1. Initiate Therapeutic Hypothermia Nutrition and Medications
Inclusion Criteria
1. Cardiac arrest with primary cardiac etiology
2. Initiation within 6-12 hours of ROSC
3. Unresponsive after ROSC (brainstem reflexes permissible)
4. Estimated time arrest to ROSC < 60 minutes
Initiate Therapeutic Hypothermia
STEMI/SHOCK: To cath lab (+/- IABP support) then to CVICU
NON-STEMI: Admit directly to CVICU
Utilize Arctic Sun with target temperature of 33°C until 24h post-arrest, rewarm at 0.25°C/hr and maintain temperature < 37.5°C for 72 hours post-arrest
Sedation, Paralysis
Preferentially propofol
(Midazolam if hypotensive)
Veuronium bolus then cistatracurium infusion
Oxygenation/Ventilation/Acid-Base/Electrolytes
ABG & electrolytes every 6 hours, continuous SpO2
Titrate to PaO /pCO /pH
Permissive hypokalemia to >/= 2.8 mEq/L
Target magnesium >/= 2 mEq/L
Glucose monitor q1h with insulin infusion to maintain glucose
Family Care
Palliative Care Consult on admission – regardless of the expected outcome
Education regarding: indications of hypothermia, effects of hypothermia, length of time, risks of rewarming process
Nutrition and Medications
No nutrition until rewarming
All medications IV until normothermic (exceptions: Clopidogrel by nasogastric tube, aspirin/acetaminophen per rectal)
Hemodynamic Monitoring
Arterial line
PA Catheter/central line
Transthoracic Echo
MAP target: 80-90
(utilize norepinephrine, IABP for shock; nicardipine for hypertension)
Neurological Assessment
Head/Neck CT if unwitnessed or traumatic fall
Seizure monitoring with continuous EEG
Neurology consult, IV keppra and IV lorazepam for seizure activity
Exclusion criteria:
1. Awakens spontaneously
2. Pregnancy, known terminal illness, recent major head trauma or traumatic arrest, bleeding, drug intoxication
3. Initial temperature < 93.2°F (34°C)
CODE ICE Protocol
Post-Cardiac Arrest Therapeutic Hypothermia
Targeted Temperature Management