Hypothermic Treatment post arrest

MunoRN, RN · Aug 31, 2013

A head bleed is a contraindication for hypothermia anyway, but a positive troponin certainly isn't and I would expect most post arrest patients to eventually produce a positive troponin, even if their arrest wasn't cardiac in origin.

My ED receives many post arrest patients flown in from outlying facilities and I've never found the need to transport to be reason to delay initiating hypothermia. Why can't they start cooling prior to transport?

lnaumu · Aug 31, 2013

I will have to ask flight EMS what their reasoning is and get that back to you. What are they using to cool and monitor temp during transport to you ? I really appreciate your response!

Anna Flaxis, BSN, RN · Sep 1, 2013

This is a great question. I volunteer for an organization that provides ACLS level care for music festivals/rock concerts. Thank goodness, I am one of the influential clinicians (not to toot my own horn, but it can be scary sometimes). Our medical director is really conservative, advocating for BLS even though we contract for ACLS, but at the same time wanting to have 3% Saline for kids in hypotonic seizure r/t OD of substances. Very confusing.

Anyway, one of our nurses suggested having chilled IVF on hand for post arrest care ( we have a fridge and keep things like tetorifice and RSI meds in it). My feeling as an ED RN was that we should only give a chilled IVF bolus if we knew for a fact that was EMS was on their way; that post arrest hypothermia is best induced in a hospital setting and that as prehospital, we should not be doing this because we cannot adequately monitor.

Am I wrong? Could we at least a couple of liters in our fridge?

I have to say, we have saved many lives here on the West Coast helping young folks through bad trips and only transporting when it's indicated. We have docs, paramedics, critical care RNs, etc. We know what we're doing. But the idea of chilled fluids....I'm uncertain. BTW, we have several fluid warmers if that's needed.

brillohead, ADN, RN · Sep 4, 2013

I had a friend survive an out-of-hospital cardiac arrest just over a year ago. Just a week or so prior to the arrest, the cardiologist who got called in on his case had read this article:

[h=1]

Optimal Treatment of Patients Surviving Out-of-Hospital Cardiac Arrest[/h]

I have no doubt that my friend would have died or suffered permanent damage without this cardiologist's intervention (both therapeutic hypothermia and PCI), especially since the hospital involved waited almost FIVE hours to bring a cardiologist in on the case.

Hopefully this article and the references included are helpful to you.

Esme12, ASN, BSN, RN · Sep 4, 2013

I will have to ask flight EMS what their reasoning is and get that back to you. What are they using to cool and monitor temp during transport to you ? I really appreciate your response!

If you are talking that your island is so isolated that even your local patients are flown in....it takes Too much time in the field. This is not really a widely site applied process that should be applied pre-hospital in all instances. You are talking about pre-hospital return-of-spontaneous-circulation (ROSC) care or transport care of the induced hypothermic patient. What is their medical control input?

Altra, BSN, RN · Sep 4, 2013

This is a great question. I volunteer for an organization that provides ACLS level care for music festivals/rock concerts. Thank goodness, I am one of the influential clinicians (not to toot my own horn, but it can be scary sometimes). Our medical director is really conservative, advocating for BLS even though we contract for ACLS, but at the same time wanting to have 3% Saline for kids in hypotonic seizure r/t OD of substances. Very confusing.
Anyway, one of our nurses suggested having chilled IVF on hand for post arrest care ( we have a fridge and keep things like tetorifice and RSI meds in it). My feeling as an ED RN was that we should only give a chilled IVF bolus if we knew for a fact that was EMS was on their way; that post arrest hypothermia is best induced in a hospital setting and that as prehospital, we should not be doing this because we cannot adequately monitor.
Am I wrong? Could we at least a couple of liters in our fridge?
I have to say, we have saved many lives here on the West Coast helping young folks through bad trips and only transporting when it's indicated. We have docs, paramedics, critical care RNs, etc. We know what we're doing. But the idea of chilled fluids....I'm uncertain. BTW, we have several fluid warmers if that's needed.

I love learning about what others do in situations different from my own, but I'm alternately getting the heebie jeebies and just shaking my head over administration of hypertonic saline pre-hospital. For seizures suspected to be related to hyponatremia? Do you have point of care lab capability? In a festival setting in particular -- what protocols are in place to r/o unwitnessed trauma? Or to definitatively identify the pharmacologic agent involved?

I'm also very uneasy with the mentality of "transporting only when indicated". I actually discussed this post with a few ED, toxicology and trauma docs, and some EMS/HEMS folks. All agreed that unless your med tent is set up and staffed to monitor (at an ACLS level) a patient for 6 - 8 hours, the risk of writing off that individual who is *currently* awake & alert was unacceptable.

Sassy5d · Sep 5, 2013

Oddly, all of our cooling instruments are in the ICU. So we have to run and grab their supplies.. Other than ice bags

Just adding 1 more step

emtb2rn, BSN, RN, EMT-B · Sep 5, 2013

We have a code chill box that has cold packs, rectal temp probes, the probe connector, temp sensing foley & the paperwork packet. We keep 4 1L bags of ns in the pyxis fridge (2 for that pt if not started in the field & 2 backup so they're cold).

Ran one a couple of days ago, door to floor (icu) in 29 minutes (including head spin).

Anna Flaxis, BSN, RN · Sep 6, 2013

I love learning about what others do in situations different from my own, but I'm alternately getting the heebie jeebies and just shaking my head over administration of hypertonic saline pre-hospital. For seizures suspected to be related to hyponatremia? Do you have point of care lab capability? In a festival setting in particular -- what protocols are in place to r/o unwitnessed trauma? Or to definitatively identify the pharmacologic agent involved?
I'm also very uneasy with the mentality of "transporting only when indicated". I actually discussed this post with a few ED, toxicology and trauma docs, and some EMS/HEMS folks. All agreed that unless your med tent is set up and staffed to monitor (at an ACLS level) a patient for 6 - 8 hours, the risk of writing off that individual who is *currently* awake & alert was unacceptable.

Hi Altra, the 3% saline would be absolute last ditch if actively seizing and known to have ingested ecstasy or similar agent. I agree that without lab capability to confirm hyponatremia that giving hypertonic saline based upon clinical suspicion is risky (and obviously, this person would be transported as rapidly as possible to the nearest medical facility capable of treating them). I'm right there with you on that, and honestly I am not especially comfortable with it. I only used it as an example of why I'm not asking our medical director this question; because I'm butting heads with him on other stuff that I won't go into detail about. I'd be happy to discuss my concerns privately.

I will just say that we do not use lay people as volunteers; we only take credentialed professionals, and we have many with years of experience in field response, emergency medicine, and critical care. We are not a fly by night outfit. We really do provide excellent service.

What I wanted to know was whether it is reasonable to keep a couple of liters of saline in our refrigerator and give a chilled saline bolus for post arrest even though we are not operating in a controlled environment like the ED (again, this person would be transported as rapidly as possible to the nearest appropriate medical facility). I asked this question at my recent ACLS recert, and my instructor said it would be fine.

As far as only transporting when necessary, I may have been unclear. I was referring to the trippers, mainly (some medical stuff too, like mild dehydration or skin lac can be treated by our docs). Just because someone took a little too much of something and is having a hard time does not mean they need to go to the ED. We have trained crisis counselors who sit with them and help them through it. These folks are also very knowledgeable about different classes of drugs and how they act on the mind and body. Eating a pot brownie and then getting anxious is not necessarily a medical emergency. Obviously if there is a medical indication for transport, we do not hesitate to do so.

And yes, we are set up and appropriately staffed to monitor at an ACLS level. We have the gear, the meds, and the trained staff, again, many with years of experience. I think if you saw us at work, you'd be shaking your head in amazement at what we do! We've been doing it for 40 years.

I appreciate your concerns. It's really hard to convey in writing the level at which we are capable of operating. Our organization really does have its act together. I think you'd be impressed if you saw it in person.

MunoRN, RN · Sep 6, 2013

I will have to ask flight EMS what their reasoning is and get that back to you. What are they using to cool and monitor temp during transport to you ? I really appreciate your response!

Our EMS use the LUCAS device for both ground and air transport and had been using the "coffin" tub for cooling, but it's not very practical. They are now trialing the EMCOOLS system which is easily transportable and supposedly can lower core temp by about 2 degrees C an hour. If the patient has already been through one of the outlying ER's they have a temp Foley in, otherwise some will place a rectal probe and some will tape a temp probe to the ET tube.