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Survey of pre-hospital therapeutic hypothermia use in France
Resuscitation 83 (2012) e147
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Survey of pre-hospital therapeutic hypothermia use in France
Conflict of interest
Sir,
All the authors have no conflict of interest. We acknowledge that if accepted, the article will become the property of Resuscitation, in conformity with its rules and copyright constraints.
Fifty thousand out-of-hospital cardiac arrests (OHCA) occur in France each year.1 As part of post-resuscitation care, therapeutic hypothermia (TH) is recommended for comatose OHCA survivors with a shockable rhythm. Recent studies show that cooling can be initiated in the prehospital setting.2–4 We have evaluated the implementation of prehospital TH by the French emergency medical service system (EMS), the cooling methods used, and barriers to spread. In February and March 2010, we conducted a telephone survey of the 105 regional EMS (SAMU: Service D’Aide Médicale Urgente), using a web-based questionnaire. All 105 regional EMS answered our questionnaire (100% response). Thirty percent (n = 32) used TH and half of these (n = 16) had a written cooling protocol. Twenty-seven of them (84%) initiated TH for all initial arrest rhythms. Most (78%) started TH after ROSC, 16% as soon as possible, and 6% before ROSC. To initiate hypothermia 54% use cold fluids, most commonly by infusing 30 ml kg−1 of cold saline over 30 min. Eighteen percent used ice-packs and 28% only used passive cooling using exposure. Temperature was monitored with a tympanic thermometer (16%), an esophageal probe (14%), other means (51%), or not at all by 19%. Most EMS (70%) do not induce TH, and even though they thought it was interesting, most (84%) had no protocol or plan for a protocol in progress. There were two common themes regarding barriers to its implementation:
1. Organizational issues: TH is not implemented by all hospital intensive care units (ICUs), so EMS do not initiate it. Increasing use by ICUs would assist in the spread of prehospital TH. An organizational model similar to ‘stroke’ or regional trauma centres could be established so that OHCA survivors are taken to ‘cardiac arrest centres’. Another organizational barrier was the proximity of the ICUs and short transfer times. However, significant cooling is possible even within a short journey time.2 2. Training issues: lack of training in cooling and that TH was not feasible were common reasons for not using TH. Prehospital TH is feasible, easy to use, and safe.2–4 Cardiac arrest management includes IV access, so cold fluid infusion instead of regular fluids could be easily achieved if the rescuers were trained and aware of the benefits for the patient.
These barriers are similar to the those reported by emergency physicians and ICU colleagues.5 The use of TH and its implementation in hospitals is supported and linked to international guideline recommendations. The availability of specific pre-hospital TH guidelines could also help implementation by EMS. 0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2012.03.002
References 1. Vacheron AGL. Recommandations de l’Acadeˇımie Nationale de Meˇıdecine concernant la prise en charge extrahospitalie`re de l’arrêt cardiocirculatoire. Bull Acad Natle Méd 2007;191:149–54. 2. Bruel C, Parienti J-J, Marie W, et al. Mild hypothermia during advanced life support: a preliminary study in out-of-hospital cardiac arrest. Critical Care 2008;12:R31. 3. Hammer L, Vitrat F, Savary D, et al. Immediate prehospital hypothermia protocol in comatose survivors of out-of-hospital cardiac arrest. Am J Emerg Med 2009;27:570–3. 4. Kamarainen A, Virkkunen I, Tenhunen J, et al. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomized controlled trial. Acta Anaesthesiol Scand 2009;53:900–7. 5. Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med 2006;34:1935–40.
Youri Yordanov ∗ Emergency Department, EMS, and Forensic Emergency Medicine, Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France Université René Descartes, Faculté de Médecine de Paris 5, France Gérald Kierzek Emergency Department, EMS, and Forensic Emergency Medicine, Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France Loic Huet SAMU 94, Hôpital Henri Mondor, Assistance Publique des Hôpitaux de Paris, Creteil, France Jean-Louis Pourriat Emergency Department, EMS, and Forensic Emergency Medicine, Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France Université René Descartes, Faculté de Médecine de Paris 5, France ∗ Corresponding author at: Urgences/Emergency Department, Hotel-Dieu, 1 Place du Parvis Notre Dame 75004 Paris, France. E-mail address: [email protected] (Y. Yordanov)
17 January 2012 22 February 2012 5 March 2012
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Survey of pre-hospital therapeutic hypothermia use in France
Conflict of interest
Sir,
All the authors have no conflict of interest. We acknowledge that if accepted, the article will become the property of Resuscitation, in conformity with its rules and copyright constraints.
Fifty thousand out-of-hospital cardiac arrests (OHCA) occur in France each year.1 As part of post-resuscitation care, therapeutic hypothermia (TH) is recommended for comatose OHCA survivors with a shockable rhythm. Recent studies show that cooling can be initiated in the prehospital setting.2–4 We have evaluated the implementation of prehospital TH by the French emergency medical service system (EMS), the cooling methods used, and barriers to spread. In February and March 2010, we conducted a telephone survey of the 105 regional EMS (SAMU: Service D’Aide Médicale Urgente), using a web-based questionnaire. All 105 regional EMS answered our questionnaire (100% response). Thirty percent (n = 32) used TH and half of these (n = 16) had a written cooling protocol. Twenty-seven of them (84%) initiated TH for all initial arrest rhythms. Most (78%) started TH after ROSC, 16% as soon as possible, and 6% before ROSC. To initiate hypothermia 54% use cold fluids, most commonly by infusing 30 ml kg−1 of cold saline over 30 min. Eighteen percent used ice-packs and 28% only used passive cooling using exposure. Temperature was monitored with a tympanic thermometer (16%), an esophageal probe (14%), other means (51%), or not at all by 19%. Most EMS (70%) do not induce TH, and even though they thought it was interesting, most (84%) had no protocol or plan for a protocol in progress. There were two common themes regarding barriers to its implementation:
1. Organizational issues: TH is not implemented by all hospital intensive care units (ICUs), so EMS do not initiate it. Increasing use by ICUs would assist in the spread of prehospital TH. An organizational model similar to ‘stroke’ or regional trauma centres could be established so that OHCA survivors are taken to ‘cardiac arrest centres’. Another organizational barrier was the proximity of the ICUs and short transfer times. However, significant cooling is possible even within a short journey time.2 2. Training issues: lack of training in cooling and that TH was not feasible were common reasons for not using TH. Prehospital TH is feasible, easy to use, and safe.2–4 Cardiac arrest management includes IV access, so cold fluid infusion instead of regular fluids could be easily achieved if the rescuers were trained and aware of the benefits for the patient.
These barriers are similar to the those reported by emergency physicians and ICU colleagues.5 The use of TH and its implementation in hospitals is supported and linked to international guideline recommendations. The availability of specific pre-hospital TH guidelines could also help implementation by EMS. 0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2012.03.002
References 1. Vacheron AGL. Recommandations de l’Acadeˇımie Nationale de Meˇıdecine concernant la prise en charge extrahospitalie`re de l’arrêt cardiocirculatoire. Bull Acad Natle Méd 2007;191:149–54. 2. Bruel C, Parienti J-J, Marie W, et al. Mild hypothermia during advanced life support: a preliminary study in out-of-hospital cardiac arrest. Critical Care 2008;12:R31. 3. Hammer L, Vitrat F, Savary D, et al. Immediate prehospital hypothermia protocol in comatose survivors of out-of-hospital cardiac arrest. Am J Emerg Med 2009;27:570–3. 4. Kamarainen A, Virkkunen I, Tenhunen J, et al. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomized controlled trial. Acta Anaesthesiol Scand 2009;53:900–7. 5. Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med 2006;34:1935–40.
Youri Yordanov ∗ Emergency Department, EMS, and Forensic Emergency Medicine, Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France Université René Descartes, Faculté de Médecine de Paris 5, France Gérald Kierzek Emergency Department, EMS, and Forensic Emergency Medicine, Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France Loic Huet SAMU 94, Hôpital Henri Mondor, Assistance Publique des Hôpitaux de Paris, Creteil, France Jean-Louis Pourriat Emergency Department, EMS, and Forensic Emergency Medicine, Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France Université René Descartes, Faculté de Médecine de Paris 5, France ∗ Corresponding author at: Urgences/Emergency Department, Hotel-Dieu, 1 Place du Parvis Notre Dame 75004 Paris, France. E-mail address: [email protected] (Y. Yordanov)
17 January 2012 22 February 2012 5 March 2012