Therapeutic Hypothermia: The Future?
Introduction
On September 9, 2007 you could hear a pin drop in Ralph Wilson Stadium. The assembled fans of the Buffalo Bills waited anxiously as TE Kevin Everett lay motionless on the turf, hoping for some sign, any sign, that he was okay. A thumbs up. A wave. Even a twitch of the hand. But no such sign ever came and eventually Everett was carted off the field. The prognosis was not good. In a Sept. 11, 2007 article filed to ESPN.com, Dr. Andrew Cappuccino, the orthopedic surgeon who repaired a break between Everett’s third and fourth vertebrae, said, “A best-case scenario is full recovery, but not likely. I believe there will be some permanent neurologic deficit.” Bottom line: Kevin Everett would be confined to a wheel-chair for the rest of his life and would forever be at great risk of blood clots and infections.
But on Sunday, December 23, 2007, Everett shocked and delighted fans when he walked into Ralph Wilson Stadium for the first time since his injury. It is true, his recovery was nothing short miraculous. In the initial months following the recovery, many articles and media outlets were quick to credit what is now being called “Theraputic Hypothermia” as playing a key role. The experimental protocol that involves lowering the body’s core temperature was initiated by doctors and paramedics in the crucial time immediately following Everett’s injury while en route to the hospital. Before and since that fateful day in September 2007, the scope of Therapeutic Hyperthermia (TH) has broadened greatly. In light of the recent conversation surrounding traumatic brain injuries in football, EMS personnel should pay close attention to TH Protocols, as their affect may not be limited to sports medicine.
Background
The goal of Therapeutic Hypothermia (TH) is the lowering of the core body temperature to anywhere from 32-34 degrees celsius (approx. 90F). This is accomplished in a number of ways. A standard practice in the treatment of traumatic injuries is the establishment of large bore (big!) IVs to administer fluid. The fluid of choice is ‘normal saline’, which is an isotonic solution which, in layman’s terms, means it is the “consistency” as blood. Often these bags of saline are kept on warmers to increase the temperature to that of the human body. What Dr. Cappuccino did was essentially the exact opposite of what I’ve just described: he infused normal saline that had been cooled. This coupled with decreasing the ambient temperature inside the ambulance itself began the TH treatment. Most TH Protocols have active cooling continue for 24 hours, with achievement of goal body temperature usually occuring at the 3-4 hour mark.
But what good does this do? It’s really pretty simple. Think about an injury to an extremity, an ankle for example. If Jon sprains his ankle playing basketball, what happens within minutes? The anke swells to 2-3 tiems its original size. This is Jon’s body going into Protection Mode, sending signals to that area that cause vasodilation (widening) allowing fluid to rush in and ‘protect’ the injury area. Here’s the problem: too much of a good thing. While swelling isn’t necessarily bad and is, in fact, a natural reaction of the body to tissue damage, too much of it can actually delay the body’s healing processes. Healthcare providers will be familiar with the RICE mneumonic: Rest Ice Compression Elevation for the treatment of isolated swelling. Keeping the swelling down will allow the body to heal more quickly.
Ice cools the body and, in essence, slows everything down. As previously stated, the swelling is a natural response of the body. However, cooling (ice) can slow down metabolism at the injury site and thus allow healing to take place.
Now consider the above principles in a spinal cord injury, such as the one sustained by Kevin Everett. The body will react in the same way to Everett’s injury as it did to Jon’s metaphorical anke sprain: swelling. The key difference here is that swelling at the site of injury means swelling of the spinal cord, brainstem, and even increasing intra-cranial pressure (ICP), all of which can cause significant long term neurologic damage. The increased pressure reduces the flow of oxygen, causing ischemia and eventually cell death. However, cases such as Everett’s are evidence that rapid induction of TH may play a role in a more favorable outcome for the patient. The action is the same as icing a sprain. The lower temperature slows metabolic processes throughout the body in this case, including the site of the injury. A delay in swelling means the damaged tissue gets more oxygen for a longer period of time as well as reduced pressure on the brain and spinal cord.
The benefits of TH are not limited to traumatic injuries, however. Studies and clinical trials have begun to show evidence that TH may have a huge affect on preservation of neurologic function following cardiac arrest. A February 2002 article in the New England Journal of Medicine reported that in 137 patients in which TH was used following cardiac, 75 (55%) had a favorable neurologic outcome at the 6 month mark, as opposed to 39% in the non-TH patients. The rate of death at six months, as reflected by the study data, was 16% lower in TH patients.
Favorable outcomes are being reported in studies around the country. Recently, Providence Tarzana Medical Center instituted an experimental cooling protocol and liked what they saw:
“With the institution of the protocol, in the first week-and-a-half, we’ve had three patients who have had complete recovery of neurologic function after prolonged cardiac arrest,” said G. Scott Brewster, M.D., medical director of the Emergency Department at Providence Tarzana…“We’ve done cooling measures for quite a long time, but there’s never been a concerted effort to go hospital-wide with the process so that anyone who has a cardiac arrest in the local community or arrests in the hospital has the ability to benefit from the protocol,” Dr. Brewster said.
The chart (above left) included in the article from Tarzana explains three big differences between warm and cool reactions within the body.
Nothing is Certain
Despite the countless studies that seem to favor HT, no one should rush out to have it put their advanced directive just yet. In a Sept. 2007 New York Times article, Dr. Robert Cantu said of the Kevin Everett case:
“It does seem to have some benefit,” said Dr. Robert Cantu, co-director of the Neurologic Sports Injury Center at Brigham and Women’s Hospital in Boston. “Whether it’s responsible exclusively for the return or the recovery in this particular case, it’s a little hard to say. It may have happened anyway. But nobody could say it didn’t contribute to this quite remarkable turnaround.”
The list of skeptics includes Dr. Kevin J. Gibbons, Director of Neurosurgical ICU at Millard Fillmore Gates Circle Hospital in Buffalo. Gibbons, who was one of the doctors that operated on Everett, had this to say in a 2008 article filed by Revolution Health.com:
It’s important to realize that this is one individual and that further study of this practice is needed before making any conclusions. Some press reports portrayed Kevin’s treatment as having a “eureka” moment — he was paralyzed, then cooled, then moving — which really was not true. There were a few different phases to the use of induced hypothermia in Kevin’s care. His body temperature was warmer than most people who arrive with severe spine injuries, even though he’d received an injection of cooled saline in the ambulance when leaving the stadium. That injection did not bring his body temperature down much.
He was cooled during surgery, and that’s fairly routine. Then he was cooled again several hours post-op, and that brought his body temperature down significantly. But it’s important to note that he was recovering motor function before that last cooling treatment was employed and before the catheter was placed.
Here are the key factors, in my opinion, in why Kevin Everett was able to make the initial recovery:1. His injury was not a transection — that is, the spinal cord was not severed, and it was not crushed. When it is, as unfortunately happens in many of these types of injuries, people do not recover.
2. He received prompt surgical decompression of the spine and got excellent pre-hospital care from the Buffalo Bills’ staff and ambulance crew.
3. He was given high-dose steroids less than 15 minutes after his injury. Steroids are very powerful anti-inflammatories. Their use in trauma is controversial. They do help protect neurological tissue from injury during planned surgery. We use steroids all the time in neurosurgery before surgical intervention. If we didn’t, the swelling would be terrible and would make the surgery exceedingly difficult. Luckily, Kevin was in good enough physical condition that he didn’t suffer the negative effects that steroids can have on people.
Gibbons, as well as others, advocates that more research must be done before anything can be said for certain.
TH Pre-Hospital
Could Therapeutic Hypothermia be the wave of the future in the pre-hospital setting? The aforementioned New York Times article said:
But Everett’s case may be the earliest application of treatment for a spinal cord injury because doctors were on the scene.
There are 11,000 spinal cord injury cases a year in the United States, according to the Spinal Cord Injury Information Network. Most victims do not have doctors standing by, thus making cases of early intervention with cold therapy difficult to study.
“How could you get treatment to a patient quickly in another scenario?” said Dr. James Weinstein, editor of the journal Spine and director of Dartmouth Institute for Health Policy and Clinical Practice.
The first step is more research, which must include experimental protocol and procedure for EMS agencies around the country. As stated above, the issue is that TH is not readily available to most patients as it was to Everett thanks to the medical staff of the Buffalo Bills. The only way to make it so is via EMS providers. A carefully documented study of TH in the EMS setting is needed to determine, if any, the benefits.
It would, of course, require special equipment on the pre-hospital side. Some ambulances now come equipt with small refrigeration units, often used to store drugs that require such cooling. These could easily be adapted to house cooled saline as well. In additional, special kits are making their way onto the market, such as this one:
This would allow EMS providers to go so far as to initiate TH on the field, essentially as soon as physically possible following the injury. The first step, EMS wise, is education. Providers must be educated regarding the proper criteria for such treatment. New, and experimental, protocols and SOP’s would be required. Moreover, the participation of the hospitals at all levels is a must. If TH is initiated, it is often continued for 24 hours, which means that once it is begun in the field it must be continued in the hospital.
Conclusion
One thing is for certain, there is growing concern regarding traumatic brain injuries, especially on the grid iron. Given the role that EMS plays in caring for athletes, from the professional level all the way down to pop warner, providers and their medical directors can hardly afford to ignore the potential benefits of TH. If it can be shown that it does, in fact, improve the outcome for the patient, it needs to be explored and implemented. After all, isn’t that what medicine is all about?
Pictures and articles used in this article are not property of the Chris Petrick. They are property of the author and his/her governing agency.




Well first just a bit of housekeeping regarding the blog… I am changing formats! In the past this site has been pretty much exclusively theology and church stuff, and while I still plan on doing that from time to time, I feel as though it’s time to broaden my scope as it were. So from this point forward, you’ll find all sorts of topics here ranging from my own personal life to my thoughts on sports (including a weekly NFL picks column ala Bill Simmons) to, well, more theology. The new format will give me freedom to write a lot more (hopefully) and provide some of you (my friends!) insight into what’s going on in my world… assuming you care. And if you don’t, then what are you doing here exactly? Now, on to the latest…
Right now I could not be more excited about the Navy. As with most things in life, I believe it is what you make of it. If you approach a thing with the attitude that it’s going to suck and generally be the worst experience you’ve ever had, I’d be willing to bet you won’t end up having a good time. On the other hand, if you come into a thing thinking that, while it will be challenging, the experience will be unique and, at times, even fun then it won’t be so bad. This is the attitude that I’m trying to have about all things. The things you have to do in life won’t always be fun, but if you can come in with a positive attitude it usually helps quite a bit. And remember, nothing lasts forever. So even if it turns out that it’s not a good time, eventually it will be over and you won’t be doing that any more. It’s a good attitude to have when working out too, just FYI.
Once I prayed for a pony. As a newly turned 8 year old, I desperately wanted a pony. Let’s be honest, what little girl doesn’t at one time or another want their own majestic stallion? And even though my family had no way of accommodating such a desire, I had the understanding that if I prayed hard enough, God would pull through and provide somehow. After all, why wouldn’t God answer a child’s prayer? His child’s prayer?…
Although we don’t have Jesus to walk around with us, he said that it would be even better that he send the Holy Spirit, the Counselor, to be with us. This means that the Spirit of God is readily available to those who believe. Sweet. 



I’m a pretty avid reader of the magazine
I have yet another confession to make: I’m bad at quiet time. Spend more than 15 minutes in any church or vaguely church-related thing and I’d be willing to lay a five-spot that someone is going to give you a speech on the importance of “quiet time with God”. And if you’re anything like me, that meant you grabbed a Bible, went and sequestered yourself somewhere, and essentially waited for God to say something… And waited… and waited… and waited. Eventually you got hungry, thirsty, bored, or got a text from a friend and quiet time effectively ended. Well, there’s always tomorrow.
The other night at worship band rehearsal I had my band try something a little different for our devotional time. I played a song by The Album Leaf (great stuff) for them and invited them to close their eyes and allow God to speak to them through the music. There were nine of us in the room and everyone came up with something different. One person saw the devastation of Parkersburg, an Iowa town ravaged by a tornado last year, and saw everything put back together around her. She saw, as she put it, restoration. Another saw a bride coming down the aisle and was overwhelemed with a sense of hope. Another shared that he and his wife, for medical reasons, were forced to terminate a pregnancy. Through the song he heard God saying, “everything is going to be all right.” What’s fascinating is that the song is five and half minutes of instrumental music. Not a single word was spoken, but much was heard.
I have to believe that God is not sitting by and watching his creation fall to pieces. I have to believe that in the moments when I would swear God is no where to be found, he is present in hidden ways. I have to believe that when we cry about death and brokeness that God cries along with us. Because if not, then