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Editor-in-Chief Center for Resuscitation Science, Andy Jagoda, MD, FACEP Julie Mayglothling, MD Emanuel P. Rivers, MD, MPH, IOM
Robert T. Arntfield, MD, FRCPC, Philadelphia, PA Professor and Chair, Department Assistant Professor, Department Vice Chairman and Director
FCCP of Emergency Medicine, Mount of Emergency Medicine, of Research, Department of
Assistant Professor, Division Lillian L. Emlet, MD, MS, FACEP Sinai School of Medicine; Medical Department of Surgery, Division Emergency Medicine, Senior
of Critical Care, Division of Assistant Professor, Department of Director, Mount Sinai Hospital, New of Trauma/Critical Care, Virginia Staff Attending, Departments of
Emergency Medicine, Western Critical Care Medicine, Department York, NY Commonwealth University, Emergency Medicine and Surgery
University, London, Ontario, of Emergency Medicine, University Richmond, VA (Surgical Critical Care), Henry
Canada of Pittsburgh Medical Center; William A. Knight, IV, MD Ford Hospital, Clinical Professor,
Program Director, EM-CCM Assistant Professor of Emergency Christopher P. Nickson, MBChB, Department of Emergency
Fellowship of the Multidisciplinary Medicine, Assistant Professor MClinEpid, FACEM Medicine and Surgery, Wayne State
Associate Editor Critical Care Training Program, of Neurosurgery, Emergency Senior Registrar, Intensive Care University School of Medicine,
Scott Weingart, MD, FACEP Pittsburgh, PA Medicine Mid-Level Program Unit, Royal Darwin Hospital, Detroit, MI
Associate Professor, Department of Medical Director, University of Darwin, Australia
Emergency Medicine, Mount Sinai Michael A. Gibbs, MD, FACEP Cincinnati College of Medicine, Isaac Tawil, MD
School of Medicine; Director of Professor and Chair, Department Cincinnati, OH Jon Rittenberger, MD, MS, FACEP Assistant Professor, Department of
Emergency Critical Care, Elmhurst of Emergency Medicine, Carolinas Assistant Professor, Department Surgery, Department of Emergency
Hospital Center, New York, NY Medical Center, University of North Haney Mallemat, MD of Emergency Medicine, Medicine, University of New
Carolina School of Medicine, Assistant Professor, Department University of Pittsburgh School Mexico Health Science Center,
Chapel Hill, NC of Emergency Medicine, University of Medicine; Attending Physician, Albuquerque, NM
Editorial Board of Maryland School of Medicine, Emergency Medicine and Post
Benjamin S. Abella, MD, MPhil, Robert Green, MD, DABEM, Baltimore, MD Cardiac Arrest Services, UPMC
FACEP Presbyterian Hospital, Pittsburgh,
Research Editor
FRCPC
Assistant Professor, Department Evie Marcolini, MD, FAAEM PA Amy Sanghvi, MD
Associate Professor, Department
of Emergency Medicine and Department of Emergency
of Anaesthesia, Division of Critical Assistant Professor, Department of
Department of Medicine / Emergency Medicine and Critical Medicine, Mount Sinai School of
Care Medicine, Department of
Section of Pulmonary Allergy Care, Yale School of Medicine, Medicine, New York, NY
Emergency Medicine, Dalhousie
and Critical Care, University of University, Halifax, Nova Scotia, New Haven, CT
Pennsylvania School of Medicine; Canada
Clinical Research Director,
Case Presentation can Heart Association and American College of
Emergency Physicians were reviewed.
You are contacted by one of the paramedics in your An important consideration to this literature
local system regarding a 54-year-old female in cardiac is that the field of postresuscitation care is rap-
arrest. The patient experienced a witnessed arrest and idly evolving, and there is limited opportunity for
received 5 minutes of bystander CPR prior to the ar- informed-consent trials. Consequently, few random-
rival of EMS. She was found to be in ventricular fibril- ized controlled trials are available, and much of the
lation and was defibrillated twice, converting her to a clinical literature is extrapolated from other disease
perfusing rhythm. Prior to the second defibrillation, states such as traumatic brain injury, hypothermic
the patient had a tibial IO line placed and was given 1 circulatory support for cardiopulmonary bypass,
mg of epinephrine. Her current vital signs are a pulse status epilepticus, and stroke care. Given the inher-
of 110 beats per minute, BP of 110/80 mm Hg, respira- ent difficulties of studying cardiac arrest, preclinical
tions of 6 (assisted with a bag-valve mask), and SpO2 data also influence clinical care of this disease. This
of 92%. She is breathing spontaneously and withdraws review reflects these issues and incorporates a broad
to noxious stimuli but does not follow commands. The array of evidence sources.
paramedics are 7 minutes from a critical access hospital
with minimal resources and 10 minutes from your ter- Goals Of Postresuscitation Care
tiary care center with a cardiac catheterization labora-
And Therapeutic Hypothermia
tory and a postarrest care team. The paramedics request
orders to address the following questions:
Cardiac arrest may be precipitated by many disease
• Should therapeutic hypothermia be initiated upon
states. Following resuscitation from cardiac arrest,
hospital arrival or en route to the hospital?
patients maintain their prearrest comorbidities along
• How should the patient’s airway be managed?
with a global anoxic insult. The degree of injury may
• What is the most appropriate destination for this
range from mild to devastating. Moreover, different
patient?
organ systems demonstrate varying ranges of injury.
This results in heterogeneous physiology during the
Introduction postarrest phase. The main focus during the postar-
rest phase is to prevent secondary injury. The role
Cardiac arrest is the third leading cause of death of therapeutic hypothermia to optimize neurologic
in the United States, resulting in approximately resuscitation and minimize organ system injury is
300,000 deaths per year.1 Disparate patient out- described below.
comes following resuscitation from cardiac arrest
are associated with variability in postarrest care.2 Neurologic Resuscitation
Dedicated postarrest care plans that include ag- Persistent coma following cardiac arrest is the most
gressive cardiocerebral resuscitation have been common reason for withdrawal of care in patients
associated with improved outcomes in this popu- successfully resuscitated from out-of-hospital
lation.3-5 Multiple organ systems are affected by cardiac arrest.8,9 Neurologic resuscitation must
anoxic injury, resulting in the need for aggressive therefore be considered a top priority. Currently, the
goal-directed care to prevent secondary neuronal cornerstone of neurologic resuscitation is the use
injury.6 These interventions are organized by organ of therapeutic hypothermia. One mechanism for
system, with a focus on cerebral resuscitation, and therapeutic hypothermia’s effect is the decrease of
have been compiled in resuscitation guidelines basal metabolic rate and oxygen consumption.10,11
promulgated by the American Heart Association.7 Other hypothesized benefits include a decrease in
Individual patients may require some or all of these free radical production, modulation of inflammatory
interventions. An understanding of the literature response, and a decrease in intracranial pressure.12-14
supporting each organ-system intervention and Therapeutic hypothermia likely exerts its effect
recommended goals of care is important to provide through multiple mechanisms.
the best care to this critically ill population. This
issue of EMCC provides an overview of the current Therapeutic Hypothermia Evidence In VF/VT Out-Of-
evidence supporting cardiocerebral resuscitation in Hospital Cardiac Arrest
the postarrest patient. Two randomized controlled studies have demon-
strated improved neurologic outcomes in subjects
Critical Appraisal Of The Literature receiving therapeutic hypothermia after resuscita-
tion from ventricular fibrillation/ventricular tachy-
A review of the literature between 1950 and 2011 cardia (VF/VT) out-of-hospital cardiac arrest.
was completed using Ovid MEDLINE®, PubMed, In the first, a European multicenter randomized
Embase, and the Cochrane Database of Systematic controlled trial of postarrest hypothermia, subjects
Reviews. Additionally, guidelines from the Ameri- were randomized to normothermia or treatment
Therapeutic Hypothermia Evidence In Pediatric Given that postresuscitation care is geared toward
Postarrest prevention of secondary neurologic injury, patients
There are a number of studies that support the use with neurologic injury after resuscitation from
of therapeutic hypothermia in the setting of perina- cardiac arrest are candidates for postresuscitation
tal hypoxic-ischemic injury,20,21 yet conclusive data care. As a practical matter, neurologic injury is
supporting this therapy following pediatric cardiac defined as not responding to commands (such as
arrest are currently lacking. One retrospective trial of “Wiggle your toes.” “Squeeze my fingers.”) – ie,
79 pediatric patients treated with either therapeutic exhibiting a score of < 6 on the motor component of
hypothermia or normothermia demonstrated a 3- to the Glasgow Come Scale. Patients with preexisting
4-fold higher 6-month mortality in patients treated advanced directives (do not intubate or do not re-
with therapeutic hypothermia (OR 3.62; 95% CI, suscitate orders) are generally excluded. Given the
multiple etiologies of cardiac arrest, the emergency
Figure 1. Guideline For Prehospital Treatment Of Patients Resuscitated From Cardiac Arrest
Abbreviations: ECG, electrocardiogram; ETCO2, end-tidal carbon dioxide; FiO2, fraction of inspired oxygen; GCS, Glasgow Coma Scale; ROSC, re-
turn of spontaneous circulation; SBP, systolic blood pressure; SpO2, oxygen saturation by pulse oximeter; STEMI, ST-segment elevation myocardial
infarction.
after cardiac arrest is stated as:
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