368 Short report
Prehospital intranasal evaporative cooling for out-of-hospital cardiac arrest: a pilot, feasibility study Richard M. Lyona,c, Jerry Van Antwerpb, Charles Hendersonb, Anne Weavera, Gareth Daviesa and David Lockeya,d Intranasal evaporative cooling presents a novel means of initiating therapeutic hypothermia after an out-of-hospital cardiac arrest (OHCA). Few studies have evaluated the use of intranasal therapeutic hypothermia using the Rhinochill device in the prehospital setting. We sought to evaluate the use of Rhinochill in the Physician Response Unit of London’s Air Ambulance, aiming to describe the feasibility of employing it during prehospital resuscitation for OHCA. We prospectively evaluated the Rhinochill device over a 7-month period. Inclusion criteria for deployment included: age above 18 years, Physician Response Unit on-scene within maximum of 10 min after return-of-spontaneous circulation (ROSC), witnessed OHCA or unwitnessed downtime of less than 10 min, pregnancy not suspected, normal nasal anatomy, and likely ICU candidate if ROSC were to be achieved. Thirteen patients were included in the evaluation. The average time from the 999 call to initiation of cooling was 39.5 min (range 22–61 min). The average prehospital temperature change in patients who achieved ROSC was – 1.98C. Patients were cooled for an average of 38 min prehospital. In all cases, the doctor and paramedic involved with the resuscitation reported that the Rhinochill was easy to set up and use during resuscitation and that
Introduction Coronary heart disease is the most common cause of premature death in the UK. Out-of-hospital cardiac arrest (OHCA) can result from coronary heart disease with an incidence of 40–60/100 000 population annually [1,2], and B275 000 patients suffer an OHCA in Europe every year [1]. OHCA results in significant mortality and significant neurological disability. Despite recent advances in management of patients suffering from OHCA, the mortality rate remains high, with the survival to discharge rate typically less than 10%. Where resuscitation is successful and return-of-spontaneous circulation (ROSC) is achieved, there is often a high incidence of both significant neurological impairment and cardiac failure, resulting in an in-hospital mortality rate of 71% for OHCA patients in the UK [3]. Therapeutic hypothermia was been shown to improve survival and neurological outcome from OHCA [4,5]. Animal studies suggest that early cooling, either during resuscitation or early after ROSC, confers additional c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546
it did not interfere with standard resuscitation practice. Intranasal evaporative cooling using the Rhinochill system is feasible in an urban, prehospital, doctor/paramedic response unit. Cooling with Rhinochill was not found to interfere with prehospital resuscitation and resulted in significant core body temperature reduction. Further research on the potential benefit of intra-arrest and early initiation of intranasal evaporative cooling is warranted. European Journal of Emergency Medicine c 2014 Wolters Kluwer Health | Lippincott 21:368–370 Williams & Wilkins. European Journal of Emergency Medicine 2014, 21:368–370 Keywords: cardiac arrest, prehospital, resuscitation, therapeutic hypothermia a London’s Air Ambulance, bLondon Ambulance Service, London, cEmergency Medicine Research Group, Edinburgh and dNorth Bristol NHS Trust, Bristol, UK
Correspondence to Richard M. Lyon, MBChB(Hons), MD, MRCP, DipIMC, Emergency Department, Royal Infirmary of Edinburgh, EH16 4SA Edinburgh, UK Tel: + 44 7967 731172; fax: + 44 131 242 1339; e-mail: [email protected] Received 24 July 2013 Accepted 4 November 2013
outcome benefit [6–8]. If therapeutic hypothermia is to be initiated early after cardiac arrest, cooling needs to commence in the prehospital phase of patient care. Several studies have evaluated the use of prehospital cold intravenous saline but have not yet demonstrated outcome benefit [9,10]. Intranasal, evaporative cooling (Rhinochill) has previously been shown to be a safe, effective method of initiating therapeutic prehospital hypothermia [11] and could potentially improve outcome from OHCA [6,7]. The Rhinochill device consists of a control unit that can use oxygen or air to deliver a coolant spray to the posterior nasopharynx through a catheter, resulting in rapid brain cooling [11,12]. The feasibility of prehospital, intranasal evaporative cooling has not yet been explored in the UK. London’s Air Ambulance Physician Response Unit (PRU) is a doctor and paramedic-manned rapid response car, which operates 5 days a week in east London. The PRU is tasked to OHCA in the east London area. We sought to evaluate the use of intranasal, evaporative cooling in the PRU of London’s Air Ambulance, aiming to DOI: 10.1097/MEJ.0000000000000100
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Prehospital intranasal evaporative cooling Lyon et al. 369
describe the effect and feasibility of employing it during prehospital resuscitation for OHCA.
Materials and methods The study was a prospective pilot evaluation with data collected between 1 March 2012 and 1 October 2012. The project was approved as a service evaluation by Barts and the London NHS Trust. An intranasal evaporative cooling device was carried by the PRU during the evaluation period and all doctors and paramedics underwent training on its use. The PRU was dispatched to suspected cases of OHCA by London Ambulance Service. On arrival at the scene, resuscitation was commenced in accordance with standard protocols. Inclusion criteria for deploying the Rhinochill device (Benechill Inc., San Diego, California, USA) deployment were as follows: (1) Age above 18 years; (2) PRU on-scene within maximum of 10 min after ROSC; (3) witnessed cardiac arrest or unwitnessed suspected downtime of less than 10 min; (4) pregnancy not suspected; (5) normal nasal anatomy; and (6) unconscious after ROSC or likely ICU candidate if ROSC were to be achieved. The Rhinochill cooling technique involves delivering a coolant in spray form using an oxygen flow rate of 40 l/min resulting in a coolant delivery rate of 32 ml/min. Two CD oxygen cylinders (460 l of oxygen per cylinder) were carried to the scene for the Rhinochill device. Oesophageal temperature was measured continuously and cooling was discontinued if oesophageal temperature reached 331C. Maintenance cooling was continued on arrival in the emergency department or angiography suite in accordance with local protocol. Therapeutic hypothermia is available in all hospitals within the PRU catchment area.
Utstein template data were recorded for all patients. Oesophageal temperature was recorded, with monitoring commenced at the discretion of the attending PRU team. After each use, the doctor/paramedic team was asked to complete a questionnaire on the use of Rhinochill. Questions covered Rhinochill set-up, use, insertion, feasibility, whether the device was too heavy or too large, and the oxygen consumption of the device.
Results During the study period, the Rhinochill device was used on 15 patients. The most common exclusion criterion was the PRU arriving more than 10 min after ROSC (n = 9) or the attending PRU team deeming the patient not suitable for aggressive resuscitation (n = 3). Of the 15 patients included in the study, one had incomplete data collection and one was found to have a core temperature of less than 331C shortly after nasal catheter placement and cooling was discontinued. Of the 13 included patients, eight (62%) were male and five (38%) were female. The mean age was 55 years. A summary of all patients is shown in Table 1. Dispatch
The average time from dispatch receiving the 999 call to the PRU being dispatched was 13 min (range 3–31 min). The average time from 999 call to PRU arrival on-scene was 21 min (range 7–40 min). The average time from PRU dispatch to arrival on-scene was 9.5 min (range 3–24 min). The average time from 999 call to initiation of cooling was 39.5 min (range 22–61 min). Patient outcome
Eight (62%) patients had documented ROSC at some point during their prehospital resuscitation. Of the 13 patients, three (23%) were pronounced dead at the scene and the remainder were transferred to hospital for intervention or management.
Table 1
Summary of patients receiving prehospital intranasal evaporative cooling
Cases
Sex
Age
Likely cause
M F M M M F M M F M F M F
72 65 77 29 80 84 60 35 62 29 65 43 19
Cardiac Resp – COPD Cardiac OD IVDU VTE Cardiac/VTE Cardiac OD IVDU Cardiac Cardiac/OD Cardiac/VTE Cardiac OD b-blocker
1 2 3 4 5 6 7 8 9 10 11 12 13
Rhythm ASY PEA ASY ASY PEA PEA VF ASY VF VF PEA VF ASY
999-PRU o/s (min)
999-Rhinochill (min)
999-ROSC (min)
Cooling time (min)
Temp. change (1C)
12 40 16 28 7 18 13 38 10 21 15 39 16
29 61 22 59 22 60 25 48 37 34 34 42 45
PLE 33 PLE 19 17 33 PLE PLE 16 14 PLE 45 22
57 64 28 30 55 44 31 26 22 49 18 49 27
– – 1.0 – – 4.3 – 4.4 – 1.0 – – – 2.0 NA – – 1.3 0.8
Cooling time, duration of Rhinochill cooling. ASY, asystole; COPD, chronic obstructive pulmonary disease; F, female; IVDU, intravenous drug user; M, male; NA, not available because of incomplete data recording; o/s, on-scene; OD, overdose; PEA, pulseless electrical activity; PLE, pronounced life extinct; PRU, Physician Response Unit; Resp, respiratory; ROSC, return-ofspontaneous circulation; VF, ventricular fibrillation; VTE, venous thromboembolism.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
370 European Journal of Emergency Medicine 2014, Vol 21 No 5
Cooling
The average initial temperature reading was 36.11C (range 34.8–37.51C). The average final temperature in those patients who had achieved ROSC was 34.31C (range 32.1–35.61C). One patient had an increase in temperature of 0.81C despite maximum cooling. The average prehospital temperature change in patients who achieved ROSC was – 1.91C. Patients were cooled for an average of 38 min prehospital. Feasibility
Of the 13 patients, questionnaires regarding feasibility were completed in 11 cases. Statements were rated on a numerical 1–5 scale. In all cases, the doctor and paramedic involved with the resuscitation reported that the Rhinochill was easy to set up and use during resuscitation and that it did not interfere with standard resuscitation practice. In two cases, it was mentioned that extra oxygen was required for Rhinochill use. The Rhinochill was not reported to be too heavy or cumbersome for prehospital use.
resulted in significant core body temperature reduction. Further research on prehospital therapeutic hypothermia should include emergency medical dispatch to ensure timely commencement of cooling. Further research on the potential benefit of intra-arrest and early initiation of intranasal evaporative cooling is warranted.
Acknowledgements C.H., J.V.A. and R.M.L. were responsible for prehospital evaluation and data collection. Data analysis and manuscript preparation were carried out by all authors. R.M.L. acts as guarantor. This study was funded by a project grant from the College of Emergency Medicine. Conflicts of interest
There are no conflicts of interest.
References 1
Adverse events
Minor epistaxis was reported in two cases.
2
Discussion
3
Confirming two previous studies [11,13], we found the use of intranasal evaporative cooling to be possible during resuscitation or shortly after ROSC. To our knowledge, this is the first reported use of prehospital intranasal evaporative cooling in the UK.
4
This study highlighted the importance of emergency medical dispatch in deploying the Rhinochill in a timely fashion. The PRU was not always tasked immediately on receipt of a possible OHCA call, resulting in a delay of PRU attendance on-scene and subsequent commencement of cooling. Timing from arrival on-scene to initiation of cooling might be improved by further advanced training and regular practice. The benefit of intranasal evaporative cooling during resuscitation has been demonstrated in animal models, and initiation of intra-arrest cooling may confer additional survival benefit in humans, with further research urgently needed in this area. The limitation of this study is the small number of patients included in the pilot evaluation. We have highlighted the difficulty in responding to OHCA quickly enough to initiate intra-arrest cooling. Conclusion
Intranasal evaporative cooling using the Rhinochill system is feasible in an urban, prehospital, doctor/ paramedic response unit. Cooling with Rhinochill was not found to interfere with prehospital resuscitation and
5 6
7
8
9
10
11
12
13
Atwood C, Eisenberg MS, Herlitz J, Rea TD. Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation 2005; 67:75–80. Herlitz J, Ekstro¨m L, Wennerblom B, Axelsson A, Ba˚ng A, Holmberg S. Hospital mortality after out-of-hospital cardiac arrest among patients found in ventricular fibrillation. Resuscitation 1995; 29:11–21. Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database. Anaesthesia 2007; 62:1207–1216. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346:557–563. Nolan JP. Optimizing outcome after cardiac arrest. Curr Opin Crit Care 2011; 17:520–526. Tsai M-S, Barbut D, Wang H, Guan J, Sun S, Inderbitzen B, et al. Intra-arrest rapid head cooling improves postresuscitation myocardial function in comparison with delayed postresuscitation surface cooling. Crit Care Med 2008; 36:S434–S439. Wang H, Barbut D, Tsai M-S, Sun S, Weil MH, Tang W. Intra-arrest selective brain cooling improves success of resuscitation in a porcine model of prolonged cardiac arrest. Resuscitation 2010; 81:617–621. Tsai M-S, Barbut D, Tang W, Wang H, Guan J, Wang T, et al. Rapid head cooling initiated coincident with cardiopulmonary resuscitation improves success of defibrillation and post-resuscitation myocardial function in a porcine model of prolonged cardiac arrest. J Am Coll Cardiol 2008; 51:1988–1990. Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*. Crit Care Med 2012; 40:747–753. Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation 2010; 122:737–742. Castren M, Nordberg P, Svensson L, Taccone F, Vincent J-L, Desruelles D, et al. Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Circulation 2010; 122:729–736. Boller M, Lampe JW, Katz JM, Barbut D, Becker LB. Feasibility of intra-arrest hypothermia induction: a novel nasopharyngeal approach achieves preferential brain cooling. Resuscitation 2010; 81:1025–1030. Busch H-J, Eichwede F, Fo¨disch M, Taccone FS, Wo¨bker G, Schwab T, et al. Safety and feasibility of nasopharyngeal evaporative cooling in the emergency department setting in survivors of cardiac arrest. Resuscitation 2010; 81:943–949.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Prehospital intranasal evaporative cooling for out-of-hospital cardiac arrest: a pilot, feasibility study Richard M. Lyona,c, Jerry Van Antwerpb, Charles Hendersonb, Anne Weavera, Gareth Daviesa and David Lockeya,d Intranasal evaporative cooling presents a novel means of initiating therapeutic hypothermia after an out-of-hospital cardiac arrest (OHCA). Few studies have evaluated the use of intranasal therapeutic hypothermia using the Rhinochill device in the prehospital setting. We sought to evaluate the use of Rhinochill in the Physician Response Unit of London’s Air Ambulance, aiming to describe the feasibility of employing it during prehospital resuscitation for OHCA. We prospectively evaluated the Rhinochill device over a 7-month period. Inclusion criteria for deployment included: age above 18 years, Physician Response Unit on-scene within maximum of 10 min after return-of-spontaneous circulation (ROSC), witnessed OHCA or unwitnessed downtime of less than 10 min, pregnancy not suspected, normal nasal anatomy, and likely ICU candidate if ROSC were to be achieved. Thirteen patients were included in the evaluation. The average time from the 999 call to initiation of cooling was 39.5 min (range 22–61 min). The average prehospital temperature change in patients who achieved ROSC was – 1.98C. Patients were cooled for an average of 38 min prehospital. In all cases, the doctor and paramedic involved with the resuscitation reported that the Rhinochill was easy to set up and use during resuscitation and that
Introduction Coronary heart disease is the most common cause of premature death in the UK. Out-of-hospital cardiac arrest (OHCA) can result from coronary heart disease with an incidence of 40–60/100 000 population annually [1,2], and B275 000 patients suffer an OHCA in Europe every year [1]. OHCA results in significant mortality and significant neurological disability. Despite recent advances in management of patients suffering from OHCA, the mortality rate remains high, with the survival to discharge rate typically less than 10%. Where resuscitation is successful and return-of-spontaneous circulation (ROSC) is achieved, there is often a high incidence of both significant neurological impairment and cardiac failure, resulting in an in-hospital mortality rate of 71% for OHCA patients in the UK [3]. Therapeutic hypothermia was been shown to improve survival and neurological outcome from OHCA [4,5]. Animal studies suggest that early cooling, either during resuscitation or early after ROSC, confers additional c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546
it did not interfere with standard resuscitation practice. Intranasal evaporative cooling using the Rhinochill system is feasible in an urban, prehospital, doctor/paramedic response unit. Cooling with Rhinochill was not found to interfere with prehospital resuscitation and resulted in significant core body temperature reduction. Further research on the potential benefit of intra-arrest and early initiation of intranasal evaporative cooling is warranted. European Journal of Emergency Medicine c 2014 Wolters Kluwer Health | Lippincott 21:368–370 Williams & Wilkins. European Journal of Emergency Medicine 2014, 21:368–370 Keywords: cardiac arrest, prehospital, resuscitation, therapeutic hypothermia a London’s Air Ambulance, bLondon Ambulance Service, London, cEmergency Medicine Research Group, Edinburgh and dNorth Bristol NHS Trust, Bristol, UK
Correspondence to Richard M. Lyon, MBChB(Hons), MD, MRCP, DipIMC, Emergency Department, Royal Infirmary of Edinburgh, EH16 4SA Edinburgh, UK Tel: + 44 7967 731172; fax: + 44 131 242 1339; e-mail: [email protected] Received 24 July 2013 Accepted 4 November 2013
outcome benefit [6–8]. If therapeutic hypothermia is to be initiated early after cardiac arrest, cooling needs to commence in the prehospital phase of patient care. Several studies have evaluated the use of prehospital cold intravenous saline but have not yet demonstrated outcome benefit [9,10]. Intranasal, evaporative cooling (Rhinochill) has previously been shown to be a safe, effective method of initiating therapeutic prehospital hypothermia [11] and could potentially improve outcome from OHCA [6,7]. The Rhinochill device consists of a control unit that can use oxygen or air to deliver a coolant spray to the posterior nasopharynx through a catheter, resulting in rapid brain cooling [11,12]. The feasibility of prehospital, intranasal evaporative cooling has not yet been explored in the UK. London’s Air Ambulance Physician Response Unit (PRU) is a doctor and paramedic-manned rapid response car, which operates 5 days a week in east London. The PRU is tasked to OHCA in the east London area. We sought to evaluate the use of intranasal, evaporative cooling in the PRU of London’s Air Ambulance, aiming to DOI: 10.1097/MEJ.0000000000000100
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Prehospital intranasal evaporative cooling Lyon et al. 369
describe the effect and feasibility of employing it during prehospital resuscitation for OHCA.
Materials and methods The study was a prospective pilot evaluation with data collected between 1 March 2012 and 1 October 2012. The project was approved as a service evaluation by Barts and the London NHS Trust. An intranasal evaporative cooling device was carried by the PRU during the evaluation period and all doctors and paramedics underwent training on its use. The PRU was dispatched to suspected cases of OHCA by London Ambulance Service. On arrival at the scene, resuscitation was commenced in accordance with standard protocols. Inclusion criteria for deploying the Rhinochill device (Benechill Inc., San Diego, California, USA) deployment were as follows: (1) Age above 18 years; (2) PRU on-scene within maximum of 10 min after ROSC; (3) witnessed cardiac arrest or unwitnessed suspected downtime of less than 10 min; (4) pregnancy not suspected; (5) normal nasal anatomy; and (6) unconscious after ROSC or likely ICU candidate if ROSC were to be achieved. The Rhinochill cooling technique involves delivering a coolant in spray form using an oxygen flow rate of 40 l/min resulting in a coolant delivery rate of 32 ml/min. Two CD oxygen cylinders (460 l of oxygen per cylinder) were carried to the scene for the Rhinochill device. Oesophageal temperature was measured continuously and cooling was discontinued if oesophageal temperature reached 331C. Maintenance cooling was continued on arrival in the emergency department or angiography suite in accordance with local protocol. Therapeutic hypothermia is available in all hospitals within the PRU catchment area.
Utstein template data were recorded for all patients. Oesophageal temperature was recorded, with monitoring commenced at the discretion of the attending PRU team. After each use, the doctor/paramedic team was asked to complete a questionnaire on the use of Rhinochill. Questions covered Rhinochill set-up, use, insertion, feasibility, whether the device was too heavy or too large, and the oxygen consumption of the device.
Results During the study period, the Rhinochill device was used on 15 patients. The most common exclusion criterion was the PRU arriving more than 10 min after ROSC (n = 9) or the attending PRU team deeming the patient not suitable for aggressive resuscitation (n = 3). Of the 15 patients included in the study, one had incomplete data collection and one was found to have a core temperature of less than 331C shortly after nasal catheter placement and cooling was discontinued. Of the 13 included patients, eight (62%) were male and five (38%) were female. The mean age was 55 years. A summary of all patients is shown in Table 1. Dispatch
The average time from dispatch receiving the 999 call to the PRU being dispatched was 13 min (range 3–31 min). The average time from 999 call to PRU arrival on-scene was 21 min (range 7–40 min). The average time from PRU dispatch to arrival on-scene was 9.5 min (range 3–24 min). The average time from 999 call to initiation of cooling was 39.5 min (range 22–61 min). Patient outcome
Eight (62%) patients had documented ROSC at some point during their prehospital resuscitation. Of the 13 patients, three (23%) were pronounced dead at the scene and the remainder were transferred to hospital for intervention or management.
Table 1
Summary of patients receiving prehospital intranasal evaporative cooling
Cases
Sex
Age
Likely cause
M F M M M F M M F M F M F
72 65 77 29 80 84 60 35 62 29 65 43 19
Cardiac Resp – COPD Cardiac OD IVDU VTE Cardiac/VTE Cardiac OD IVDU Cardiac Cardiac/OD Cardiac/VTE Cardiac OD b-blocker
1 2 3 4 5 6 7 8 9 10 11 12 13
Rhythm ASY PEA ASY ASY PEA PEA VF ASY VF VF PEA VF ASY
999-PRU o/s (min)
999-Rhinochill (min)
999-ROSC (min)
Cooling time (min)
Temp. change (1C)
12 40 16 28 7 18 13 38 10 21 15 39 16
29 61 22 59 22 60 25 48 37 34 34 42 45
PLE 33 PLE 19 17 33 PLE PLE 16 14 PLE 45 22
57 64 28 30 55 44 31 26 22 49 18 49 27
– – 1.0 – – 4.3 – 4.4 – 1.0 – – – 2.0 NA – – 1.3 0.8
Cooling time, duration of Rhinochill cooling. ASY, asystole; COPD, chronic obstructive pulmonary disease; F, female; IVDU, intravenous drug user; M, male; NA, not available because of incomplete data recording; o/s, on-scene; OD, overdose; PEA, pulseless electrical activity; PLE, pronounced life extinct; PRU, Physician Response Unit; Resp, respiratory; ROSC, return-ofspontaneous circulation; VF, ventricular fibrillation; VTE, venous thromboembolism.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
370 European Journal of Emergency Medicine 2014, Vol 21 No 5
Cooling
The average initial temperature reading was 36.11C (range 34.8–37.51C). The average final temperature in those patients who had achieved ROSC was 34.31C (range 32.1–35.61C). One patient had an increase in temperature of 0.81C despite maximum cooling. The average prehospital temperature change in patients who achieved ROSC was – 1.91C. Patients were cooled for an average of 38 min prehospital. Feasibility
Of the 13 patients, questionnaires regarding feasibility were completed in 11 cases. Statements were rated on a numerical 1–5 scale. In all cases, the doctor and paramedic involved with the resuscitation reported that the Rhinochill was easy to set up and use during resuscitation and that it did not interfere with standard resuscitation practice. In two cases, it was mentioned that extra oxygen was required for Rhinochill use. The Rhinochill was not reported to be too heavy or cumbersome for prehospital use.
resulted in significant core body temperature reduction. Further research on prehospital therapeutic hypothermia should include emergency medical dispatch to ensure timely commencement of cooling. Further research on the potential benefit of intra-arrest and early initiation of intranasal evaporative cooling is warranted.
Acknowledgements C.H., J.V.A. and R.M.L. were responsible for prehospital evaluation and data collection. Data analysis and manuscript preparation were carried out by all authors. R.M.L. acts as guarantor. This study was funded by a project grant from the College of Emergency Medicine. Conflicts of interest
There are no conflicts of interest.
References 1
Adverse events
Minor epistaxis was reported in two cases.
2
Discussion
3
Confirming two previous studies [11,13], we found the use of intranasal evaporative cooling to be possible during resuscitation or shortly after ROSC. To our knowledge, this is the first reported use of prehospital intranasal evaporative cooling in the UK.
4
This study highlighted the importance of emergency medical dispatch in deploying the Rhinochill in a timely fashion. The PRU was not always tasked immediately on receipt of a possible OHCA call, resulting in a delay of PRU attendance on-scene and subsequent commencement of cooling. Timing from arrival on-scene to initiation of cooling might be improved by further advanced training and regular practice. The benefit of intranasal evaporative cooling during resuscitation has been demonstrated in animal models, and initiation of intra-arrest cooling may confer additional survival benefit in humans, with further research urgently needed in this area. The limitation of this study is the small number of patients included in the pilot evaluation. We have highlighted the difficulty in responding to OHCA quickly enough to initiate intra-arrest cooling. Conclusion
Intranasal evaporative cooling using the Rhinochill system is feasible in an urban, prehospital, doctor/ paramedic response unit. Cooling with Rhinochill was not found to interfere with prehospital resuscitation and
5 6
7
8
9
10
11
12
13
Atwood C, Eisenberg MS, Herlitz J, Rea TD. Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation 2005; 67:75–80. Herlitz J, Ekstro¨m L, Wennerblom B, Axelsson A, Ba˚ng A, Holmberg S. Hospital mortality after out-of-hospital cardiac arrest among patients found in ventricular fibrillation. Resuscitation 1995; 29:11–21. Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database. Anaesthesia 2007; 62:1207–1216. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346:557–563. Nolan JP. Optimizing outcome after cardiac arrest. Curr Opin Crit Care 2011; 17:520–526. Tsai M-S, Barbut D, Wang H, Guan J, Sun S, Inderbitzen B, et al. Intra-arrest rapid head cooling improves postresuscitation myocardial function in comparison with delayed postresuscitation surface cooling. Crit Care Med 2008; 36:S434–S439. Wang H, Barbut D, Tsai M-S, Sun S, Weil MH, Tang W. Intra-arrest selective brain cooling improves success of resuscitation in a porcine model of prolonged cardiac arrest. Resuscitation 2010; 81:617–621. Tsai M-S, Barbut D, Tang W, Wang H, Guan J, Wang T, et al. Rapid head cooling initiated coincident with cardiopulmonary resuscitation improves success of defibrillation and post-resuscitation myocardial function in a porcine model of prolonged cardiac arrest. J Am Coll Cardiol 2008; 51:1988–1990. Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*. Crit Care Med 2012; 40:747–753. Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation 2010; 122:737–742. Castren M, Nordberg P, Svensson L, Taccone F, Vincent J-L, Desruelles D, et al. Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Circulation 2010; 122:729–736. Boller M, Lampe JW, Katz JM, Barbut D, Becker LB. Feasibility of intra-arrest hypothermia induction: a novel nasopharyngeal approach achieves preferential brain cooling. Resuscitation 2010; 81:1025–1030. Busch H-J, Eichwede F, Fo¨disch M, Taccone FS, Wo¨bker G, Schwab T, et al. Safety and feasibility of nasopharyngeal evaporative cooling in the emergency department setting in survivors of cardiac arrest. Resuscitation 2010; 81:943–949.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
