actep2014: therapeutic hypothermia for actep 2014
DESCRIPTION
Therapeutic hypothermia after cardiac arrest: Should we start at the ED - อ.นพ.วินชนะ ศรีวิไลทนต์, พญ.สมจินตนา เอี่ยมสรรพางค์TRANSCRIPT
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THERAPEUTIC HYPOTHERMIA
AFTER CARDIAC ARREST:
SHOULD WE START AT
THE EMERGENCY DEPARTMENT
นพ.วินชนะ ศรีวิไลทนต์
ภาควิชาเวชศาสตร์ฉุกเฉิน
คณะแพทยศาสตร์ มหาวิทยาลัยธรรมศาสตร์
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OBJECTIVE
Definition of Therapeutic hypothermia
after cardiac arrest
Benefits of Therapeutic hypothermia
Apply into your emergency department
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DISCLOSURE
No disclosures related to this presentation
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WHAT IS
THERAPEUTIC
HYPOTHERMIA?
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OUTCOME OF OHCA
ROSC
Survival to D/C
THAI 22.5 – 39.2 % 0 – 5.6 %
USA 26.3 % 8.5 – 11.2 %
Europe 33.5 % 10.7 %
Japan 20 – 33.1 % 12 %
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CHAIN OF SURVIVAL : AHA 2010
• Immediate recognition and activated EMS (1669)
• Early CPR
• Rapid defibrillation
• Effective ALS
• Integrated Post-Cardiac Arrest Care
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MANAGEMENT OF THE PATIENT
AFTER CARDIAC ARREST
Airway
and Breathing
Circulation
Neurological
Metabolic
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POST-CARDIAC ARREST SYNDROME
Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome. Resuscitation. 2008;79(3):350-79. Epub 2008/10/31.
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• Induce mild therapeutic hypothermia
post cardiac arrest patient that not
response to verbal command with
–Initial EKG was VF arrest
(Class I LOE B)
–Initial EKG was PEA or asystole
(Class IIb LOE B)
Peberdy M, Callaway C, Neumar R, et al. Part 9: Post–Cardiac Arrest Care: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation 2010;122(18 suppl 3):768-86
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BENEFITS OF
THERAPEUTIC
HYPOTHERMIA?
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CEREBRAL PERFORMANCE
CATEGORY SCALE (CPC)
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Induce mild therapeutic
hypothermia
“solitary treatment that
prove to increase neurological outcome”
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RCT 273 patients : 136 in Hypothermia,
137 in Normothermia
Post VF or pulseless VT
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MILD THERAPEUTIC HYPOTHERMIA TO
IMPROVE THE NEUROLOGIC
OUTCOME AFTER CARDIAC ARREST
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RCT 77 patients : 43 in Hypothermia,
34 in Normothermia
Post VF or pulseless VT
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TREATMENT OF COMATOSE SURVIVORS OF
OUT-OF-HOSPITAL CARDIAC
ARREST WITH INDUCED HYPOTHERMIA
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Good neurological outcome (normal or with
minimal or moderate disability)
Hypothermia VS Normothermia
= 49% VS 26% (95%CI 13 to 43,P=0.046)
TREATMENT OF COMATOSE SURVIVORS OF
OUT-OF-HOSPITAL CARDIAC
ARREST WITH INDUCED HYPOTHERMIA
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EFFECT OF THERAPEUTIC HYPOTHERMIA ON
PATIENTS AFTER CARDIAC ARREST ASSOCIATED
WITH NON-SHOCKABLE RHYTHMS
Eugene A. Hessel. Therapeutic Hypothermia After In-Hospital Cardiac Arrest: A
Critique. Journal of Cardiothoracic and Vascular Anesthesia 2014;28(3):789–99.
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HOW TO APPLY INTO
YOUR EMERGENCY
DEPARTMENT?
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PHASE OF INDUCE MILD
THERAPEUTIC HYPOTHERMIA
TEMP
TIME
GOAL
Keep core temperature 32-34C for 12-24 hr.
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PHASE OF INDUCE MILD
THERAPEUTIC HYPOTHERMIA
ผศ.นพ.สมบตั ิมุง่ทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. Integrated Post Cardiac
Arrest Care.ส านกัพิมพ์มหาวิทยาลยัธรรมศาสตร์ 2013:63-76
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TIMING TO START THERAPEUTIC
HYPOTHERMIA
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Increase short term survival (ROSC)
Not difference in long term
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THERAPEUTIC HYPOTHERMIA
IN EMERGENCY DEPARTMENT
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TEMPERATURE ON HOSPITAL ADMISSION
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SURVIVAL OUTCOME
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PHASE OF INDUCE MILD
THERAPEUTIC HYPOTHERMIA
ผศ.นพ.สมบตั ิมุง่ทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. Integrated Post Cardiac
Arrest Care.ส านกัพิมพ์มหาวิทยาลยัธรรมศาสตร์ 2013:63-76
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IMPLEMENTATION OF MILD
THERAPEUTIC HYPOTHERMIA
Requires a multidisciplinary approach
Include prehospital personnel, emergency
physicians and staff
Intensivists and ICU staff
Specialists in neurology and cardiology
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Invasive techniques Non-invasive techniques
- Infusion of cold intravenous fluid
- Heat exchange catheter
- Extracorporeal circulating cooled
blood
- Intraventricular cerebral hypothermia
- Peritoneal lavage with cool exchanges
- Retrograde jugular vein flush
- Nasal, nasogastric and rectal lavage
- Nasopharyngeal balloon catheters
- Caps or helmets
- Cooling blankets
- Hydrogel-coated cooling pads
- Ice packs
- Immersion in cold water
METHODS TO INDUCE
HYPOTHERMIA
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COLD INTRAVENOUS FLUID
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HEAT EXCHANGE CATHETER
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COOLING CAPS
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COOLING BLANKETS
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ICE PACKS
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ICE PACKS
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HYDROGEL-COATED COOLING
PADS
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SURFACE COOLING
Simple to implement
Usually take 2-8 hr to achieving goal
temperature
Often combined with additional cooling method
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SURFACE COOLING
Hydrogel-coated cooling pads with devices control
temperature through feedback mechanism
More expensive
Mean rate temperature reduction 1.4C/hr
Median time to goal temperature 137 min.
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COLD INTRAVENOUS FLUID
Effective in emergency and
prehospital setting
4C Ringer’s lactate solution or normal
saline solution
30 ml/kg or 2,000 ml within 20-30 min
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RCT : +4 degrees C Ringer's lactate solution or
conventional fluid therapy
19 in the treatment group and 18 in the control group
At the time of hospital admission
core temperature was lower in hypothermia group
34.1+/-0.9 degrees C vs. 35.2+/-0.8 degrees C, P<0.001
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CLINICAL TRIALS ON COOLING
Farid Sadaka. Prehospital Therapeutic Hypothermia for Cardiac Arrest. Mercy Hospital St Louis/St Louis University
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REFERENCES
Peberdy M, Callaway C, Neumar R, et al. Part 9: Post–Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 suppl 3):768-86.
Bryan G, Robert A, Joseph L, et al. Therapeutic Hypothermia for Acute Myocardial Infarction and Cardiac Arrest. The American Journal of Cardiology 2012;03(048):461-66.
Eugene A. Hessel. Therapeutic Hypothermia After In-Hospital Cardiac Arrest: A Critique. Journal of Cardiothoracic and Vascular Anesthesia 2014;28(3):789–99.
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Bernard S, Smith K, Cameron P. et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation.2010; 122: 737–42.
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