part 1 union hospital, inc. emergency department
TRANSCRIPT
Part 1Union Hospital, Inc.
Emergency Department
Newsweek July 2007
New York Times Dec 2008
Historical Perspective of HypothermiaHypothermia for
clinical purposes has ancient roots, used by Egyptians, Greeks, and Romans
Hippocrates advocated packing wounded patients in snow and ice to reduce hemorrhage
1950’s Hypothermia was utilized for intracranial aneurysm clipping and for cardiac surgery during circulatory arrest
1960’s Clinical trials with hypothermia (30 degrees Celsius or lower) were discontinued because of the side effects, uncertain benefits, and management problems
Historical Perspective of Hypothermia1980’s Animal studies
showed benefits of mild (32-35 degrees Celsius) hypothermia rather than moderate or deep hypothermia (less severe side effects)
1997 first human study by Dr. Bernard with mild hypothermia
Two landmark studies in 2002.
55% in the hypothermia group had favorable neurologic outcome within six months compared to 39% in normothermic group.
49% hypothermia vs 29% normothermia DC to home or rehab
Recommendations2010 ILCOR (2010
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations)
2010 AHA guidelines for Post Resuscitation Induced Hypothermia
The StudiesThe Studies-1. Bernard SA, Gray TW Treatment of comatose survivors
of out-of-hospital cardiac arrest with induced hypothermia NEJM 2002;346:557-563, Australia
Results: 49% vs 26%, hypo vs normo, had a “good outcome”- as defined by discharge to home or rehab
2. Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest NEJM 2002;346:549-556 Austria
Results: 55% vs 39%, hypo vs normo, had a CPC-cerebral performance category score of “good recovery” or “moderate disability”
Epidemiology of Cardiac ArrestApproximately 450,000 people
experience Sudden Cardiac Arrest (SCD) every year
95% of patients that have experienced SCD died before they reach the hospital
PathophysiologyBrain loses oxygen stores within 20 secondsDamage starts 4-6 minutes after the heart
stopsGlucose and adenosine triphosphate stores
deplete (brain energy)Membrane depolarizationCalcium influxesGlutamine is releasedAcidosis and edema develop
Ischemia may persist for several hours after resuscitation (re-perfusion injury)
CoolingCooling inhibits the process of cell
destruction (apoptosis) caused by traditional resuscitation during reperfusion.
When a patient is resuscitated, reperfusion sets off a series of chemical reactions that continue for up to 24 hrs, possibly causing significant inflammation in the brain.
Why make them Cool?↓ Free Radical production↓ ICP ↓ Cerebral metabolic rate ↓ Brains demand for 02 consumption Prevents mitochondrial damage and
apoptosis Better chance of recovery with neurological
function intact.
CardiovascularBradycardiaSlight increase in
blood Pressure (10mmHG)
Mild arrhythmias Increased PR intervalIncreased QT intervalWidened QRS
Increased Systemic Vascular Resistance
Increased Central Venous Pressure
Decreased Cardiac Output
Hematologic
ThrombocytopeniaImpaired platelet
functionLeukopeniaImpaired Leukocyte
functionIncreased PT/PTT
Gastrointestinal
Impaired Bowel Function
Decreased GI motility/ Ileus
Mild Pancreatitis (increased amylase)
Increased liver enzymes
Pharmacokinetics
Altered clearance of medicationsClearance is slowed
having a prolonged effect
Keep this in mind when re-warming.
GeneralBody attempts to
maintain homeostasisShiveringPeripheral
vasoconstrictionDecreased
circulation to skin
MetabolismIncreased fat
metabolism with increased production of glycerol, free fatty acids, ketonic acids, lactate
Metabolic acidosisDecreased oxygen
consumptionDecrease CO2
production
NeurologicDecreased metabolic rate 5-7 % for each 1
degree CDecreased Cerebral Blood Flow
(vasoconstriction)Decreased Magnesium- associated with
worse outcomes. MayCause Cerebral and Coronary
Vasoconstriction
Endocrine
Increased epinephrine, Nor epinephrine, and Cortisol levels
Hyperglycemia due to decreased insulin sensitivity and decreased insulin levels
Renal
DiuresisRenal Tubular
DysfunctionElectrolyte loss (K,
MG, Ca, Phos)
Mechanics of CoolingPassive Cooling
Ineffective have to wait on temperature to decrease to 33◦ Celsius
Active CoolingConvection
Air Cooling Blanket Therma cool Bair Hugger
Conduction Ice packs Cold Blankets
Infusion Cold NS infusion (2L
over 4 hours)
Exclusion CriteriaPregnancyAge less than 18 years of ageKnown terminal illness/ Do Not ResuscitateHead TraumaComatose state prior to cardiac arrestComa for reasons other than cardiac arrest, such as
drug overdose or seizureActive bleedingCore temp less than 86° F on admissionActive infection requiring antibiotics at time of
admission (systemic infection/sepsis)
Inclusion CriteriaCardiac arrest defined as absence of pulse requiring
chest compressions regardless of location or presenting rhythm with return of spontaneous circulation (ROSC).
Coma (does not follow verbal commands, no eye opening, no purposeful response to noxious stimuli) - Prior to sedation. Brainstem reflexes and pathologic posturing are permissible.
Time down less than 60 minutes.Systolic Blood Pressure (SBP) > 90 mmHg and Mean
Arterial Pressure (MAP) > 60 with or without the use of vasoactive medications.
Intubated and ventilated via bag valve mask or mechanical ventilator.
Initial temperature greater than 86° F.Confirmation of ICU Bed assignment.
MonitoringVital Signs Q 15 min X 1
hour, then hourly.
Core Temperature Q15 min until target reached then hourly.
Continuous ECG monitoring.
BIS Monitoring
Glasgow Coma Scale hourly.
FSBS hourly.
I & O hourly.
Assess skin Q2 hour.
Obtain patient weight.
Complications of HypothermiaPneumonia RiskVentilator DependencyDecreased WBC / BM
SuppressionDecreased Inflammatory
cytokinesElevated Glucose
Miscellaneous ComplicationsDoes NOT significantly increase metabolic
acidosisor Lactate levelsWill often cause mild HYPOTENSION, use
Pressorsto maintain MAP > 80 for cerebral perfusion
(90 – 100)Drug Metabolism slowed significantly(Propofol / Fentanyl / Verapamil / Propanolol)
ShiveringIncreases O2 Consumption between 40 – 100%Shivering responses occur primarily between 30 –
35 CSedation and anesthesia to halt shivering also
increasePeripheral Blood FlowIf you paralyze, you can’t screen for seizuresBuspirone (Buspar) 30mg PO q 8hrs / hold for SCr
> 1.7Fentanyl 75mcg IVUse Paralytics as second line
The Future is in Our Hands