Chilling a Heart attack Victim May Save the Brain


 
 

Josie Huang | | Sunday, October 7, 2007


PORTLAND, Maine-- As the LifeFlight helicopter darted toward the nearest trauma center, the medical crew on board was doing its part to save Albert Nutter's brain.

The nurse shot icy-cold salt water into the unconscious man's veins. The paramedic packed bags of ice around his neck, his armpits, his groin.

They were, literally, trying to chill him to the bone. And it was working.

From the body's norm of 98.6 degrees, Nutter's temperature had dropped to 97 degrees.

Then 96 degrees.

Then 95 degrees.

The colder it got, the better the potential outcome for Nutter, who risked severe and irreversible brain damage from the cardiac arrest that shocked his entire body a half-hour earlier.

Researchers are not entirely sure why, but chilling the body slows the metabolism and reduces the brain's need for oxygen, giving it time to heal from the trauma.

Studies have shown hypothermia therapy to be so simple, yet effective, that it has increasingly become a standard of care in hospitals across the country, including Maine's three trauma centers.

But the treatment is rarely found in the field, despite indications that hypothermia is more effective the sooner it occurs after a cardiac arrest.

Doctors at LifeFlight of Maine, the only medical helicopter service in the state, decided it made sense to start cooling patients in transit to the intensive care unit. They began in April.

''We'd be like a flying ICU,'' said Dr. Kevin Kendall, the LifeFlight medical director who developed the hypothermia protocol for the service.

LifeFlight was charting new territory. Officials at the Association of Air Medical Services said just one other of their 350 members were doing it.

And it was unclear whether the therapy would always be worthwhile. Would giving the person hypothermia therapy be as beneficial on a minutes-long flight to the hospital as on an hourlong flight?

Why take any chances, thought LifeFlight nurse Sandy Benton, who cared for Nutter during his June 9 transit.

At 36, Nutter was one of the youngest cardiac patients Benton had ever treated. She felt for him and his family.

''A good outcome - that's all we can hope for,'' Benton said to herself.

Earlier in the day, Nutter had been the picture of health.

A father of four who sells Budweiser for a local beer distributor, Nutter had driven half an hour from his home in Waterville to a softball tournament in Pittsfield.

His spirits were high. Nutter, an avid athlete since high school whose near-daily workouts were apparent from his trim 6-foot-tall, 170-pound frame, was doing particularly well for his team.

Early in the game, Nutter hit a home run.

''You got it, Al!'' his teammates cheered, as Nutter easily circled the bases, chewing gum.

Then, as Nutter crossed home plate and doubled back to the dugout, the color started to drain from his face.

His eyes rolled into the back of his head. Teammate Jeff Bourget watched stunned, as his friend of nearly 20 years crumpled to the ground.

''He's the last person you would think something like this would happen to,'' said Bourget, a roofing foreman from Winslow.

Nutter had no pulse - and for all intents and purposes was dead.

Doctors would later say Nutter's heart's electrical system had inexplicably short-circuited, and unless his heart started beating again - very soon - he could be among the estimated 95 percent of cardiac arrest victims who die before reaching the hospital.

Bourget and another ball player instantly started CPR and got Nutter breathing again.

Paramedics who arrived minutes later shocked his heart into a normal rhythm with a defibrillator.

At that point, most patients would have awakened with a start and asked where they were.

They would be promptly taken to the nearest hospital for evalution.

But Nutter is among the quarter of cardiac arrest who had been deprived of blood pressure in the brain long enough that they remain unconscious after rescusitation. He would need something more.

An ambulance rushed Nutter across town to Sebasticook Valley Hospital where his heart appeared to be stable, but his brain was a big question mark.

He was prepared for a flight to the nearest trauma center, Eastern Maine Medical Center in Bangor.

The flight crew carried Nutter on a longboard, onto the waiting helicopter.

Bourget, who had followed the ambulance to the hospital, was there when the helicopter took off.

''I hope Al will still be Al,'' he thought.

Maintaining the Chill

The saline solution, chilled to about 40 degrees Fahrenheit, coursed through IV lines stuck into Nutter's forearms. Mixed in the liquid were paralyzing and sedating drugs so Nutter would stay in a coma. That kept neurological activity to a minimum and kept him from shivering to generate warmth.

To cool the body efficiently, the paramedic placed ice packs where the biggest blood vessels of his body were: one on each side of his neck, one under each armpit, two on both sides of his groin.

Every second felt crucial. During a cardiac arrest, brain cells start to die because the heart stops pumping, cutting off the oxygen-rich blood supply to the brain. More than any other organ, the brain, with its delicate network of nerves, needs oxygen to survive.

The damage continues once the patient is resuscitated and the blood starts to flow again. The burst of activity releases toxins built up in the body during the cardiac arrest, killing other cells and causing inflammation in the brain.

Patients can end up with stroke-like symptoms, losing function on one side of the body, or losing so many brain cells they end up in a vegetative state.

''You could fix the heart, but the person could wind up in the nursing home because their brain is so damaged,'' Kendall said.

Over the past decade, several studies have suggested that patients who were cooled to as low as 89.6 degrees for hours at a time were less likely to have brain damage than survivors who were not.

In a study published in the New England Journal of Medicine in 2002, 55 percent of the chilled patients were able to live independently and work part time six months later, compared with 39 percent of those kept at a normal temperature. Forty-one percent of the hypothermia patients died within six months, compared with 55 percent in the normal temperature group.

The American Heart Association found support for hypothermia so convincing that in 2003 it recommended its widespread use among unconscious cardiac arrest patients. That prompted Maine's three trauma centers to establish therapeutic hypothermia protocols, starting with Maine Medical Center in Portland in 2005, followed by EMMC, then Central Maine Medical Center.

The Long Wait

It took about 12 minutes to airlift Nutter to EMMC, where the cooling process continued unabated. Nurses placed a giant blanket filled with freezing cold water on top of him, which brought his body temperature down to 89 degrees.

The blanket's temperature was modulated by readings from a catheter in his bladder.

Nutter was kept in a coma for the next 24 hours, while medical staff monitored his heart with an echocardiagram and withdrew blood for testing.

His heart looked good. But his older sister and closest friend, Rhonda Cote of Oakland, was terrified watching a ventilator breathe for him.

''You just sit there and keep praying, and asking 'Is it going to be OK?' '' Cote said.

After the day of cooling, nurses took off the blanket and waited for Nutter's body temperature to rise back to normal. They stopped pumping him with the coma-inducing drugs.

''We watched and waited to see if he would wake up,'' said Dr. Peter Ver Lee, Nutter's cardiologist at EMMC.

Four days after his arrival in the hospital, Nutter groggily opened his eyes, and the breathing tube was removed.

''What in the world happened?'' Nutter asked, looking bewildered. ''Last thing I knew, I hit the home run, and I woke up here.''

Nutter's cardiac arrest wasn't because of coronary artery disease, the leading cause of death in the country and a major cause of sudden cardiac arrest. Testing showed his arteries were healthy.

What actually happened could not have been predicted: His heart's electrical activity had been disrupted in a condition known as primary ventricular fibrillation. The heart's muscular, lower chambers had stopped pumping blood and quivered like Jell-O.

Five days later, Nutter got a defibrillator surgically implanted that will shock the heart into a normal rhythm if cardiac arrest ever strikes again.

Outside the slight indentation in his chest caused by the defibrillator, nothing has changed about him, Ver Lee said.

''The hypothermia seems to have worked very well for him,'' Ver Lee said. ''I'm going to assume there are no long-term effects.''

Nutter joked: ''It must have worked because I'm no more screwed up than before.''

CPR, Paramedics Crucial

Nutter is one of five Maine people who have undergone hypothermia therapy during helicopter transit over the past six months, according to LifeFlight.

The outcomes for all of them are not known.

But Benton, the flight nurse, said that for the therapy even to be an option, bystanders at a cardiac arrest need to have the wherewithal to provide CPR to the patient, and the paramedics must get there fast with a defibrillator.

''They are the real heroes,'' Benton said of those who assisted Nutter. ''This was a day where everybody was at the right place, at the right time, and the whole system worked very well collectively.''

Nutter was back to work within two weeks of being discharged from the hospital, and a week later, he was playing softball again - setting his teammates' hearts racing every time he went up to bat.

Nutter said he is convinced his teammates and paradmedics saved him, but the early cooling allowed him to preserve his quality of life.

''If they hadn't done that - well, who knows what could have happened?'' Nutter said.

Staff Writer Josie Huang can be contacted at 791-6364 or at:

jhuang@pressherald.com


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Related Topics: Industry News, Cardiac and Circulation, Provider Wellness and Safety, Operations and Protcols, Research

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