NYC Project Hypothermia Working Group* represented by

John Freese, M.D. Chief Medical Director

Fire Department of New York and

Principal Investigator NYC Project Hypothermia

Timeline 2003-2008: Fire Department of New York (FDNY)and

New York City Regional Emergency Medical Advisory Committee (REMAC) work to optimize prehospital resuscitation protocols

2008: FDNY, REMAC, Greater New York

Hospital Association, Health and Hospitals Corporation, New York City Department of Health and Mental Hygiene, and New York State Department of Health develop NYC Project Hypothermia

Jan 5, 2009: NYC Project Hypothermia – Phase I initiated (selective transport of successfully resuscitated cardiac arrest patients to hospitals providing therapeutic hypothermia)

Aug 1, 2010: NYC Project Hypothermia – Phase II initiated (intra-arrest induction of therapeutic hypothermia via large-volume, ice-cold saline infusion)

We sought to assess the effects of intra-arrest induction of therapeutic hypothermia via large-volume, ice-cold saline (LVICS) infusion on immediate survival end-points for out-of-hospital cardiac arrest (OOHCA).

Data was gathered from the FDNY’s Cardiac Arrest Registry for the periods in question with data derived from:

- automated Computer Aided Dispatch entries

- post-resuscitation phone interview with paramedics

- prehospital medical record reviews - ECG data review - mandatory hospital data reporting

Control Period = August 1, 2009 – May 31, 2010 Study Period = August 1, 2010 – May 31, 2011

Control Period = August 1, 2009 – May 31, 2010 Advanced Cardiac Life Support-style protocol - CPR (including delayed defibrillation for non-EMS

witnessed arrests) - initial defibrillation attempts - airway management (including intubation) - consider treatments for reversible causes of

bradyasystolic arrests - vasopressin - epinephrine - atropine - amiodarone - additional treatments after consultation with medical

control physicians

Study Period = August 1, 2010 – May 31, 2011 Advanced Cardiac Life Support-style protocol - CPR (including delayed defibrillation for non-EMS

witnessed arrests) - initial defibrillation attempts - airway management (including intubation) - consider treatments for reversible causes of

bradyasystolic arrests - intra-arrest initiation of therapeutic hypothermia - vasopressin - epinephrine - atropine - amiodarone - additional treatments after consultation with medical

control physicians

Intra-arrest initiation of therapeutic hypothermia - large-bore (>18g or greater) IV or IO access - ice-cold saline (stored at 2.5oC, infusion ~4oC) - large-volume (30cc/kg, maximum 2 liters) - pressure infusion sleeve Exclusions - pulmonary edema - neurologically intact following initial resuscitation - loss of or inability to maintain IV/IO access - ice-cold saline not available at the time of

resuscitaiton

Neither group included traumatic arrests or those of hemorrhagic etiology.

All other arrests were included regardless of

presenting rhythm, etiology, or arrest characteristics.

Standard Utstein definitions were utilized. Chi-square analyses without Yates’ correction were

utilized (p<0.05 = significant).

Control Period = 5,738 resuscitations Study Period = 5,856 resuscitations with LVICS 4,571** ** Due to the lack of required equipment among

some advanced life support ambulances in the New York City 911 system during the study period.

Control Period Study Period (with LVICS) p

N 5,738 4,571 0.821

Male gender 3,008 (52.4%) 2,386 (52.2%) 0.837

Age < 80 3,777 (65.8%) 2,938 (64.3%) 0.105

Race (black) 1,644 (28.7%) 1,338 (29.3%) 0.504

EMS < 5 min 3,819 (66.6%) 3,124 (68.3%) 0.057

Cardiac Etiology 4,447 (77.5%) 3,578 (78.3%) 0.359

Bystander Witnessed 1,731 (30.2%) 1,444 (31.6%) 0.125

EMS Witnessed 516 (8.9%) 364 (8.0%) 0.068

Bystander CPR 1,853 (32.3%) 1,509 (33.0%) 0.769

Average infusion volume: 1260ml (range 100-2000) On-scene termination of resuscitation: 1,866 (40.8%) End-tidal CO2 values No difference in the percentage of patients

receiving ALS medications during the resuscitation (89.1% vs 94.2%, p=0.096).

Initial CO2 (mean) Ten Minute CO2 (mean) Control 21.4mmHg 21.7mmHg Study Period 21.8mmHg 22.8mmHg

P<0.001

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Control Period Study Period (LVICS)

27.90%

32.57%

ROSC

P<0.001

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Control Period Study Period (LVICS)

21.05% 24.75%

SROSC

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Control Period Study Period (LVICS) Study Period (>150cc)

27.90%

32.57%

38.04%

ROSC

P<0.001

P<0.001

P<0.001

Control Period Study Period (LVICS) Study Period (>1,500 ml LVICS)

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Control Period Study Period (LVICS) Study Period (>150cc)

21.05% 24.75%

26.76%

SROSC

P<0.001

P<0.001

P=0.094

Control Period Study Period (LVICS) Study Period (>1,500 ml LVICS)

The administration of large-volume, ice-cold saline for the intra-arrest initiation of therapeutic hypothermia improves immediate survival for out-of-hospital cardiac arrest.

Further work is required to assess the impact of

this effect on long-term, neurologically intact survival and specific patient populations for which this therapy may be of greatest benefit.

Co-Investigators

Stephan Mayer, MD

Scott Weingart, MD

David Prezant, MD

Greater New York Hosp ital Association

Zeynep Sumer

New York Downtown Hospital

Alexander Slotwiner, MD

Bellevue Hospital Center

Norma Keller, MD

Priscilla Legette, RN

Robert Roswell, MD

Beth Israel Medical Center – Petrie Division

Pierre Daniel Kory, MD

Harlem Hospital Center

Reynold Trowers, MD

Lenox Hill Hospital

Bushra Mina, MD

Metropolitan Hospital Center

Elliott Perla, MD

Mount Sinai Medical Center

Jennifer Frontera

New York Presbyterian Hospital – Cornell

Maureen McCauley, RN

Oren Friedman, MD

New York University Medical Center – Tisch

Margaret Myburgh

New York Presbyterian Hospital – Columbia

Stephan Mayer, MD

Hector Lantigua

St. Luke’s – Roosevelt Hospital

Dan Wiener, MD

Montefiore Medical Center

Robert Forman, MD

Angela Toro

Laura Gallo

Bronx Lebanon Hospital – Concourse

Charles Martinez, MD

Stacy Nunberg

John Coffey, MD

Jacobi Medical Center

Alex Cohen, MD

Lincoln Medical and Mental Health Center

Raghu Loganathan, MD

Rafalena Estrella

Montefiore Medical Center

Mank Menegus, MD

Elmhurst Hospital Center

Scott Weingart, MD

Flushing Medical Center

Wei Chen, MD

Jamaica Hospital

Geoffrey Doughlin, MD

North Shore – Long Island Jewish Medical Center

Paul Mayo, MD

Peninsula Hospital Center

Phyllis Prawzinsky, RN

Queens Hospital Center

Ricardo Lopez

St. John’s Episcopal Hospital

Eric Nazziola, MD

Brookdale University Hospital

Lewis Marshall, MD

Coney Island Hospital

Edmund Giegrich, MD

David Neckritz

Svetlana Makhover

Alisa Milevich

Marie Longo

Woodhull Medical and Mental Health Center

Samuel Agyare, MD

Tahira Chaudhry, MD

Kingsbrook Jewish Medical Center

Phillip Hew, MD

Kings County Hospital Center

Robert Kurtz, MD

Long Island College Hospital

Joshua Rosenberg, MD

Lutheran Medical Center

Beth Raucher, MD

Mary Margaret Heaney, RN

Gloria Tsan, MD

Maimonides Medical Center

Sheila Namm

New York Methodist Hospital

Josef Schenker, MD

Jessica Van Voorhees, MD

Interfaith Medical Center

Russell Robinson

Staten Island University

Theodore Maniatis, MD

Richmond University Medical Center

Jay Nfonoyim, MD

Mount Sinai Hospital of Queens

Yi-An Lee, MD

Arunakumari Timmireddy

North Shore University Hospital

Todd Slesinger, MD

St. Barnabas Hospital

Ernest Patti, MD

NY Westchester Square Medical Center

Jasminder Luthra, MD

NY Community Hospital of Brooklyn

Una Morrissey, RN

Beth Israel Medical Center – Kings Highway

Susanne Stefko

Ann O’Neill

Kimberly Henderson

Ramy Yakobi

Brooklyn Hospital Center

Sylvie DeSauza, MD

NYC Regional Emergency Medical Advisory Committee

Joe Bove, MD

NYC Department of Health and Mental Hygiene

Olivette Burton (IRB Chair)

NYS Department of Health

Lee Burns

Mark Henry, MD

All of the Certified First Responders, Emergency Medical Technicians, and Paramedics of the FDNY and the New York City 9-1-1 System.