SUMNER REGIONAL MEDICAL CENTER
DIAGNOSIS: ___________________________________
(Or Chief Complaint)
_______________________________________________
ALLERGIES: ___________________________________
_______________________________________________
PRESS FIRMLY - USE BALL POINT PEN ONLY - PRESS FIRMLY
DATE
PHYSICIAN'S ORDERS
INDUCED HYPOTHERMIA POST-CARDIAC ARREST ORDERS
FOR EMERGENCY DEPARTMENT AND CRITICAL CARE USE ONLY
INDICATIONS:
1) Ability to initiate protocol is within 6 hours since return of spontaneous circulation
2) Age of 18 years or older
3) Coma related to anoxic event
4) Status post cardiac/respiratory arrest with return of spontaneous circulation
5) Estimated time without CPR greater than 5 minutes but less than 30 minutes
EXCLUSION CRITERIA:
1) Awakes spontaneously with purposeful movement
2) Pregnant
3) Initial temperature less than 30 degrees C
4) Unstable BP less than 90/50 after fluid resuscitation and/or vasopressors.
5) Sepsis suspected
6) Terminal illness
7) Platelets less than 50,000 or active bleeding
8) Major head trauma
9) Major surgery within past 14 days
GOAL:
1) Facilitate cerebral resuscitation and minimize brain damage after a severely anoxic event
2) Cool patient to target temperature of 32-34 degrees C (90.0 – 93.2 degrees F).
3) Maintain induced hypothermia for 24 hours after target temperature is reached.
EMERGENCY DEPARTMENT / CCU ORDERS
(If patient is an in-house arrest, CCU will begin treatment at this point).
Check boxes where appropriate, mark through undesired orders.
INITIAL TREATMENT
□ Initial temperature obtained of ________
□ Clothing removed
□ Cold packs applied to axilla and groin
□ Intubated □ Primary IV line started
□ Secondary IV line started
Labs:
□ CBC □ Platelets, PT, PTT, INR □ BMP □ Troponin □ Cardiac Enzymes □ Magnesium
□ Phosphorous □ Calcium □ Other: _______________________________________________________
_______________________________________________________________________________________
Radiology:
□ Stat portable CXR
□ Other ________________________________________________________________________________
Respiratory:
□ ABG’s
Cardiac:
□ Stat 12 Lead EKG
Cooling Phase – Nursing Care ED or CCU (if in-house arrest)
TIME COOLING PHASE STARTED ______________
□ Connect rectal probe for continuous monitoring. Monitor and record rectal temperature every 15 minutes until
temperature of 32-34 degrees Celsius is obtained and then every 1 hours.
□ Insert foley catheter
□ Start 2nd IV line (if not already ) with IVF of 0.9% NS to run at KVO rate.
Intubated patients:
A) Shivering suppression before starting cooling:
□ Vecuronium 0.1 mg./kg IV loading dose then begin a continuous infusion of Vecuronium at
0.1mg/kg/hr.
□ Cisatracurium if renal failure is present. Start Cisatracurium at 3 mcg/kg/min and titrate up to 10
mcg/kg./min.
□ Initiate surface cooling by applying ice packs to back of neck, axilla and groin areas.
□ Set up for Arterial line insertion. Document BP, MAP, HR, SpO2 and cardiac rhythm hourly and prn.
□ If patient develops recurring arrhythmias, discontinue active cooling, begin re-warming and notify ERMD or
attending physician stat.
ADMISSION ORDERS – Nursing Care CCU
Admit to CCU:
□ Inpatient
□ Observation
□ Hospitalist
Admitting Physician Consult the following Physicians
□ Anesthesia for A-line placement and Central line Placement
□ Neurologist _________________________ □ Pulmonologist ________________________
□ Rectal probe for continuous temperature monitoring.
□ Obtain the cooling machine and apply one cooling blanket below the patient and one cooling blanket above the
patient directly in contact with the skin. Cover patient with sheet or thin blanket. Set and adjust cooling rate.
Maintain HOB at 30 degrees.
□ Supplement cooling with ice packs to back of neck, axilla and groin areas prn.
□ BP, MAP, HR, SPO2 and cardiac rhythm hourly and prn during cooling phase.
□ Monitor CVP every 2 hours.
□ Monitor rectal temperature every 15 minutes until core temperature of 32-34 degrees Celsius is achieved, then
monitor every 1 hour and prn. Do not cool to less than 32 degrees Celsius.
□ 0.9% Normal Saline IVF at ___________ml/hr.
Intubated patient – Sedation and Analgesia:
□ Use Ramsey scale for sedation. Goal for sedation _________.
□ Ativan (Lorazepam) at ________mg/hr (0.01 mg/kg/hr initially) continuous infusion, titrate to goal.
□ Propofol (Diprivan) at _________ mcg.min (5 mcg/kg./min initially) continuous infusion, titrate to goal.
□ Morphine ________mg every _______ hours IV prn as needed for analgesia
□ Meperidine (Demerol) _________mg every _________ . IV prn for shivering.
Vent settings: __________________________________________
□ No warm humidified air
□ ABG every 6 hours to monitor oxygenation and/or acid/base status. Goal PaCo2 = 35-45
□ Insert NG/ OG tube to low intermittent wall suction
□ Do not bathe or clothe patient during hypothermic or rewarming period.
□ May use rotation bed if appropriate.
Labs:
□ BMP, CBC, Renal profile, Mg, Phos, PT/PTT/INR every 4 hours until patient re-warming is completed.
Call critical values initially only and afterwards if not trending in correct direction, unless otherwise ordered.
Do not replace potassium unless it is less than 3 meq/L during cooling phase or within 6 hours of the re-warming
phase. Notify MD for specific replacement dose. Make sure that time to re-warm phase is communicated to MD.
□ Blood cultures x2, 12 hours after initiation of protocols. Date _____________ Time ______________
Daily during hypothermic protocols:
□ Portable CXR
□ ABG’s
□ 12-Lead EKG
RE-WARMING PHASE
□ Begin re-warming 24 hours after start of therapeutic hypothermia
Date to begin __________________ Time to begin _____________________
□ Notify RT that rewarming is to begin in order to re-establish ventilator humidification
□ Turn off cooling blanket and remove ice packs.
□ Initiate passive rewarming measures (warm blankets, gown, slipper socks, room temperature fluids)
□ If patient’s temperature fails to rise above 36 degrees Celsius (96.8 degrees F), within 10 hours of re-warming,
notify physician.
□ Monitor temp/ VS/ rhythm closely every 30 minutes until target temp is reached, then every 1 hour x 12
additional hours.
□ Do not permit hyperthermia in first 24 hours after cooling phase. If temperature becomes greater than 37
degrees Celsius (98.6 F) administer acetaminophen.
□ Continue labs as ordered, anticipate increase in potassium. Do not replace potassium unless it is less than 3
meq/L during cooling phase or within 6 hours of the re-warming phase.
□ Monitor I&O every hour. Anticipate hypovolemia.
□ To avoid thermal injury, hypotension or cardiac arrhythmias, DO NOT bathe patient or use a warming blanket
until patient’s temperature is greater than 36 degrees Celsius.
.
_______________________________, M.D
___________________________Date/Time
Form
DO NOT WRITE IN THIS SPACE.