When the Heart Stops, Hypothermia Helps;

N.C. EMS Pioneers Cooling Patients to Save Lives & Protect Brains


 
 

Jean P. Fisher | | Monday, October 15, 2007


It was a typical Monday night. Walter Davis took his son Randy to tae kwon do, ate dinner at home with his wife and son, and then stretched out in his recliner to watch television. Shortly before 9 p.m., with no warning at all, his heart stopped.

His wife, Amy, heard him make a gasping noise and rushed to his side, but he stared blankly ahead. His skin was tinged blue.

Walter Davis was dead.

About 95 percent of patients who suffer sudden cardiac arrest die from it, usually within minutes. Those whose hearts are restarted often suffer brain damage and lasting physical disability.

But today, Walter Davis, an engineer who runs his own design-build firm, is walking, talking, working full time and looking forward to resuming golf, mountain biking, weight training and martial arts.

Davis, 50, thinks he owes his recovery to therapeutic hypothermia an intervention Wake County paramedics began pioneering in the field last year.

The treatment, which uses cold packs and intravenous fluids to quickly cool a patient s body, is thought to reduce inflammation and slow the natural process of cell death that occurs after trauma.

Last October, Wake County Emergency Medical Services became one of the first in the nation to use hypothermia in the field for cardiac arrest patients.

Now the treatment is becoming widely available across the Triangle. This month Orange County Emergency Medical Services and UNC Hospitals in Chapel Hill started cooling patients in the field, just as Wake County does.

Paramedics in Durham aren t yet cooling cardiac arrest patients, but Duke Hospital has developed standards for cooling certain cardiac arrest patients once they reach the hospital. Duke, which receives patients from Orange EMS, will continue to cool patients when paramedics have started ice packs and ice cold saline solution.

The treatment is also expanding to other types of trauma. Last month, it was used on Buffalo Bills tight end Kevin Everett, who suffered a spinal cord injury during a National Football League game. Doctors have speculated that cooling might have saved Everett from being paralyzed from the shoulders down.

It makes sense that it would work, said Dr. Laurence Katz, an associate professor of emergency medicine at UNC Hospitals. The brain dies the same way, no matter how it s injured.

Perfect health
As far as Davis knew, he was in perfect health. He worked out at the gym three days a week and took tae kwon do classes three nights on top of that. He also watched his diet. Doctors have told Davis his cardiac arrest in July was caused by a blood clot, possibly one that formed due to a recent foot injury.

Traditionally doctors thought most of the damage caused by cardiac arrest was instant, occurring when the brain and vital organs are cut off from blood, which delivers oxygen and nutrients to the body s tissues. Now doctors know that much of the damage that leads to brain death in cardiac arrest patients occurs after the heart is restarted. Blood rushes back to tissues, speeding decay in cells that have already started to self-destruct.

It s like adding fuel to a fire, said Dr. Brent Myers, medical director of Wake EMS and an attending emergency room physician at WakeMed Raleigh campus.

Doctors don t fully understand how such damage is stopped by hypothermia, but one explanation is that cooling dramatically reduces the body s metabolism. Cooling also reduces inflammation and swelling, which might prevent damage in the nervous system.

Doctors do know that hypothermia saves lives and preserves brains.

Since 2002, when two studies of therapeutic hypothermia for cardiac arrest reported that it reduces death and disability, the American College of Cardiology and an influential group that recommends best practices for resuscitation have come out in favor of the therapy.

Still, few hospitals routinely cool cardiac arrest patients, and even fewer EMS systems start cooling in the field, as Wake and Orange counties do. Wake County EMS induced hypothermia in 70 patients between October 2006 and Aug. 31

Wake County EMS hasn t completed a formal analysis of its hypothermia program, so no one can say for sure that outcomes here are better than they were before the therapy was available. But Myers said his impression is that the program has been a very positive change to our system.

Speed saves lives
For hypothermia to work well, experts say, time is crucial.

Patients survive with more function if someone performs cardiopulmonary resuscitation, or CPR, until the patient s circulation is restored, usually with a defibrillator.

If you don t have bystander CPR, your outcomes are much worse, Myers said. Even if you just get a small amount of flow, there are parts of the brain that are [getting blood].

Amy Davis called 911 within seconds of finding her husband. The dispatcher instantly recognized what Amy Davis described as a cardiac arrest and instructed Davis to get her 6-foot-4-inch husband out of the chair and lay him flat on the floor. She administered CPR.

The fire department was first to arrive at their North Raleigh home, followed a moment later by Wake EMS. An EMS supervisor brought in ice-cold saline solution and medications to keep Walter Davis from shivering during the hypothermia treatment. After jump-starting his heart, paramedics placed ice packs around his head, armpits and groin and started him on the cold saline, then took him directly to WakeMed on New Bern Avenue.

It had been 29 minutes since Amy Davis 911 call. During that time, Walter Davis was clinically dead. His body was alive, but it would be days before Amy Davis would know whether her husband s brain had made it.

Davis remained under sedation in the intensive-care unit for nearly two weeks as his body healed.

Finally, 11 days into his stay at WakeMed, doctors said it was time to wake him up. Amy Davis said the ICU team told her some patients open their eyes within 15 minutes of coming off sedation.

But Walter Davis eyes stayed shut. He slept all day that Friday and most of Saturday. Amy Davis began to fear the worst -- that her husband was brain-dead. But, toward the end of his second day off sedation, his eyes flicked open.

He didn t speak until a few more days passed. Randy Davis, 7, was telling his father about winning the camper of the week award at a YMCA day camp and Walter Davis responded, Wow.

It was just dramatic progress every day after that, Amy Davis recalls.

Thirty nine days after his heart stopped, Walter Davis left the hospital Aug. 31. He made it to the car on his own steam, using a walker.

jean.fisher@newsobserver.com or (919) 829-4753




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