Comatose patients resuscitated from cardiac arrest with restoration of spontaneous circulation (ROSC)
INCLUSION CRITERIA
Post–cardiac arrest
ROSC < 30 minutes from the time of EMS arrival
Time < 6 hours from ROSC
Comatose (does not follow commands)
EXCLUSION CRITERIA
Contraindications
Patients without a pulse
Patients responsive to verbal commands
Traumatic etiology of arrest
Active or intracranial bleeding
Patient has DNR, poor baseline status, or terminal illness
ROSC >30 minutes from the time of EMS arrival
Time of initiation >6 hours from ROSC
Pregnancy
Age >80 (relative)
Asystole as initial rhythm (relative)
Severe sepsis/septic shock as cause of arrest (relative)
Cryoglobulinemia (relative)
SUPPLIES
Temperature Probe
Esophageal
Bladder
Cooling Methods
Surface cooling with ice packs
Surface cooling with blankets or surface heat-exchange device and ice
Surface cooling helmet
Internal cooling methods using catheter-based technologies
Internal cooling methods using infusion of cold fluids
Warming Methods
Warm blankets
Bair Hugger
Room temperature IV fluids
General Basic Steps
Preparation
Induction
Maintenance
Supportive therapy
Withdrawal/rewarming
TECHNIQUE
Patient Preparation
Place definitive airway
Completely expose patient
Apply cooling blankets or gel pads (if available) with nothing between skin and blankets/pads
Place core temperature probe (esophageal preferred)
Hook blankets/pads to hypothermia machine, set to 36°C
Optimize analgesia and sedation (suggestions below)
Analgesia (optimize first): Fentanyl
Sedation: Propofol (preferred); alternate: Midazolam
Titrate to Richmond Agitation Sedation Scale (RASS) −3/−4 (TABLE 13.1)
Monitor vital signs and oxygen saturation and place the patient on a continuous cardiac monitor, with particular attention to arrhythmia detection and hypotension
Induction
Keep temperature between 35°C and 36°C
If initial temperature >36°C, infuse refrigerated crystalloid at 100 mL/min to maximum initial bolus 30 cc/kg
If initial temperature remains >36°C after this amount, wait 15 minutes before giving additional 250-cc boluses every 10 minutes until goal temperature is attained
If initial temperature <36°C, allow machine to warm the patient to 35°C
Use cold IV fluids or place ice packs on the axilla/groin to reach and maintain target temperature if cooling blankets/pads are unavailable
Target temperature should be reached as quickly as possible
Start antishivering protocol (TABLE 13.2)
RICHMOND AGITATION SEDATION SCALE (RASS) |
Score | Term | Description |
+4 | Combative | Overtly combative, violent, immediate danger to staff |
+3 | Very agitated | Pulls or removes tube(s) or catheter(s); aggressive |
+2 | Agitated | Frequent nonpurposeful movement, fights ventilator |
+1 | Restless | Anxious but movements not aggressive or vigorous |
0 | Alert and Calm |
|
–1 | Drowsy | Not fully alert, but has sustained awakening |
–2 | Light sedation | Briefly awakens with eye contact to voice (<10 seconds) (eye opening/eye contact) to voice (≥10 seconds) |
–3 | Moderate sedation | Movement or eye opening to voice (but no eye contact) |
–4 | Deep sedation | No response to voice, but movement or eye opening to physical stimulation |
–5 | Unarousable | No response to voice or physical stimulation |
ANTISHIVERING PROTOCOL |
Bedside shivering assessment (BSAS) (N. Badjatia. Neurocrit Care 2007)
0 – None—no shivering. Must not have shivering on ECG or palpation.
1 – Mild—localized to neck/thorax. May be noticed only on palpation or ECG.
2 – Moderate—intermittent involvement of upper extremities with or without thorax.
3 – Severe—generalized shivering or sustained upper extremity shivering.
All patients receive:
Acetaminophen 850 mg GT q6h unless allergic and buspirone 30 mg GT q8h (unless pt on MAO inhibitor)
If BSAS >1, add fentanyl drip
If BSAS still >1, add propofol drip
If BSAS still >1, add Bair Hugger device for counterwarming on both of patient’s arms
If BSAS still >1, administer MgSO4 2 g IVSS (intravenous soluset), then 0.5–1 g/h for target serum Mg 3 mg/dL
If BSAS still >1, administer dexmedetomidine 1 µg/kg over 10 min, followed by an infusion
If BSAS still >1, administer ketamine 0.5 mg/kg IVP (intravenous push), may start drip at same dose per hour
If BSAS still >1 after titration of above meds, add Nimbex 0.15 mg/kg IV q1h PRN
Paralysis after induction should be necessary only under extraordinary circumstances.
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