1. Part 2 Union Hospital, Inc. Emergency Department

2. 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.

3. 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.

4. 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.

5. Implement Induction Orders Nursing 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.

6. 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.

7. ER Cold Kit Temp sensing Foley BIS electrode 14 Chemical cold packs Stockingette sleeves NG with irrigation set Copy of Induction Order Set

8. 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

9. 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.

10. 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.

11. 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

12. Monitoring Parameters Notify MD if: Shivering-notify MD immediately. Seizure-Notify MD immediately. Hypotension SBP< 90mmHg Or bradycardia HR < 50.

13. Documentation in Ibex

14. References Hazinski et al. (2010) Circulation, October 2010; 122(162): S250 - S275. Peberdy et 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/documents/HypothermiaGuideline052710.pdf http://www.med.upenn.edu/resuscitation/hypothermia/protocols.shtml