Code Cool Post ROSC Induced Hypothermia

Section 4 - CARDIAC

4.12 CODE COOL – POST ROSC INDUCED HYPOTHERMIA

Indication

ROSC (return of spontaneous circulation) post VF/VT resuscitation (non – trauma)

Utilization:

• ROSC
• Age ≥ 18
• Temperatures > 34°C (Tympanic measurement) repeat measurement for possible change.
• Unresponsiveness to pain
• Intubated with EtCO2 > 20 mm Hg
• Not obviously pregnant

Preparation for Induction – Hypothermia

• NEURO assessment:
• Pupils (size, reactivity, equality)
• Motor Response to Pain
• Remove clothing, protect modesty
• Apply cold packs to axilla and groin
• Goal EtCO2 = 40; NO Hyperventilation
• Attempt second IV/IO (if not in place)

Transport to the closest hospital with cooling capabilities:

• Central Florida Regional Hospital
• Florida Hospital facilities
• South Seminole Community Hospital

Induction of Paralysis: (prevention of shivering)

• Administer VERSED or Morphine (IV/IO/IN) or Valium (IV/IO) titrated dose to effect.

Saline infusion and Maintenance of Mean Arterial Pressure (MAP)

• Initiate cold saline bolus through up to two (2) IV or IO access points
• Infuse cold saline at 30mL/kg to max of 2 Liters

Weight (lbs)	Weight (kg)	Volume Target (mL)
88	40	1200
110	50	1500
132	60	1800
≥143	≥65	2000

• Target Mean Arterial Pressure (MAP) 90 – 100
• Check MAP on the LP12, but manually monitor

Systolic	Diastolic	MAP
110	80	90
120	75-90	90-100
130	70-85	90-100
140	65-80	90-100

MAP = Diastolic Value + 1/3 Pulse Pressure

Target Diastolic: 80 – 90

If chilled saline does not maintain MAP continue to maintenance of MAP with vasopressors

Maintenance of MAP with vasopressors

• Support B/P with Dopamine as required to Maintain MAP of 90-100

Dopamine 400mg/250mL/NaCl

Weight (lbs)	Weight (kg)	5mcg/kg/min	10mcg/kg/min	20mcg/kg/min
88	40	8	15	30
110	50	9	19	38
132	60	11	23	45
154	70	13	26	53
176	80	15	30	60
198	90	17	34	68
220	100	19	38	75
242	110	21	41	83

• Patient assessment is critical for ongoing care, with any new signs of patient movement (i.e., gasping, eye fluttering, shivering, seizure activity, movement) during ICE therapy, administration of 10mg Versed and 10mg Morphine is required. (Additional may be needed)
• Reassess patient’s airway frequently and with every movement
• Cold saline is a strong vasoconstrictor, maintaining cerebral perfusion is essential during the therapeutic hypothermia process. Maintain MAP at 90 – 100 mmHg
• Monitor EtCO2 frequently and target 40 mm Hg, If EtCO2 falls below 20 mm Hg, consider possible loss of pulses.
• If there is a loss of ROSC at any time, discontinue cooling and go to appropriate protocol for treatment. Chilled saline infusion should be slowed to KVO rate during the resuscitative process. Upon ROSC (if attained) return chilled saline to wide open infusion.
• Chilled saline is infused at 30mL/kg to a maximum of 2000 mL.
• Continue to address specific differentials (H’s and T’s) associated with original dysrhythmia or cause of arrest

Contraindications for “Code Cool”

• PEA and Asystole
• Active Bleeding
• Hemodynamically unstable arrhythmias
• Sickle Cell Anemia
• End Stage Terminal Disease
• Obviously Pregnant

Relative contraindications for “Code Cool”

• Prolonged QT (consider pacing)
• Cryoglobulinemia (single or mixed immunoglobulins that undergo reversible precipitation at low temperatures)
• Raynaud’s Phenomenon