Therapeutic Hypothermia Part 2 Union Hospital, Inc. Emergency Department
UHTH ER Policy • Patient must satisfy all of the inclusion criteria and have no exclusion criteria prior to the initiation of cooling. • Once criteria decision met, Notify House Supervisor, Bed Control and ICU Charge Nurse of TH patient. Confirm ICU bed assignment. • Initiate Induction Therapeutic Hypothermia Post Arrest Routine Order Set per physician orders. • 1:1 staffing will be maintained for this patient by a RN or paramedic that has demonstrated competency. • During the cooling phase the patient will be intubated to maintain a patent airway and oxygenation, as well as sedated and paralyzed to prevent shivering. • Provide patient’s family education and support. • 1. Explain the purpose of hypothermia and the need for pharmacologic paralysis. • 2. Encourage the family to continue to talk to the patient. • 3. Provide emotional support and answer any questions. • 4. Offer pastoral care support to the family. Facilitate communication between the family and the physician.
1:1 Staffing • Upon notification of the ICU charge nurse that this patient will have Therapeutic Hypothermia induced, ICU charge nurse to come to ER to assist with patient monitoring/transfer.
Determining Inclusion/Exclusion • Patient must meet Criteria • We must have a confirmed ICU Bed Assignment from ICU Charge Nurse • Do not delay transferring to Cardiac Cath Lab to initiate protocol.
Implement Induction OrdersNursing Protocol • Target Temp 33° C • Initial Core Temp_________ • Time Cooling Initiated_________ • Confirm eligibility criteria met. • Notify ICU, House Supervisor of TH patient. • Patient Monitoring • Vital Signs Q 15 min X 1 hour, then hourly. • Core Temperature Q15 min until target reached then hourly. • Continuous ECG monitoring. • BIS Monitoring • Glasgow Coma Scale hourly. • FSBS hourly. • I & O hourly. • Assess skin Q2 hour. • Obtain patient weight.
Nursing Protocol-Cont’d. • NPO • Insert NG/OG Tube to low intermittent suction. • Insert Thermistor Foley with urometer • Insert 2 Lg Bore peripheral IV’s. Preferrably 18 gauge no smaller than 20. • HOB elevated to 30° • Administer sedation and neuromuscular blockade before initiating cooling measures.
ER Cold Kit • Temp sensing Foley BIS electrode • 14 Chemical cold packs • Stockingette sleeves • NG with irrigation set • Copy of Induction Order Set
Physician Protocol • Patient meets criteria for Induced Therapeutic Hypothermia • Admit Inpatient to ICU. • Labs-CBC, CMP, Phos, Mag, PT INR, PTT, Lactate, Amylase/Lipase, ABG, UA, LDH, Troponin, CKMB, BC X 2, Urine Tox, Urine Hcg if indicated. • Diagnostics-CXR, 12 Lead EKG • Consults: Notify of Post Arrest Induced Therapeutic Hypothermia Protocol- Cardiology, Neurology, or Other • Vent-Vent setting per vent orders. Remove heat from ventilator circuit. • Arterial Line
Pharmacy Protocol • Prior to initiating cooling measures • Induction • Acetaminophen 650mg per NG/OG Q6hr. • Buspirone 30mg per NG/OG Q8hr. (Buspar_ • Midazolam 5mg IVP once. (Versed) • Cisatracurium 0.2mg/kg IV once. (Nimbex) • Fentanyl 50mcg IV once.
ED Cooling Measures • Fluids-Infuse 2 liters 0.9% NS chilled to 4° C over 30 minutes- Do Not give if clinical evidence of CHF . Do Not give cold fluid via a jugular or subclavian line. • Place each chemical cold pack in stockingette prior to applying to patient. • Place 14 chemical cold packs to patient’s neck, axilla, groin and chest. • (2) 1 each axilla • (4) 1 under neck • 1 on top of neck • 1 on each side of neck • (2) 1 in each groin • (2) 2 on the chest • (4) 1 on inner and outer thigh • Remove cold packs for temps less than 32°C.
Pharmacy Protocol-Maintenance • Maintenance • Midazolam 1mg/ml IV continuous infusion. May increase by 1mg/hr every 15 min to maintain sedation. (Maximum 10mg/hr) • Cisatracurium 3mcg/kg/min IV • Fentanyl 0.5mcg/kg/hr IV
Monitoring Parameters • Notify MD if: • Shivering-notify MD immediately. • Seizure-Notify MD immediately. • Hypotension SBP< 90mmHg Or bradycardia HR < 50.
References • Hazinski et al. (2010) Circulation, October 2010; 122(162): S250 - S275. • Peberdyet al.. (2010) Post–Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care . Circulation, November 2010; 122(183): S768 - S786. Class IIb, LOE B. • The Ohio State Medical Center Induced Hypothermia after Cardiac Arrest Algorithm obtained 05/28/2011 from http://www.med.upenn.edu/resuscitation/hypothermia/documents/HypothermiaGuideline052710.pdf • http://www.med.upenn.edu/resuscitation/hypothermia/protocols.shtml