Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest

Abstract

Background-Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. Methods and Results-The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (nϭ107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non-ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (nϭ68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non-ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. Conclusions-A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA. (Circulation. 2011;124:206-214.)

Early Access to the Cardiac Catheterization Laboratory for Patients Resuscitated From Cardiac Arrest Due to a Shockable Rhythm: The Minnesota Resuscitation Consortium Twin Cities Unified Protocol

“…Since the seminal observation by Spaulding et al, many studies have validated the role of angiography and PCI in survivors of OHCA with ST‐segment elevation on their postresuscitation ECG 6, 7, 8, 9, 10, 11, 12, 19. The positive results with the MRC protocol are most noticeable in the group without ST elevation because a well‐defined postarrest treatment pathway is lacking and early access to the CCL is controversial 9, 10.…”

“…Under MRC guidelines, emergency medical services providers, emergency medical services directors, paramedics‐receiving emergency departments, CCL directors, and cardiology groups work together to provide optimal resuscitation and postresuscitation care, including therapeutic hypothermia and early access to the CCL 11. The Minneapolis‐St.…”

Importance of Both Early Reperfusion and Therapeutic Hypothermia in Limiting Myocardial Infarct Size Post–Cardiac Arrest in a Porcine Model

“…In cohort population studies, aggressive post resuscitation care including targeted temperature management (therapeutic hypothermia) and early coronary angiography, has resulted in improved long-term survival rates of 50-60% among those whose initial cardiac arrest rhythm was ventricular fibrillation (9). Nearly 90% of such survivors achieve long-term, favorable neurological function (9,10).…”

Caring for Patients Treated With Therapeutic Hypothermia

“…Of those, 73% had good neurological outcome according to scores less than 3 on a modified Rankin Scale. 9,13 Interprofessional collaboration was also a factor addressed by Mooney et al 11 These authors challenged the current practice that after cardiac arrest, various treatments, including therapeutic hypothermia, should be offered in all hospitals. They advised developing cardiac resuscitation centers of excellence, which would offer more intensive, interprofessional services beyond the initial Advanced Cardiac Life Support efforts after resuscitation.…”