Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors.

BACKGROUND: The implementation of therapeutic hypothermia (TH) into daily clinical practice appears to be slow. We present our experiences with rapid implementation of a simple protocol for TH in comatose out-of-hospital cardiac arrest (OHCA) survivors. METHODS: From June 2002, we started cooling pre-hospitally with sport ice packs in the groin and over the neck. In the intensive care unit (ICU), we used ice-water soaked towels over the torso. All patients were endotracheally intubated, on mechanical ventilation and sedated and paralysed. The target temperature was 33 +/- 1 degrees C to be maintained for 12-24 h. We used simple inclusion criteria: (i) no response to verbal command during the ambulance transport independent of initial rhythm and cause of CA; (ii) age 18-80 years; and (iii) absence of cardiogenic shock (SBP < 90 mmHg despite vasopressors). We compared the first 27 comatose survivors with a presumed cardiac origin of their OHCA with 34 historic controls treated just before implementation. RESULTS: TH was initiated in all 27 eligible patients. The target temperature was reached in 24 patients (89% success rate). ICU- and hospital- length of stay did not differ significantly before and after implementation of TH. Hypokalemia (P= 0.001) and insulin resistance (P= 0.025) were more common and seizures (P= 0.01) less frequently reported with the use of TH. The implementation of TH was associated with a higher hospital survival rate (16/27; 59% vs. 11/34; 32%, respectively; P< or = 0.05). Our results indicate a population-based need of approximately seven cooling patients per 100,000 person-years served. CONCLUSION: Our simple, external cooling protocol can be implemented overnight in any system already treating post-resuscitation patients. It was well accepted, feasible and safe, but not optimal in terms of cooling rate. Neither safety concerns nor costs should be a barrier for implementation of TH.

In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway.

INTRODUCTION: While pre-hospital factors related to outcome after out-of-hospital cardiac arrest (OHCA) are well known, little is known about possible in-hospitals factors related to outcome. HYPOTHESIS: Some in-hospital factors are associated with outcome in terms of survival. MATERIAL AND METHODS: An historical cohort observational study of all patients admitted to hospital with a spontaneous circulation after OHCA due to a cardiac cause in four different regions in Norway 1995-1999: Oslo, Akershus, Østfold and Stavanger. RESULTS: In Oslo, Akershus, Østfold and Stavanger 98, 84, 91 and 186 patients were included, respectively. Hospital mortality was higher in Oslo (66%) and Akershus (64%) than in Østfold (56%) and Stavanger (44%), P=0.002. By multivariate analysis the following pre-arrest and pre-hospital factors were associated with in-hospital survival: age -3.5 mmol l(-1), body temperature

Resuscitation in Europe: a tale of five European regions.

AIM: To describe cardiac arrest data from five emergency medical services (EMS) systems in Europe with regard to survival from an out-of-hospital cardiac arrest. METHODS: Based on recommendations from various countries in Europe EMS systems were approached with regard to survival from out-of-hospital cardiac arrest. Five EMS systems were asked to report their cardiac arrest data according to the Utstein style. RESULTS: The five selected EMS systems were: Bonn (Germany), Göttingen (Germany), Helsinki (Finland), Reykjavik (Iceland) and Stavanger (Norway). For patients with a bystander witnessed arrest of cardiac aetiology the percentage of patients being discharged alive from hospital in these regions were: 21, 33, 23, 23 and 35. The corresponding percentages for patients fulfilling criteria as above and being found in ventricular fibrillation were: 32, 42, 32, 27 and 55. CONCLUSIONS: Many EMS systems in Europe show extremely good results in terms of survival after an out-of-hospital cardiac arrest. Some of the results should be interpreted with caution since they were based on relatively small sample sizes. Furthermore, the results from one of the regions (Stavanger) was unit based and not community based.

[Time for integrated emergency medicine air ambulance services in Scandinavia?]. / Tid for enhetlig akuttmedisinsk luftambulansetjeneste i Norden?

The initiative has been taken to develop an integrated system of aeromedical services in the Nordic countries, it is proposed that the system will form a part of public health services, and thus be based on medical rather than commercial criteria.

Severe accidental hypothermia: survival after 6 hours 30 minutes of cardiopulmonary resuscitation.

This report describes a severely hypothermic victim, who was treated with conventional cardiopulmonary resuscitation and conventional rewarming technique using warm-water bags, warm fluids intravenously and peritoneal lavage. This case demonstrates more than any previous report that hypothermic victims with cardiac arrest may survive for many hours if CPR is carried out vigorously until core temperature is raised. 6 hours continuous CPR is, as far as the author knows, the longest reported conventional PCR in a hypothermic victim followed by survival.

[Accidental hypothermia. Physiopathology, clinical manifestations and treatment]. / Aksidentell hypotermi. Patofysiologi, klinikk og behandling.

The article reviews pathophysiology and clinical problems. During deep hypothermia, criteria for death are obscured. Prehospital treatment should be vigorous resuscitation on broad indications. Asystole or ventricular fibrillation is common. Drugs are contraindicated, with the possible exception of bretyllium. Electro-conversion of the heart is usually impossible below 28-30 degrees Centigrade. Hypothermic victims must be handled with the utmost care. Rewarming may cause life-threatening arrythmias, afterdrop and "rewarming collapse". Rewarming should take place in hospital only. Different methods of rewarming are discussed. Probably the best way to treat deeply hypothermic victims is by cardiopulmonary bypass.