PLACE LABEL HERE

POST CARDIAC ARREST COMA

TARGETED TEMPURATURE MANAGEMENT (TTM)

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT ordered unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Inclusion Criteria / Contraindications
  • Persistent coma (GCS < 9) as evidenced by
  • No eye opening to pain
  • Does not follow commands
  • No purposeful movement to noxious stimuli
/
  • Pregnant
  • Trauma
  • Active Bleeding
  • Age < 18 years old
  • Devastating illness / injury

  1. For VT/VF arrest: Admit to Cardiologist Dr.______

Consult Intensivist Dr.______Reason:Critical Care Management Notified

  1. All other arrests: Admit to Intensivist Dr.______

Consult Cardiology Dr.______Reason:______Notified

  1. Other Consults: ______Notified
  2. Central Venous Catheter placed in ED (ICU if inpatient).
  3. EEG within 24 hours of admission. Reason: Cardiac Arrest; Encephalopathy. Notify Neurology tech on-call.
  4. 12-Lead EKG Stat after Return of Spontaneous Circulation (ROSC) if not already done.
  5. Portable chest XR stat if not already done after intubation. Reason: intubation
  6. Labs:  CBC  CMP  PT/INR Other:______
  7. Monitor VS hourly
  8. Assess forshivering hourly until completion of maintenance of normothermia
  9. Neurological checks hourly
  10. Hourly I & O
  11. Continuous Temperature Monitoring; document core temperature hourly.
  12. Reposition patient and inspect skin q 1 hr; provide skin care per protocol (policy # 6106).

MECHANICAL VENTILATION

  1. Calculate Ideal Body Weight:

Male IBW = 50 + 2.3 (height in inches – 60) / Female IBW = 45.5 + 2.3(height in inches – 60)

  1. Select Assist Control Mode:

Set VT to 6-8 ml/kg IBWSet PEEP to +5 cm H2O

Set Initial rate to 10-12 bpmUse Non-heated humidification (HME)

Set Initial FiO2 to maintain SpO2≥ 94%

  1. Insert Arterial Line ASAP (if unsuccessful, contact Attending Physician)
  2. Adjust ventilator settings to maintain:

pH = 7.35 - 7.45 orpH = ______

PaCO2 =35 – 45 mmHg or PaCO2 =______

SpO2= or ≥ 94% or SpO2 =______

  1. Rewarming: place on heated humidification
  2. Head of bed at 30o
  3. Peridex (chlorahexidine) oral rinse 15 ml bid. May discontinue once patient is extubated.
  4. Isoptotears (hypromellose) 2 drops in each eye q 6 hours PRN dry eyes.

INDUCTION OFMILD HYPOTHERMIA

Maintain core temperature between 95-96.8°F (35-36°C) 28 hours.

  1. Ice packs on axilla, groin and neck. Remove once core temperature reaches 95-96.8°F (35-36°C).
  2. Apply Rapr*Rounds per manufacturer guidelines. Set Altrix(hypothermia machine) toAutomatic mode, Set target temperature to35.5ºC, and Full Power (max) setting.
  3. Chilled 0.9% Normal Saline IV Bolus: ______Liters. (Preferred except in fluid overload or ESRD)

The following orders will be implemented. Orders with a “” are choices and are NOT ordered unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Chilled Gastric Lavage (preferred method in fluid overload or ESRD)

Rapidly instill 250-500 ml iced tap water

Suction stomach contents via OGT

After 5 min (for 250 ml) or 10 min (for 500 ml), suction fluid from stomach

Repeat above for target volume of ______Liters (30 ml/kg, max 3 liters)

Document lavage input and output volumes

  1. If arrival core temperature is < 95°F (35°C), use hypothermia machine to increase patient temperature to goal range no faster than 0.25°C (0.45°F) / hour

REWARMING (Rewarming should be initiated 28 hours from the time cooling was initiated).

Start rewarming at: Date: ______Time: ______

  1. Set Altrixto Automatic mode. Set target temperature to 36ºC, and0.17ºC per hour (min)mode.
  2. Rewarm patient no faster than 0.25°C (0.45°F) / per hour.

MAINTENANCE OF NORMOTHERMIA – Prevention of Hyperthermia

Maintain core temperature between 96.8-99.3°F (36-37.4°C) for an additional 48 hours.

  1. Maintain Rapr*Rounds on patient. Set Altrixto Automatic mode.Set target temperature to 36.5ºC, 0.33 ºC per hour (med)mode.
  2. If unable to maintain normothermia:

Ice packs on axilla, groin and neck. Remove once core temperature reaches < 99.3ºF (37.4ºC).

Medications for hyperthermia: If core temperature > 99.3ºF (37.4ºC), give one of the following:

 Tylenol (acetaminophen) 1 gm PR or per FT. Then in 6 hrs, begin 650 mg PR or FT q 6h hrs x 3 doses (Avoid with liver injury)

or

Motrin (ibuprofen) 400mg per FT q 6 hrs x 24 hrs (Avoid with AKI/CKD)

MEDICATIONS:

  1. VTE prophylaxis: Heparin 5000 units SQ q 8 hours

 Anticoagulation SQcontraindication reason:______

  1.  Heparin Infusion Protocol  High intensity (form # 39814) Low intensity (form # 39815)
  2. Electrolyte Replacement:Electrolyte Replacement Orders (form # 21340), contraindicated if GFR <30
  3. Glycemic Control: Insulin Subcutaneous Standing OrdersCritical Care (form # 21386).

If BG >200 x 2, inform physician, request insulin infusion.

Initiate EndoTool standing orders (form # 38635); use Critical Care/Sepsis range (BG range 120-180 mg/dl) if BG >200mg/dl x 2.

Obtain blood glucose sample from central line or arterial line ONLY.

DO NOTperform finger stick blood glucose.

  1. Treatment for Shivering(increases O2 consumption and may negate the effects of TTM):

Counter warming measures: Warm blankets/towels applied to hands and feet.

Demerol (meperidine) 12.5-25 mg IV q 4 hrs prn for 24 hrs

ADDITIONAL ORDERS:

______

______

______

DateTimeEmergency Department Physician SignaturePID Number

(if applicable)

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-29938 REV. 05/2017 Page 1 of 2