DOCTORS’ LOUNGE
DOCTORS’ LOUNGE
( continued from page 27) to a recommendation.
A summary of their strongest recommendations follows:
• Use TTM in adults after resuscitation from cardiac arrest especially in patients who presented with ventricular fibrillation or pulseless ventricular tachycardia, whether or not it was in or out of hospital cardiac arrest.
• No routine imaging of the brain is necessary before the initiation of treatment.- Patients who are comatose or unable to respond for consent remain eligible for treatment.
• Uncontrolled bleeding and refractory shock are considered contraindications; hypotension is a relative contraindication that can be managed with aggressive resuscitation to improve the chance of offering treatment.
• Target core temperature should be between 32 and 34 ° C and should be achieved as rapidly as possible, with sedation and analgesia throughout.
• Any medical facility with the capability to do this should do so, not just a university or research hospital.
Interestingly, various follow-up studies done by neurosurgery groups after traumatic brain injury have failed to show prognostic or survival benefit, regardless of the stability of the intracranial pressure, after initial studies projected some improvement. However, for the person presenting with cardiac arrest the data point to both improved survival and daily functioning.
But what about other trauma? What about the American scourge, gunshot wounds? Nicola Twilley, writing about this in The New Yorker(“ Cold Remedy” 11-28- 16), spent a long time with the staff of the R Adams Cowley Shock Trauma Unit at the University of Maryland in Baltimore. In the
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1960s Dr. Cowley taught about“ the Golden Hour” of trauma resuscitation, that to save critically injured patients, immediate, rapid, comprehensive treatment must be achieved. The Shock Trauma Unit treated a majority of the more than 900 people who were shot in Baltimore last year, 90 percent of whom were young, male and African-American. At least 300 of them died. Trauma researchers have long sought to extend the Golden Hour, and have worked for years to try therapeutic hypothermia as the means of doing that. This year, a new trial was announced that could help. It was originally attempted at the University of Pittsburgh in 2014, however not many people got shot, and adequate enrollment was not possible. So its chief author and designer Dr. Sam Tisherman then moved to the University of Maryland. Prof of Surgery Dr. Sam Tisherman, his team, and the Unit announced last year that the Univ. of Maryland would begin a trial of“ Emergency Preservation and Resuscitation,” to study and perfect the use of TTM in gunshot victims who are bleeding out. All trauma surgeons know the frustration and grief of losing patients minutes into their resuscitation from“ fixable” stab or bullet wounds, if only the bleeding could be stopped, the brain perfused and the acidosis prevented in time. But all too often the bleeding is too rapid and the person dies when the surgeon had only needed three or four more minutes to get control.
The E. P. R. trial has been in the making for more than 30 years of Dr. Tisherman’ s and others’ research. Hypothermia has long been thought to be lethal to the patient dying of trauma, so the modern surgeon would regard it as adding only danger. Yet Ms. Twilley notes that doctors from Hippocrates to Napoleon’ s Surgeon General Dr. Larrey also observed that packing the bleeding man in snow and ice could help, and that keeping them farthest from the campfire could help.“ Cold buys time by slowing things down,” she writes. What Dr. Bigelow began in the 1940s, Dr. Tisherman and his mentor, Dr. Peter Safar, have been working on since the
1990s. They eventually proved that pigs who were clinically dead( bled out, resuscitated with therapeutic hypothermia and brought back to life) could still remember the one box of many in a maze, that would reward them with the food treat. Their brains, their legs, their appetites and their personalities survived intact. Translating the trial to a human being who is rapidly dying after critical injury has been incredibly difficult with all manner of ethical and procedural questions. Because of what happened to Freddie Gray in Baltimore, there is particular sensitivity about proceeding- as they must to save the life- without prior informed consent, in the young African-American man who is statistically most likely to be a gunshot victim. Yet after a very detailed public information campaign, the trial has begun.
I find it comforting that the Canadian group recommended most strongly that comatose patients or those unable to give consent in any way should still be treated with therapeutic hypothermia. The tireless, utterly painstaking work of military and civilian trauma teams and researchers has saved countless lives. Other studies by EMS services have successfully involved the inability to give consent because of unconsciousness. Extending the Golden Hour long enough for true resuscitation is a noble goal. The new catchphrase might become,“ You’ re not dead till you’ re warm, but only after we freeze you first.”
Baby, it’ s colder inside the coffin than out.
Dr. Barry practices Internal Medicine with Norton Community Medical Associates-Barret. She is a clinical associate professor at the University of Louisville School of Medicine, Department of Medicine.