Here’s Dr. Jegede with today’s Morning Report!
Therapeutic Hypothermia
- It’s benefits are compared to early defibrillation for improving survival in patients post cardiac arrest
- NNT to improve survival is 7. NNT to improve neurologic outcome is 5
- Should be started as early as possible. According to 1 study, there is a 20% increase in mortality for every hour of delay in the initiation of therapeutic hypothermia.
Indications
- Class I recommendation for patients who achieved Return of Spontaneous Circulation (ROSC) after a V tach/fib arrest.
- Protocol extended to patients who achieved ROSC with rhythms other than v tach/v fib (Class IIb recommendation)
- Comatose after ROSC, and by comatose meaning failure to respond to meaningful verbal commands
Contraindications
- Risk of starting hypothermia protocol may be greater in patients who went into cardiac arrest due to other causes such as: severe sepsis, exsanguinations, intracranial hemorrhage, or pts with hypotension not responsive to vasopressors
Methods of Inducing Hypothermia
- Initiation: The easiest way is to use cooled IV fluids during or immediately after resuscitation to achieve a temp of 32 to 34 deg Celsius. You may also use ice packs and cooling blankets to achieve hypothermia.
- Placing a central line and using a cooling system. This allows for closer titration and maintenance of core temperature in the 32°C-34°C range can be accomplished using endovascular catheters
- Maintenance: can be accomplished using external cooling techniques such as ice packs on the groin, neck and axilla.
- Pts should remain in the hypothermic state for 12 to 24hours
Complications/Consequences
- Shivering: most common complication. Sedation and analgesia should be provided to reduce shivering. Benzodiazepines are typically used for sedation and opiates for analgesia.
- Magnesium sulfate can raise the shivering threshold. 4gm of Mag sulfate is recommended
- If shivering persists, neuromuscular blockade with paralytics is recommended
- Hemodynamics
- Bradycardia and prolongation of QT interval: typically well tolerated; treat only if it causes hemodynamic instability
- Hypotension: common; Goal MAP: 80-100mm Hg to achieve adequate cerebral perfusion. Vasopressors may be started to achieve this goal.
- Hyperglycemia: due to decrease insulin secretion and increase insulin resistance. Do not treat unless blood glucose >200mg/dl
- Hypokalemia: hypothermia decrease k+ level by intracellular shift of K+. replete K+ with goal of 3.5 or above.
Rewarming:
- Should be slow with a target rate of 0.25 deg Celsius every hour until the patient achieves normothermia
- Will take 12 to 16hrs to achieve normothermia.
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Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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