With some of the latest literature, the recommendation has been to transfer patients with STEMI post resuscitation if they are responsive. This latest article from the Journal of the American College of Cardiology just published this gem that talks about what we do if they are still comatose!

This algorithm starts pre-hospitally. Return of circulation occurs and we transport to the nearest hospital. Within 10 minutes, the physician is to have a 12-lead ECG done and initiate mild therapeutic hypothermia (like the studies suggest, avoiding fever is the goal).

So, now we see the massive STEMI. As the previous literature suggests, we push these guys for emergent angiography and PCI should the patient not have unfavourable conditions. Nothing changes here.

What about those patients  that the physician finds that is non-STEMI?

They introduce the “ACT” abbreviation. Essentially, Assess for unfavourable resuscitation features. Consult with cardiology and intensive care.  Transport to cath lab once the decision has been made for angiography.

What is an unfavourable feature you might ask? Well, they include the following:

• Unwitnessed arrest
• Initial rhythm: Non-VF
• No bystander CPR
• >30 min to ROSC
• Ongoing CPR
• pH <7.2
• Lactate >7
• Age >85
• End stage renal disease
• Noncardiac causes (e.g.,traumatic arrest)

(Rab et al. 2015, p. 64)

With multiple unfavourable features, the patient should be considered for individualised care. Those who are deemed suitable should be sent for early angiogram and PCI.

We may start to see this coming into play within your local ED. What are your local policies and procedures involving this?

As practitioners, remember the value of your history. We can relay important information, such as down time, bystander CPR, initial rhythm and so on.

“Successfully resuscitated comatose patients represent a heterogeneous population with a baseline survival rate of only 25%. With hypothermia and PCI, survival improves to 60%, with favorable neurological outcomes achieved in 86% of survivors” (Rab et al. 2015, p. 63)

Rab, T., Kern, K., Tamis-Holland, J., Henry, T., McDaniel, M., & Dickert, N. et al. (2015). Cardiac Arrest. Journal Of The American College Of Cardiology, 66(1), 62-73. doi:10.1016/j.jacc.2015.05.009

Post arrest hypothermia study says no!

The debate has been happening for a while now! Do we actively cool or not? Well, many guidelines have us pushing our patients for that deep hypothermia to below 33 degrees. Nielson in 2013, found that patient outcomes did not change with the maintaining normothermia when compaired to hypothermia.

So fever is bad, and we ultimately need to avoid it.

While the debate continues with adults, there has been little evidence with pediatrics surrounding this.

Until now!

In an article published in the New England Journal of Medicine, Moler et al (2015) find that “in comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year”.

Here is a link to the abstract

This study showed there was a difference, however not significant. Perhaps a larger study would be required. Let me know your thoughts in the comment section!

References

Moler, Frank W. et al. ‘Therapeutic Hypothermia After Out-Of-Hospital Cardiac Arrest In Children’.New England Journal of Medicine 372.20 (2015): 1898-1908. Web. 17 June 201

Nielsen et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest NEJM 2013;epub Nov 17, 2013