Download Therapeutic Hypothermia

Therapeutic Hypothermia
After Cardiac Arrest
Angelita Ramos, RN, BSN
Michelle Margerum, RN, BSN
Sonam Norbu, RN, BSN
Objectives
• Discuss cardiac arrest, therapeutic hypothermia (TH)
• Review goals of therapy
• Discuss guidelines of therapeutic hypothermia postcardiac arrest, indications and contraindications
• Discuss clinical evidence for TH
• Discuss mechanism of action, pathophysiology of
hypothermia post cardiac arrest
• Review cooling methods/procedure
• Review treatment protocols
Case Scenario
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TJ, a 65 year old African-American Male
Hx CAD, CHF, DM-type 2, HTN, COPD
Patient called 911 for SOB
Witnessed cardiac arrest at the scene with
initial rhythm VTach
• Defibrillated x2 with
ROSC
• Intubated at the scene
• Total down time 15 min
Case Scenario Cont.
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BP 100/50
HR 126
ST
RR 12
SPO2 100% on 100% FiO2
GCS 5
Intubated
Head CT negative
To cool or not to cool
Does this patient meet the criteria for induced
hypothermia post cardiac arrest ?????
Why should we cool
Cardiac Arrest
Statistical
Update
Out of hospital cardiac
arrest (OHCA)
In hospital cardiac arrest
(IHCA)
Incidence
Survival rate
Incidence
Survival rate
2013
359,400
9.5%
209,900
23.9%
2012
382,800
11.45
209,900
23.1%
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Abrupt loss of cardiac function
Cardiac arrest is the leading cause of death in North America
330,000 deaths per year in the US
Leading cause of neurologic injury
1/3rd of survivors have irreversible cognitive dysfunction
Erb, Hravnak & Rittenberger, 2012; AHA statistical Update, 2013
Cardiac Arrest
Picture from http://www.firstaidforfree.com/what-is-the-chain-of-survival
Historical Perspective
• Fourth and fifth century BC: Hippocrates advised
snow and ice packing to reduce hemorrhage
• 1700: Dr. Currie used cold water therapy for the
treatment of several clinical disorders
• 1803: Covering a patient with snow hoping for the
resuscitation in Russia
• 1812: Hypothermia (HT) was used for numbing
before limb amputation in Russia
• 1937: Dr. Fay adopted HT as an attempt to prevent
cancer cells from multiplying
History Cont.
• 1950: Biglow introduced moderate hypothermia
(28 °C to 32 °C) during cardiac surgeries in
animals to protect the brain
• 1958: The first reported use of TH for comatose
patients after cardiac arrest by use of HT as
compared to normothermia
• 2002: Two prospective RCT were conducted in
Australia and Europe of patients with anoxic brain
injury after OHCA
• 2002: Recommendation of TH by the International
Liaison Committee on Resuscitation (ILCOR) and
subsequently the American Heart Association (AHA)
TH Post Cardiac Arrest
• Inducing hypothermia in patients after ROSC
following a cardiac arrest
• Initiated ASAP with a target core temperature
of 32° to 34° C for 12 to 24 hours
• Decreases reperfusion injury
• Preserves cerebral function
• Decreases ischemic injury
AHA Guidelines
• Post VF/VT arrest patients who are unresponsive
with a ROSC after OHCA should be cooled to 32 to
34° C (89.6-93.2 ° F) for 12 to 24 hours (Level of
evidence Ib)
• IHCA of any initial rhythms or OHCA with an
PEA/asystole (Level of Evidence IIb)
• Active rewarming should be avoided in comatose
patients who spontaneously develops a mild
hypothermia (>32 °C) during the first 48 hours after
ROSC (Level of Evidence IIIc)
Inclusion Criteria for TH
• Witnessed arrest
• Post-cardiac arrest patient regardless of initial
rhythm with ROSC within 60 min of initiation
of ACLS
• Within 6 hours following cardiac arrest
• Maximum down time = 15 minutes
• Comatose state GCS ≤ 5
• Intubated
Exclusion Criteria for TH
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Intracranial hemorrhage
Major surgery within 14 days
Severe systemic infection/sepsis
Preexisting coagulopathies
Pregnancy
DNR status/terminal illness
Drug induced coma
MAP <60mmHg for > 30 min after ROSC
Temperature < 30 °C (86F)
GCS > 5
Alternative Applications of TH
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Traumatic brain injury
Acute liver failure
Aortic arch repair
Cardiac bypass surgery
Clinical Trials
Clinical Data
• The Hypothermia after Cardiac Arrest Study
Group
• Large randomized, controlled trial of 275 patients
in nine centers in five European countries
• Comparison of mild hypothermia (n=137) with
standard normothermia (n=138) in patients in
patients who suffered cardiac arrest due to
ventricular fibrillation
Clinical Data
Primary Endpoint
• Favorable neurologic
outcome within six
months after cardiac
arrest
• Pittsburgh cerebralperformance category
of 1 (good recovery); 2
(moderate disability); 3
(severe disability); 4
(vegetative state), and
5 (death)
Secondary Endpoints
• Overall mortality at six
months and the incidence
of complications during the
first seven days
• Severe bleeding;
pneumonia; sepsis;
pancreatitis; renal failure;
pulmonary edema;
seizures; arrhythmias; and
pressure sores
Clinical Data-Treatment
• All patients received standard intensive care per
protocol
• Patients randomly assigned to the hypothermia group
were cooled to a target temperature of 32°C to
34°C with the use of an external cooling device
• Temperature was maintained at 32°C to 34°C for
24 hours from the start of cooling
• Followed by passive rewarming, over a period of 8
hours
Clinical Data-Results
• A total of 75 of the 136 patients (55 percent) in the
hypothermia group had a favorable neurologic
outcome, as compared with 54 of the 137 (39
percent) in the normothermia group (risk ratio 1.40;
95 percent confidence interval, 1.08 to 1.81).
• Mortality at six months was 41% in the hypothermia
group and 55% in the normothermia group (risk ratio
0.74; 95% Confidence interval, 0.58 to 0.95)
The Hypothermia after Cardiac Arrest Study Group (2002). Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. New England Journal
of Medicine, 346(8), 549-556. doi:10.1056/NEJMoa012689
Clinical Data
• Cochrane Database review: systematic review and metaanalysis of RCT’s to assess the effectiveness of TH in
patients after cardiac arrest
• Main outcomes: neurologic outcome, survival, and
adverse events
• Conclusions: Mild TH improves survival and neurologic
outcomes after cardiac arrest
• The feasibility of TH in non-VF cardiac arrest has been
confirmed, but studies have not yet shown a survival or
neurological benefit
• Poor prognosis associated with asystole is one possible
reason for this observation
Arrich J, Holzer M, Havel C, Müllner M, Herkner H. (2012); Delhaye, C., Mahmoudi,
M., & Waksman, R. (2011)
ICE ICE BABY
Pathophysiology and Mechanism of Action
Hypothermia
http://positivemed.com/2013/10/12/10-amazing-medical-
procedures-20th-century
Mild
Hypothermia
Moderate
Hypothermia
• Confusion,
impaired
judgement, slurred
speech
• Tachycardia, ↑CO
• Tachypnea
• Cold diuresis
• ↑Hct, ↓platelet,
WBC,
↑coagulopathy
• Ileus, pancreatitis,
gastric stress
ulcers
• ↑ metabolic rate,
hyperglycemia
• Increased shivering
• Lethargy, loss of
pupillary reflex,
EEG abnormalities
• Progressive
bradycardia, ↓CO,
arrhythmias, J wave
on ECG
• Cold diuresis
• Altered GI drug
metabolism
• ↓metabolic rate,
hyper-or
hypoglycemia
• Decreased
shivering
Severe
Hypothermia
• Decline in EEG
activity, coma, loss
of ocular reflex
• ↓in BP and CO
• VF and systole
• Pulmonary edema,
apnea
• ↓renal perfusion,
oliguria, anuria
• Patient appears
dead, “pseudorigor mortis”
Kobeissi, Z., Zimmerman J. L. (2015).
Hypothermia. In J.B Hall, G.A Schmidt,
& J.P.Kress (Eds.), Principles of Critical
Care, 4e.
Hypothermia
Mechanism of Action of TH
• There are several hypothesis about the
neuroprotective effects of TH
• 1954- hypothermia could lower cerebral
oxygen consumption in dogs by ~ 7%
Abella, B. S., & Leary, M. ( 2015). Therapeutic hypothermia. In J. B. Hall , G. A. Schmidt, & J. P. Kress (Eds.). Principles
of critical care, (4e).
Reperfusion Injury
• Reperfusion injury occurs after restoration of
oxygen to the brain
• During reperfusion the immune system
releases proinflammatory mediators: TNF-,
interleukin-1, neutrophils, and macrophages
• Leads to cell death
• Therapeutic hypothermia can reduce
the quantities and effects of these
mediators
•
Lee, R. & Asare, K. (2010). Therapeutic hypothermia for out-of-hospital arrest. American Journal of Heath-System Pharmacy, 67,
MOA
• This process leads to:
• Accumulation of oxygen free radials
• Activation of degradative enzymes
• Cellular death
Therapeutic hypothermia helps to
prevent this cascade of reactions by
promoting cell membrane stability
during oxygen deprivation
Lee, R. & Asare, 2010; Scirica, B. M. (2013)
Mechanism of Action
Reperfusion Injury
• Reperfusion injury occurs after restoration of
oxygen to the brain
• During reperfusion the immune system
releases proinflammatory mediators: TNF-,
interleukin-1, neutrophils, and macrophages
• Leads to cell death
• Therapeutic hypothermia can reduce
the quantities and effects of these
mediators
Scirica, B. M. (2013). Therapeutic hypothermia after cardiac arrest. Circulation, 127, 24-250.
Let the cooling BEGIN….
Treatment Protocols
Goal: Achieving the target temperature 32-34 degrees C as
quickly as possible.
 Start cooling process ASAP.
 For every hour delay to onset of cooling, mortality
increased by 20%.
– Can be achieved within 3-4 hrs of initiaing cooling.
– Effective hypothermia treatment can be less than
24 hours if initiated rapidly after ROSC.
– With long duration of cardiac arrest and delayed
initiation of hypothermia, treatment for 48 hrs is
needed to achieve good neurological outcomes.
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Treatment Protocols
Preparation: Shivering, the body’s attempt at
maintaining temp homeostasis, is a concern when trying
to chieve a hypothermic state.
– Do not actively rewarm patients who are spontaneously
hypothermic
– Treatment can be continued while in PCI laboratory and ICU
– Place an arterial line early for BP monitoring
– Continuous core temp monitor should be used: Esophageal,
rectal or bladder temp
– Several cooling system including liquid or get heat transfer
and endovascular systems incorporate a temp probe
– A secondary temp device should be used to monitor temp as
well
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Treatment Protocols
Methods: Medication
– Patient comfort and sedation:
 Narcotic nalgesia-morphine or fentanyl
 Sedation-midazolam or propofol
– Paralysis to prevent shivering: Buspirone and
meperidine
– Train-of-four method
– Cold saline infusion
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Treatment Protocols
External cooling with cooling blanket or
suface heat ex-change device
– Eligibility should be confirmed, and materials should be
gathered
– Obtain 2 cooling blankets and cables
– Alternatively, place heat-exchange pads on the patient
– Pack the patient in ice (groin, axillae, side of neck)
– Monitor VS and oxygen saturation
– Once a temp below 34 degrees C is reached, remove
ice bags, and the cooling blanket or heat-exchange
device
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Treatment Protocols
Supportive therapy
– A mean arterial pressure (MAP) goal of more than 80
mmhg is preferred from a cerebral perfusion
standpoint.
– Placing the head of the bed at 30 degrees.
– Monitor the patient for arrhythmia associated with
hypothermia
– Hematolohic testing recommendation include:
 CBC, Chem 7, PTT, troponin, and ABG
– K+ values less than 3.5 mEq/L should be treated while
patient is being cooled.
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Treatment Protocols
• Supportive therapy (cont.)
– Elevated serum glucose is deleterious to the injured
brain.
– PCO2 should be maintained in the reference range (3545 mm Hg)
– Skin care should be checked every 2-6 hrs for thermal
injury caused by cold blankets.
– Regularly check the patient’s temp with a secondary
temp monitoring device when cooling.
– Do not provide nutrition to the patient during initiation,
maintenance, or rewarming phase of the therapy.
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Treatment Protocols
• Controlled rewarming
– Rewarming of the patient is begun 24 hrs after the
initiation of cooling.
– Rewarming phase may be the most critical, as
constricted peripheral vascular beds start to dilate.
– Peripheral hyperemia may cause hypotension.
– Literature recommends rewarming slowly at a temp
of 0.3-0.5 degrees C every hour.
– Rewarming will take approximately 8 hrs.
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Cooling Methods
Cooling methods include the following:
– Surface cooling with ice packs
– Suface cooling with blankets or surface heatexchange device and ice
– Surface cooling helmet
– Internal cooling methods using catheter-based
technoogies
– Internal cooling methods using infusion of cold
fluids.
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Cooling Methods
• Surface cooling with ice packs
– This method is inexpensive and represents an
appropriate way to initiate cooling.
– It can be messy and is less than optimal in the
rate of cooling and target tem maintaenance.
– In addition to ice packs, evaporate cooling
fans has been used.
Cooling Methods
• Suface cooling with blankets or surface heatexchange device and ice
– Conventional surface cooling balnkets are also
suboptimal because of poor surface contact with the
patient’s skin. However, a combination of watercirculating cooling device and ice packs
are effective at rapidly cooling patients
and are fair at maintaining target temp.
Cooling Methods
• Surface cooling helmet
– The soft bonnetlike helmet contained a solution of aqueous
glycerol that facilitated heat exchange.
Cooling Methods
• Internal cooling methods using catheterbased technoogies
– Two devices are currently available for use: Celsius Control
System and Cool Line System. These technologies are also
referred to as endovascular heat-exchange catheters. Heat
exchange occurs between cooled saline that passes through
the heat exchange portion of the catheter and the blood that
flows over the outer surface of the catheter.
Endovascular cooling and rewarming is
reported to be faster and better at
maintaining target temperature.
Cooling Methods
• Internal cooling methods using infusion of
cold fluids
– Many have studied the effect of cold fluid infusion for the
induction of mild-to-moderate hypothermia in humans.
– The rates of induction are variable but otherwise considered
to be rapid.
– Cold fluid infusion with concomitant use of cooling blankets
has also been shown to be efficacious.
– Typical infusion volume is either 30 mL/kg or 2 L of fluid
using either normal saline or lactated Ringer solution.
How to (BE) Cool?
Cooling Procedure
• Set up cooling monitors
 Monitor core temp: foley cath with temp probe or
rectal temp probe
• Cooling device
 Internal: Alsius cooling catheter-set rate for max
cooling, set target temp to 33 °C
 External: turn down room temp, ice packs to neck,
axilla, groin, torso, 2 cooling blankets-one above
and one below the patient, set to 4° C
Deckard, M. E., & Ebright, P. R. (2011, July). Therapeutic hypothermia after cardiac arrest: What, why, who, and how. American Nurse Today, 7, 2328. Retrieved from http://www.americannursetoday.com/therapeutic-hypothermia-after-cardiac-arrest-what-why-who-and-how/
How to (BE) Cool?
• Cold IV therapy
 30 ml/kg of cold LR or NS 0.9% over 30-60 mins
ASAP post arrest
• Will give 2.25 C temp reduction
• Medications
 For hypotension
• 500 cc NS 0.9% bolus q hr 3X doses for MAP below 70
• Norepinephrine drip, titrate to keep MAP above 80
• Dopamine drip, for MAP below 70, titrate to keep MAP
70-80 mmHg
 If need to increase CO
• Dobutamine drip, titrate to maximum rate of 10
mcq/kg/min
How to (BE) Cool?
• Medications (cont)
 For comfort
• Fentanyl IVP
• Fentanyl drip
• Morphine (monitor closely BP)
 Sedation
• Versed (use with caution in renal failure patient)
• Propofol Drip
 Shivering
• Demerol
• Nimbex – start at 3 mcq/kg/min, to maintain train of foru
(TOF) 2/4
Deckard, M. E., & Ebright, P. R. (2011, July). Therapeutic hypothermia after cardiac arrest: What, why, who, and how. American Nurse Today, 7, 2328. Retrieved from http://www.americannursetoday.com/therapeutic-hypothermia-after-cardiac-arrest-what-why-who-and-how/
Stages of Therapeutic Hypothermia
Three phases of therapeutic hypothermia
• Induction or initiation of cooling
 Refers to the rapid cooling of the patient by means of
either invasive or noninvasive techniques.
• Maintenance
 Refers to the period during which the patient is kept at
the target temperature of 32 to 34 degrees C.
• Rewarming or De-cooling
 Begin 18 to 24 hrs after the initiation of cooling. May be
passive or actively manage.
Erb, J.L., Hravnak, M., & Rittenberger, J., 2012. Therapeutic Hypothermia After Cardiac Arrest. American Journal of Nursing, 112 (7), 38-44
Induction Phase
• Obtained head CT
• Record an initial temperatures - rectal is the
best
• Central line, peripheral IV or an intravascular
cooling catheter
• Baseline labs: CBC and electrolytes
• Initiate sedation or paralytic medications
• Shivering- must give sedation first!!!
• Transfer appropriate critical care unit
Deckard, M. E., & Ebright, P. R. (2011, July). Therapeutic hypothermia after cardiac arrest: What, why, who, and how. American Nurse Today, 7, 2328. Retrieved from http://www.americannursetoday.com/therapeutic-hypothermia-after-cardiac-arrest-what-why-who-and-how/
Maintenance Phase
• During the maintenance phase, controlling the
patient’s temperature within the patient’s temp
the target range: 32-34 degrees C (core temp 33
degrees C)
• Monitor blood glucose: 100-150 mg/dl
• Monitor BP MAP: 65-95 mmHg
• This phase can last up to 18-24 hours
from the time the target temp is
reached (depending on facility protocol)
• Suppress shivering!!!
Deckard, M. E., & Ebright, P. R. (2011, July). Therapeutic hypothermia after cardiac arrest: What, why, who, and how. American Nurse Today, 7, 2328. Retrieved from http://www.americannursetoday.com/therapeutic-hypothermia-after-cardiac-arrest-what-why-who-and-how/
Rewarming Phase
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Rewarming begins 12 to 24 hours after the initiation of cooling.
Rewarm slowly at a rate of 0.3-0.5 degrees C every hour
Remove cooling blankets (and all ice )
One method is to set the water temperature in the cooling
device to 35°C, then increase the water temperature by 0.5°C
every 1-2 hours until a stable core body temperature of 36°C
has been reached for 1 hour
Maintain the paralytic agent and sedation until the patient’s
temperature reaches 35°C
Monitor the patient for hypotension secondary to vasodilation r/t
rewarming
D/C potassium infusion
Avoid hyperthermia
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from http://emedicine.medscape.com/article/812407-overview
Potential Adverse Effects
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Fluid and electrolytes imbalances
Arrhythmias
Insulin resistance
Shivering
Coagulation problems
Pain and sedation management
Deckard, M. E., & Ebright, P. R. (2011, July). Therapeutic hypothermia after cardiac arrest: What, why, who, and how. American Nurse Today, 7, 2328. Retrieved from http://www.americannursetoday.com/therapeutic-hypothermia-after-cardiac-arrest-what-why-who-and-how/
Summary
Conclusion
• Studies have shown that therapeutic hypothermia is
an effective method for improving neurologic
outcomes of patients after out-of-hospital cardiac
arrest after VF
• The AHA/ILCOR states unconscious adult patients
with spontaneous circulation after out-of-hospital
cardiac arrest should be cooled to 32°C to 34°C
for 12 to 24 hours when the initial rhythm was VF.
• Such cooling may also be beneficial for other rhythms
or in-hospital cardiac arrest
• Established guidelines can improve the quality of TH
and effective post-resuscitation care
QUESTIONS
QUESTIONS
1. Hourly monitoring of blood glucose is recommended in the
cooling phase because hypothermia leads to increased insulin
resistance and decreased pancreatic activity leading to:
a. Hyperglycemia
b. Hypoglycemia
c. Normal blood glucose level
d. Unchanged glucose level
2. How does therapeutic hypothermia work in cardiac arrest?
a. It reduces the brain tissue oxygen demand and slows
metabolism.
b. It increases intracellular acidosis and increase cerebral perfusion.
c. It increases the brain tissue oxygen demand and increases
metabolism.
QUESTIONS Cont.
3. What has been shown to increase the survival after cardiac arrest?
a. Immediate recognition and activation of emergency response system,
early CPR with emphasis on chest compression, rapid defibrillation,
effective advanced life support, integrated post-cardiac arrest care
including therapeutic hypothermia.
b. Therapeutic hypothermia, early CPR.
c. Early CPR with emphasis on chest compression, effective advanced
life support.
4. What clinical manifestation would you not see with moderate
hypothermia?
a. Decreased shivering
b. Loss of ocular reflex
c. Cold diuresis
d. Hallucinations
QUESTION Cont.
5. What is not an exclusion criterion for post-cardiac
arrest therapeutic hypothermia?
a. DNR
b. Uncontrollable bleeding
c. Glasgow Motor Score < 5
d. Significant trauma
e. 12 hours since return of spontaneous breathing
References
Abella B.S., Leary M (2015). Therapeutic Hypothermia. In Hall J.B., Schmidt G.A., Kress J.P. (Eds), Principles of Critical
Care, 4e. Retrieved from
http://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu/content.aspx?bookid=1340&Sectionid=80030178
Adler, J. (2014, April 30). Therapeutic Hypothermia. Medscape. Retrieved from
http://emedicine.medscape.com/article/812407-overview
Arrich J, Havel C, Holzer M, Herkner H. Prehospital versus in-hospital initiation of mild therapeutic hypothermia for
survival and neuroprotection after out-of-hospital cardiac arrest. Cochrane Database of Systematic Reviews 2013, Issue
6. Art. No.:
CD010570. DOI: 10.1002/14651858.CD010570.
AHA Statistical Update, 2013. Heart Disease and Stroke Statistics-2-13 Update, A Report From the American Heart
Association. Circulation, 1-240. doi: 10.1161/CIR.0B013E31828124AD
Deckard, M. E., & Ebright, P. R. (2011, July). Therapeutic hypothermia after cardiac arrest: What, why, who, and how.
American Nurse Today, 7, 23-28. Retrieved from http://www.americannursetoday.com/therapeutic-hypothermia-aftercardiac-arrest-what-why-who-and-how/
Delhaye, C., Mahmoudi, M. & Waksman, R. (2012). Hypothermia therapy: Neurological and cardiac benefits. Journal of
the American College of Cardiology, 59(3). doi:10.1016/j.jace.2011.06.077
Erb, J.L., Hravnak, M., & Rittenberger, J., 2012. Therapeutic Hypothermia After Cardiac Arrest. American Journal of
Nursing, 112 (7), 38-44
Field, J.M., Hazinski, M.F., Sayre, M.R., Chameides, L., Schexnayder, S.M., Hemphill, R., …Vanden Hoek., T.L., (2010).
Part 1: Executive Summary. American Heart Association Guidelines on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation, 652-656, doi: 10.1161/CIRCULATIONAHA.110.970889
References
Gardner,G., & MacDonald, S., 2013. Caring for Patients Receiving Therapeutic Hypothermia Post Cardiac Arrest
in the Intensive Care Unit. Canadian Journal Of Cardiovascular Nursing, 23(3), 15-17
Field, J.M., Hazinski, M.F., Sayre, M.R., Chameides, L., Schexnayder, S.M., Hemphill, R., …Vanden Hoek., T.L.,
(2010). Part 1: Executive Summary. American Heart Association Guidelines on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation, 652-656, doi: 10.1161/CIRCULATIONAHA.110.970889
Gardner,G., & MacDonald, S., 2013. Caring for Patients Receiving Therapeutic Hypothermia Post Cardiac Arrest
in the Intensive Care Unit. Canadian Journal Of Cardiovascular Nursing, 23(3), 15-17
Karnatovskaia, L.V., Wartenberg, K. E., & Freeman, W. D., (2014). Therapeutic Hypothermia for Neuroprotection.
Neurohospitalist, 4(3), 153-163. doi: 10.1177/1941874413519802
Kobeissi, Z., Zimmerman J. L. (2015). Hypothermia. In J.B Hall, G.A Schmidt, & J.P.Kress (Eds.), Principles of
Critical Care, 4e. Retrieved from
http://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu/content.aspx?bookid=1340&Sectionid=80030
178.
Lee, R. & Asare, K. (2010). Therapeutic hypothermia for out-of-hospital arrest. American Journal of HeathSystem Pharmacy, 67, 1229-1237. doi: 10.2146/ajhp090626
Scirica, B.M. (2015). Therapeutic Hypothermia After Cardiac Arrest. Circulation, 244-250. doi:
10.1161/CIRCULATIONAHA.111.076851
The Hypothermia after Cardiac Arrest Study Group (2002). Mild therapeutic hypothermia to improve the
neurologic outcome after cardiac arrest. New England Journal of Medicine, 346 (8), 549-556.
doi:10.1056/NEJMoa012689