Allergies:
Date:
Time:
Height (cm):____________Weight (kg):____________
Relative INCLUSION Criteria:
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Non Traumatic Cardiac Arrest with Return of Spontaneous Circulation (ROSC)
Core Temperature > 33° C at presentation
Time to initiation of therapeutic hypothermia is less than 6 hours
Comatose after ROSC: GCS less than 8, AND no purposeful response to pain
Relative EXCLUSION Criteria:
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Conflict with Advanced medical Directive or DNR status
Uncontrolled Bleeding (Absolute Exclusion)
Cardiovascular instability as evidenced by uncontrollable arrhythmias
Refractory hypotension (unable to achieve MAP of 60 mmHg despite interventions)
Sepsis or other (as suspected cause of cardiac arrest)
Suspected intracranial hemorrhage
Major intracranial, intrathoracic, or intrabdominal surgery in past 14 days
IVC filters (placement of intravascular cooling catheter should be IJ or subclavian NOT femoral if patient has an IVC filter)

Initiation of Therapeutic Hypothermia Protocol
GOAL: achieve core temperature to 32°-34°C within 60 minutes of initiation of cooling and within 6 hours of onset of arrest
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If core temperature > 33°C at initiation of protocol, bolus with cold (4°C/39°F) 0.9%NS (available in ED/cath lab) @ 30ml/kg over 3060 minutes with a maximum of 2 liters (Cold saline is NOT to be given via jugular or subclavian line; a peripheral or femoral line must
be used); omit if already given in ED.
Set target temperature on intravascular cooling system (Alsius) to 33°C with rate at “max” (default) for 24 hours
If unable to initiate intravascular cooling, initiate external cooling by applying cooling blanket* and/or vest to patient’s head, torso, and
limbs, set target temperature to 33° C for 24 hours, and observe skin every 2 hours for breakdown
* In cath lab/ED, may utilize ice packs (neck, axilla, and groin) to achieve initial cooling if blanket unavailable
Insert temperature sensing device (foley [preferred], rectal,) for secondary temperature source
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DATE / TIME Initiated:_________________________ / @_____________ Signature:________________________________________
DATE / TIME Goal Reached**:____________________ / @____________ Signature:________________________________________
** COOL x 24 hours once target temperature is reached **
IF patient has recurring arrhythmias call MD STAT (may need to discontinue cooling and begin re-warming)
IF unable to achieve target core temperature within 2 hours consult MD for further orders
Initiation of Hypothermia Protocol Below
(Additional Hypothermia Protocol Orders pages 2-4)
T.O. / READ BACK
NURSE NOTED
DATE
TIME
12 HR. CHART CHECK BY NURSE
DATE
TIME
DATE/TIME
PHYSICIAN SIGNATURE
OR AUTHENTICATION
FAXED
Initial
Time

ORDERS will be initiated automatically
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Vital Signs
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BP, MAP, HR, O2 Saturation, Temperature, and Cardiac Rhythm every 15minutes x 4, every 30 minutes x 4 then hourly and PRN
Record core temperature source (foley or rectal) every 15 minutes until core target temperature (32°-34°C) is achieved, then every 30
minutes until re-warming completed.
DO NOT COOL TO LESS THAN 32° C
 IV** Solution:_____________________________________@________________________ml/hour
Solution:_____________________________________@________________________ml/hour
**All IV solutions during cooling and re-warming phase should be dextrose free if possible
 BP & Volume Management
Observe closely for fluid/volume overload
MAP Goal:_______________
(Recommendation for MAP>80 if tolerated/not contraindicated)
CVP Goal:_______________
Additional IV volume / support:__________________________________________________________________________________
 Analgesia & Sedation
Analgesia:____________________________________________________________________________________________________
Goal for Analgesia: _______________( ≤ 3) on 1-10 scale, or minimal pain behaviors
Sedation: Please see 48 Hour Sedation Orders (use of Propofol in conjunction with Benzodiazepine agent recommended)
 Neuromuscular Blocking Agent (NMBA)
AVOID if possible NMBA for prevention of shivering and ability to achieve core target temperature, if NMBA necessary
recommend IVP Bolus at induction of therapeutic hypothermia, not a continuous infusion; attempt shivering management with sedation
Obtain baseline “train of four” (TOF) prior to initiation of NMBA, then every hour if continuous infusion
Lacrilube to both eyes every 4 hours and PRN dryness while on NMBA
Nimbex initial bolus @ 0.1mg/kg, if unable to reach target temperature within 60--90 minutes due to shivering or RATE of cooling
inadequate to reach target temperature within 120 minutes
 Nimbex infusion start at 3mcg/kg/min IF INITIAL BOLUS INEFFECTIVE or if CONTINUES TO SHIVER
Alternate NMBA:________________________________________________________________________________________________
Adjust NMBA to achieve TOF 1-2/4; if unable to obtain TOF titrate NMBA to prevent shivering
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Before starting NMBA, verify that the patient is adequately medicated with analgesia and sedative agents at goal, and
receiving mechanical ventilation.
 Ventilator Management
Vent Settings: (NO Humidified Air)_____________________________________________
ABGs drawn during cooling and re-warming must be adjusted for temperature
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VAP Protocol
Additional Orders:___________________________________________________________
 Stress Ulcer Prophylaxis
Medication:______________________________________________________________
 DVT Prophylaxis
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Standard ICU procedure for SCDs (unless contraindicated)
Medication:______________________________________________________________
 Glucose Management (check one)
 Standard IV Insulin Protocol (recommended)
OR
 Blood Sugar every 4 hours with standard sliding scale insulin
Additional Orders:_________________________________________________________
 STAT Initial Labs, if not already done in ED/Cath Lab

CBC with diff, BMP, PT/INR, ACT, Calcium, Magnesium, Phosphorus, Troponin, UA, Lactate, Urine HCG (childbearing women),
Blood Cultures x 2, ABG (RT to adjust for temperature), EKG
Additional Labs:___________________________________________________________ [ ACT GOAL = 150-210]
 Routine Labs Every 4 hours until re-warming phase completed
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CBC with diff, BMP, PT/INR, ACT, Calcium, Magnesium, Phosphorus
Additional Labs:___________________________________________________________ [ACT GOAL = 150-210]
 Labs 12 hours after initiation of protocol
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Blood Cultures x 2
Additional Labs:___________________________________________________________
 Daily Labs / Diagnostics
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CBC, BMP
CXR and ABG (RT to adjust for temperature) while on ventilator
Additional Labs / Diagnostics:________________________________________________
 Additional Labs /Diagnostics:______________________________________________
 Electrolyte Replacement
Do NOT replace potassium unless it is less than 3mEq/L during
cooling phase. CALL MD for specific replacement dose
Do NOT use pre-existing electrolyte replacement orders
STOP potassium replacement @ re-warming phase (K+ shifts out
of cells and in to serum)
 General Nursing
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NG tube to low continuous suction
Monitor invasive lines
Hourly I&O, call MD if UOP is less than 0.5ml/kg/hour
Document shivering hourly, using Bedside Shivering
Assessment Scale (BSAS):
0 – None: No Shivering
1 – Mild: Shivering localized to head/thorax; may only
be seen by artifact on ECG or with palpation
2 – Moderate: Intermittent involvement of upper
extremities +/- thorax
3 – Severe: Generalized shivering or sustained upper/
lower extremity shivering
Notify MD if uncontrolled shivering occurs
 Re-Warming Phase
Target Temperature 36°C
Do NOT bathe patient during cooling OR
re-warming phase
Target temperature to be obtained in 12 hours
STOP re-warming once 36°C reached to prevent overshoot
Watch for cardiac arrhythmias – Notify MD if frequently
occurring
 Re-Warming Phase
DATE / TIME Started:_________________________ / @_________________________ / Signature:_________________________
DATE / TIME Completed:______________________ / @_________________________ / Signature:__________________________
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Empty foley catheter at start of re-warming
Strict hourly I&O (anticipate increase UOP / hypovolemia)
Activate re-warming (program intravascular cooling device for 0.25°C/hour and 36°C).
If external cooling devices used, remove them at this time
Monitor VS, including temperature, cardiac rhythm every 30 minutes until target temperature reached, every 1 hour x 12, then
Routinely
Continue sedation until temperature is equal to or greater than 36°C (highest incidence of seizure with re-warming)
Once target re-warming temperature (36°C) reached turn off NMBA
Once effects of NMBA worn off, begin weaning sedation as tolerated
Do Not permit hyperthermia in first 24 hours after cooling phase
Continue labs as ordered (anticipate increase in potassium)
Maintain lines for 24 hours after re-warming completed to maintain temperature of 36 to 37°C (If temperature greater than
37°C NOTIFY MD); then consult MD regarding removal of invasive lines
T.O. / READ BACK
NURSE NOTED
DATE
TIME
12 HR. CHART CHECK BY NURSE
DATE
TIME
DATE/TIME
PHYSICIAN SIGNATURE
OR AUTHENTICATION
FAXED
Initial
Time