Lessons in Transport Medicine - To Cool or Not to Cool?

Chain of survival
Chain of survival

To COOL or NOT To COOL that is the question...

(Read each of the following scenarios & honestly ask yourself if this is a patient suitable for therapeutic hypothermia)

Scenario 1: 67 yo male scene STEMI, witnessed Vfib arrest with ROSC, GCS 3T, stable vitals

Scenario 2: 24 yo female MVC, ejected, hypotensive for EMS, 10 minute cardiac arrest with ROSC, GCS 3T

Scenario 3: 2 yo female cardiac arrest suspected choking, ROSC after removing food from her airway. GCS 4T (1T2)

Scenario 4: 18 yo male cardiac arrest suspected drug over dose, ROSC at outside hospital. GCS 9T (2T6)

Scenario 5: 30 yo female sudden onset of dyspnea then 30 min arrest with ROSC, hysterectomy 2 weeks ago, GCS 3T

Therapeutic Hypothermia Inclusion Criteria:

  • Cardiac arrest with return of spontaneous circulation (Note: any presenting rhythm can be cooled)
  • NOTfollowing commands
  • Trauma is NOTthe cause of cardiac arrest
  • No DNR/DNI 

Hypothermia Exclusion Criteria:

  • Patient is currentlyfollowing commands
  • Trauma is the cause of cardiac arrest
  • Age < 15 yo (AT THIS TIME CCHMC IS NOT PERFORMING THERAPEUTIC HYPOTHERMIA FOR POST ARREST PEDIATRICS)
  • Known intracranial hemorrhage or stroke.
  • Active DNR/DNI paper
  • Hypothermia as the cause for the cardiac arrest. (These patients should be actively rewarmed)

Caution: these are cases that can still receive therapeutic hypothermia on a case-by-case basis but discussion with medical control or neurocritical care is advised before initiation of hypothermia

  • Major surgery within 1 week (ideal to discuss with surgeon first)
  • Female < 55 yo (consider pregnancy test prior to initiation of hypothermia)
  • Presenting temperature is < 32*C (and hypothermia is NOT the cause of the arrest) 
  • Known intrinsic coagulopathy (Therapeutic anti-platelet or anticoagulation therapy is NOT a contraindication. Recommend discussing with neurocritical care before initiation)
  • Difficulty maintaining MAP > 70 mmHg (may use vasopressors as needed)
  • > 12 hours after ROSC
  • Pulselessness for greater than 60 minutes

***PEARL*** Save the attached UCMC inclusion and exclusion criteria to your mobile device for easy access

Therapeutic Hypothermia Inclusion Criteria

Authored by Ryan Gerecht, MD, CMTE and Diana Deimling, RN, BSN