Patient Label
ED Adult Therapeutic Hypothermia Order Set
Drug Allergies:
Ht. ________ Wt. _______Kg.
Living Will:
 Yes  No
Code Status:  Full Code
Limited Code to include:
Durable Healthcare Power of Attorney:  Yes  No
 Do Not Resuscitate (Tan Chart Required)
 CPR
 Intubation  Defibrillation  Cardiac Drugs
 Pacemaker
ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise
DATE/TIME indicated.
Noted by
Date/Time
Diagnosis:
Inclusion and exclusion criteria are to serve as a guide for decision-making.
Inclusion Criteria: (requires all four components)
1. Nontraumatic cardiac arrest with return of spontaneous circulation (ROSC)
2. Core Temperature greater than 34º Celsius (94º F) at presentation.
3. Time to initiation of hypothermia is less than 6 hours from ROSC
4. Comatose after ROSC: GCS less than 8 AND No purposeful movement to pain
Exclusion Criteria: (any one of the following)
1. Conflict with advanced directives DNR/DNI status
2. Uncontrolled Gastrointestinal Bleeding
3. Patient requiring Mannitol therapy
4. Cardiovascular instability as evidenced by: uncontrollable arrhythmias, refractory
hypotension (unable to achieve target MAP 65 mmHg despite interventions)
5. Sepsis as suspected cause of cardiac arrest
6. Suspected intracranial hemorrhage
7. Major intracranial, intrathoracic, or intraabdominal surgery within 14 days
8. Gravid pregnancy
Interventions:
 Infuse 2 liters 4° Celsius (39.2º F) of 0.9% Normal Saline IV over 30 minutes if not
already administered by EMS.
 Apply ice packs to axilla and groin to maintain hypothermic state
 No heated Humidification on the ventilator
 Insert temperature sensing foley to monitor core body temperature
 Insert Naso-Gastric Tube or Oral-Gastric Tube and connect to intermittent low wall
suction
 Arterial line placement, Hypothermia Catheter Placement and additional central
venous catheter or PA catheter as needed (To be placed by physician or surgeon on
call as soon as possible)
***** If Endovascular Cooling Catheter can not be obtained, the following cooling
techniques will be implemented: *****
Passive Convective Cooling – check appropriate boxes
 Expose patient, dampen skin, cooling fan
 Cooling blanket set to 33º Celsius (91º F)
 Reduce temperature in patient’s room, as appropriate
 Ice packs applied to axilla / skin
 Naso-Gastric lavage with ice cold 0.9% Normal Saline repeat as needed
*2PO*
*2PO*
Physician’s Signature
Form No. P9894 (03/09)
Medical Services
Page 1 of 2
Patient Label
ED Adult Therapeutic Hypothermia Order Set
ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise
Noted by
Date/Time
DATE/TIME indicated.
Labs:
Labs to be drawn NOW:






Complete Blood Count (CBC), PT/PTT, INR ABG’s (temp corrected)
Complete metabolic profile (CMP)
Creatine phosphokinase (CPK), Troponin I, Creatine Kinase Myocardial Bands (CK-MB)
Progressive Urinalysis
Lactate
HCG if child bearing age female
Diagnostic Testing:
 Portable Chest X-Ray
 12 Lead Electrocardiogram (EKG).
MEDICATION ORDERS:
Patient’s total body weight: ________ Kilograms
Sedation/Narcotics:
Administer the following medications prior to initiation of cooling:
Administer sedation prior to initiation of neuromuscular blocking agents
 1. Fentanyl ________ micrograms per hour intravenous continuous infusion (suggested
initial rate: 2 micrograms per kilogram per hour- not to exceed 150 micrograms in an hour)
 2. Fentanyl _________ micrograms intravenously PRN every 4 hours for agitation or
breakthrough pain (suggested: 25 – 50 micrograms)
 3. Propofol___________ micrograms per kilogram per minute continuous intravenous
infusion while receiving chemical paralysis (suggested initial rate: 5 micrograms per
kilogram per minute). Increase rate in 5 – 10 microgram per kilogram per minute
increments every 5 minutes until goal Ramsey Sedation Scale less than 3 achieved
 4. Vecuronium Bolus: 0.1 milligrams per kilogram intravenous bolus
Continuous Infusion: Start continuous infusion 20-40 minutes after initial bolus dose at 1
microgram per kilogram per minute
 5. Vecuronium 0.1 milligrams per kilogram intravenously every 1 hour as needed for
shivering
Vasopressors:
 6. Norepinephrine (Levophed) IV-start at 0.5 micrograms per minute and titrate as needed
to keep MAP greater than 65
 7. Other pressor agent: ______________________________________________
Vasodilators:
 8. Nitroglycerin IV-start if systolic blood pressure over ____________________
Start at 5 micrograms per minute and titrate until systolic blood pressure is less than
_____________
Physician’s Signature/Date/Time:
Form No. P9894 (03/09)
Medical Services
Page 2 of 2