On the topic of critical care, I thought we could bring up the idea of therapeutic hypothermia after cardiac arrest. We’re talking about a patient who comes in with v-fib or v-tach arrest (for less than 25-30 minutes) and is shocked, their rhythm is restored but they’re still not getting up. What to do?
Cooling the patient down to 32-34 C (metric system?!) has been shown to improve neurologic outcome by decreasing free radicals, cell death, calcium shifts and mitochondrial damage.
How to do it? Ice packs or cooled IV fluids, that’s about what we can do in the ER. The ICU may have some fancier devices, maybe be good to ask them what they do.
Watch out for
- dysrhthmias (usually not too significant),
- hyperglycemia (as insulin release is inhibited – also not usually too significant)
- hyperkalemia
- infection
- seizures
- hemorrhage
Basically, should we be putting IV bags in the fridge? What do you guys think? Have you seen an instance when we could have done this?
my peripheral brain 
We actually have a cooling device here in the ED- the Innercool (the same machine the ICUs used for therapeutic hypothermia (cardiac arrest and brain).The Critical Care actually decided that since our policy stated that hypothermia should b initiated within 6 hrs of cardiac arrest- the ICU will initiate it- I know that other EDs initiate it because their patient stays longer in the ED due to boarding. We hope it will not happen to us… but moving to an ED with more beds and but keeping same number of inpatient beds… that can be a possibility.
Tes, what about the Innercool hypothermia unit? The MICU and NSICU have cooling protocols. If the ED thinks this would be useful for our patients the MICU staff will institute the protocol when the patient is transferred?
Janine and a recent ACEP e-mail point to an article in the Philadelphia Inquirer. It discusses paramedic initiation of therapeutic hypothermia. While no studies have shown that it improves anything (most ambulance rides are only 15 minutes long and the hypothermia goes on for 1-2 days), but it seems innocuous enough (it cost them $250 to buy all the materials for the ambulances). One doc commented that a potential downside is that the hypothermia may be interrupted during transport from the rig to the ED.
Transport from the rig is usually less than ten minutes; the cooling could be augmented with ice packs to inguinal, axillae, cervical areas?
THe MICU and NSICU have cooling protocols for brain and cardiac arrest. Initially, we have decided that we will not start the protocol as we transfer the patient pretty quickly. And the ICUs agreed. Lately it has been explored at the chest pain meeting re: cooling for cardiac arrest patients and should we start it.What are your thoughts about it?
Personally, I think we should start it in the ER, Tes. If I have a patient in whom I regain spontaneous circulation, I'm going to have someone fill some of ice bags up and put 'em in the groin and arm pits, and I'm going to run the IV tubing through some ice water. The stuff I've been reading says, the earlier the better. And it doesn't require anything fancy (i.e., InnerCool).