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THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST

INDICATION: Unconscious adult patients with return of spontaneous circulation (ROSC) after cardiac arrest.

GOAL:

1. Cool to 32°- 34° Celsius (89.6°- 93.2° Fahrenheit) within 4 hours of ROSC

2. Maintain the target temperature for 24 hours.

CONTRAINDICATIONS: Confirm that the patient does not have any of the following:

Severe cardiogenic shock (systolic blood pressure < 90 mmHg despite use of inotropes)

Primary coagulopathy (includes massive bleeding)

Causes of coma other than cardiac arrest (e.g. CVA, head trauma, Drug OD)

Glasgow Coma Scale >5 or patient is following commands

DNR

>12 hours since ROSC (Data supports cooling patients as soon as possible post cardiac arrest)

Sepsis as etiology for arrest

PROTOCOL:

❑ Admit to CCU

❑ Admit to: Dr. ___________________________________________

❑ Allergies: ____________________________________________

❑ Diagnosis: ____________________________________________

❑ Code Status: ____________________________________________

❑ Time of Arrest: ______

❑ Time of ROSC: ______

❑ Time Cooling initiated: ______

❑ Time Re-warming to be initiated: ______

❑ Mechanically ventilate patient with a cool circuit and heat moisture exchanger

❑ Arterial line monitoring

❑ Central line insertion

❑ Maintain 2 large bore peripheral IV lines at all times

TO REACH AND MAINTAIN TEMPERATURE GOAL OF 32°- 34° CELSIUS:

❑ Infuse cold saline: 2 Liters 0.9% NaCl IV over 30 min if no Pulmonary Edema.

❑ Ice packs to neck, armpits, and groin

❑ Cooling blanket (Place a sheet between the patient and cooling blanket)

❑ Insert temperature sensing Foley catheter for continuous temp monitoring

❑ Monitor and document temperature every 15 min until temp reaches 33° Celsius, then every 1 hr.

❑ Maintain temp 32°-34° Celsius.

❑ Central venous pressure monitoring every 1 hr during cooling phase.

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MEDICATIONS:

SEDATION: Titrate to maintain a Modified Ramsay Sedation Scale Score of 3 to 4 to prevent shivering.

❑ Diprivan: Initiate drip at 3 mcg/kg/min.

❑ Fentanyl: Initiate drip at 25 mcg/hr.

❑ Midazolam: Initiate drip at 4 mg/hour.

If shivering occurs despite sedation, initiate paralytic to prevent shivering.

Titrate to maintain Train-of-Four of 2 out of 4.

❑ Vecuronium (1 mg/ml) Initial dose 0.1 mg/kg IVP bolus, then initiate drip at 1 mcg/kg/min.

❑ Rocuronium (1 mg/ml) Initial dose 0.6 mg/kg IVP bolus, then initiate drip at 4 mcg/kg/min.

❑ Lorazepam 1 mg IV prn seizure. May repeat every 15 minutes x 3 doses. If seizure continues contact MD.

❑ Levetiracetam 1 Gm every 12 hour IVPB if patient has seizure activity

❑ Opthalmic Lubricant Ointment 3.5 Gm. 1 application to both eyes every 6 hours.

❑ Pantoprazole 40mg IVPB q 24 hours

DVT prophylaxis:

❑ SCDs

❑ Enoxaparin 30 mg SQ q 24 hours

❑ Enoxaparin 40 mg SQ q 24 hours

❑ Heparin 5000 units SQ q 12 hours

❑ Maintain the Mean Arterial Pressure (MAP) 70-90 mmHg

❑ For MAP less than 70 mmHg: Give 0.9% NaCl 250 cc IV bolus over 15 minutes.

If MAP still 100

❑ Labetalol 20 mg IV q 4 hours for MAP > 110

❑ Hydralazine 10 mg IV q 4 hours for MAP > 100

❑ Hydralazine 20 mg IV q 4 hours for MAP > 110

❑ Diltiazem 10 mg IV then initiate Diltiazem drip at 5 mg/hr

❑ Esmolol: Initial bolus 1mg/kg over 30 seconds and initiate drip at 150 mcg/kg/min

❑ Nitroprusside: Initiate drip at 0.25 mcg/kg/min and titrate to maintain MAP 70 – 90 mmHg

IV Fluids:

❑ 0.9% NaCl @ 75cc/hr

❑ 0.45% NaCl @ 75 cc/hr

❑ LR @ 75 cc/hour

❑ ______________________

❑ If Potassium less than 4.0, give 20mEq KCl rider IVPB (requires a central line)

❑ If Potassium less than 3.5, give 20mEq KCl rider x 2 IVPB (requires a central line)

❑ If Potassium less than 3.0, call MD for orders

❑ NO TPN or Enteral Feeding

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ADDITIONAL ORDERS:

❑ Vital signs per CCU protocol

❑ Insert and maintain NGT or OGT to intermittent low suction

❑ Strict I & O

❑ Neurology Consult

❑ Cardiology Consult

❑ Keep Head of Bed (HOB) at 30°

❑ Portable CXR q AM

❑ Brain CT to rule out intracranial hemorrhage or other causes of coma, if not done in ER.

❑ EEG STAT

❑ ECG STAT q AM

❑ ECG STAT for change in rhythm

❑ Continuous End Tidal CO2 monitoring. Goal: EtCO2 35-40 mmHg

❑ Continuous pulse oximetry to keep O2 saturations between 94 – 99%

LABS:

❑ CBC, BMP, Phosphorus, Magnesium, PT, CK, CKMB, Troponin q 6 hrs x 24 hrs

❑ ABG q AM

❑ UA, Urine Culture, Sputum Culture, Blood Cultures x 2, if not done in ER.

❑ Beta HCG on all women of childbearing age, if not done in ER.

RE-WARMING:

❑ Begin re-warming 24 hours after initiation of hypothermia

❑ Re-warm to 37° Celsius over 12 hours. Increase core temp slowly (approximately 0.5° Celsius per hr)

❑ If K+ >3.5 when re-warming is initiated, DC all fluids containing Potassium.

❑ Stop infusion of paralytic medication after temperature reaches 96.8° Fahrenheit

❑ Neuro checks during re-warming phase: every 1 hr x 4, then every 4 hrs x 24 hrs.

❑ Remove all cooling devices

❑ Place Bair Hugger warming device PRN

❑ BMP every 6 hours x 24 hours

❑ Morphine Sulfate 2 mg IVP q 1 hour PRN shivering.

❑ Morphine Sulfate 4 mg IVP q 1 hour PRN shivering.

❑ Give Acetaminophen 650 mg PR q 6 hours if temperature > 99° Fahrenheit within 12 hours after re-warming.

❑ If temperature remains > 99° Fahrenheit use cooling blanket to actively maintain temperature of 98.6° Fahrenheit.

MD Signature: __________________________________________ Date and Time: ___________________

Revised: 12/10/12

________________________________________________________________________________________________

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