What we'll see in the years ahead.

For those of us who got comfortably used to seeing changes in resuscitation science every five years, the past few years have seemed fast-paced. But the rate of change is accelerating. It's time to fasten your seat belt.

Thanks to the pioneering work of the past few years, we are now beginning to accumulate solid data on what works and what doesn't.

Here's what I suspect lies ahead:

First, the age of five-year updates is behind us. I think we'll see changes in resuscitation science guidelines far more frequently than every five years.

Second, a dirty little secret has surfaced: most people don't do CPR well enough. I think we will see an increasing focus on the quality of the resuscitation effort: fewer and shorter interruptions in chest compressions, compressions more compliant with the two inches or more guideline, and shorter pauses between the cessation of chest compressions and the delivery of the shock.

Additionally, the evidence is growing compellingly in favor of more broadly pursuing therapeutic hypothermia, not only for cardiac arrest victims, but others. The trick here is to get the hospitals who receive cardiac arrest patients from ambulances to get the equipment and establish the protocols that will permit them to continue therapeutic hypothermia, once a chilled patient arrives in their ED. (You really shouldn't be initiating TH in the ambulance unless the hospital to which you are transporting the resuscitated victim can continue it.)

I, for one, will be spending considerable energy pushing for these changes over the next few years. i hope that my pre-hospital companions across the land will press for the same changes in their geographic areas. There is no reasonable excuse to lose the number of people to cardiac arrest as we do, particularly in light of the fact that there is a 10:1 difference in success rates in different geographies.

We have never been so close to being able to make a difference. Please help make it happen.

Bob

Therapeutic Hypothermia. AKA "Ice 'em down"

Tim Larsen was sprawled out on the men's restroom floor, purple and lifeless, but his job supervisor had been trained for such an emergency.

Tim Evans, another employee at Crane/Pacific Valves, 3201 Walnut Ave. in Signal Hill, immediately applied cardiopulmonary resuscitation, compressing Larsen's chest cavity until the paramedics arrived.

Every moment was critical April 18, and Evans continued to perform CPR while the paramedics set up defibrillator paddles.

"He's a heck of a good guy," Larsen said of Evans. "I just can't thank him enough."

Once a heartbeat was detected, Larsen was rushed to Long Beach Memorial Medical Center, where doctors worked to stabilize him, intensifying their efforts to prevent brain damage by using a high- tech process known as Arctic Sun.

The technique requires putting a patient's body into a hypothermic state with cooling pads that are connected to a machine that regulates their temperature.

The hypothermia process is relatively new at Memorial, where it's been used on about 20 patients during the past 18 months, according to Dr. Nima Ramezan, director of Neuro-Science and Stroke.

Evans' work on Larsen had given the doctors hope that the hypothermia treatment would succeed.

Dr. Omid Vahdat, who treated Larsen, said that when using the Arctic Sun equipment, a heart patient's body remains in a hypothermic state for at least 48 hours while doctors check on the well-being of the brain.

"The brain is the most sensitive organ," Vahdat said.

Vahdat said that using hypothermia is similar to the effort to keep an injured ankle from swelling.

Without slightly cooling the body, the brain could be damaged. But the cooling reduces the potential inflammation.

"This is the same concept," Vahdat said. "And it helps the healing process."

The Arctic Sun cooling pads are attached to the patient's legs, chest and arms.

A team of doctors - the cardiologist, neurologist, intensive care unit and primary physicians - work with the nurses in monitoring the patient's temperature, which drops only a few degrees.

"The temperature is not that cold," Vahdat said.

The cardiologist said he's pleased by the results of the cases he's handled.

"We've had exceptional success using this methodology," he said.

Larsen - nicknamed "Lucky 19" Arctic Sun patient - benefited from the hypothermia process, displaying his wellness afterward by answering his doctor's questions and demonstrating memory skills, Vahdat recalled.

Two studies show that using induced hypothermia has contributed to improved neurological outcomes, Ramezan said.

Patients benefiting from induced hypothermia include those who are comatose within six hours after a cardiac arrest; those able to maintain a blood pressure after CPR; or those in coma at the time of cooling, according to a report by the Perelman School of Medicine, University of Pennsylvania.

Patients who might be at risk from the hypothermia treatment may include those with major head trauma; those who have had major surgery within 14 days, since hypothermia may increase the risk of infection and bleeding; and those with a systemic infection because hypothermia inhibits immune function, the report says.

Larsen, however, met the criteria for the hypothermia process, doctors said.

In general, patients are cooled using the induced hypothermia protocol for 24 hours to a goal temperature of 89 to 93degrees, just slightly lower than 97.8 degrees, which is the lowof the regular human body temperature range. The target time to reach the temperature goal is six to eight hours.

The doctors worked to keep Larsen's body from shivering by giving him a sedative, Vahdat said. Shivering is considered very uncomfortable, and it generates heat, impairing the patient's ability to achieve the target cool temperature.

The doctors also monitor Arctic Sun-treated patients for arrhythmia associated with hypothermia. They also provide skin care, checking for burns every six hours.

To warm back up to a normal body temperature takes patients about eight hours.

Ramezan, the director of Neuro-Science and Stroke, declined to give the exact percentage of success rate at Memorial, saying that the numbers are too small to give a clear indication.

One patient, Dave San Jose, has high praise for the medical method, and he marked the one-year anniversary of his victory over death Thursday. San Jose is a well-known North Long Beach resident whose heart attack and return from the brink of death were well- publicized.

"I can't prove it, but I know the Arctic Sun is responsible for me being alive," said San Jose, 70.

San Jose said there's a need for more Arctic Sun machines, adding that two were in use at Memorial when he arrived there last year, and one had to be borrowed from another hospital.

"That machine is the only reason I'm talking now," he emphasized.

Vahdat said he is impressed by the success of the process.

"These are people who truly cheated death," he said.



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