Addressograph
La Crosse, WI 54601
EPIC ORDER # 1531
ADULT TEC POST CARDIAC ARREST
HYPOTHERMIA ORDER
Instructions for use: Check the box in front of each applicable order and sign at the bottom of the order set. If a
default order (box is checked) does not apply, draw a single line through the order and initial. Blank spaces
within orders must be completed.
Nursing Interventions
 Place/maintain Nasogastric tube, STAT, one time – today.
Suction setting:  no suction  low  medium  high
Type of suction:  no suction  intermittent  continuous
Do not use this order for Nasojejunal feeding tube placement, see orderset 232. Consider placing NG
under fluoroscopy for patient with history of gastric surgery.
 Place/maintain Foley catheter with temperature probe, STAT, one time – today. Nursing to select latex
free product if patient has latex allergy.
 Place/maintain Peripheral IV catheter, STAT, one time – today.
Labs
Blood Gases
 Blood Gas – Arterial, STAT, one time – today. Lab collect.
 Calcium – Ionized, STAT, one time – today. Lab collect.
Chemistry
 AST, STAT, one time – today. Lab collect.
 Lipase, STAT, one time – today. Lab collect.
 Lactate, STAT, one time – today. Lab collect.
 HCG – serum, (Pregnancy test), STAT, one time – today. Lab collect.
 Electrolytes, STAT, one time – today. Lab collect.
 Phosphorus, STAT, one time – today. Lab collect.
 Magnesium, STAT, one time – today. Lab collect.
 BUN, STAT, one time – today. Lab collect.
 Glucose, STAT, one time – today. Lab collect.
 Creatinine, STAT, one time – today. Lab collect.
 Troponin T, STAT, one time – today. Lab collect.
 ALT, STAT, one time – today. Lab collect.
 LDH, STAT, one time – today. Lab collect.
Coagulation
 INR, STAT, one time – today. Lab collect.
 PTT, STAT, one time – today. Lab collect.
Hematology
 CBC, STAT, one time – today. Lab collect.
Imaging
 Chest x-ray PA or AP, STAT, one time imaging.
Reason for exam: _______________________________________________________
Is the patient pregnant:  Yes  No  Uncertain
Bedside:  Yes  No
Weight bearing restrictions:  non-weight bearing  partial weight bearing  full weight bearing
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Addressograph
La Crosse, WI 54601
EPIC ORDER # 1531
ADULT TEC POST CARDIAC ARREST
HYPOTHERMIA ORDER
Diagnostics
 EKG, 12 – lead, STAT, one time – today.
Reason for EKG: ___Post Cardiac Arrest_______________________________________
IV Fluids
 sodium chloride 0.9% **CHILLED** bolus infusion. 2,000 mL, IV, infused over 30 minutes, times one
dose. **Chilled saline is stored in Pyxis refrigerator** Fluid cooled to four degrees centigrade. Infuse 2
liters (2,000 mL) over 30 minutes. Follow fluid bolus with normal temperature Normal Saline at 125 mL
per hr.
 sodium chloride 0.9 % IV infusion. 125 mL per hour, IV, continuous. Start after fluid bolus given.
Medications
NO BENZODIAZEPINES
 aspirin suppository, 300 mg, rectal, STAT, times one dose. For rectal use only.
 fentanyl (SUBLIMAZE) 50 mcg bolus every 30 minutes as needed for sedation while in TEC. Look
alike/sound alike drug, use with care.
 propofol (DIPRIVAN): ** Patient must be on ventilator** Titrate in increments of 5 – 10 mcg/kg/min
every 3 – 5 minutes until adequate sedation is achieved. If hemodynamically stable, may bolus from
bottle 10 – 20 mg every 3 – 5 minutes for no more than three doses per agitated episode. If greater
than three doses are necessary, contact physician for additional sedation orders. (Note: infusion
greater than 50 mcg/kg/min must be approved by Pulmonary). Maximum rate of infusion: __________
50 mcg/kg/min (absolute maximum 80 mcg/kg/min)
 acetaminophen (TYLENOL) 650 mg solution, STAT, per nasogastric tube, times one dose.
 busPIRone (BUSPAR) 30 mg tablet, STAT, per nasogastric, times one dose. Do not give to patients
who are also taking a monoamine oxidase inhibitor or who have an allergy to buspirone.
 cisatracurium (NIMBEX) 0.1 mg/kg, times one dose as needed for shivering (must be on ventilator.)
 No benzodiazepines should be ordered, routine, one time – today.
Consults
 Consult to Cardiology, STAT, one time – today.
Reason for Consult: ___Post Cardiac Arrest______________________________________
Signature: _______________________________________ Pager: _______ Date: _______ Time: _______
July 2011
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