Download North Hawaii Community Hospital, Hypothermia Protocol

THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST
INDICATION: Unconscious adult patients with return of spontaneous circulation (ROSC) after cardiac arrest.
GOAL:
1.
2.
Cool to 32°- 34° Celsius (89.6°- 93.2° Fahrenheit) within 4 hours of ROSC
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.
1
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 <70 after NS bolus completed begin Norepinephrine Infusion (4mg/250 ml) at 2 mcg/min,
titrate to maintain MAP 70 – 90 mmHg.

For MAP greater than 100 mmHg:
 Labetalol 10 mg IV q 4 hours for MAP > 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
2
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%




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.
LABS:
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 rewarming.
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
________________________________________________________________________________________________
3