DOCTOR’S ORDERS



ED Adult Therapeutic Hypothermia Order Set |

Patient Label | |

|Drug Allergies: | Ht. ________ Wt. _______Kg. |

|Living Will: |( Yes ( No | |Durable Healthcare Power of Attorney: |( Yes ( No | | |

|Code Status: |( Full Code | |( Do Not Resuscitate (Tan Chart Required) | | |

|Limited Code to include: |( CPR |( Intubation |( Defibrillation |( Cardiac Drugs |( Pacemaker |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

| |Diagnosis: | |

| |Inclusion and exclusion criteria are to serve as a guide for decision-making. | |

| |Inclusion Criteria: (requires all four components) | |

| |1. Nontraumatic cardiac arrest with return of spontaneous circulation (ROSC) | |

| |2. Core Temperature greater than 34º Celsius (94º F) at presentation. | |

| |3. Time to initiation of hypothermia is less than 6 hours from ROSC | |

| |4. Comatose after ROSC: GCS less than 8 AND No purposeful movement to pain | |

| |Exclusion Criteria: (any one of the following) | |

| |1. Conflict with advanced directives DNR/DNI status | |

| |2. Uncontrolled Gastrointestinal Bleeding | |

| |3. Patient requiring Mannitol therapy | |

| |4. Cardiovascular instability as evidenced by: uncontrollable arrhythmias, refractory | |

| |hypotension (unable to achieve target MAP 65 mmHg despite interventions) | |

| |5. Sepsis as suspected cause of cardiac arrest | |

| |6. Suspected intracranial hemorrhage | |

| |7. Major intracranial, intrathoracic, or intraabdominal surgery within 14 days | |

| |8. Gravid pregnancy | |

| |Interventions: | |

| |( Infuse 2 liters 4° Celsius (39.2º F) of 0.9% Normal Saline IV over 30 minutes if not already administered by EMS. | |

| |( Apply ice packs to axilla and groin to maintain hypothermic state | |

| |( No heated Humidification on the ventilator | |

| |( Insert temperature sensing foley to monitor core body temperature | |

| |( Insert Naso-Gastric Tube or Oral-Gastric Tube and connect to intermittent low wall suction | |

| |( Arterial line placement, Hypothermia Catheter Placement and additional central venous catheter or PA catheter as needed (To be | |

| |placed by physician or surgeon on call as soon as possible) | |

| |***** If Endovascular Cooling Catheter can not be obtained, the following cooling techniques will be implemented: ***** | |

| |Passive Convective Cooling – check appropriate boxes | |

| |( Expose patient, dampen skin, cooling fan | |

| |( Cooling blanket set to 33º Celsius (91º F) | |

| |( Reduce temperature in patient’s room, as appropriate | |

| |( Ice packs applied to axilla / skin | |

| |( Naso-Gastric lavage with ice cold 0.9% Normal Saline repeat as needed | |

|*2PO* |Physician’s Signature |

|*2PO* | |

| | |Form No. P9894 (03/09) Medical Services Page 1 of 2|

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|ED Adult Therapeutic Hypothermia Order Set | |

| |Patient Label |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

| |Labs: | |

| |Labs to be drawn NOW: | |

| |( Complete Blood Count (CBC), PT/PTT, INR ABG’s (temp corrected) | |

| |( Complete metabolic profile (CMP) | |

| |( Creatine phosphokinase (CPK), Troponin I, Creatine Kinase Myocardial Bands (CK-MB) | |

| |Progressive Urinalysis | |

| |Lactate | |

| |HCG if child bearing age female | |

| |Diagnostic Testing: | |

| |( Portable Chest X-Ray | |

| |( 12 Lead Electrocardiogram (EKG). | |

| |MEDICATION ORDERS: | |

| |Patient’s total body weight: ________ Kilograms | |

| |Sedation/Narcotics: | |

| |Administer the following medications prior to initiation of cooling: | |

| |Administer sedation prior to initiation of neuromuscular blocking agents | |

| |( 1. Fentanyl ________ micrograms per hour intravenous continuous infusion (suggested initial rate: 2 micrograms per kilogram per hour-| |

| |not to exceed 150 micrograms in an hour) | |

| | | |

| |( 2. Fentanyl _________ micrograms intravenously PRN every 4 hours for agitation or breakthrough pain (suggested: 25 – 50 micrograms) | |

| | | |

| |( 3. Propofol___________ micrograms per kilogram per minute continuous intravenous infusion while receiving chemical paralysis (suggested | |

| |initial rate: 5 micrograms per kilogram per minute). Increase rate in 5 – 10 microgram per kilogram per minute increments every 5 minutes | |

| |until goal Ramsey Sedation Scale less than 3 achieved | |

| | | |

| |( 4. Vecuronium Bolus: 0.1 milligrams per kilogram intravenous bolus | |

| |Continuous Infusion: Start continuous infusion 20-40 minutes after initial bolus dose at 1 microgram per kilogram per minute | |

| | | |

| |( 5. Vecuronium 0.1 milligrams per kilogram intravenously every 1 hour as needed for shivering | |

| |Vasopressors: | |

| |( 6. Norepinephrine (Levophed) IV-start at 0.5 micrograms per minute and titrate as needed to keep MAP greater than 65 | |

| | | |

| |( 7. Other pressor agent: ______________________________________________ | |

| | | |

| |Vasodilators: | |

| |( 8. Nitroglycerin IV-start if systolic blood pressure over ____________________ | |

| |Start at 5 micrograms per minute and titrate until systolic blood pressure is less than _____________ | |

| |Physician’s Signature/Date/Time: |

| | |Form No. P9894 (03/09) Medical Services Page 2 of 2 |

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