a little more detail if you like.

MM

 

[Melbourne MICA]

You're joking

As an aside, my county is going to do away with ACLS and PALS within a few years! Our medical director (Ventura and SBC) thinks ACLS is crap.

Do away with ACLS and PALS? Who is he kidding? He obviosuly hasn't done much in the way of lit reviews or looked at current EMS and other research.

Perhaps he can explain to staff how a chest decompression in a paediatric pt is useless or how ROSC management is not producing any benefits. And there is the reduced time to balloon plasty AMI pts who are benefiting from 12lead telemetry straight to the cath lab/cardiologist or the cardiac pts who have resolved tachy and brady arrhythmias through early ACLS interventions just to name a few examples.

MM

 

[fma08]

Do away with ACLS and PALS? Who is he kidding? He obviosuly hasn't done much in the way of lit reviews or looked at current EMS and other research.

Perhaps he can explain to staff how a chest decompression in a paediatric pt is useless or how ROSC management is not producing any benefits. And there is the reduced time to balloon plasty AMI pts who are benefiting from 12lead telemetry straight to the cath lab/cardiologist or the cardiac pts who have resolved tachy and brady arrhythmias through early ACLS interventions just to name a few examples.

MM

He may be referring to the ACLS and PALS protocols specifically. There has been debate before if they are really what we should be going by or not. But, I may be wrong ^_^

 

[daedalus]

Do away with ACLS and PALS? Who is he kidding? He obviosuly hasn't done much in the way of lit reviews or looked at current EMS and other research.

Perhaps he can explain to staff how a chest decompression in a paediatric pt is useless or how ROSC management is not producing any benefits. And there is the reduced time to balloon plasty AMI pts who are benefiting from 12lead telemetry straight to the cath lab/cardiologist or the cardiac pts who have resolved tachy and brady arrhythmias through early ACLS interventions just to name a few examples.

MM

Yes. We are doing away with ACLS certification and algorithms. Information can be found on Ventura County EMS website under meeting minutes. We are moving to something called ART/BART. I do am not aware of what that is yet and I have been unable to find anything about it on the internet, but I am assured it is not dumbed down crap like ACLS.

I am not sure what you are getting at, because it is not ACLS that tells us to activate the cath lab after field 12 leads, or to preform ROSC management. We already do all of that and it has nothing to do with ACLS.

EDIT: Link to minutes http://portal.countyofventura.org/p...EASECONTROL/EMS/COMMITTEES/PSC_PKT_FEB_09.PDF
Los Angeles is now on board, I have heard that most SoCal counties are doing away with ACLS.

 

[Melbourne MICA]

Yes. We are doing away with ACLS certification and algorithms. Information can be found on Ventura County EMS website under meeting minutes. We are moving to something called ART/BART. I do am not aware of what that is yet and I have been unable to find anything about it on the internet, but I am assured it is not dumbed down crap like ACLS.

I am not sure what you are getting at, because it is not ACLS that tells us to activate the cath lab after field 12 leads, or to preform ROSC management. We already do all of that and it has nothing to do with ACLS.

EDIT: Link to minutes http://portal.countyofventura.org/p...EASECONTROL/EMS/COMMITTEES/PSC_PKT_FEB_09.PDF
Los Angeles is now on board, I have heard that most SoCal counties are doing away with ACLS.

Sorry perhaps we are not on the same page re the term "ACLS". By this I mean Advanced Cardiac Life Support which for us is half our guidelines and more - arrhythmia management, cardiovascular collapse, arrests etc. By the PALS I assume you mean Advanced Paediatric Life Support. Once again for us, far more limited in scope but we still cover arrhythmia Mx, trauma, resp and airway stuff including sedate to tube and even possibly RSI for kids coming up. Our chopper guys can Crike kids as well.

Sorry if I got the terms muddled up - it's a bit of a common problem for me as I learn the US/Euro/Canadian definitions and interpretations etc.

Let us know what the "BART" term refers to.

MICA in Melbourne started in 1973 and was all cardiac stuff to begin with.

Cheers
MM

 

[daedalus]

Yes I see where the misunderstanding is. Our medical director wants to move more away from algorithms and more towards medicine. We still of course provide advanced life support, including advanced techniques for cardiac emergencies. What we are planning on is doing away with American Heart Association ACLS certification because the class encourages cookbook medicine and is very dumbed down. We are moving to something more advanced. I think that Rid made a case describing how ACLS is a joke in another thread, ill track it down.

EDIT:
I see that you are in Australia, you may not be aware, but most American Paramedics hold a certification card from the AHA, it is a two day course that teaches protocols for cardiac arrest senarios. It is more or less useless in its present state.

 

[Melbourne MICA]

Thanks

Yes I see where the misunderstanding is. Our medical director wants to move more away from algorithms and more towards medicine. We still of course provide advanced life support, including advanced techniques for cardiac emergencies. What we are planning on is doing away with American Heart Association ACLS certification because the class encourages cookbook medicine and is very dumbed down. We are moving to something more advanced. I think that Rid made a case describing how ACLS is a joke in another thread, ill track it down.

EDIT:
I see that you are in Australia, you may not be aware, but most American Paramedics hold a certification card from the AHA, it is a two day course that teaches protocols for cardiac arrest senarios. It is more or less useless in its present state.

Yes thats right sunny Oz. I've been posting for a while now and your comment about the card from the AHA is the first time I have come across it. Our medical standards committee formulate our guidelines on current research and practice all evidence based methodology, no schools of thought stuff. Our in-house medical directors run the general management of our practice, auditing, trials etc. Our arrest guidelines are based upon ILCOR. The cardiac theoretical base comes from AHA, EHA, Aus HA.

But we certainly don't have to get a card or go to some outside course for certification and the like. We do our training, are passed to practice through exams and panel interviews and then practice according to the guidelines with a fair bit of scope to step outside them as well. Nice and simple.

The MICA guys themselves can put in suggestions for changes to guidelines through our med standards committee. The guys will do the research then formulate a proposition and submit it. Lots of our MICA guidleines have been changed this way. It encourages the guys to be ahead of the curve and keeping up with current level A evidence based pratice.

Thanks for the clarification. It sounds like your Doc is on the right track after all so to him I apologise.

MM

 

[drdique]

Thanks for your feedback.

Specifically, M.M.

We work on the same principles of haemodilution/hypothermia Though I havent yet seen the hypertension side of it used here. Makes good sense for reperfusing cerebral tissues, though i'm curious about the use of epi and the possible increase in myocardial demand. Does the administration of epi not create an issue for these patients with compromised cardiac circulation by vasoconstricting and increasing myocardial ischemia prior to reaching a cath lab?

 

[Melbourne MICA]

Thanks for your feedback.

Specifically, M.M.

We work on the same principles of haemodilution/hypothermia Though I havent yet seen the hypertension side of it used here. Makes good sense for reperfusing cerebral tissues, though i'm curious about the use of epi and the possible increase in myocardial demand. Does the administration of epi not create an issue for these patients with compromised cardiac circulation by vasoconstricting and increasing myocardial ischemia prior to reaching a cath lab?

Apparently not. In a non arrested pt with cardiac problems the situation would be different of course. Thats why we manage our cardiac pts more delicately whilst alive especially as far as Epi goes.

In the arrested pt the Epi situation is different.

Adequate right ventricular filling pressures prior to diastole are vital for coronary artery reperfusion and for left ventricular ejection fraction and hence cardiac output and further reperfusion.

Peripheral vasoconstriction through alpha effects of Epi (which I think is what you are getting at) is beneficial though diminished initially (venodilation and vessel wall leakage is peaking at this point). The beta agonist effects of Epi are also affected - (there are cellular and blood chemistry reasons for this). Also, Epi is known to not be pro-arrhythmic at this point. We've all seen this - bucket loads of epi in the Mx of the arrested pt but they don't often go into any sort of tachyarrhymia as a side effect of it.

But systemic BP and hence mean arterial pressures are markedly improved with Epi as reperfusion progresses and need to be maintained throughout. This can be the case for as much as 24hrs or more after the event. This has both neuro and cardiac benefits - in fact general tissue perfusion benefits.

There is already widespread ischaemia because of the arrest so the aim is to correct this as quickly as possible by restoring filling pressures and using supplemented oxygenation (100% O2) etc.

A pt who arrives on the cath lab with a poor MAP will probably re-arrest on the table and be highly unstable at best. Alternatively the pt with a good MAP will survive the procedure, have the corrective plasty and reduce the likelihood of long term (myocardial and neuro) functional deficits caused by heart failure.

I hope that helps a bit. I'm still reading up on our background stuff for this area which goes into a fair bit of detail about enzymes, platelet aggregation, calcium movement in the cells, endothelial changes, release of free radicals (sounds like a political lefties dream), thromboxane production etc etc.

Cheers
MM

 

[boingo]

We have a hypothermia protocol, with a target MAP of 90, not quite as high as our friends down under, temp target of 34 C and etCO2 40 We infuse 4 degree C saline in 500 mL increments to a max of 2L. We use an esophageal temperature probe to measure core temp, paralyze w/vecuronium and ativan for sedation.

 

[Ridryder911]

There is a JEMS Webcast on this topic with standard protocols. Very good speaker and discussion, and it's free for CEU's.

http://www.jems.com/webcasts/Prehos...l;jsessionid=8BBBB90B76316A65B99C7B9C18CE542C


R/r 911

 

[austinmedic77]

Been doing it for quite a while now you are welcome to review or guidlines for inclusion and procedure at our medical directors website www.atcomd.org listed under post resucitation. We dont have a full years data for solid numbers however having discussed the issue with our medical officers anticdotally we have had significant success and positive results with this and we also have very short urban transport times. Hope this helps.

 

[marineman]

No hypothermia protocols here yet but I can see it coming, if the results are really as good as first reported I can see it being required on ALS ambulances.

daedalus we too have (partially) moved away from ACLS. We are in a trial study for the zoll autopulse so we have protocols set forth by the study management but we're still required to be ACLS certified. We are also using PEPP instead of PALS.

 

[Streetdoc740]

We recently started doing this in a suburb of Pittsburgh. We have a hypothermia protocol that states the post arrest we are to rapidly infuse 2 liters of cooled saline (4 degrees celcius) if

1. ROSC for 5 minutes as result of CPR or defibrillation/ACLS measures
2. systolic pressure of at least 90 systolic
3. Less then 60 yrs old
4. Pt remains intubated and is not responsive

My service have installed portable refrigerators in our units to ensure a constant temperature.

We have as of yet to have a person that fits our protocol which went into effect 6 months ago.