Therapeutic Hypothermia: Prehospital

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Mattyirie

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Hello EMT life,

I am looking into writing a proposal regarding the institution some formal method of inducing hypothermia in CA patients in my county's EMS system. The reason being is that both area hospitals are instituting protocols for it and I would like to get experience "pioneering" new protocols and changes within an EMS system. It can be complex and challenging and I would feel that Hypothermia in cardiac arrest is something I am passionate about sorting through. At this point it is still a thought in my head and to my knowledge no one else in my county is considering it.

A bit about me:

I am an EMT-Basic with a busy 911 system in a location I'd rather not specify for personal reasons. I have about 4 months of experience in EMS. I also work as a tech in the ICU at one of the area hospitals where we are capable of handling/do handle cardiac cases. I am also a BSN student about a year from graduating. Some concerns that I have are my limited experience with EMS and my low level of certification not giving me enough credit to be taken seriously. Again, I am not sure if this will be a factor or not, I have never attempted this. I just feel that I am ready to begin acting outside of what is expected and do something more.

What I am looking for from EMT life is experience. There are many on this forum that have done this a time or two and could help me learn lessons the easy way. The first thing I would like is direction toward resources on writing proposals, components of a proposal for protocol change. How the whole process works! Obviously I will need to be thoroughly educated on the subject and have a breadth of quality research to justify its institution as well as local case studies/evaluations where the benefit would be clear (ideas at this point..bear with me).

Anything constructive that can be added to the thread is welcome.

Thanks for reading
 
It's good that you are looking towards advancing your system. However, I would like to share a few thoughts about therapeutic hypothermia (TH) coming from a service that uses it and has done a fair amount of research on it - some ongoing. These are just my thoughts, my opinions based on what I have seen, done and read. They are not gospel and I'm not providing references.

First of all, the biggest thing to consider is the fact that there is no evidence that pre-hospital commencement of TH is of any benefit to the patient in and of itself. That's maybe a pretty big sticking point there.
You'll notice that the research that was posted by Wolfman is about using hypothermia to get the hospital to think about hypothermia. That is, if you start it, the patient is more likely to get it. Which is a good thing, but then should you really be responsible for improving the systems performance of hospitals?
This phenomenon is what saw us continue to use hypothermia even though it confers no survival benefit. We are now researching hypothermia during the arrest as opposed to after the arrest. Watch this space.

So if you decide to press on with hypothermia there are other things that need to be considered. Given that it is a nice to do thing, not a need to do thing, you have to consider the performance of your service and medics more broadly. You want to be working in a service where the performance during resuscitation is pretty well optimised already. Your crews need to be confident and competent in providing excellent arrest and post-arrest care. There is no point in trying to add another layer if you aren't as on the ball with standard care as you should be (using you in a generic sense, not you personally)

Post arrest care needs to include aggressive BP management using epi or nor-epi, preferably via infusion to avoid peaks and troughs (one of the basic premises of TH is cerebral resuscitation, and to resuscitate brains we need to perfuse them) excellent ventilation/oxygenation (no hypoxia, no hyperoxia) and so on.

Now, in my opinion there is really only one way of providing TH in the field that makes sense from a logistics, price and efficacy standpoint. That is, rapid infusion of ice cold crystalloids. It is effective, it is cheap, it is relatively easy and it doesn't rely on ridiculously expensive and sometimes complicated proprietary devices. It also helps achieve hemodilution and BP management (I've written a rant about this over here)

So cold fluid is great, but you have to be able to deal with shivering, which will obviously negate what you are trying to achieve in the first place. Now, there are many approaches that can be taken here. Most ICU's will working on what is basically a sliding scale of sedation, using fentanyl, benzo's and so on to manage shivering. All that takes a lot of time, very close monitoring and some heroic doses of drugs sometimes (bringing up the problem of BP management again)

So again, to my way of thinking, there is one simple way of dealing with shivering: remove the ability to shiver in one easy step. Ergo, paralytics. We use pancuronium, but vec or roc would be fine too. This immediately, easily and effectively eliminates shivering, but also introduces some other issues. Whilst not needing to mess around with different levels and types of sedation, you clearly still need sedation when you are paralysing someone. It may be that their brain is scrambled egg already, but it's not a gamble I would be willing to take. So you need to be able to provide continuous sedation and analgesia. For me this is morphine/midazolam or fentanyl/midazolam via continuous infusion (again minimizing peaks and troughs). So there is a bunch more logistical and medical issues to deal with.

There is also the issue of airway management when you have paralytics on board. Now, opinions vary, but for me personally, there is no way on gods green earth that I am paralysing without an ETT in place. And once that ETT is in place there needs to be continuous capnography at all times (ensuring the tube is in place and also providing important info about the patient)
So you now need to have medics who are capable of accurately and safely placing an ETT during an arrest (without interrupting CPR) or carrying out an RSI in the post arrest patient if necessary, and the equipment necessary to facilitate that. So if your medics aren't getting many tubes, or aren't having a great deal of success on the ones they attempt you need to make sure they are getting OR time and plenty of QA/QI is going on.

So those are my thoughts. I'm not saying you shouldn't look at TH, I just think there are a lot of things to consider.
 
We introduced therapeutic hypothermia after a RINSE trial here some time ago

TH started in the prehospital setting and then carried on in hispital was show to signigicantly improve survival to discharge

This is one of the reasons we have a survival to discharge of over 30% here

Basically they get 2L of normal saline at 8 degrees celcius with their temp maintained at 32-34 degrees

But as you pointed out about shivering these guys get RSI'd and paralysed.

Waveform capnography is always present

B/P maintained with adrenaline infusion +/- fluid challenge

So, pretty much what the last guy said..

**edit**

Actually, i wonder if i work for the same mob smash works for anyway?
 
Last edited by a moderator:
@Smash:

Those are all excellent points. I looked around last night and inevitably stumbled upon the 2010 articles Castren et al. and Bernard et al. in circulation. Interesting reads and I do agree with your views in the use of TH pre-hospital, definitely in systems with short transport times to definitive care. NOW, my system is a mix of city (transport times of 5-10 minutes) and county (30+ times). I feel that TH would be more than appropriate in this arena providing, as you state, the rest of the care is up to standard. No sense trying to polish a turd right? The "code care" in our system is OK, ETC02 is standard for any advanced airway be it supraglottic or ETT however looking deeper, our existing protocols and level of training and QA/QI would not support TH at this time.

Thanks for the response.
 
Mattyirie said:
Hello EMT life,

I am looking into writing a proposal regarding the institution some formal method of inducing hypothermia in CA patients in my county's EMS system. The reason being is that both area hospitals are instituting protocols for it and I would like to get experience "pioneering" new protocols and changes within an EMS system. It can be complex and challenging and I would feel that Hypothermia in cardiac arrest is something I am passionate about sorting through. At this point it is still a thought in my head and to my knowledge no one else in my county is considering it.

A bit about me:

I am an EMT-Basic with a busy 911 system in a location I'd rather not specify for personal reasons. I have about 4 months of experience in EMS. I also work as a tech in the ICU at one of the area hospitals where we are capable of handling/do handle cardiac cases. I am also a BSN student about a year from graduating. Some concerns that I have are my limited experience with EMS and my low level of certification not giving me enough credit to be taken seriously. Again, I am not sure if this will be a factor or not, I have never attempted this. I just feel that I am ready to begin acting outside of what is expected and do something more.

What I am looking for from EMT life is experience. There are many on this forum that have done this a time or two and could help me learn lessons the easy way. The first thing I would like is direction toward resources on writing proposals, components of a proposal for protocol change. How the whole process works! Obviously I will need to be thoroughly educated on the subject and have a breadth of quality research to justify its institution as well as local case studies/evaluations where the benefit would be clear (ideas at this point..bear with me).

Anything constructive that can be added to the thread is welcome.

Thanks for reading
Click to expand...

We run both types (intra-arrest and post-arrest) in our area with success. However, getting EMS on board with it is the easy part. Getting the hospital involved is the hard part!

You need to find somebody on the hospital side to partner up with to drive it from both sides. Once you've got that initial conversation going, you can look up EMS protocols from your favorite agency (NC's 2012 protocols have a good start) and run from there.
 
Christopher said:
We run both types (intra-arrest and post-arrest) in our area with success. However, getting EMS on board with it is the easy part. Getting the hospital involved is the hard part!

You need to find somebody on the hospital side to partner up with to drive it from both sides. Once you've got that initial conversation going, you can look up EMS protocols from your favorite agency (NC's 2012 protocols have a good start) and run from there.
Click to expand...

The benefit of being in a large city. For example, FDNY more or less said we will not bring out post-cardiac arrest patients to you if you don't work with us. Anyway I think its a bit more difficult to set up the hospital part as you are doing more long term. When I worked in a cath lab, we used like the coolgard system. The lab put in the Icy catheter for it. There were so many different protocols for the lab and then the CCU.

Anyway in NYC REMSCO has a lot of information out on their research and I believe protocols.
 
Mattyirie said:
@Smash:
No sense trying to polish a turd right? /QUOTE]

You may not be able to polish a turd, but you can sprinkle it with glitter! :P
Click to expand...
 
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