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Effect of prehospital initiation of therapeutic hypothermia in adults with cardiac arrest on time-to-target temperature

Published online by Cambridge University Press:  02 June 2015

Eric M. Schenfeld ,
Jonathan Studnek ,
Alan C. Heffner ,
Marcy Nussbaum ,
Kathi Kraft  and
David A. Pearson
Eric M. Schenfeld*
Affiliation:
Utah Emergency Physicians, Department of Emergency Medicine, Intermountain Medical Center, Intermountain Healthcare, Salt Lake City, UT
Jonathan Studnek
Affiliation:
Mecklenburg EMS Agency, Charlotte, NC
Alan C. Heffner
Affiliation:
Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
Marcy Nussbaum
Affiliation:
Carolinas Health Care System, Dickson Advanced Analytics Group, Charlotte, NC
Kathi Kraft
Affiliation:
Carolinas Health Care System, Dickson Advanced Analytics Group, Charlotte, NC
David A. Pearson
Affiliation:
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
*
Correspondence to: Dr. Eric M. Schenfeld, Utah Emergency Physicians, Intermountain Healthcare, PO Box 571117, Murray, UT 84157-1117; [email protected]; [email protected].

Abstract

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Objective: Despite growing adoption, the impact of prehospital initiation of therapeutic hypothermia on outcomes of cardiac arrest patients is unknown. The objective of this study was to determine if prehospital administration of cold intravenous fluids improved the time-to-target temperature.

Methods: All patients enrolled in an institutional post– cardiac arrest treatment pathway were prospectively registered into a quality assurance database. Patients undergoing cooling induction on hospital arrival were compared to those receiving a new treatment protocol initiated during the study period involving prehospital cooling with 4°C (39.2°F) normal saline. The primary outcome was the time-to-target temperature. Secondary outcomes included emergency medicine system transport time metrics, mortality, and neurologic status at discharge and 1 year.

Results: One hundred thirty-two patients were enrolled during the study period. The initial rhythm was ventricular fibrillation/tachycardia in 63% and asystole/pulseless electrical activity in 36%. Eighty patients received prehospital cooling and 52 patients did not and comprised the historical control group. Time-to-target temperatures were not significantly different between prehospital and hospital cooled groups (256 v. 271 minutes, respectively, p=0.64), nor was there any improvement in hospital survival (54% v. 50%, p=0.67), good neurologic outcome (49% v. 44%, p=0.61), or 1- year survival (49% v. 42%, p=0.46) between the two groups. Transport times were longer in the prehospital cooled group.

Conclusions: Out-of-hospital cardiac arrest patients treated with prehospital cooling before arrival at our urban hospital did not have faster time-to-target temperature or improvement in outcomes compared to patients cooled immediately on emergency department arrival. Further research is needed to determine if any benefits exist from prehospital cooling prior to its widespread adoption.

Résumé

Objectif: Bien que l’amorce de l’hypothermie thérapeutique en phase préhospitalière soit de plus en plus répandue, on n’en connaît pas l’effet sur les résultats, chez les patients victimes d’un arrêt cardiaque. L’étude visait à déterminer si l’administration intraveineuse de liquides froids, en phase préhospitalière, permettait d’atteindre plus rapidement la température cible.

Méthode: Tous les patients soumis à un parcours de traitement, en établissement, pour un arrêt cardiaque ont été inscrits de manière prospective dans une base de données sur l’assurance de la qualité. Les patients soumis au refroidissement à leur arrivée à l’hôpital ont été comparés avec ceux soumis au nouveau protocole de traitement mis en oeuvre durant la période à l’étude, comportant un refroidissement préhospitalier à l’aide de l’administration d’une solution physiologique salée maintenue à 4°C (39.2°F). Le principal critère d’évaluation était le temps nécessaire à l’atteinte de la température cible. Les critères d’évaluation secondaires comprenaient les mesures du temps de transport médical d’urgence, la mortalité, l’état neurologique au moment du congé et au bout de 1 an.

Résultats: Cent trente-deux patients ont été inscrits durant la période à l’étude. Les rythmes enregistrés au départ étaient la fibrillation ou la tachycardie ventriculaires dans 63% des cas ou encore l’asystole ou une activité électrique non pulsatile dans 36% des cas. Quatre-vingt patients ont été soumis au refroidissement préhospitalier et 52 patients, formant le groupe témoin historique, ne l’ont pas été. Le temps nécessaire à l’atteinte de la température cible n’était pas sensiblement différent entre le groupe de refroidissement préhospitalier et le groupe de refroidissement hospitalier (256 minutes contre [c.] 271, respectivement; p=0.64), pas plus qu’il n’y avait d’amélioration en ce qui concerne la survie à l’hôpital (54% c. 50%; p=0.67), l’état neurologique (49% c. 44%; p=0.61) et la survie au bout de 1 an (49% c. 42%; p=0.46) entre les deux groupes. Le temps de transport était toutefois plus long dans le groupe de refroidissement préhospitalier.

Conclusions: Le refroidissement préhospitalier chez les patients ayant subi un arrêt cardiaque, avant l’arrivée dans un hôpital urbain, n’a pas permis d’atteindre plus rapidement la température cible ou d’améliorer les résultats comparativement aux patients soumis au refroidissement dès leur arrivée au service des urgences. Aussi une recherche approfondie s’impose-t-elle afin de déterminer si le refroidissement préhospitalier comporte quelque avantage, et ce, avant l’adoption élargie de la pratique.

Keywords

cardiac arrestprehospital medicinetherapeutic hypothermia
Type
Original Research
Information
Canadian Journal of Emergency Medicine , Volume 17 , Issue 3 , May 2015 , pp. 240 - 247
Copyright
Copyright © Canadian Association of Emergency Physicians 2015 

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