In last weeks Lessons in Transport we reviewed who should & should not receive therapeutic hypothermia post return of spontaneous circulation from cardiac arrest...
Here are the answers to the scenarios
Scenario 1: YES... Cool this gentleman. No exclusion criteria are present.
Scenario 2: NO, this is a blunt traumatic arrest. Trauma as the cause of cardiac arrest is a strict CONTRAINDICATION to therapeutic hypothermia.
Scenario 3: No, this is a pediatric cardiac arrest. Your initiation of hypothermia will NOT be continued at Cincinnati Childrens.
Scenario 4: No, this is tricky but the patient's GCS motor score was 6 ie: he is following commands & thus he should NOT recieve therpeutic hypothermia
Scenario 5: Yes... surgery within 1 week of cardiac arrest is only a relative contraindication/consideration. This patient's surgery was 2 weeks ago.
Our Target Temperature: 32-34*C within 1 hour of return of spontaneous circulation
Initiate Cooling Measures:
Expose the patient (while protecting patient privacy)
Apply ICE PACKS to the neck, axilla, torso, trunk, and groin
Make the environment cold (thermostat control, open a window in the helicopter, etc.)
Some EMS agencies and referring hospitals have pre-cooled saline: Administer 30ml/kg (or 2L) saline at 4*C IV Bolus. Must be given under pressure to avoid re-warming of the fluid during administration.
***PEARL*** Try to pack ice around the IV tubing to avoid re-warming of the chilled saline during administration
Continuous Vital Sign Monitoring:
Cardiac Monitoring & defib pads
Pulse Oximetry: Goal SaO2 95-98%
Blood Pressure: Goal MAP 70-110Respiration: Titrate FIO2 and PEEP to maintain SaO2 95-98%
May use NER drip to maintain MAP > 70mmHg
Glucose: Maintain blood glucose 100-180mg/dl
Urine output: relative goal 0.7-1cc/kg/hr
***PEARL*** Hypoxia, hyperoxia, hypocapnia, & hypercapnia are all associated with poor neurological outcomes.
Initiate & maintain sedation:Titrate to RASS -4-5
Fentanyl + Propofol
Fentanyl + Versed
***PEARL*** Do NOT initiate paralysis without first making aggressive attempts at providing adequate sedation and pain control.
Stay tuned for next weeks Lessons in Transport for more on therapeutic hypothermia...