Cutting Edge Cardiac Care

   Unconsciously Cool: ROSC, Survival Soar With ARCTIC Program

      Therapeutic hypothermia for cardiac arrest patients is increasingly coming to the field, but that doesn't mean all the questions surrounding it have been definitively resolved. Among the most prominent yet unanswered is, when should cooling optimally begin?

   Typically, for EMS systems, the answer has been after return of spontaneous circulation. But under a novel program in Virginia, it's happening even earlier--with striking results.

   Under the ARCTIC program--a joint effort of the Richmond Ambulance Authority and Virginia Commonwealth University Medical Center--patients are cooled as resuscitation attempts occur, and receive a broad complement of additional therapies and support both pre- and in hospital. The cumulative results: an almost twofold improvement in ROSC, from 25% in 2001 to 46% in 2008, and an increase in survival to discharge from 9.7% in 2003 to 17.9% by the end of 2008.

   "Our approach was to do something a bit different," says Joseph Ornato, MD, chair of VCU's Department of Emergency Medicine and medical director of the Richmond Ambulance Authority. "The basis is animal data that pretty consistently suggests that the earlier you initiate cooling, particularly during the resuscitation process, the more likely you are to get a good neurologic outcome."

   The most comprehensive program of its kind in the United States, ARCTIC (for Advanced Resuscitation Cooling Therapeutics and Intensive Care) has two goals: to restart the heart as quickly as possible, and to start cooling as early as possible and transport patients to a single specialized postresuscitation facility in hopes of preserving their brains.

   Aspects of the program include:

• Good quality CPR, with automated chest compressions and interposed ventilations, performed for 2-3 minutes before the rhythm is analyzed and not stopped during defibrillation;
• Simplified airway management: Medics make one pass with an ET tube. If they can't see cords easily, or can't quickly confirm they're in the right place, they abort and use a King airway.
• Drugs to restart the heart: a regimen of alternating vasopressin and epinephrine. If IV access isn't gained on the first pass, drugs are given IO. Cooling is achieved with 4°C saline.

   The last two components have contributed to a reduction of almost six minutes in time to first drug.

   The high-level care continues at VCU under the auspices of physicians and nurses trained and experienced in postresuscitation care. They continue cooling by placing a high-tech plastic coil into a large vein and maintaining a patient body temperature of 93ºF for at least 24 hours.

   The ARCTIC data should be of interest to EMS systems looking at prehospital cooling, in particular cooling after ROSC. While that may represent the emerging norm, it's not really supported by the literature, Ornato says.

   "There have really only been two published studies that looked at whether cooling initiated after return of spontaneous circulation improves survival, and both were negative," he notes. One, from Seattle, had a small number of cases but did not show any overall improvement. The other, from Australia, ended early when cooling after ROSC showed no benefit.

   "The trend in EMS to initiate cooling early may ultimately be proven to have benefit, and I certainly hope that's the case," Ornato says. "But I think it's up for grabs as to whether cooling after ROSC will have any benefit."

   Feedback May Help ID Tired Rescuers

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