Resuscitative Care Gets Second Wind

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LUCAS mechanical CPR device from Physio-Control.

No single device or strategy carries the day; rather it is the culmination of many innovative protocols and technologies that have galvanized the field of resuscitative care.

Last year, Philips Healthcare unveiled a comprehensive strategy to improve care for patients who suffer a sudden cardiac arrest, beginning with the emergency medical team’s arrival on the scene, through the ambulance ride, to arrival at the emergency department. Additionally, many institutions took up the cause to dramatically shorten door-to-balloon times, resulting in a plethora of data regarding best practices. Experts in the field say there is no one single device or strategy that works best, but it is the combination of many strategies working in concert that helps reduce mortality from sudden cardiac arrest.

The goal for every cardiac arrest patient is to limit damage to the heart, brain, and other vital organs, so the person has as full of a functional recovery as possible. In recent years, researchers have recognized that it is not necessarily the lack of oxygen during a cardiac arrest that causes brain damage. Rather, it is the rapid re-initiation of normal blood flow and delivery of oxygen that triggers a series of metabolic and inflammatory responses, which cause damage on the cellular level.

“We now understand that while return of spontaneous circulation may represent winning the first battle, there is much more that can be done to win the war—that is, to achieve neurologically intact survival,” says Vincent N. Mosesso Jr., MD, an associate professor of emergency medicine at the University of Pittsburgh School of Medicine and medical director of the University of Pittsburgh Medical Center Prehospital Care.

To slow the rapid return of blood flow following a sudden cardiac arrest, most ED’s now utilize hypothermia therapy. There is some debate when it should be started and how it should be delivered, but the consensus is that cooling benefits the return of neurological function in this patient population. Hypothermia therapy can be initiated by EMS at the scene, during transport or at the hospital through intravenous chilled saline or external cooling devices.

The Hospital of the University of Pennsylvania (HUP) has seen some impressive gains in survival and outcomes since adopting a very aggressive use of hypothermia for sudden cardiac arrest patients, according to Benjamin Abella, MD, an assistant professor of emergency medicine at HUP. The hospital, however, doesn’t initiate cold therapy in the pre-hospital setting. “It’s unclear to me whether we need to do it in the field,” Abella says.

Nevertheless, the era of therapeutic hypothermia is here and it’s difficult to justify not cooling patients, he says. Some smaller hospitals may not have the resources to initiate intravenous hypothermia. It can be expensive, ranging from $1,500 to $2,000 for each cooling infusion. Since chilled saline is not approved specifically in post-cardiac arrest, Medicare doesn’t reimbursement for this application. In addition, outlying rural hospitals may not gain overall expertise in treating sudden cardiac arrest patients with only a small number treated per month. One idea is to create regional Centers of Excellence for sudden cardiac arrest patients, similar to what exists for stroke patients (see sidebar, page 30).

“There is a very serious effort underway to determine whether the American Heart Association might wish to come out with a position statement regarding Centers of Excellence for post-cardiac arrest care,” says Joseph P. Ornato, MD, chairman of the department of emergency medicine at Virginia Commonwealth University Medical Center in Richmond and medical director of the Richmond Ambulance Authority. “We’ve clearly seen that there is a learning curve involved in treating this patient population and studies suggest a significant jump in survival occurs when providers handle 40 or more cases per month.”

Early, rapid and aggressive therapy

Virginia Commonwealth University uses a combination of early mechanical CPR and aggressive and rapid intravenous cooling in the field, says Ornato. Patients reach the ideal core temperature in one hour, compared to four or five hours with external cooling. Ornato says they are discharging about 40 percent of patients alive and neurologically intact, compared with a national average below 10 percent.

About a year ago, the center decided to initiate