Louisville Medicine Volume 64, Issue 9 | Page 30

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 .