Prehospital Hypothermia Q and A

Prehospital Hypothermic Resuscitation Webcast

• 2009 Jul 9

On April 15, 2009, J. Brent Myers, MD, director and medical director for the Wake County EMS System in Raleigh, N.C. presented a webcast on the science supporting the 2005 AHA guidelines. (Watch the archived webcast here.) We received more questions than could be addressed during the webcast, so Dr. Myers took the time to respond to all those that weren't answered during the live webcast.

 

Jeff in Texas: How do you keep the patient continually cool throughout the continuum of care and multiple transfers from department to department?
Dr. Myers: Each emergency department has a plan for this; if things don’t go according to plan, the cold IV fluid is continued until arrival in the ICU. One department has the emergency physician place a central line for intravascular cooling in the emergency department while another uses a blanket cooling device in the emergency department and has the ICU physician place the central line.

 

David in Alaska: Have medevac aircraft been successfully modified to transport cooled patients? How can we get information in this regard?
Dr. Myers: We’re working on this now. At the moment, the aircraft uses cool fluid, like the ground EMS units do.

 

Robert in New York: How is the process of inducing hypothermia going to work when many crews are not able to provide paralytics to patients as a part of their scope of practice?
Dr. Myers: Our new protocol calls for cold fluid only and paralytics only in the event of shivering. We have not encountered any shivering since we changed the protocol; obviously, you should follow local medical direction, but everyone is welcome to use our protocols as a guide. They can be found online at http://wakeems.com/ICE2008/index.html.

 

Mike in Oregon: Have you encountered any complications with administering the chilled fluid via IO? 
Dr. Myers: No -- we use the IO exclusively in ~50% of cases and in combination with peripheral access in ~25% of cases. We have encountered no complications save for one infiltrated line.

 

Carrie in Maryland: We have one hospital in our immediate area that supports therapeutic hypothermia; however, our medical director is very interested in possibly applying it. How many hospitals in your area support therapeutic hypothermia and if more than one, were they all “on-board” from the start?
Dr. Myers: We spent six months in the run-in phases gathering hospital support. We have two of seven receiving hospitals that support hypothermia, and a third to come on board soon. The bottom line is this: from my perspective, it’s worth driving by non-hypothermia hospitals to the hypothermia hospital, particularly if the hypothermia hospital can also provide prompt PCI. Obviously, follow local protocols -- these are just some suggestions.

 

Paul in Florida: There are barriers, like it or not, to getting the EDs to follow through with prehospital induced hypothermia. How do we overcome these obstacles? Bypass of non-participating centers?
Dr. Myers: Two suggestions: 1) Use a nurse champion at your proposed hospital, and 2) Yes, bypass non-participating centers.

 

Robert in Florida: What does this do to our on-scene times and our scene-to-ER/cath lab times?
Dr. Myers: We work all cardiac arrests onscene and rarely do CPR in the back of the ambulance. In any event, the time it takes to do this is simply changing out one IV bag for another -- less than one minute. Once at the hospital, you’ll need a plan to get to the cath that includes hypothermia. In our facilities, the cold IV fluid is continued and the patient is moved rapidly to the cath lab.

 

Kevin in Connecticut: What are the costs involved with implementing therapeutic hypothermia? Is it acceptable to use a traditional, non-powered cooler for chilling fluids?
Dr. Myers: The cost of the powered cooler is ~$500. Yes, you can use whatever you want -- the frequency of replacing the ice and temperature monitoring will need to be determined by the local climate.

 

Keishone in New York: With EMS systems in NYC being underfunded as it is, do you think this would be an easy thing to integrate?
Dr. Myers: Yes -- the cost of this is less than the IO needle or other interventions. Planned correctly, this can be a very inexpensive thing.

 

Joe Lemmons in Florida: Are there any contraindications or detriment to patients if prehospital hypothermia is appropriately initiated and the hospital does not continue the hypothermia?
Dr. Myers: This area of hypothermia has not been studied. In theory, there could be harm for patients from such a brief period of cooling, but there is no evidence to actually evaluate this notion.

 

Bill in Minnesota: Are you using paralytics on these patients?
Dr. Myers: Yes, but only if they shiver. The protocol can be found at http://wakeems.com/ICE2008/index.html.

 

Bill in Minnesota: How much of a temperature increase do you see between the saline bag and the administration of the cold saline?
Dr. Myers: I assume you mean decrease. We see ~1 degree centigrade temperature drop in our patients. Seattle saw ~1.5 degrees, so we feel pretty confident in the rate of decrease.

 

Robert in New York: How does your system identify APP designation?
Dr. Myers: Medics had to have over 2,000 patient encounters in our system and participated in a competitive evaluation process. We had 40 applicants for 14 positions. Selected applicants entered an academy that was eight weeks long and involved education in public health, substance abuse and advanced clinical care.

 

David in Colorado: Why are the “hypothermia kit”/coolers not stocked on every ALS ambulance rather than just a rapid response vehicle? The vast geography of our area prohibits these rapid response vehicles.
Dr. Myers: Cost is the main reason. We have 10 APP/District Chief vehicles and more than 50 ambulances.

 

Matt in Utah: Are the checklists and hospital sheets available other than as part of the slide download?
Dr. Myers: They are available at http://wakeems.com/ICE2008/index.html.

 

Darrel in Florida: Are you looking at 12-lead/STEMI in your ROSC patients?
Dr. Myers: Yes, with prehospital activation of the cath lab for positive ECGs.

 

Michaele in Ohio: How is temperature monitored and maintained when there is a 1–2 degree variance?
Dr. Myers: In the coolers with a digital thermometer. The coolers keep the fluid at a very steady temperature. In patients, we previously used tympanic thermometers and we’re now moving to esophageal temperature probes.

 

Michael in Ohio: Did I see that chest compressions continue after ROSC for patients who have received hypothermic therapy?
Dr. Myers: No -- we use continuous compressions for resuscitation and then treat the patient after ROSC in the traditional fashion.

 

Randall in Arizona: Some of the literature I’ve been keeping up on states that therapeutic hypothermia has the same statistical benefit up to six hours after the initial insult, possibly negating the prehospital role. With that statement, have you been able to study the specific benefit to the field use of the hypothermic procedure.
Dr. Myers: We have not been able to do that just yet. I would caution you, however, as you read the New England Journal papers. Six hours was not chosen based on any clinical reasoning but rather was chosen because that is how long it took to achieve target temperature with the ice bath and other mechanisms they were using. Animal studies seem to indicate earlier is better, so this is still an open question. You may be correct in stating that earlier doesn’t matter, but we just don’t have the data to evaluate that notion at this time.

 

Scott in Tennessee: The Center for Medicare and Medicaid Services (CMS) has a strong stance against hospital protocols. How will this affect your program?
Dr. Myers: We have standing orders, not protocols, on the in-hospital side of things.

 

John in North Carolina: As a field medic here in North Carolina who is not aware of whether my administration or medical director is pursuing or interested in this, how should I go about broaching this topic with them?
Dr. Myers: We give this presentation at many N.C. conferences, including last year at Emergency Medicine Today in Greensboro. Have them give us a call if needed.

Richard in Missouri: What is your average transport time from incident to hospital and what was the average amount of cooling you achieved in the prehospital transport?
Dr. Myers: Our average transport time is ~20 minutes. We infuse ~900 ml of cold fluid on average, with an average temperature drop of ~0.9 degrees C. Most of our patients are ~36 degrees C at ROSC, so we’re arriving at hospital around 35 degrees, or halfway to target.

 

Greg Scott, EMS Director, McLean County Area EMS System, Bloomington, Ill.: In a time of economic downturn when EMS providers and hospitals are struggling financially, what manner would you suggest to present the associated costs for implementation?
Dr. Myers: I would put this in the context of care for a STEMI patient -- hypothermia is much less expensive than many other established therapies.

 

Vahe Ender, EMT-P, ProEMS, Cambridge, Mass.: What has been the recorded incidence of PAIH requiring sedation and paralysis?
Dr. Myers: Initially, we were providing paralytics to everyone. Since protocol revisions, we haven’t seen any shivering (~40 patients).

 

Ralph in New York: First, thanks a ton for doing this. As far as keeping IV fluids cooled and ready for use in IH have you heard of anyone simply using a cooler with reusable ice packs that are changed out every shift instead of using a mini-fridge?
Dr. Myers: I don’t know of anyone doing that, but it should work if individuals are focused on making sure the temperature is monitored and the ice is changed out.

 

Mark in California: What are the temps you achieve on admission to the ER? What cooling rates are you managing to achieve?
Dr. Myers: Our average transport time is ~20 minutes. We infuse ~900 ml of cold fluid on average, with an average temperature drop of ~0.9 degrees C. Most of our patients are ~36 degrees C at ROSC, so we’re arriving at hospital around 35 degrees, or halfway to target.

 

Krikor in California: Is there any evidence supporting or against EMT-Bs using cold packs to key lymph node areas to begin the process of induced hypothermia with close monitoring while in transport or waiting for ALS back up?
Dr. Myers: No specific BLS studies have been done, but it stands to reason that this would work.

 

Tom Green, Division Chief, Virginia Beach EMS: Dr. Myers, what was the reception of the hospital staff when you wanted to implement? In other words, what issues were there in the transfer of the patient from EMS to ED to ICU? 
Dr. Myers: As we spent six months prior to implementation working with our hospital colleagues, this went very well in most cases. Examples of the prehospital and in-hospital guidelines are available at http://wakeems.com/ICE2008/index.html.

 

David in Colorado: How much shivering have you experienced with your patients? Our state does not permit RSI meds without a labor intensive waiver process. We would like to explore the use of benzos for shivering. Thoughts? Experience?
Dr. Myers: Initially, we were providing paralytics to everyone. Since protocol revisions, we have not seen any shivering (~40 patients). I would not let lack of paralytics stop you from implementation.

 

Rod Kimble, AHA staff: If you involved the FDA, at what point in your protocol development, did you get them involved?
Dr. Myers: We did not involve the FDA -- temperature management is within the EMS scope of practice, as is use of sedatives and paralytics.

 

Christina in Wyoming: How difficult was it for you to get the medical community on board with the decision to do prehospital induced hypothermia?
Dr. Myers: Actually, not too difficult -- the evidence speaks for itself. As with any large group, there are some who are opposed, but the vast majority are in support of our efforts.

 

Deb in Washington: Our hospital is very rural. If a cardiac patient is critical, we fly them to Seattle. Will hypothermia still work in our setting and during air transport?
Dr. Myers: Yes, it will. Our air service uses cold IVF during transport.

 

Michael Hunter, NREMT-P, Education Coordinator, Harrison County Hospital, Corydon, Ind.:  Is the use of induced hypothermia feasible in rural areas of the U.S., i.e. limited hospital services, long transport times to larger hospitals?
Dr. Myers: Yes, I think it is, so long as it’s part of a regional transport plan. Barb Ungar in Minnesota probably has the best example of a regional hypothermia network.

 

Mike Resnick, Senior Transport Medic: Do you see hospitals wanting to be receiving facilities for IH patients as they seem to be interested in the money to be made by STEMI and stroke patients?
Dr. Myers: Yes, I think hospitals will come to want these patients. The only hold up will be making sure folks don’t get demerits from CMS from taking care of sicker patients.

 

Michael in Illinois: Our EMS system is implementing cooling through external icepack use only. Do you believe this will produce anywhere close to the needed temperatures?
Dr. Myers: Others have done that, and it is certainly better than nothing. I would encourage you to monitor your temperatures and report your findings.

 

Dave Sloane GSCEMS KY: Can the cold saline bolus be given IO?
Dr. Myers: Yes -- 50% of our patients are treated with the IO alone, with another 25% getting cold fluids in a combination of IO and peripheral IV.

 

Pete Fejkowki, Chief, Lower Kiski Emergency Services: What about the higher risk of VF induced by longer “rougher” ground transport to select facilities?
Dr. Myers: We have not experienced this. The best evidence seems to suggest the risk for VF from hypothermia does not begin until the patient is less than 32 degrees C. Given our patients are in the 34 to 36 degree range (and in-hospital we stop cooling at 33), this has not been a problem for us. From my perspective, the benefit of the hypothermia center outweighs any negative.

 

Tom Evans, RN, EMT: Will you have the information available to share with our medical command and the critical care committee?
Dr. Myers: All of our information can be downloaded from http://wakeems.com/ICE2008/index.html.

 

Amy Turley, Paramedic, Washington: Dr. Myers, I am very impressed and cannot wait to start this where I work. We will be inducing hypothermia in the next year. I have developed a new backboard pad for patient comfort, to prevent pressure sores and it can also be heated and cooled. All studies show the quicker you cool the patient the better off they are. My pads can be cooled to about 33 degrees F. We are looking at putting one under the pt. and one over the pt. along with cooled IV fluids and ice packs. What do you think of this?
Dr. Myers: Has some potential benefit -- would love to see human data regarding temperature change, complications, etc.

 

Ron Audette, Somerset Fire, Mass.: What percentage of patients who are “shivering” requiring meds? 
Dr. Myers: None have required it since we changed the protocol (~40 patients).

 

Tom Green, Division Chief, Virginia Beach EMS: Dr. Myers, does the ED use cooling blankets or do they use cooled saline or other fluids? 
Dr. Myers: Each emergency department has a plan for this; if things don’t go according to plan, the cold IV fluid is continued until arrival in the ICU. One department has the emergency physician place a central line for intravascular cooling in the emergency department while another uses a blanket cooling device in the emergency department and has the ICU physician place the central line.

 

Darrel Donatto, Division Chief of EMS, Palm Beach Fire Rescue: Brent, do you think that ALL ROSC patients need to go to a PCI capable facility, or would 12-lead screening for STEMI be an appropriate tool for deciding transport destination?
Dr. Myers: My personal opinion is yes, for this reason: The STEMI may evolve over time, and once the patient is induced on an inpatient basis, transfer can become difficult.

 

Richard in Maryland: How many people do you have to use paralytics on? Are you cooling them quickly enough to necessitate sedatives and paralytics and if so, what are your transport times?
Dr. Myers: Since we changed the protocols, we have not seen any shivering (~40 patients) -- none of whom have received paralytics or sedatives from EMS.

 

Christopher in New York: Is this something you would recommend for a BLS provider to be able to begin?
Dr. Myers: YES -- ice packs and misting fans are BLS skills, as is temperature monitoring.

 

Dave in Kansas: Dr. Myers: A previous slide mentioned the use of dopamine as a vasopressor to maintain a MAP of 90 mmHg. Is this the target pressure following ROSC and does pressure affect implementation of induced hypothermia?
Dr. Myers: Yes, a MAP of 90 is our target pressure. This is placed more for cardiac effects than for induction of hypothermia. Hypothermia can be induced at any pressure.

 

John in Virginia: Did you see an increase in ROSC in the field when you went with the Rescue Pod?
Dr. Myers: We did, but our data is not powered to detect the incremental benefit of that device, so I can’t say what (if anything) that device contributed to our observed increase.

 

Marv Wayne, MD, Bellingham/Whatcom County Washington EMS: Because of an ongoing NIH study we have not started prehospital cooling beyond a cool patient compartment and limited covering. What we do is to apply the head covering of our in-hospital cooling system. Since starting our program we have cooled over 150 patients with a go home of 23% with Mean Rankin Score of 2 or less. Do you think with starting the cooling in the field we can get this even higher?
Dr. Myers: Marv -- can’t say for certain. In your situation, the induction on the in-hospital side is likely seamless and predictable. The prehospital use of the fluid and cooling in a system with reliable and rapid in hospital cooling is going to be hard to study for benefit. We are considering using cool IV fluid as our resuscitative fluid (i.e. during CPR), and perhaps a greater benefit will be found there.

 

Woyengi in Maryland: I worked in Richmond, Va., where I first heard of induced hypothermia. Although they are only utilizing it in-hospital at the Medical College of Virginia, Richmond Ambulance Authority uses the AutoPulse for non-traumatic cardiac arrests. My question is, do you use such a device in your system? If not have you considered using such a device to increase ROSC in the field?
Dr. Myers: We do not use a mechanical CPR device and are not currently considering using one.

 

Richard in Maryland: Do you know of any studies looking at the use of anti-inflammatory agents or steroids with ROSC to combat the inflammatory cascade?
Dr. Myers: I am not familiar with any such studies.

 

Carrie in Maryland:  Since induction of the prehospital therapeutic hypothermia protocol, have all compressions been performed by lay professionals, or have you also implemented the use of automated compression devices?
Dr. Myers: By firefighters and EMS personnel -- no mechanical devices.

 

Tom Green, Division Chief, Virginia Beach EMS: Can you explain the ITD and what role this has in resuscitation?
Dr. Myers: The ITD creates negative pressure in the chest, thus increasing venous return (at least in theory). In non-randomized trials, the ITD has demonstrated benefit. There is a large, randomized trial going on right now to better evaluate the device.

 

Mark in Kansas: What percentage of patients experience shivering and at what point do you usually see it?
Dr. Myers: We have not seen any shivering in ~40 patients since we changed the protocol. In theory, it should occur at ~34 degrees.

 

Jason in North Carolina Since most field personnel learn by the technical aspect best, is there an option to allow select department/training head(s) to visit and/or ride with Wake County to better map out logistic/field aspects of this program (as well as the APP program)?
Dr. Myers: Absolutely – we would love to have you. Call 919-856-6020 and ask to speak to Chris Colangelo. 

 

Vern Lore, EMT-P, Bandera EMS, Texas: Besides cooling by way of IVs and ice packs, have you tried any other methods? I saw one method at a conference in Texas that wrapped the head to chill the pt.
Dr. Myers: We have not tried any other methods.

 

Andrew in Missouri: I am curious as to why the EMS-witnessed arrests were precluded.
Dr. Myers: They were excluded from analysis because they truly are a different case -- the “chain of survival” with bystander CPR, etc. does not apply to these patients. We will be studying EMS-witnessed arrest separately.

 

Peter Dyer, EMS Chief, Des Plaines, Ill.: Brent, looking at a cost benefit of starting hypothermia resuscitation upon ROSC, how does this work with resuscitations involving short transport times to emergency departments?
Dr. Myers: I think there is benefit regardless of transport times for two reasons. First, most codes should be worked onscene until ROSC, so there is the time from ROSC to get to the ambulance, re-stabilize the patient in the ambulance, etc. -- the cooling time is longer than the transport time. Second, this serves as a reminder to the hospital that this is the right thing to do.

 

Theodore Byrd, Fort Jackson EMS: Is there any data on the use of induced hypothermia for post-resuscitation care of hyperthermia arrest?
Dr. Myers: No, although anecdotally we have used the cold fluid on heat stroke with good effect.

 

Sean in Ohio: What is the Hawthorne effect?
Dr. Myers: The notion that health-care providers perform better just because they are being studied. For example, you will perform better compressions because you are being monitoring in a study and not just because the protocol has changed.

 

Anne Clouatre, EMS Regional Program Director, Porter, Littleton and Parker EMS: Why is it necessary to transmit 12-lead ECGs and deal with the headache of this? Wouldn’t you agree that it makes more sense to appropriately educate EMS to interpret 12-leads, be competent with infarct identification, know MI mimics, identify bifascicular, trifascicular and bundle branch blocks and be familiar with pacemakers? Our EMS medical directors are getting HACA implemented in Denver and appreciate you helping lead the way. Dr. Paul Davidson is our EMS physician champion.
Dr. Myers: I agree that medics should be able to activate the cath lab on their read of the ECG (and ours do). In some cases, however, an old ECG for comparison or some such thing will be required. In that case, transmission is helpful. I also agree, though, that these are a minority of patients and that ECG transmission is a community-specific thing.

 

Mike, St. Charles County Ambulance: Does your system use an automated CPR device (AutoPulse) and did that have any effect on your data?
Dr. Myers: We do not use an automated CPR device.

 

Ray Altman, EMT-P, Div Chief of Training, Boynton Beach Fire Rescue: Have there been any noticeable differences related to the patient’s down time prior to ROSC?
Dr. Myers: We do not have enough patients to completely evaluate this. I will say this, however: we have several patients with seven defibrillations from the EMS monitor (~3 minutes apart with an 8 minute arrival time = ~30 minutes) who have left the hospital neurologically intact. It remains true that “down time” prior to bystander CPR is important, but I am not sure how long one can have compressions now, but it appears to be quite some time.

 

Richard in Florida: What methods/presentations did you use to get other hospitals in your system to agree on the hypothermia and participate in the program? How did you convince other intensivists who are not exposed to and lack faith in the knowledge/clinical competence of the paramedic to provide hypothermia care?
Dr. Myers: This was the most difficult part. The key: getting nurses to buy in, and they brought the intensivists along. Although not true “evidence-based medicine,” once you have a good save, the nurses will see the results and keep the docs inline.

 

Ron in Rhode Island: Are your providers intubating with a Bougie through the King airway or removing it?
Dr. Myers: We are leaving the King in place and monitoring it with EtCO2.

 

Daniel in Massachusetts: Is there any harm to cooling all resuscitations?
Dr. Myers: We have very few exclusion criteria, but if by “all” you mean all non-traumatic arrests regardless of initial rhythm, it appears there is no harm (although the question of PEA and asystole remains unanswered). Our protocol (with the few exclusion criteria we utilize) is available at: http://wakeems.com/ICE2008/index.htm.

 

Candy in Massachusetts: Have you considered the utilization of the AutoPulse or Thumper devices(s) to maintain uninterrupted compressions during resuscitation? Thanks for your great work.
Dr. Myers: We have and we do not utilize these devices at the current time.

 

Dustin in Virginia: With the overwhelming information supporting hypothermic therapy do you see this idea becoming the standard of care?
Dr. Myers: Yes, I do. In point of fact, I believe it already is for VF/VT patients who are not neurologically intact at time of ROSC.

 

David in Maryland: Is there any difference in cold solutions using a cooler and ice vs. a special cooler as you described?
Dr. Myers: No, no known difference.

 

Richard in Missouri: What were you using to monitor temperatures in the prehospital field before the new device you’re trying?
Dr. Myers: Tympanic temperature.

 

David in Maryland: Refresh please, why are you considering a blind inserted airway over intubation?
Dr. Myers: In a nutshell, we strive to avoid interruption in compressions for any reason. What we have found is that we can insert an IO and successfully place a King before even an experienced operator can check the light on the laryngoscope. Use of the BIAD allows us to focus on compressions, defibrillation and correctable causes -- EMTs and paramedics use their brains rather than wasting time on procedures that can be safely deferred until ROSC.

 

Skip E., Wake Co. EMS, Raleigh, N.C.: If we are to begin cold fluid early on where does this lead with discontinuing resuscitation and the old saying “They are not dead until they are warm and dead”?
Dr. Myers: The “warm dead” refers to the initially hypothermic patient. As we are starting with the normothermic patient, this is less of a concern.

 

Patricia in New Jersey: If you are not using paralytics, how are the patients tolerating the King airway? What are you doing if the patient starts to gag on the airway?
Dr. Myers: As I am sure you know, paralytics are not the only medication that is needed to help a patient tolerate an advanced airway -- sedation is always required in conjunction. In our system, if the patient is not shivering, IV benzodiazepines are utilized. If the patient shivers, etomidate is used. If there’s no relief after sedation, IV paralysis may then be utilized.

 

Christopher in New York: In an area where there is a long-term transport due to locations of EDs, do you recommend starting the hypothermia process ASAP?
Dr. Myers: Yes, but I don’t have any evidence to confirm this notion. Cold IV fluids and ice packs are easy to use. Barb Ungar’s work from Minnesota is an excellent example of long-range transport for hypothermia.

 

Al Herndon in Florida: Dr. Myers, Do any of your crews transfer care to a helo team to transport the patient to a PCI facility? If so how does that work?
Dr. Myers: Our crews do not, but outlying hospitals do. At the present time, they are using cool IV fluid during transport by air, just as we do by ground.

 

Richard in Maryland: Given you only transport ROSC, are there any statics that show use of hypothermic resuscitation and cardiac arrest in total? Example call stats show 100 CA and total transports of ROSC is 4. Showing a percentage of CA calls benefiting from this protocol?
Dr. Myers: Excellent question. Patients are entered into the database if they have CPR performed at all, whether they are ultimately transported are not. In other words, the only excluded cases from that standpoint are obvious deaths (rigor, livor mortis, trauma incompatible with life). All cases where resuscitation is started and stopped on-scene are included in the percentages you see in the presentation.

 

Paul in Florida: What about labeling the fluid bags or BLUE IV bags emphasizing the therapy?
Dr. Myers: Excellent idea -- we are just trying to keep costs to an absolute minimum.

 

Mike in North Carolina: What technology is next to increase cooling or speed up cooling in the field? Obviously, there is only so much we can do with 2 L of fluid and icepacks.
Dr. Myers: Great question -- lots of ideas floating around out there, but I don’t know of any that have made it to trial.

 

Nathan in Tennessee: It seems that the goal is to delay rapid reperfusion of oxygen to the brain to reduce free radicals and cell damage. Vasopressin is shown to more quickly increase perfusion to the brain according to an article in the New England Journal of Medicine. This seems counter-intuitive with the hypothermia train of thought. What are your thoughts on the use of vasopressin in regards to induced hypothermia?
Dr. Myers: This is only my opinion, as there is no evidence to directly address this issue. The question of vasopressin use in cardiac arrest is up for debate, but I subscribe to the school of thought that the more pressors we use early in the resuscitation, the better off we are. Because we need that for a successful resuscitation (in my opinion), then to the extent the free radical formation may be increased by pressor use, the need for hypothermia is even more pronounced.

 

Ron in Rhode Island: Just a quick thanks to you folks for offering this webinar ... AWESOME.

 

Rob in Alberta, Canada: Thanks a lot for sharing your valuable insight on this topic. I agree we should be moving forward with this protocol, the big challenge is with the hospital system.

 

Michael in Ohio: FANTASTIC Presentation!!!!!! Thank you SO MUCH.

 

William in Kentucky: Thank you for the great info!

 

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• 

• J. Brent Myers, MD

  J. Brent Myers, MD, serves as the director and medical director for the Wake County EMS System in Raleigh, N.C. He also serves as an adjunct assistant professor of emergency medicine at UNC Hospitals in Chapel Hill and sees patients as an attending physician with Wake Emergency Physicians.