Out of Hospital Cardiac Arrest:
A Common Disease
• ~1000 Americans will suffer OHCA today
• ~1000 Americans will suffer OHCA tomorrow
• 25+ will suffer OHCA during this talk
• High morbidity and mortality
 47% never make it to the hospital
Where Can EMS Make A
Difference in Outcomes?
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Cancer
Pneumonia
AIDS
Kidney Disease
Diabetes
Alzheimer’s
• NOT YET
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Cardiac Arrest
Major Trauma
ST-Elevation MI
Acute Stroke
• PROVEN!
Different Approach to OHCA
• OHCA is a major public health problem
• We SHOULD maximize our resources and
collaborations with the goal of improving survival
• We NEED to have a REALISTIC idea of what
happens in the field where the battle is fought
• Emergency medicine leaders MUST guide the
community on how to bridge the gap between current
knowledge and practice
Many Reasons for Low OHCA
Survival:
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Poor public knowledge of cardiac arrest
Delayed time to first defibrillation
Low rates of bystander CPR
Inconsistent quality of professional CPR
Inconsistent post cardiac arrest care
• WE haven’t adequately implemented what we
already know
Hyperventilation during CPR
86%
100%
p= 0.006
80%
% survival 60%
13%
40%
20%
0%
12
30
# ventilations per minute
Aufderheide et al. Circulation 2004; 109:1960-5
HOW DO WE FURTHER IMPROVE SURVIVAL?
Therapeutic
Hypothermia
Hypothermia in Cardiac Arrest
the Melbourne experience
• Outcomes:
 49% of the HT group had a “good outcome”
compared with 26% in the NT group,
(p<0.05)
 mortality was 51% in the HT group and
68% in the NT group, (p=NS)
Alsius IVTM™
Vein Placement options:
Femoral
Subclavian
Internal jugular
Alsius catheters also provide triple-lumen central venous access.
Medivance “Arctic Sun”
The LRS ThermoSuit® System
Treatment of Comatose Survivors of Out-Of-Hospital Cardiac Arrest with
Induced Hypothermia (Bernard) Cooling Device
What could EMS offer the pt?
• 22 pts post ROSC who remained comatose
• 30ml/kg of ice-cold saline given via peripheral IV
or femoral central line over 30 min after patient
evaluated and paralyzed
• Decreased core temp from 35.5 to 33.8°C
Bernard SA, et al. Resuscitation 2003;
56:9-13
Prehospital Cooling
Hypothermia post-cardiac arrest
• Use of ice cold IV LR in pre-hospital for
comatose pts post arrest
• Pts given 30cc/Kg at rate of 100 ml/min
• Air ambulance with 25 min infusion
• Pts reached target temp of 34 C with arrival
to ED
Resuscitation. 2004:62:299-302
Hypothermia Videos
• Mike Neubert Story
• Paul’s Life after a cardiac arrest
• Therapeutic Hypothermia for heart attack
victims
“Cool It”: Therapeutic Hypothermia for
Recovery of Neurologic Function in
High Risk Patients Following Cardiac Arrest
Leah A. Swanson, Kalie M. Edelstein, William M. Parham,
Jon S. Hokanson, Richard F. Shronts, Barbara T. Unger, Wendy B. George,
Ivan J. Chavez, Timothy D. Henry, Michael R. Mooney
Minneapolis Heart Institute Foundation
Abbott Northwestern Hospital
March 29, 2009
Cardiac Arrest
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Out-of-hospital cardiac arrest (OOHCA)
295,000 people annually in the US
7.9% median survival rate
Anoxic encephalopathy and neurologic deficits
Therapeutic hypothermia (TH) clinical trials
ILCOR recommendation for TH after resuscitation
Lloyd-Jones D, Adams R, Carnethon M et al. Heart disease and stroke statistics-2009 update. Circulation 2009;119:e21-e181.
Hypothermia History
• 1950s - cardiac and neurologic surgeries
• Late 1950s - after cardiac arrest
 uncertain benefits
 difficulties with implementation
• 1990s - studies in animal models
 histological benefits
 functional benefits
• 2002 - randomized clinical trials of TH
Mechanisms
hypothermia
ischemia
lower
metabolic rate
glutamate
release
less oxygen
consumption
reperfusion
calcium shifts
mitochondrial
dysfunction
excitotoxicity
inflammatory
cascades
cell death
blood brain barrier
disruption & cerebral
edema
oxygen-free radicals
Geocadin RG, Koenig MA, Jia X et al. Management of brain injury after resuscitation from cardiac arrest. Neurol Clin. 2008;22:487-506.
HACA Study Group
• Randomized trial 2002 -hypothermia vs normothermia
• Methods
 Inclusion - OOHCA due to VF
 Exclusion – cardiogenic shock
• Hypothermia group
 32°C - 34°C
 cooled for 24 hrs
 rewarming over 8 hrs
3351
assessed
3246
30
275
ineligible
not included
enrolled
137
138
hypothermia
normothermia
The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac
arrest. N Engl J Med. 2002;346:549-556.
HACA Study Group
• Neurologic outcome
• Pittsburgh cerebral performance category scale
Cerebral Performance Category (CPC)
Positive Outcomes
CPC 1
Good cerebral performance
CPC 2
Moderate cerebral disability
CPC 3
Severe cerebral disability
CPC 4
Coma or vegetative state
CPC 5
Brain death
Negative Outcomes
HACA Study Outcomes
Survival and Neurologic Outcome at Discharge
Hypothermia Normothermia
Survival
87/137 (64%)
69/138 (50%)
Favorable neurologic
64/134 (47%)
outcome
42/135 (31%)
“Cool It” Methods
Level 1 Heart Attack Program – STEMI transfers
“Cool It” Program - regional TH system - Feb 2006
Inclusion
Exclusion
 non-traumatic OOHCA
 comatose before arrest
 ROSC within 60 min
 DNR
 unresponsive
 active bleeding
 cardiogenic shock
 all ages
“Cool It” Methods
• Transfer patients
 standardized protocols
 ice during transfer
• STEMI – immediate
angiography and PCI
• Arctic Sun® TH device
• Target temperature 33°C for 24 hrs
• Rewarming at 0.5°C/hr
• Cerebral function at discharge
“Cool It” Patient Demographics
• 103 patients (Feb 2006-Oct 2008)
• 78 male, 25 female
• Average age 62 years
• 76% transferred
• 50% “Cool It” & STEMI
• 40% cardiogenic shock
Asystole
PEA
Vtach
Vfib
“Cool It” Outcomes
All Patients
HACA
criteria
Non-HACA
criteria
(VT & VF)
(PEA, asystole,
shock)
Total
Number
103
52
51
Survival at
Discharge
58 (56%)
38 (73%)
20 (39%)
P
Value
0.0007
“Cool It” vs. HACA Survivors
70%
"Cool It"
n =58
HACA
n=84
8.6%
23.8%
60%
% of Survivors
50%
40%
30%
20%
10%
0%
CPC 1
CPC 2
CPC 3
Neurologic Outcome at Discharge
CPC 4
Methods Comparison
HACA
“Cool It”
Cooling
Shivering
Protocol Activation
Prevention
Cooling
Protocol Activation
Shivering
Prevention
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••
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field, referring
••• possible
Atracurium
ice packs in the field,
no prehospital cooling
emergency
Pancuronium
mattress cooling device
department
target temp
IV
bolus every two
randomization
ice packs after 4 hrs
hrs
• target temp – as soon as
hospital, in transfer
referring hospital, or in
transfer
•• Infusion
education- –TOF
early
• Arctic
Sun® cooling
device
recognition
& initiation
monitoring
“Cool It” vs. HACA Cooling
800
Arctic Sun to
Target Temp
700
ROSC to
Arctic Sun
600
relative
hazard
estimate
= 1.25
(for 1 hr
delay to TH)
Time ( minutes)
ROSC to
Target Temp
720
500
400
309
300
200
100
0
HACA n=136
"Cool It" n=103
Summary
• “Cool It” protocol applied TH to high risk
patients
 cardiogenic shock
 PEA & asystole
• “Cool It” TH enhanced survival in HACA
criteria patients
• “Cool It” TH preserved neurologic and
functional status in a broader patient
population
• “Cool It” survivors discharged with
higher neurologic outcomes
• “Cool It” patients cooled to target
temperature in less time
Conclusions
• OOHCA is a significant health issue
• TH is a markedly underutilized treatment
• “Cool It” TH program
 high survival rate
 high quality of life and cognitive and functional abilities
• “Cool It” TH - early & organized treatment
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standardized protocols
outstate education
rapid & early initiation of TH
multidisciplinary team
data collection and feedback
• TH can effectively be applied to a higher risk patient population
than previously examined
• Neuroprotective adjunct to regional STEMI programs