Therapeutic Hypothermia Protocol
Hammersmith, Queen Charlotte’s and Charing Cross Hospitals
1. Introduction
Despite considerable investment in training, organisation, technology and the
continuing acquirement of knowledge, outcome from both out-of-hospital and inhospital resuscitation remains disappointing. A contributory factor is in part due to the
paucity of studies in relation to the acute post-resuscitation phase of management.
Evidence indicates (1,2, 3) that the use of mild therapeutic hypothermia will lead to
improved outcome and enhanced neurological recovery following initially successful
resuscitation from cardiac arrest. The following protocol aims to provide appropriate
guidance in order to achieve improvement in long-term outcome for patients recovering
from cardiac arrest.
Aim of the protocol
1.1. This protocol will cover the management of therapeutic hypothermia in patients
who remain obtunded following successful resuscitation from a cardiac arrest, with the
exceptions of those patients identified in section 5.
1.2. This protocol should be used in conjunction with the current Resuscitation Council
(UK) / European Resuscitation Council guidelines and existing resuscitation policy.
1.3. Methods of cooling vary from simple topical ice packs to invasive cooling devices
requiring intravascular access. No one method has been shown to be more
effective and the use of cooled intravenous fluids has be shown to be easy to
achieve, inexpensive and effective 4.
2. Definitions
2.1. For purposes of clarity we acknowledge the following definition; The Utstein
template for resuscitation registries defines cardiac arrest as “the cessation of
cardiac mechanical activity as confirmed by the absence of signs of circulation” 5.
2.2. The European Resuscitation Council define Mild therapeutic Hypothermia – as
cooling to attain a core body temperature of between 32º and 34º C 6.
1
Barnard et al, 2002.
Hypothermia After Cardiac Arrest Study Group, 2002.
3
Sunde, K et al, 2007.
4
Poldermann et al 2005.
5
Jacobs et al 2004.
6
European Resuscitation Council. 2005
2
3. Applicability
3.1. This protocol will apply to all patients successfully resuscitated from cardiac arrest
in Emergency Depts (CXH and HH), ICU, CCU, 5 South, B2 and Theatres, in
accordance with the inclusion criteria outlined in section 4.
3.2. This protocol covers the initial identification of appropriate patients, their
subsequent management and timing of the interventions.
4. Inclusion criteria
4.1. Patients who recover spontaneous circulation and have a Glasgow Coma Score of
<10 with no other likely cause of coma (eg. Trauma, intracranial event).
5. Exclusion criteria
5.1. Patients who have a return of spontaneous circulation and breathing and a GCS
>10 or who are responding to commands.
5.2. Patients that may be excluded as a consequence of decisions made in view of
relative contraindications (Section 6) to this treatment as decided upon by
Emergency Medicine / ICU Consultant.
6. Relative contraindications
6.1. Relative contraindication should be discussed with an Emergency Medicine or ICU
Consultant prior to any decision regarding commencement of therapeutic
hypothermia
 Terminal disease
 Coagulopathy
 Life threatening arrhythmias
 Severe cardiogenic shock
 Sepsis
 Pregnancy
7. Initial management
7.1. Initially, unless core temperature is <32º C. patients should not be warmed post
cardiac arrest. Active cooling should be commenced if the patient’s temperature is
>34º.
7.2. The patient should be sedated, intubated and mechanically ventilated as
necessary. Paralysis should be considered to prevent shivering.
7.3. Charing Cross Hospital and Hammersmith Hospital Emergency Dept; cooling
commenced by London Ambulance Service must be maintained in accordance
with this protocol (part of an integrated evaluation with London Ambulance
Service).
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7.4. Management should proceed in accordance with the Therapeutic Hypothermia
algorithm (Appendix 1).
8. Further management in ICU
8.1. Further management should take place in ICU where the management algorithm
(appendix 1) should be continued. The maximum time for cooling is 24hrs.
9. Safety
9.1. Continuous ECG monitoring is required as arrhythmias are common.
9.2. Ice packs should not be placed in direct contact with the patient’s skin.
9.3. Careful drying of the chest must be conducted prior to placement of defibrillator /
pacing pads.
9.4. Core temperature should be monitored (ideally continuously) by nasopharyngeal,
bladder or rectal temperature probes unless there is a pulmonary artery catheter
placed in the patient.
9.5. Coagulation should be monitored every 12 hrs.
10. Audit
10.1.Instigation of cooling in every therapeutic hypothermia patient should be recorded
on the resuscitation audit form (Appendix 2.)
10.2. Completion of the Therapeutic Hypothermia observation chart must be
maintained and completed and kept with the patient’s records. (Appendix 3.)
Bibliography
Behringer, W., Bernard, S., Holzer, M., Polderman, K., Tiainen, M. And Roine, R.
Prevention of postresuscitation neurologic dysfunction and injury by the use of therapeutic
mild hypothermia. (2007) In N. Paradis., H. Halperin., K. Kern., V. Wenzel and D.
Chamberlain (Eds. 2nd Edition) Cardiac Arrest: The Science and Practice of Resuscitation
Medicine (pp. 848 – 884). Cambridge: Cambridge University Press.
Bernard, S. A., Gray, T.W., Buist M. D., Jones, B. M., Silvester, W., Gutteridge, G., and
Smith, K. (2002). Treatment of comatose survivors of out-of –hospital cardiac arrest with
induced hypothermia. N Engl J Med. 346: 557-63.
Jacobs, I. and Nadkarni, V. (2004) Cardiac Arrest and Cardiopulmonary Resuscitation
Outcome Reports: Update and Simplification of the Utstein templates for Resuscitation
Registries. Circulation. 110. 3385-3397.
3
Polderman, K., Rijnsburger, E. R., Peederman, S. M., and Girbes, A.R.J. (2005). Induction
of hypothermia in patients with various types of neurologic injury with use of large volumes
of ice-cold intravenous fluid. Crit Care Med. 33. 2744-2751
Resuscitation Council (UK) Resuscitation Guidelines 2005. pp.56-57
Sunde, K., Pytte, M., Jacobsen, D., Mangschau, A., Jensen, L. P., Smedsrud, C., Draegni,
T., and Steen, P. (2007) Implementation of a standardised treatment protocol for post
resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 73. 29-39.
The Hypothermia after Cardiac Arrest Study Group. (2002). Mild therapeutic hypothermia
to improve neurologic outcome after cardiac arrest. N Engl J Med. 346. 549-556.
Penn Medicine Hypothermia protocols;
http://www.med.upenn.edu/resuscitation/hypothermia/protocols.shtml [Accessed
12/11/2007).
Acknowledgements
Grateful thanks to staff at UCLH and St Mary’s ICU for sharing their Therapeutic
Hypothermia Protocol.
Therapeutic Hypothermia Protocol Team
Ken Spearpoint, Consultant Nurse, Resuscitation
Dr Stephen Brett, Consultant, ICU
Dr Glyn Barnett, Consultant in Emergency Medicine
Dr David Zideman, Consultant Aneasthetist
Miss Fionna Moore, Consultant in Emergency Medicine, Medical Director London
Ambulance Service.
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Appendix 1.
Hammersmith, Charing Cross and Queen Charlotte’s Hospitals Therapeutic
Hypothermia Algorithm
[Emergency Dept., General ICU, A6-CCU, 5 South and B2]
Inclusion Criteria
Not suitable
RoSC and GCS <10
post Cardiac Arrest
Patient intubated and ventilated.
NO
Decision
YES






TRAUMA / HAEMORRHAGE / SHOCK ?
PREGNANCY ?
COAGULOPATHY?
SEPSIS ?
POOR FUNCTIONAL STATUS?
TERMINAL DISEASE?
NO
Decision
Temp <32
remove cooling packs
allow patient to passively re-warm
to 32 - 34oC
Consider administration of iced saline IVI
at 4oC 40ml / Kg over 1 hour

Apply cooling packs to axillae, groins,
head, neck.

Aim to reach core temp of 34o - 32o C
within 4 hours

Nurse head up at 30 o

Measure bladder / tympanic / oesophageal
temperatures

PaO2 > 11KPa: PaCO2 4.5 - 5.0 Kpa

Systolic BP >90mmHg

Blood glucose 4.4 - 7 mmol/l

Avoid tight ties for tracheal tubes

Patient shivering - consider paralysing
YES
RELATIVE EXCLUSION CRITERIA
Discuss with
Emergency Medicine /
ICU Consultant

Commence cooling
Temp 32 - 34oC
Temp > 34oC
continue surface cooling
maintain temp for 24 hours
consider infusion of cooled fluids
under oesophageal doppler
guidance
After 24 hours
Consider re-warming if there is:
stop cooling, allow patient to
passively re-warm (0.5 - 1oC / hr)
stop paralysis / sedation when temp
> 36 oC
1. development of significant arrhythmias (uncontrolled
AF, VF or VT)
2. Coagulopathy or bleeding
3. cardiovascular instability
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Appendix 2. Resuscitation Audit Form
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Appendix 3.
Therpeutic hypothermia observation chart
Name of Patient:
Time
No of hours
Temperature
Hospital Number:
Action Taken
(eg ice packs
changed, fluid
bolus given,
muscle
Bloods
relaxants
to be
started)
taken
Taken?
cooling + 1
cooling + 2
cooling + 3
cooling + 4
Position/Number of gel
pads (tick)
axillae R  L, Groin R  L

Neck , Back , Abdomen

Other -
cooling + 5
cooling + 6
cooling + 7
cooling + 8
cooling + 9
cooling + 10
cooling + 11
cooling + 13
axillae R  L, Groin R  L

Neck , Back , Abdomen

cooling + 14
Other -
cooling + 12
Clotting
cooling + 15
cooling + 16
cooling + 17
cooling + 18
cooling + 19
cooling + 20
cooling + 21
cooling + 22
cooling + 23
cooling + 24
Rewarm
Rewarm
Rewarm
Rewarm
Rewarm
Rewarm
Rewarm
Rewarm
+1
+2
+3
+4
+5
+6
+7
+8
Clotting
axillae R  L, Groin R  L

Neck , Back , Abdomen

Other -
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