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minimize cerebral injury and improve recovery. Therapeutic hypo- Jon Rittenberger, MD, MS, FACEP
thermia is a cornerstone of this early postresuscitation care. Despite Assistant Professor, Department of Emergency Medicine,
University of Pittsburgh School of Medicine; Attending
accumulating evidence and widespread endorsement, adoption Physician, Emergency Medicine and Post Cardiac Arrest
of therapeutic hypothermia is incomplete. This review focuses on Services, UPMC Presbyterian Hospital, Pittsburgh, PA
overcoming barriers to enable practical application of this life-saving Scott D. Weingart, MD, FCCM
Associate Professor, Department of Emergency Medicine,
treatment. Director, Division of Emergency Department Critical Care,
Icahn School of Medicine at Mount Sinai, New York, NY
Note From The Editor-In-Chief CME Objectives
Readers of EM Critical Care will recall our 2012 issue by Ritten- Upon completion of this article, you should be able to:
berger et al that emphasized the guiding principles of cardiocerebral 1. Describe the indications and contraindications of
resuscitation in the emergency department after cardiac arrest. In therapeutic hypothermia in postcardiac arrest.
this issue, we will expand on the discussion of the use of therapeutic 2. Describe the most effective strategy to implement
therapeutic hypothermia in your institution.
hypothermia after cardiac arrest and will address a number of the 3. Troubleshoot or prevent common complications of
challenges and logistical considerations for implementing hypother- therapeutic cooling.
mia. More than a decade after the landmark trials by Bernard et al
Prior to beginning this activity, see the back page for faculty
and the Hypothermia After Cardiac Arrest (HACA) Study Group, disclosures and CME accreditation information.
there remain challenges with uptake, implementation, and inclu-
sion/exclusion criteria for therapeutic hypothermia. This issue by
Pearson and Heffner succinctly addresses the spectrum of questions
and complexities that have evolved since therapeutic hypothermias
powerful benefit was demonstrated. Enjoy! - Rob Arntfield
Editor-in-Chief Clinical Research Director, Andy Jagoda, MD, FACEP Julie Mayglothling, MD Emanuel P. Rivers, MD, MPH, IOM
Robert T. Arntfield, MD, FACEP, Center for Resuscitation Science, Professor and Chair, Department Assistant Professor, Department Vice Chairman and Director
FRCPC, FCCP Philadelphia, PA of Emergency Medicine, Icahn of Emergency Medicine, of Research, Department of
Assistant Professor, Division School of Medicine at Mount Sinai; Department of Surgery, Division Emergency Medicine, Senior
of Critical Care, Division of Lillian L. Emlet, MD, MS, FACEP Medical Director, Mount Sinai of Trauma/Critical Care, Virginia Staff Attending, Departments of
Emergency Medicine, Western Assistant Professor, Department of Hospital, New York, NY Commonwealth University, Emergency Medicine and Surgery
University, London, Ontario, Critical Care Medicine, Department Richmond, VA (Surgical Critical Care), Henry
Canada of Emergency Medicine, University William A. Knight, IV, MD, FACEP Ford Hospital; Clinical Professor,
of Pittsburgh Medical Center; Assistant Professor of Emergency Christopher P. Nickson, MBChB, Department of Emergency
Program Director, EM-CCM Medicine, Assistant Professor of MClinEpid, FACEM Medicine and Surgery, Wayne State
Associate Editor Fellowship of the Multidisciplinary Neurosurgery, Medical Director - Senior Registrar, Intensive Care University School of Medicine,
Scott D. Weingart, MD, FCCM Critical Care Training Program, Emergency Medicine Mid-Level Unit, Royal Darwin Hospital, Detroit, MI
Associate Professor, Department Pittsburgh, PA Provider Program, Associate Darwin, Australia
of Emergency Medicine, Director, Medical Director of Neuroscience Isaac Tawil, MD, FCCM
Division of Emergency Department Michael A. Gibbs, MD, FACEP ICU, University of Cincinnati Jon Rittenberger, MD, MS, FACEP Assistant Professor, Department
Critical Care, Icahn School of Professor and Chair, Department College of Medicine, Cincinnati, Assistant Professor, Department of Anesthesia and Critical Care /
Medicine at Mount Sinai, New of Emergency Medicine, Carolinas OH of Emergency Medicine, Department of Emergency Medicine,
York, NY Medical Center, University of North University of Pittsburgh School Director, Neurosciences ICU,
Carolina School of Medicine, Haney Mallemat, MD of Medicine; Attending Physician, University of New Mexico Health
Chapel Hill, NC Assistant Professor, Department Emergency Medicine and Post Science Center, Albuquerque, NM
Editorial Board of Emergency Medicine, University Cardiac Arrest Services, UPMC
Benjamin S. Abella, MD, MPhil, Robert Green, MD, DABEM, of Maryland School of Medicine, Presbyterian Hospital, Pittsburgh,
FACEP Baltimore, MD PA
Research Editor
FRCPC
Assistant Professor, Department Amy Sanghvi, MD
Professor, Department of
of Emergency Medicine and Evie Marcolini, MD, FAAEM Department of Emergency
Anaesthesia, Division of Critical
Department of Medicine / Assistant Professor, Department of Medicine, Icahn School of
Care Medicine, Department of
Section of Pulmonary Allergy Emergency Medicine and Critical Medicine at Mount Sinai, New York,
Emergency Medicine, Dalhousie
and Critical Care, University of Care, Yale School of Medicine, NY
University, Halifax, Nova Scotia,
Pennsylvania School of Medicine; Canada New Haven, CT
Case Presentations Critical Appraisal Of The Literature
A 63-year-old male experienced a witnessed, out-of- The PubMed database was searched for articles
hospital collapse. The patients wife called 911 and initi- published from 1950 to August 2012. The terms
ated CPR. Ventricular fibrillation was recognized upon used in the search included English publications
paramedic arrival, but it was resistant to initial biphasic containing 1 or more of the following key words:
countershock. ROSC was ultimately achieved 21 min- therapeutic hypothermia, induced hypothermia, car-
utes following cardiac arrest. Hypotension (BP of 92/42 diopulmonary resuscitation, and cardiac arrest. This
mm Hg, MAP of 59 mm Hg) and persistent coma (GCS search revealed over 440 publications. The results
score = 3) are noted upon arrival to the ED. The nurse were reviewed, and relevant citations from each
asks you if this patient is a candidate for the therapeutic study were searched manually. An Internet search
hypothermia protocol, despite his prolonged downtime. for practice guidelines and clinical policies identified
A short time later, EMS brings in a 39-year-old woman the following:
with a history of asthma who called 911 for shortness of American Heart Association: 2010 International
breath. When EMS arrived, the patient was in severe Consensus on Cardiopulmonary Resuscitation
respiratory distress. During transport, her respiratory status and Emergency Cardiovascular Care Science
worsened, and she became unresponsive. The monitor re- With Treatment Recommendations
vealed a bradycardic idioventricular rhythm, and the patient Australian Resuscitation Council: Adult Ad-
was noted to be pulseless. ACLS was started by EMS, and vanced Life Support Guidelines 2006
ROSC was achieved following 10 minutes of resuscitation. Canadian Association of Emergency Physicians,
The patient remains comatose upon arrival to the ED. The Critical Care Committee: The Use of Hypother-
exam reveals symmetric diffuse expiratory wheezes, and her mia After Cardiac Arrest
chest x-ray is negative for pneumothorax. You continue to Scandinavian Society of Anesthesiology and
aggressively treat the status asthmaticus and initiate consul- Intensive Care Medicine: Task Force on Scandi-
tation with the critical care team. You consider postcardiac navian Therapeutic Hypothermia Guidelines,
arrest therapeutic hypothermia, but you wonder whether you Clinical Practice Committee
should cool this patient following PEA arrest? The Hong Kong Society of Critical Care Medi-
cine Position Statement: The Use of Hypother-
Introduction mia After Cardiac Arrest
Over 300,000 patients per year in the United States Efficacy Of Therapeutic Cooling
experience sudden cardiac arrest.1 Despite initial
resuscitation, neurological injury sustained dur- Evidence For Cooling Patients With
ing cardiac arrest is the leading cause of death and Ventricular Tachycardia And Ventricular
contributes to the historic survival rate of only 6% Fibrillation
to 8%.1,2 Additionally, 30% of survivors have perma- Therapeutic hypothermia is the only neuroprotec-
nent neurological injury. tive therapy that demonstrates neurological and
Therapeutic hypothermia has emerged as the survival benefit following cardiac arrest.11-13 A decade
only effective intervention to ameliorate anoxic brain of supportive investigation culminated in comple-
injury and improve neurological outcome.3 Despite tion of 2 multicenter randomized trials of therapeutic
strong evidence and endorsement by the American hypothermia in 2002. Both trials enrolled comatose
Heart Association, therapeutic hypothermia remains survivors of out-of-hospital cardiac arrest with a
an underutilized modality, with implementation first recognized rhythm of ventricular tachycardia
rates as low as 30% to 40%.4-8 and ventricular fibrillation (VT/VF).11,12 Nonshock-
Perceived barriers to implementation of able rhythms were excluded to avoid experiment
therapeutic hypothermia include lack of treatment confounding. Both trials showed improved survival
awareness, premature negative prognostication, and with good neurological outcome. (See Table 1.) The
perceived high workload demands.9,10 Regardless of Hypothermia After Cardiac Arrest (HACA) study
the reason, failure to implement this evidence-based defined a Cerebral Performance Category (CPC) score
therapy deems its ineffectiveness absolute. of 1 (patient is alert with normal cerebral function) or
This review focuses on the practical aspects of 2 (patient is alert and has sufficient cerebral function
implementing therapeutic hypothermia for post- to live independently and work part time) as a good
cardiac arrest patients, regardless of practice locale, neurological outcome. The Bernard study defined
and highlights the key resuscitation adjuncts in a good outcome as normal or minimal disability
the immediate and early postresuscitation phase (able to care for self; discharged directly to home). A
of illness that provide the greatest opportunity to powerful treatment impact was demonstrated with 1
achieve the goal of neurologically intact survival of survivor, with good neurological outcome achieved
cardiac arrest victims. for every 6 patients treated (ie, the number needed
Assess inclusion & exclusion criteria for postcardiac arrest resusci- Perform and document neurological examination.
tation bundle. Consult interventional cardiologist for assessment for coronary
VT / VF arrest (Class I) angiography. (Induction of cooling should be performed concur-
PEA / asystole arrest (Class II) rently with preparation for PCI.)
Induction: Maintenance:
Infuse cold IV fluids. Goal temperature of 32C-34C.
Administer NS 30 cc/kg IV bolus as tolerated. Continue cooling for 24 h.
Apply ice packs to groin, axilla, and neck. Assess for shivering: short-acting analgesia or sedation (paraly-
Maintain early sedation and paralysis until goal temperature sis if shivering uncontrolled with these measures).
achieved. Assess electrolytes.
Initiate cooling device for 33C. Monitor fluid status: input & output.
Rewarming:
Controlled normothermia:
Rewarm approximately 0.5C/h. (Class I)
Keep the cooling device in place for 2 to 3 days after rewarming
Assess electrolytes closely.
to maintain normothermia (37C).
Assess neurological status once at normothermia.
Abbreviations: CVP, central venous pressure; FiO2, fraction of inspired oxygen; IV, intravenous; MAP, mean arterial pressure; NS, normal saline; PaCO2,
partial pressure of carbon dioxide; PEA, pulseless electrical activity; PCI, percutaneous coronary intervention; ScvO2, central venous oxygen satura-
tion; VT/VF, ventricular tachycardia/ventricular fibrillation
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2013 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
Brain Injury
By targeting these clinical components of the
Anoxic brain insult
postarrest state with a comprehensive resuscitative
Impaired autoregulation
protocol, the emergency physician can have the Ischemic reperfusion injury
greatest impact on improving outcomes.
Therapeutic cooling is only one aspect of an ef- Persistent Precipitating Pathology
fective, multipronged resuscitative protocol.81,82 The Decompensated cardiomyopathy
early postarrest period is an opportunity to address Myocardial ischemia
additional priorities for effective cardiocerebral re- Pulmonary embolism
suscitation. Priorities of the postarrest period include
stabilization of organ perfusion and oxygenation, Systemic Ischemia-Reperfusion Injury
identification and treatment of reversible causes Dysregulated coagulation
Early organ dysfunction
of cardiac arrest, and initiation of neuroprotective
Impaired microvascular function
therapy. As such, contemporary emergency care now
Inappropriate vasodilation
emphasizes intensive support during this vulnerable
Systemic inflammatory response syndrome
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