Name:

EHC ED Critical Care

Induced Hypothermia Protocol

Date:

MRN:

Place Sticker

Time of Screening:

Inclusion Criteria (Must have All)

Exclusion Criteria

Post Cardiac Arrest (Any rhythm as cause of arrest is eligible)

ROSC < 30 min from EMS/Code Team Arrival
Time now <6 hrs from ROSC
Comatose (Does not follow commands)
MAP > 65 on no more than one vasopressor

Pt has DNR, MOLST, poor baseline status, or terminal disease

Active or Intracranial Bleeding
Traumatic etiology for arrest
Cryoglobulinemia
Pregnancy (Relative-Consider OB/Gyn consult)
Recent Major Surgery (Relative)
Sepsis as cause of Arrest (Relative)

Neurologic Exam
Eye Opening

Spontaneous---------* 4
Voice------------------ 3
Pain------------------- 2
None------------------ 1

Verbal

Motor

Oriented--------------* 5 Obeys-----------------* 6
Confused-------------* 4 Localizes------------- 5
Inappropriate-------- 3 Withdraws----------- 4
Sounds---------------- 2 Decorticate----------- 3
None------------------ 1 Decerebrate---------- 2
Intubated------------- 1 None------------------ 1
DTRs:
Bicep L
R
Knee L
R
List any Sedatives or Paralytics On-Board at time of Exam:

Brainstem

Pupils React
Corneal
Spontaneous
Respirations
Dolls Eyes
Toes

yes no
yes no
yes no
yes no
R

If any Starred (*) Item is checked off on the neuro exam, the patient is ineligible for the protocol.

Protocol

Discuss Case with ICU Fellow or Attending (They must agree with the plan for hypothermia)
Time of Discussion: :
If pt is deemed ineligible by ICU, list reason:
List Initial Arrest Rhythm:
List Number of Minutes from Start of CPR to ROSC:
Send blood for: CMP, LFTs, Superstat I, Lactate, CBC, PT/PTT, CK/MB/Troponin, Lipase/Amylase
Place foley catheter and monitor urine output.
Completely expose patient and place cooling blanket above and below with nothing between blanket & skin.
Place temp probe in mid-esophagus (~4 cm above xiphoid via oral/nasal); if unable to place in esophagus, probe can be placed rectally (5 cm)
Hook both cooling blankets and the probe to the same blanketrol machine.
Set temperature to 33 C and Set the machine to Auto Control.
:
List time Now:

List Initial Patient Temperature:
C
If initial temperature is < 33 C, allow patient to warm to 33 C.
Begin opioids & sedation. Titrate to Ramsay Score 4/5.
Infuse refrigerated crystalloid, preferably through large bore, peripheral IV.
Administer at ~100 ml per minute using pressure bag (evacuate air first). Maximum initial infusion is 30 cc/kg;
if patient not < 34 C after this amount, wait 15 minutes before giving further 250 cc boluses Q 10 minutes.
Administer Tylenol 650 mg GT Q 6 hours unless pt has allergy.
If during induction, pt has shivering unrelieved by the above meds, Vecuronium 0.1 mg/kg x1 can be used
:
Total Cold Crystalloid Infused:

Time that Pt reaches 34 C:
If patients temperature rises above 34.5 C, infuse 250 cc boluses of cold crystalloid Q 10 min until <34 C.
Assess for shivering Q 15 minutes. If any signs of shivering, see the protocol on page 4.
Maintain temperature 32-34 C for 24 hours (ideal temperature is 33 C).
If significant bleeding or severe hemodynamic instability, consider rewarming. See ehced.org for protocol.
:
Time of Rewarming:
Reason Necessary:
Maintain MAP>80: Pressors and/or Dobutamine may be used during protocol, if fluid loading ineffective.

1/5/09

Scan this worksheet when pts bed is ready and Give Original to ICU Resident

EHC ED Critical Care

Post-ROSC Care Package

Induction of Hypothermia
See First Page

Procedures

Full sterile neck line with CVP monitoring

Full sterile femoral arterial line (Axillary if femoral contraindicated/unsuccessful)
Foley Catheter with hourly urine monitoring
Orogastric Tube on suction

Ventilation

Place patient on AC Mode

Set Vt to 8 ml/kg IBW (see last page)
Set IFR to 60 lpm
Set Initial rate to 18 bpm
Set Initial O2 to 50%
Titrate FiO2/PEEP to achieve corrected ABG Saturation 94-96%.
Often pulse ox will not read well due to peripheral vasoconstriction
Send an ABG, DO NOT INDICATE THE PATIENTS TEMPERATURE ON THE ABG ORDER

Hemodynamic Goals
Ensure Adequate Preload
Assess by passive leg raise, pulse pressure variation, and echo. CVP may provide some indication if very low. Use
normal saline or lactated ringers boluses. Use room temperature fluid if patient at goal temperature. Replace
patients urine losses 1:1
MAP > 65 at all times, MAP > 80 is preferred to augment cerebral perfusion
Preferred initial pressor is norepinephrine, may add vasopressin if necessary
If MAP is < 80 and CVP > 10 perform passive straight leg raise to assess fluid responsiveness.
If MAP > 100, start nitroglycerin infusion
Corrected ScvO2 > 70
Can be measured by PreSEP catheter or central venous O2 saturation (send blood gas as mixed venous)
If ScvO2 < 70 and HB < 7 (some would advocate <10 as trigger), transfuse patient
If HB > 7, evaluate echocardiogram and consider inotropes vs. balloon pump/revascularization
Lactate
Hypothermia will raise lactate levels and post-arrest patients will have high lactate. Send a baseline level after
the patient achieves goal temperature. From this point on, the lactate should stay the same or drop. If lactate is
increasing, the patient is under-resuscitated or seizing

Sedation

To gain the full benefits of hypothermia, it is imperative that the patient is adequately sedated
Optimize fentanyl infusion rate first
Add on propofol or dexmedetomidine if necessary
Titrate to Ramsay Score of 4/5 (see last page)

EHC ED Critical Care

Post-ROSC Care Package

Labs & Electrolytes

Send Superstat I (ABG with Electrolytes) and Lactate Q 1 hour for first 4 hours, then Q 4 hours
On arrival, send CMP, CBC, Lytes, PT/PTT, Lipase, Cardiac Enzymes, Type and Hold, & Pan-Cultures
Send CMP (complete metabolic panel) and CBC Q 4 hours
Send Cardiac Enzymes Q 6 hours
Keep Magnesium at high-normal at all times with aggressive IV repletion
Replete Potassium if < 3.4 with IV KCl
Keep iCal at high normal at all times
Keep Sodium at least 140 at all times, 150 is preferable
Keep Glucose < 150 with Insulin Drip (preferred) or Subcutaneous Regular Insulin

Cardiac Testing
Get EKG immediately upon arrival; at the start of hypothermia induction; and Q 1 hour for the first 4 hours
If possible, get a bedside transthoracic echo at the start of induction. In the ED, this should be performed by the
emergency physician or cardiology. Look specifically for qualitative LV function, RV function, pericardial effusion/
tamponade, & gross valve function

DVT Prophylaxis
If no contraindication, Heparin 5000 units subcutaneous Q 8 hours

Stress Ulcer Prophylaxis

Nexium 40 mg IVSS x 1

VAP Prophylaxis
Head of bed to 30
Place in-line closed suction and perform aggressive pulmonary toilet

Additional Testing
Consider Head CT if possible neurologic cause to arrest. Note: even an intracranial bleed is not a contra-indication to
continuation of induced hypothermia. Consider letting the patient drift to 34C and administration of dDAVP.
Consider CTA if strong suspicion of PE as the cause of arrest. Bedside dopplers by EP or sono technician may be a
good first step
EEG if seizures (convulsive or non-convulsive) are suspected

Revascularization for STEMI

PCI is preferred, consult with CPORT fellow/attending and CCU fellow. Hypothermia does not need to be
discontinued for PCI
If PCI is not available or will be delayed, thrombolysis should be administered. Thrombolysis can be given during
hypothermia. CPR performed prior to ROSC should not stop reperfusion therapy. Use standard doses of Retevase.
Consult with CPORT fellow/attending.

This package outlines suggestions for the care of the Post-Arrest patient. It does not set a standard of care and individual patient circumstances should always be taken
into account when making treatment decisions.

EHC ED Critical Care

Post-ROSC Care Package

Ramsay Sedation Scale

1
2
3
4
5
6

Patient is anxious and agitated or restless, or both

Patient is co-operative, oriented, and tranquil
Patient responds to commands only
Patient exhibits brisk response to light glabellar tap or loud auditory stimulus
Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus
Patient exhibits no response

EHC ED Critical Care

Induced Hypothermia Shivering Protocol

Shivering Protocol After Induction

Bedside Shivering Assessment (BSAS) (Neurocrit Care 2007;6:213)

0-None, no shivering. Must not have shivering on EKG or palpation.
1-Mild-localized to neck/thorax. May only be noticed on palpation or EKG.
2-Moderate-intermittent involvement of upper extremities +/- thorax
3-Severe-generalized shivering or sustaine dupper extremity shivering
All patients receive:
Acetaminophen 650 mg GT Q 6 hours unless allergic
If BSAS > 1, add Fentanyl Drip (titrate as per EHCED drip sheet)
If BSAS still > 1, add Propofol Drip (titrate as per EHCED drip sheet)
If BSAS still > 1, administer MgSO4 2 grams IVSS, then 0.5-1 gram/hr for target serum Mg 3 mg/dl
If BSAS still > 1, add Bair Hugger Device on both of patients arms
If BSAS still > 1, administer Ketamine 0.5 mg/kg IVP
If BSAS still > 1 after titration of above meds, add Nimbex 0.15 mg/kg IV Q 1 hour PRN
Paralysis should only be necessary under extraordinary circumstances!

EHC ED Critical Care

ARDSNet Vent Protocol

ARDSNet

_____________________________________________________________
OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 88-95%
Use incremental FiO 2/PEEP combinations below to achieve goal
FiO2
PEEP

NIH NHLBI ARDS Clinical Network

Mechanical Vent ilation Protocol Summary
www.ardsnet.org
INCLUSION CRITERIA: Acute onset of
1. PaO2/FiO 2 300 (corrected for altitude)
2. Bilateral (patchy, diffuse, or homogeneous) infiltrates
consistent with pulmonary edema
3. No clinical evidence of left atrial hypertension
PART I: VENTILATOR SETUP AND ADJUSTMENT
1. Calculate predicted body weight (PBW)
Males = 50 + 2.3 [height (inches) - 60]
Females = 45.5 + 2.3 [height (inches) -60]
2. Select Assist Control Mode
3. Set initial TV to 8 ml/kg PBW
4. Reduce TV by 1 ml/kg at intervals 2 hours until TV = 6ml/kg PBW.
5. Set initial rate to approximate baseline VE (not > 35 bpm).
6. Adjust TV and RR to achieve pH and plateau pressure goals below.
7. Set inspiratory flow rate above patient demand (usually > 80L/min)

0.3
5

0.4
5

0.4
8

0.5
8

0.5
10

0.6
10

0.7
10

0.7
12

FiO2
0.7
0.8
0.9
0.9
0.9
1.0
1.0
1.0
PEEP
14
14
14
16
18
20
22
24
_____________________________________________________________
PLATEAU PRESSURE GOAL: 30 cm H2O
Check Pplat (0.5 second inspiratory pause), SpO2, Total RR, TV and pH (if
available) at least q 4h and after each change in PEEP or TV.
If Pplat > 30 cm H2O: decrease TV by 1 ml/kg steps (minimum = 4
ml/kg).
If Pplat < 25 cm H2O: TV < 6 ml/kg, increase TV by 1 ml/kg until Pplat
> 25 cm H2O or TV = 6 ml/kg.
If Pplat < 30 and breath stacking occurs: may increase TV in 1 ml/kg
increments (maximum = 8 ml/kg).
_____________________________________________________________
pH GOAL: 7.30-7.45
Acidosis Management: (pH < 7.30)
If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25
(Maximum RR = 35).
If RR = 35 and PaCO2 < 25, may give NaHCO3.
If pH < 7.15: Increase RR to 35.
If pH remains < 7.15 and NaHCO 3 considered or infused, TV may be
increased in 1 ml/kg steps until pH > 7.15 (Pplat target may be
exceeded).
Alkalosis Management: (pH > 7.45) Decrease vent rate if possible.