| Enlarge By Jeff W. Reinking,
USA TODAY
12/11/2006
TRAINING, ACTION SAVED A LIFE
The first thing that caught Oscar Rojas' attention was a grunting sound, he recalls, like somebody trying to lift a heavy box. Rojas rounded the corner to find his friend, Dean Cowles, in serious trouble. Over the next five minutes, Rojas and his colleagues would save a life in a step-by-step manner pulled right from the American Heart Association guidelines. The help they gave to Cowles, doctors say, is a reminder that simple steps can turn a workplace into a safer place. "If this had happened to Dean at home, he most likely would not be here now," says his cardiologist, Mark Vossler. Cowles' employer had offered training in cardiopulmonary resuscitation. And the company had equipped its offices with an automated external defibrillator or AED, the device so simple that children can use it to save a life. Having an AED on hand is a no-brainer for this particular office Medtronic's Emergency Response Systems, which manufactures external defibrillators. But it's the people, studies have found, who save lives. In fact, in places where the devices have been locked away in cabinets or where employees were untrained, people have died near AEDs that were never turned on. Cowles was one of the lucky ones because his friends were ready. As Rojas checked Cowles, Steve Copeland and another colleague grabbed the AED, and they rushed to Dean's desk. Copeland and Rojas performed CPR and shocked Cowles 31 seconds after turning on the AED. As they gathered recently to recall that day, the co-workers described the surreal feeling when the machine they made told them to shock a friend. "I thought, 'This is not a test. This is not a patient simulator,' " Rojas says. " 'My God, this is Dean!' " Two shocks and good CPR restarted Cowles' heart. His face, which had turned a shade of ash, began to flush again with pink. "It's amazing," Copeland says, "to see all of the training, all of the technology built into the units; everything doing what it's supposed to do." HOW THE PROCESS WORKS
1. After a heartbeat is restored, paramedics put cold packs in the armpits and groin and infuse chilled intravenous fluids. 2. Doctors and nurses can use ice or cold packs, a catheter to cool the bloodstream, or apply external pads to keep the body at 91.4 degrees. 3. Doctors keep the patient cooled and sedated for 12 to 24 hours before rewarming the patient. By Robert Davis, USA TODAY When his heart stopped in the middle of his workday, Dean Cowles fell clinically dead in one of the best places in the world to suffer sudden cardiac arrest. The 57-year-old engineer collapsed on July 18 in King County just outside Seattle, a community that leads the USA in saving lives because of a commitment to cutting-edge emergency medicine. He was surrounded by co-workers who knew what to do when his body seized and he gasped for air; for years they have taken classes in cardiopulmonary resuscitation. His heart quivered in an electrical short-circuit in a building in which Dean and his friends make defibrillators, the device he would need — fast — if he were to be revived. A by-the-book rescue restarted Cowles' heart. But when he did not wake up after his heart was restarted, his doctors say, he needed a treatment that most Americans don't get — induced hypothermia — in which doctors lowered his body temperature to about 91 degrees. As Cowles' body struggled to recover from a cascade of biological problems that can follow sudden clinical death, his heartbeat was strong but his brain was competing with every other organ for oxygen. Hypothermia therapy has for years been used in the operating room when doctors want to slowly reduce a patient's need for oxygenated blood during heart and other surgeries. While researchers do not fully understand why, studies have shown that cooling allows the body to get by with less oxygen by decreasing the metabolic demand. When King County paramedics rolled Cowles into the emergency department at Evergreen Hospital Medical Center two miles from his office, he had a strong pulse but was still unconscious. The hospital team applied pads to his legs and chest and used a machine to lower his body temperature. "It's pretty much become the standard of care," says Cowles' cardiologist, Mark Vossler. "Cooling slows down the metabolism and decreases the brain's demand for blood flow. That's the theory." Cooling the body gives the brain a break while other organs compete for oxygen in a crisis, doctors say. Hypothermia protects the brain cells from damage, a common problem following sudden death. Cowles doesn't remember his hypothermic "coma," which lasted about 24 hours. The steps taken to save Cowles' brain illuminate a sharp medical disparity across the nation. This hypothermia treatment is standard care in a few cities, but it's unavailable in most. Most doctors continue to give hypothermia the cold shoulder, despite studies detailing the benefits in the New England Journal of Medicine in 2002, international recommendations in 2005 urging the treatment, and inclusion in the most recent American Heart Association's lifesaving guidelines for cardiac arrest care. Most physicians (87%) surveyed in a study published this year in the journal Critical Care Medicine said they had not used hypothermia after cardiac arrest. But doctors who have seen their own patient survival rates soar say people in the same condition that Cowles faced should not be denied cooling therapy. "Delaying acceptance of a therapy that has little risk but potentially great benefit and really little cost is not patient-oriented," says Clifton Callaway of the Safar Center for Resuscitation Research at the University of Pittsburgh. He says doctors must include cooling so that if a patient who arrives at the hospital with a heartbeat after suffering a cardiac arrest goes on to die, "it's not because of something we neglected to do for the patient." "Sometimes nature just holds all the cards," says Callaway. "But you don't want for it to be that you left cards on the table." How cooling helps As Cowles' co-workers at Medtronic's Emergency Response Systems office performed CPR, they each saw for the first time what a freshly dead person looks like. After his body tensed up like he was having a seizure and he made gasping and groaning noises, all of his muscles went flaccid. He was lifeless. "He started to go gray," says Cowles' boss, Steve Firman. After CPR and two shocks from the automated external defibrillator (AED) kept on the kitchen wall at the office, "Dean's pulse came back," Firman says. "He started breathing on his own. It was like a field of pink washed over his face." But, Firman adds, all his co-workers could then do was "hover" and wait for paramedics to arrive about eight minutes later. "Dean did not regain consciousness on the spot," he says. They knew their friend was still in serious trouble. Many of the cardiac arrest victims who are revived across the USA with CPR and rapid defibrillation make it to the hospital with a pulse, but they do not walk out. Brain damage can be severe. Cowles collapsed in a city that leads the nation in its attempts to save more lives — by training more residents in CPR, deploying more AEDs and measuring the performance of its paramedics. Nearly half of the people like Cowles survive and walk out of Seattle-area hospitals. On average across the nation, experts say, fewer than 10% are that lucky. But increasingly, other cities — among them Rochester, Minn., and Austin — are following Seattle's lead and using hypothermia and other strategies to increase survival rates for sudden cardiac arrest. While last year's survey indicated some doctors are waiting for more research, and one study underway is trying to determine the best time to start and stop the cooling therapy, the gold standard of studies may no longer be possible because of ethical concerns. The best test of a clinical treatment is often to randomly put patients with the same medical condition into two groups, one that gets the therapy and one that does not, and then measure the results to determine if those who got the treatment fared better. But some doctors say hypothermia treatment is so clearly beneficial that it is now unethical to deny one group a procedure known to be effective. "I could no longer participate in a study that randomized somebody to not get cooled," says Mary Ann Peberdy, an associate professor of medicine at Virginia Commonwealth University in Richmond. In her hospital, VCU Medical Center, staffers began cooling their cardiac arrest survivors more than two years ago and doubled survival rates. "I've made my survival twice as good. I couldn't go back." Nurses from the intensive care unit tell Peberdy "we've never seen people wake up and walk out of here like we are seeing now," she says. "We're really doing something good. It gives you chills." Raleigh, N.C., is not waiting. The doctors who oversee Wake County EMS, which serves about 775,000 residents across 860 square miles surrounding the city, reviewed the scientific literature and in October began cooling their cardiac-arrest survivors. "We believed it was not ethical to withhold the treatment in a randomized way," says Brent Myers, EMS medical director. "All patients who meet criteria are considered for treatment." In Wake County, and across the nation, each segment of the emergency medical system tends to operate in its own narrowly focused trench. Paramedics are the first to treat cardiac arrest patients with advanced life support. The patient is then handed off to emergency room physicians. If they're still alive after an hour or more, the patient is then moved to an intensive care unit, where that team takes over. "Hypothermia is a therapy that, for the patient to benefit from it, the whole system has to be integrated," says Callaway, an associate professor in emergency medicine at the University of Pittsburgh. In Wake County, it was the ambulance service that led the way. "Typically, the EMS field waits years for hospital-based or lab-based treatment protocols to trickle down to pre-hospital care," says Jeffrey Hammerstein, Wake County EMS spokesman. "Our docs did the research and pushed this program up through the hospitals. With a lot of cooperation and work, they came on board." Myers says "willing champions … both doctors and nurses" in the hospitals' emergency departments and intensive care units gave the program a lift. "Without their support, we would not have been able to have the unified approach we have today." Now, Wake paramedics begin the hypothermia treatment in the field by administering a sedative that prevents shivering, applying ice packs and infusing chilled intravenous fluids. The paramedics then bypass three hospitals with cardiac arrest survivors to take those patients to two hospitals, WakeMed Raleigh and Rex health care, that provide cooling therapy. Callaway says that by bypassing the closest hospitals to go to more specialized heart centers, Wake County EMS may be taking the next big step in cardiac-arrest care. Just as some trauma centers specialize in critical care, some hospitals might concentrate on treating cardiac arrest survivors. "In some ways, cardiac arrest patients are sicker than trauma patients," he says. "Right now we take them to the closest hospital, and that facility might see one or two of those patients a month. It's not an equitable matching of resources and patient need." A happy ending In Redmond, Wash., Dean Cowles is back at work as a troubleshooting engineer, as sharp as ever, his friends say. His emotions are closer to the surface. He's more likely to laugh or shed a tear. Cowles says he is enjoying the holiday season more with his wife, Diana, and his sons, Dan and Ray. But he can't enjoy his vices anymore. When he collapsed, he says, "I had what you call butter veins." Now, on his heart-healthy diet, the rule appears to him to be: "If it tastes good, spit it out." He jokes that the hypothermia treatment helped him quit his smoking habit. He says he got to sleep through the first day of nicotine withdrawal. "I went down a smoker and woke up a non-smoker," he says. On a serious note, he says that "hypothermia probably prevented brain damage." He looks at his co-workers, who begin to laugh. "Well," he says, "the jury is still out on my brain damage." Posted 12/11/2006 12:18 AM ET |
Cryotherapy in ankle sprainsAmerican Journal of Sports Medicine, Vol 10, Issue 5 316-319, Copyright © 1982 by American Orthopaedic Society for Sports Medicine Cryotherapy in ankle sprainsJE Hocutt Jr, R Jaffe, CR Rylander and JK Beebe This study assesses recovery from ankle sprains. Thirty-seven final participants were categorized according to the severity of their injury and the use of cryotherapy (15 minutes, one to three times per day) versus heat therapy (15 minutes, one to three times per day) for a minimum of three days. Therapy commenced either less than one hour, from one to 36 hours, or greater than 36 hours after traumatic event. Sprains were graded into five categories based on severity of the injury, but only two categories, subject to conservative treatment, are considered in this study. The study showed that cryotherapy started within 36 hours after the injury was statistically more effective than heat therapy for complete and rapid recovery. Patients in a group with Grade four sprains (unable to bear weight because of pain) reached full activity in 13.2 days compared to 30.4 days in a group using cryotherapy initiated 36 hours after injury or to 33.3 days in a group using heat therapy. Therefore, early use of cryotherapy, continued with adhesive compression, is an effective treatment of ankle sprains yielding earlier complete recovery than late cryotherapy or heat therapy. |
Even A Little Cooling Helps After Cardiac ArrestMain Category: Cardiovascular
/ Cardiology News In a paper presented at the 2006 Society for Academic Emergency Medicine Annual Meeting, May 18-21, in San Francisco, investigators from the University of Pittsburgh discussed the results of an animal model study to evaluate whether the simpler procedure might provide equivalent benefit. Cooling a person by 3-4 ºC during the first day after resuscitation has been demonstrated to improve the odds of a good recovery, but few patients receive this therapy. There may be fear of complications or logistical difficulties in carrying out the therapy in most hospitals. Practically speaking, cooling a person by 2 ºC is more manageable than cooling by 4 ºC. By using rats that had been anesthetized and subjected to cardiac arrest, the severity and duration of brain injury observed in humans was replicated. The rats were resuscitated with chest compression and epinephrine, and cranial temperatures were monitored and controlled at 37 ºC (normal), 35 ºC (2 ºC cooling) and 33 ºC (4 ºC cooling). Neurological scores were measured daily, and at the end of 14 days, their brains were examined for damage. Rats cooled to 33 ºC did best, as measured by neurological scores, median days to return to normal, and neuron density in the hippocampus. The 35ºC group had somewhat lower results while the normal group had the worst outcomes. Overall, the benefit of cooling only 2 ºC was similar to 4 ºC cooling. These results suggest that even modest cooling of the brain might have significant benefit to humans who have been resuscitated after cardiac arrest. The presentation is entitled "Comparison of 33ºC and 35ºC hypothermia after cardiac arrest" by Eric S Logue, Melissa R McMichael, and Clifton W Callaway MD. This paper will be presented at the 2006 SAEM Annual Meeting, May 18-21, 2006, San Francisco, CA on Thursday, May 18, in the Plenary Session beginning at 8:00 AM in Salon 9 of the San Francisco Marriott. Abstracts of the papers presented are published in the May issue of the official journal of the SAEM, Academic Emergency Medicine. About The Society for Academic Emergency Medicine saem.org The Society for Academic Emergency Medicine (SAEM) is a national non-profit organization of over 6,000 academic emergency physicians, emergency medicine residents and medical students. SAEM's mission is to improve patient care by advancing research and education in emergency medicine. SAEM's vision is to promote ready access to quality emergency care for all patients, to advance emergency medicine as an academic and clinical discipline, and to maintain the highest professional standards as clinicians, teachers, and researchers. The SAEM Annual Meeting attracts approximately 2,000 medical students, residents and academic emergency physicians. It provides the largest forum for the presentation of original research in the specialty of Emergency Medicine. About Academic Emergency Medicine aemj.org |
Exercise in cold water may increase appetite, UF study finds05 May 2005
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| Hospitals
Chill Heart Attack Victims
MINNEAPOLIS - A handful of Minnesota hospitals are now chilling some heart attack patients in an effort partly to protect their brains, a therapy that has produced results one doctor called "breathtaking." Take the case of Robert Kempenich, 52, of Little Falls. On Dec. 5, he collapsed at a SuperAmerica store and was rushed to a St. Cloud hospital where he was hooked up to a machine that lowered his body temperature to 92 degrees. Under normal circumstances, only about 5 percent of patients who collapse after a sudden heart attack survive. Even if emergency workers get the heart started again, the brain damage is often permanent. Yet two days after Kempenich collapsed he awoke from a coma and gave the "thumbs up" sign. His wife, Mary, was there. The sign meant, "He knows," she said. "He knows what he's doing." Less than a week later, Kempenich went home from the hospital. He was back at work at the SuperAmerica last week. His doctors say there are no signs of lasting brain damage. Scott Davis, head of the critical care unit, called the results "breathtaking." National guidelines distributed in November urged hospitals to start cooling some heart attack patients for 24 hours to try to prevent brain damage. Kempenich was among the first in Minnesota to get the treatment. "He was in a condition that we would never have thought him capable of waking up from again," said Dr. Keith Lurie, a cardiologist at St. Cloud Hospital and professor at the University of Minnesota. "That's what's so exciting about this. We are redrawing the border between life and death with this technology." Studies done in the past few years have shown that, if done quickly and on the right patients, cooling the body can increase survival rates. A few Minnesota hospitals are putting the idea into practice with the help of the Arctic Sun cooling device — which Marcy Kempenich calls her "favorite major appliance." The $25,000 device has made its debut in the past two months at the Mayo Clinic in Rochester and at Abbott Northwestern Hospital in Minneapolis, among others. "We've already seen great outcomes," said Barbara Unger, the director of cardiac emergencies at Abbott. Davis said the effect of the machine is similar to putting ice on an injured ankle. "When you injure a tissue, whether it's an ankle or a brain, there's two things that happen," he said. The injured cells release toxins, and the toxins attack other cells, in a domino effect of destruction. "What cooling down does is make the cells go to sleep so they're not active. So they don't release the (toxins)." The Arctic Sun machine uses foam pads and tubes to circulate cool water around the body. At the same time, Kempenich was sedated and paralyzed, to keep his body from warming itself through shivering. Doctors depressed his body temperature for 24 hours before slowly bringing it back to normal over 14 hours. Experts caution that the therapy isn't perfect — it won't help most heart attack victims — but it should reduce brain damage and improve survival rates, said Lurie, the St. Cloud cardiologist. "Although most people can still die, if we can show a 50 percent improvement ... that's a lot of patients." |
| Hypothermia
for 21 days
TOKYO - A man who went missing in western Japan survived in near-freezing weather without food and water for over three weeks by falling into a state similar to hibernation, doctors said. Mitsutaka Uchikoshi had almost no pulse, his organs had all but shut down and his body temperature was 71 degrees Fahrenheit when he was discovered on Rokko mountain in late October, said doctors who treated him at the nearby Kobe City General Hospital. He had been missing for 24 days. "On the second day, the sun was out, I was in a field, and I felt very comfortable. That's my last memory," Uchikoshi, 35, told reporters Tuesday before returning home from hospital. "I must have fallen asleep after that." Doctors believe Uchikoshi, a city official from neighboring Nishinomiya who was visiting the mountain for a barbecue party, tripped and later lost consciousness in a remote mountainous area. His body temperature soon plunged as he lay in 50-degree weather, greatly slowing down his metabolism. "(Uchikoshi) fell into a state similar to hibernation and many of his organs slowed, but his brain was protected," said Dr. Shinichi Sato, head of the hospital's emergency unit. "I believe his brain capacity has recovered 100 percent." Uchikoshi was treated for severe hypothermia, multiple organ failure and blood loss from his fall, but was unlikely to experience any lasting ill effects, Sato said. Doctors were still uncertain how exactly Uchikoshi survived for weeks with his metabolism almost at a standstill. In animals like squirrels or bears, hibernation reduces the amount of oxygen that cells need to survive, protecting them from damage to the brain and other organs.
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| Cryotherapy
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