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LWW/AENJ AENJ3004˙03REV October 22, 2008 17:59 Char Count= 0

Advanced Emergency Nursing Journal


Vol. 30, No. 4, pp. 319–330
Copyright 
c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Therapeutic Hypothermia in the


Postresuscitation Patient
The Development and Implementation
of an Evidence-Based Protocol for the
Emergency Department
Zeb Koran, RN, APN, DNP, CEN, CCRN

Abstract
Studies have shown that therapeutic hypothermia (TH) improves outcomes in patients who have
experienced a cardiac arrest (Bernard et al., 2002; Hypothermia After Cardiac Arrest Study Group,
2002). This article discusses TH and the process used by one emergency department to develop
and implement an evidence-based protocol on TH for the postresuscitation patient. Key words:
cardiac arrest, hypothermia, induced hypothermia, therapeutic hypothermia

T HERAPEUTIC HYPOTHERMIA (TH) is ment a protocol for TH in the postresuscitated


not a new concept. It has been tri- patient. The primary sponsors of the proto-
aled in patients with various diagnoses col were the ED clinical nurse specialist and
and trialed in various methods in an effort the ED medical director. Ad hoc consultants
to improve patient outcomes. For the last 6– included ED nurses, physicians, and the med-
7 years, the literature has addressed using hy- ical director of critical care.
pothermia for patients after cardiac arrest.
Northwest Community Hospital (NCH) sees
approximately 71,000 patients in the emer- HISTORY OF THERAPEUTIC HYPOTHERMIA
gency department (ED) per year. Of these
In 1803, Russians attempted to use hypother-
patients, approximately 12–13 patients per
mia therapeutically when they covered pa-
month arrive to the ED in cardiac arrest. It is
tients with snow in an attempt to resusci-
for this population that the ED decided to re-
tate them (Liss, 1981). In the late 1930s,
view the literature and if appropriate, imple-
hypothermia was studied in cancer patients
with the hope that the decreased tempera-
From the Northwest Community Hospital, Arlington ture would slow the division of cancer cells
Heights, Ill. (Smith & Fay, 1940). The first study that ad-
The author would like to acknowledge Laura Aagesen, dressed TH in cardiac arrest patients was pub-
Dr Michael J. Born, Sharon Esterquest, Ed Fitch, Carol lished in 1959 (Benson, Williams, Spencer, &
Howat, Rosemary Kucewicz, the ED staff, and the Criti-
cal Care Leadership at Northwest Community Hospital. Yates, 1959). Unfortunately, that study and
studies that followed found that patients ex-
Corresponding author: Zeb Koran, RN, APN, DNP,
CEN, CCRN, Northwest Community Hospital, Arlington perienced complications, such as pneumonia,
Heights, IL 60005. bacteremia, and ventricular fibrillation from

319
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320 Advanced Emergency Nursing Journal

the hypothermia. As a result, studies slowed imately 30% of cardiac arrest survivors have
down until approximately the 1990s. In 2003, severe brain damage (Xiao, 2002).
TH received positive attention and support
when the American Heart Association recom- POSTRESUSCITATION
mended it for patients who had a cardiac ar-
Immediately postresuscitation, there is an
rest (Nolan, Morley, Vanden Hoek, & Hickey,
excessive increase in cerebral blood flow
2003). American Heart Association support of
(Green & Howes, 2005). Following this pe-
TH was based on two randomized controlled
riod, for 90 min to 12 hr after the arrest,
studies. One study involved patients from
cerebral blood flow is only 50% of its base-
four hospitals in Australia, whereas the sec-
line value, which is inadequate for cellular
ond study involved patients from five coun-
oxygen demands (Maramattom & Wijdicks,
tries in Europe. In the Australian study, 49%
2005). During this postresuscitative period,
of the patients who were treated with TH
a separate chain of events occurs, even after
had minimal neurological impairment upon
perfusion has returned to its baseline level,
discharge from the hospital. In the normoth-
which further increases tissue injury and is-
ermia group, only 26% had minimal neuro-
chemia (Holzer et al., 2005). These events in-
logical impairment (Bernard et al., 2002). In
clude, but are not limited to, the generation
the European study, 55% of the hypother-
of oxygen free radicals, inflammatory cell in-
mia group had neurological outcomes that
vasion, and ion imbalances (Varon & Acosta,
were favorable in comparison with 39% in the
2008).
normothermia group (Hypothermia After Car-
In postresuscitation patients, where neu-
diac Arrest Study Group, 2002). These studies
ronal damage has occurred, increased body
rekindled interest in the use of hypothermia
temperature increases negative outcomes. In
for patients after a cardiac arrest.
a study by Diringer, Reaven, Funk, and Uman
(2004), there was a significant correlation be-
CARDIAC ARREST tween temperature elevation in neurology pa-
tients and poorer outcomes, higher mortality,
Each year, either out of hospital or in the
and increased length of stay.
ED, approximately 310,000 people in the
United States experience sudden cardiac
PHYSIOLOGY OF HYPOTHERMIA
death (American Heart Association, 2008). An
additional 375,000–750,000 people are resus- Hypothermia counteracts some of the neg-
citated each year (Maramattom & Wijdicks, ative physiologic effects that occur after re-
2005). Approximately 40% of those resusci- suscitation. By lowering a patient’s body
tated will have a return of spontaneous cir- temperature, the patient’s metabolic rate is
culation (Maramattom & Wijdicks, 2005). Al- decreased. This is advantageous because it
though they survive the arrest, some still have results in a decrease in oxygen demand by
negative repercussions from the physiological the cells, the same cells that are already de-
responses that occur as a result of the arrest prived. For each 1◦ C decrease in body temper-
state. ature, the cerebral metabolic rate is decreased
When cardiac arrest occurs, there is an by 6%–7% (Keresztes & Brick, 2006). Various
immediate cessation of blood flow to the studies, as cited by Smith and Bleck (2002),
brain. As a result, cerebral oxygen becomes have shown that the negative events that oc-
depleted. Neurons experience lack of oxygen cur with ischemia in the postresuscitative
within the first 20 s of arrest and the cen- period (release of radicals, ion pump fail-
tral nervous system is affected within the first ure, etc.) are slowed in the presence of hy-
5 min. Once cardiopulmonary resuscitation pothermia. It is also believed that hypother-
is initiated, only 30% of cerebral blood flow mia, through vasoconstriction, can decrease
is restored (Green & Howes, 2005). Approx- intracranial pressure (Clifton et al., 2001).
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October–December 2008 r Vol. 30, No. 4 Therapeutic Hypothermia in the Postresuscitation Patient 321

Recognizing the effect that arrest and atic reviews and evidence-based guidelines,
postresuscitation have on the neurovascular would be used. This brought the review to
system and understanding the effect that hy- approximately 70 articles. After eliminating
pothermia has on the neurovascular system, all articles that were not research articles,
it appears reasonable that hypothermia could research-based guidelines, case studies, meta-
be advantageous in caring for the patient who analyses, or literature reviews, there were ap-
has experienced cardiac arrest. These find- proximately 35 articles. The next step was to
ings supported the concept of developing read the literature in-depth, grade it, and iden-
a TH protocol. Therefore, the literature was tify the information that was pertinent for im-
reviewed again for the specific information plementing TH in the ED. The following grad-
needed to develop a protocol. ing scale was used:
• I: Meta-analysis
• II: Randomized controlled trials
LITERATURE REVIEW FOR PROTOCOL • III: Quantitative studies
DEVELOPMENT • IV: Literature reviews, research-based
After scanning the literature, the ED team rec- guidelines, and case studies
ognized that there were practice variations Of the 35 articles, a few were elimi-
in the studies. The studies regarding TH and nated because they were repetitive reviews
cardiac arrest have been very progressive; as of the same research. Because there were
a result, the time period in which the stud- enough studies with human subjects, stud-
ies were conducted made a difference in the ies that were conducted on animals were
findings. For example, some studies used only also eliminated. Of all the literature re-
TH when the patient’s initial rhythm was ven- viewed, nine were published from 2005 to
tricular fibrillation, whereas other studies in- 2008 and appeared to give an overall review
cluded various dysrhythmias. Some studies of the findings in the literature (Table 1).
recommended initiating TH after the return of Of these studies, the following facts were
spontaneous circulation, whereas other stud- identified:
ies explored the option of beginning TH prior • the rhythm at the time of the arrest could
to a return of spontaneous circulation. The in- vary rather than be limited to ventricular
formation that was of particular importance fibrillation;
in developing a protocol for the ED is as • mild hypothermia is defined as 32–34◦ C
follows and is the goal of TH;
• Criteria for initiating TH • there were various effective methods
• Exclusion criteria used for cooling the patient; helmets, ice
• The point in the arrest cycle to initiate TH packs, cold crystalloids, cooling blankets,
• The preferred method to monitor body and combinations of the same; and
temperature • medications would be needed to para-
• The target temperature range for “mild lyze, sedate, and prevent shivering.
hypothermia” The nine studies included in the final lit-
• Medications to be administered erature review addressed various methods of
• The method of cooling that would best cooling the patient and the method that im-
meet the needs of the ED by being rapid, mediately had an appeal was the infusion
efficient, and simple to initiate in a busy, of cold crystalloids. Initiation of cold fluids
chaotic environment. would be far less difficult than cooling blan-
The initial search used the keywords of kets and other methods discussed. However,
“induced hypothermia” and “therapeutic hy- because the current literature search was
pothermia.” After reviewing the literature, it broad, another literature search was neces-
was decided that only the studies from 2005 sary to specifically look for information on TH
to the present, with the exception of system- and cold infusions of either lactated Ringer’s
LWW/AENJ

Table 1. Literature findings


322

Method to
Specific Initiate monitor
Initial TH with Cooling body Complications Exclusion
Authors Year Grade rhythm ROSC Temperature method temperature Medications from TH criteria
AENJ3004˙03REV

Alzaga, Cerdan, & 2006 4 32–34◦ C Mixed methods Mixed Neuromuscular Dysrhythmias, Cardiogenic shock;
Varon. (literature blocking coagulopa- pregnancy;
review) agents thy, primary
infection coagulopathy
Arrich, The 2007 3 Varied Yes 32–34◦ C Mixed methods Hemorrhage; Trauma; severe
European arrhythmias bleeding;
Resuscitation coagulopathy;
Council terminal disease;
October 22, 2008

Hypothermia DNR status;


After Cardiac obeying verbal
Arrest Registry commands after
Study Group ROSC
17:59

(composite study
from numerous
sites)
Bernard & Rosalion 2008 4 During 33◦ C Lactated Ringer’s @
(case study) cardiopul- 4◦ C
monary
resuscitation
Cheung, Green, & 2006 1 V-fib, PEA, 32–34◦ C Varied between the Varied Hyperglycemia
Char Count= 0

Magee asystole four studies


(systematic
review)
Kim et al. 2005 3 All cardiac Yes 32–34◦ C 2 L of saline at 4◦ C Midazolam; None Trauma; body
arrest over 30 min Vecuronium weight under
rhythms 50 kg
Kliegel et al. 2007 2 V-fib, asystole, Yes; within 93 32–34◦ C 30 ml/kg of Bladder Midazolam and None Pulmonary edema;
PEA, V-tach min Lactated Ringer’s Fentanyl terminal illness;
or normal saline coagulopathy;
over 30 min pregnancy;
reduced left
ventricular
function; coma;
renal
replacement
therapy

(continues)
Advanced Emergency Nursing Journal
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October–December 2008 r Vol. 30, No. 4 Therapeutic Hypothermia in the Postresuscitation Patient 323

or normal saline. The review was also in-


creased to include those years back to 2002.
The search yielded 10 studies specific to TH

coagulopathy
cardiogenic

pregnancy;
being initiated with the administration of cold
Complications Exclusion

Profound

shock;
fluids. However, 2 of the 10 studies were
criteria

eliminated as they used animals for the study,


whereas 8 studies used human subjects and
Difficult to NOT
therefore would provide more pertinent infor-
overcool mation (Table 2).
from TH

Minimal On the basis of the literature, the follow-


ing, specific interventions were selected for
the protocol. One other consideration to the
Medications

Fentanyl with
midazolam

development of the protocol was the standard


Norcuro-

Note: TH = therapeutic hypothermia; ROSC = return of spontaneous circulation; V-fib = ventricular fibrillation; PEA = pulseless electrical activity.
Midazolam;

propofol
and/or

of practice for these patients in critical care.


nium

There had to be consistency of care between


the two departments.
• The contraindications in the various stud-
temperature

Tympanic or
Method to

ies were not consistent (Table 1). Con-


bladder
monitor

Bladder

sidering this and the fact that most pa-


body

tients did not experience negative out-


comes from TH, especially when cold in-
(4–6◦ C) followed
4◦ C over 30 min

Refrigerated saline
30 ml/kg saline at

fusions were used (Table 2), the decision


and ice packs

Mixed methods

by cooling

was made that the ED protocol would


blanket

keep the list of contraindications to a min-


Cooling
Temperature method

imum and include only those with consis-


tency in the literature.
• Hypothermia is most beneficial when it is
Under 34◦ C

started within 2–6 hr after the patient ar-


32–34◦ C

rests (Green & Howes, 2005). Cold intra-


venous infusions can decrease the body’s
temperature by 1.4◦ C within 30 min (Kim
et al., 2005). Kliegel et al. (2007) found
TH with
Initiate

that by using cold infusions, patients


ROSC
Yes

Yes

could reach the targeted hypothermic


state within 60 min. This information sup-
Table 1. Literature findings (Continued)

V-fib; asystole;

ports the usage of cold infusions in the ED


and because of the ease may also be a fu-
Specific

Year Grade rhythm


Initial

PEA

ture consideration for prehospital care.


V-fib

• Both normal saline and lactated Ringer’s


were used in the studies for cold infu-
3

sions (Table 2). Because the majority of


the existing protocols in the ED at NCH
2007

2006

2005

used normal saline rather than lactated


Ringer’s, normal saline was chosen for the
Ploj, & Noc (PCI

Peerdeman, &

TH protocol.
Knafelj, Radsel,

Merchant et al.

Rijnsburger,

• While cold infusions perform well to


patients)

Polderman,

Girbes
Authors

reach hypothermia rapidly, it is not the


best choice for maintaining a hypother-
mic state. Although cooling blankets are
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324 Advanced Emergency Nursing Journal

Table 2. Literature review specific to cold infusions

Fluid/ Amount/time Method of Side effects/


Author Year temperature to initiate TH temperature comments

Bernard, Buist, 2003 Lactated 30 ml/kg over None; Australia


Monteiro, & Ringer’s at 30 min
Smith 4◦ C
Bernard & 2008 Lactated None; case study
Rosalion Ringer’s at of one person;
4◦ C initiated before
ROSC; Australia
Kim et al. 2005 0.9 normal 2 L over 20–30 Esophageal None; passive
saline at 4◦ C min probe cooling
measures could
not sustain
hypothermia;
United States
American Heart
Association
Kliegel et al. 2007 Crystalloids at 30 ml/kg over Bladder None; most
4◦ C 30 min effective if
cooled within
60 min of
initiation of TH;
Europe
Kliegel et al. 2005 Lactated 2,000 ml Bladder None; target body
Ringer’s at rapidly temperature
4◦ C achieved in
<200 min from
ROSC; Europe
Knafelj, Radsel, 2007 0.9 normal 30 ml/kg over Bladder Increased tracheal
Ploj, & Noc saline at 4◦ C 30 min aspirates
Polderman, 2005 0.9 normal 1500 ml over None;
Rijnsburger, saline at 30 min; if temperature
Peerdeman, 4–6◦ C cardiogenic maintained with
& Girbes shock, cooling
infused over blankets;
60 min Netherlands
Virkunen, 2004 Cold Ringer’s 30 ml/kg at a Esophageal None; occurred
Yli-Hankala, rate of 100 prehospital;
& Silfvast ml/min problems with
esophageal
temperature
monitoring;
Helsinki

Note: ROSC = return of spontaneous circulation, TH = therapeutic hypothermia.


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October–December 2008 r Vol. 30, No. 4 Therapeutic Hypothermia in the Postresuscitation Patient 325

not the best method for rapidly cooling Table 3. Summary of therapeutic hypother-
a patient, they function well in maintain- mia protocol
ing hypothermia (Kliegel et al., 2007). Us-
ing a cooling blanket to maintain the tem-
Indications
perature is also consistent with NCH’s Cardiac arrest with return of spontaneous
present hypothermia protocol in criti- circulation
cal care. Therefore, cold infusions were Contraindications
chosen to induce hypothermia and cool- • Pregnancy
ing blankets were selected to maintain • Pediatrics
hypothermia. • Trauma
• Most patients that experience cardiac • Rapidly improving neurologic deficits
arrest have a urinary catheter inserted Procedure
at some point during resuscitation or • Intubate and place on a ventilator
• Insert urinary catheter with
postresuscitation. The bladder was used
temperature monitoring capabilities
in some of the studies to measure the
• Obtain baseline vital signs, including a
patient’s temperature (Table 2) and it is core body temperature and a
less invasive than some of the other op- neurological examination
tions; for example, esophageal probe. Be- • Monitor and document the temperature
cause of this, the TH protocol decision a minimum of every 15 min
was to monitor temperature via a uri- • Notify critical care upon initiating the
nary catheter with a thermistor that was cold saline infusion.
compatible with the existing monitoring • Begin propofol (Diprivan) at 10 mcg/
equipment in the ED and in critical care. kg/min intravenous infusion
• Hypothermia is an uncomfortable state • Administer Vecuronium 0.1 mg/kg
bolus (maximum of 10 mg)
and shivering may occur as a result of
• Infuse 2 L of cold saline (4◦ C) over
the low body temperature (Green &
30 min
Howes, 2005). Shivering also increases • Place ice packs to the groin, both
the metabolic rate and generates heat; axillae, and behind the neck.
therefore, medications need to be admin- • Place the patient on a cooling blanket
istered to prevent shivering (neuromus- immediately after completion of the
cular blockers) and to minimize discom- infusion.
fort (sedatives).
• Propofol and midazolam are two med-
ications that were used frequently for
sedation in hypothermic patients in the used for paralysis and to prevent shiv-
studies reviewed (Bernard et al., 2002; ering in the literature (Bernard et al.,
Bernard, Buist, Monteiro, & Smith, 2002; Bernard et al., 2003; Hypother-
2003; Hypothermia After Cardiac mia After Cardiac Arrest Study Group,
Arrest Study Group, 2002; Kim et al., 2002; Kim et al., 2005; Knafelj, Radsel,
2005; Kliegel et al., 2007; Knafelj, Ploj, & Noc, 2007). Vecuronium was
Radsel, Ploj, & Noc, 2007; Polderman, chosen because it was already used in
Rijnsburger, Peerdeman, & Girbes, the ED and would not require addi-
2005). Because the NCH-ED staff was tional education.
most familiar with the use of propofol These findings and decisions were utilized
for extended sedation, it was chosen to create the TH protocol for the ED. See
for the TH protocol. Propofol is also Table 3 for a summary of the protocol.
used in the critical care protocol. When the patient leaves the ED for criti-
• Vecuronium and pancuronium were cal care, they are maintained on propofol. In
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326 Advanced Emergency Nursing Journal

critical care, both fentanyl and cisatracurium EDUCATION


are also administered. Train-of-four monitor-
Once the protocol was developed and the
ing every 1 hr and as necessary is used for
process was created, the next step was to ed-
titration of the cisatracurium. The patient re-
ucate the staff. One strategy that was used to
mains hypothermic for 24 hr before the re-
make everyone aware of the topic of TH, be-
warming process begins.
fore the structured education began, was to
set the new, empty refrigerator in the ED. It
PROCESS was turned on, with an external thermometer
attached, to obtain the temperature of 4◦ C. A
After determining the details for TH, the next
sign was placed on it stating, “Do not use.”
step was to create the process for the pro-
A new, unused, refrigerator immediately at-
cedure. A guiding principle used to create
tracted attention and the ED staff began ask-
this process was to keep it simple and con-
ing about it. This provided the opportunity to
venient. The most obvious challenge was the
give short, informal in-services. They showed
cold saline; how would it be kept cold, who
great interest in TH and appeared to look for-
would stock it, and how would it be billed.
ward to the education and the implementa-
A refrigerator needed to be purchased that
tion of the protocol.
could maintain the fluids at 4◦ C but with
Because the knowledge needs were dif-
the department’s already limited space, the
ferent, although sometimes overlapping, for
dilemma became where to keep it that would
the various ED staff, one educational plan
be easily accessible. For the location of the re-
was created for the physicians, one for the
frigerator, input was sought from the nurses.
nurses, and one for the transporters who
This was advantageous in not only getting
would be responsible for checking the re-
their opinions and involving them but also
frigerator. The remaining staff would become
in making them aware of TH. To check and
familiar with the concept through the ED
record the temperature of the refrigerator, in-
newsletter. The newsletter was also used as
put was obtained from a few of the trans-
an avenue to help with the change process.
porters; the transporters are responsible for
Information went into the monthly newslet-
monitoring the temperatures of all refrigera-
ter to let the staff know that TH was coming
tors in the department. The director of phar-
and to give updates regarding its implementa-
macy was consulted in regards to stocking the
tion. Posters were also used to keep the staff
saline.
informed.
At the end of all of these conversations,
the process had been identified. The refrig-
Physicians
erator would be located in the main room of
the ED where it would be easily accessible The ED medical director was actively involved
to the staff. A new checklist was created that in, and committed to, the implementation of
emphasized that the refrigerator for saline, TH. To educate the physicians, three differ-
unlike the others in the ED, needs to be main- ent methods were used. The first was through
tained at a temperature of 4◦ C. The refrigera- informal conversations. During the develop-
tor is stocked with six 1-L bags of saline. Two ment of the protocol and whenever the medi-
bags of saline are located on each shelf. When cal director had an opportunity to mention it,
the nurse needs the cold saline for a patient, the topic of TH was discussed with the emer-
it is removed from the refrigerator. Once the gency physicians. This raised the interest level
patient’s care is complete, the nurse accesses at an early phase.
the medication dispensing cabinet, where the The second method that was used for edu-
bags of saline are kept, and using the patient’s cating the physicians occurred after the proto-
name, removes two bags of saline to restock col and process had been developed and was
the refrigerator. at an ED physician meeting. These meetings
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October–December 2008 r Vol. 30, No. 4 Therapeutic Hypothermia in the Postresuscitation Patient 327

are held monthly and TH was discussed at took it upon themselves to seek out an ed-
the meeting 1 month prior to the go-live date. ucator. Two days prior to the go-live date,
Both the protocol and the process were dis- all nurses, with the exception of two, had
cussed. The physicians were also shown the been educated to the protocol and the urinary
new urinary catheters with a thermistor that catheter.
would now be available in the ED. These
catheters were not only to be used on TH pa- Transporters
tients but also on any other patient in whom
continuous monitoring of the temperature Every morning, the thermometer on the re-
would be advantageous. frigerator for saline must be checked and the
The third method was through e-mail. temperature recorded on the log sheet. The
Minutes from the physician’s meeting were primary difference between this refrigerator
shared, via e-mail, and these minutes included and the others in the ED was that the temper-
the topic of TH. The medical director also ature was displayed and recorded in Celsius
e-mailed additional information regarding TH rather than Fahrenheit. A note about the new
and attached two studies that discussed the refrigerator was placed on the transporter’s
advantages of TH. assignment sheet to inform them about the
In a study conducted by Merchant et al. change. Information pertaining to the re-
(2006), 84% of the emergency physicians sur- frigerator temperature was also addressed
veyed had never used hypothermia for a pa- on an individual basis with the day shift
tient after cardiac arrest. Of these same physi- transporters.
cians, 35% cited the reason as the procedure
being technically too difficult. Because of this,
EVALUATION
it was emphasized frequently to the physi-
cians how easy the process was and that by Once the protocol was developed, the next
using the protocol with all the details of care step was to monitor it for success and to see
defined, it would be even easier. whether there was a need for revisions to the
process. Within the first week of go-live, three
patients had the benefit of TH. During this
Nurses
week, a gap in the process of replenishing
The implementation of TH created two differ- the saline was also noted. Because refriger-
ent educational components for the nurses; ation dates were not marked on the saline,
the protocol and the new urinary catheters a nurse did not know how long the saline
with a thermistor. Because a new piece of had been in the refrigerator and theoretically,
equipment was involved, it was decided to could take two bags that had just been placed
provide hands-on education either individu- in the refrigerator moments before. For this
ally or in small groups. It was also decided to reason, the process of pulling saline from
make it convenient for the nurses and for this the refrigerator and restocking it was revised.
reason, no set education times were posted. The new procedure included labeling the
Instead, a show on the road was offered dur- saline bag with the date and placing the new
ing downtimes in the ED to review the proto- saline bags on the bottom shelf. This also
col and demonstrate usage of the catheter for meant rotating the remaining four bags up
monitoring temperatures. Education was also to the top two shelves. By implementing this
offered at the beginning of each shift. This process, taking saline from the top shelf en-
was done by having a stand, with the equip- sured the nurse would be obtaining the cold-
ment, outside the locker room, and “catching” est bag of fluid.
nurses as they exited the locker room to Another event that required attention was
start their shift. The positive aspect was that the patient going to the cardiac catheteriza-
some nurses heard about the in-service and tion lab (CCL) from the ED. A priority was
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328 Advanced Emergency Nursing Journal

to prevent lengthening the time from door In a study by Qiu et al. (2007), patients with
to balloon. To meet this expectation, it was a severe traumatic brain injury and a cran-
decided that the ED staff would carry out as iotomy who were maintained in a hypother-
much of the protocol as possible without in- mic state had better neurologic outcomes
creasing the time to the CCL, and the cardiolo- than the same type of patients who were not
gists were comfortable with this. In a later re- kept hypothermic. Both groups had compli-
vision, the part of the protocol that involved cations but none related to TH. In a meta-
the cooling blanket was finessed. If time al- analysis by Peterson, Carson, and Carney
lowed, the ED would place the pads on the (2008), mortality risk and neurologic out-
patient before transporting the patient to the comes were positive when patients with trau-
CCL. The ED would also call critical care, who matic brain injuries were kept hypothermic
would immediately respond to the CCL with for more than 48 hr. However, there was also
the cooling blanket. an increased risk of pneumonia in these same
Each month the critical care leadership and patients.
ED leadership meet to discuss any patient care As cited by Bernard and Buist (2003), stud-
issues and discuss the cases of patients who ies are also being done to see whether TH pro-
have been treated with TH. At the time of vides better outcomes in patients who have
this writing, a new report has been created experienced traumatic cardiac arrest. Wu
that identifies all patients who arrived to the et al. (2008) are conducting studies on an-
ED in cardiac arrest. This report is utilized to imals to determine whether hypothermia
follow-up and see how many patients receive improves neurologic outcomes in cardiac ar-
TH and what their outcomes are. It is also rest due to exsanguination. Other popula-
helpful to audit charts of patients who do not tions where TH is being explored include
receive TH and determine why they did not patients with a diagnosis of stroke, hep-
and whether there are issues that need to be atic encephalopathy, bacterial meningitis, and
addressed. adult respiratory distress syndrome (Bernard
& Buist, 2003).
Therapeutic hypothermia is also being ex-
FUTURE OF THERAPEUTIC HYPOTHERMIA
plored in the pediatric population. Hutchison
At the present time, literature recommends et al. (2008) studied the effects of hypother-
that TH be initiated for patients who have ex- mia on pediatric patients with severe trau-
perienced a cardiac arrest and had a return of matic brain injury and found no neurologic
spontaneous circulation. Studies are already improvement. The American Heart Associa-
showing benefit to not only beginning this tion recommends consideration of hypother-
procedure sooner, while the patient is still in mia in the pediatric patient who has a car-
the ambulance, but also before spontaneous diac arrest. Many pediatric experts are calling
circulation has returned and while cardiopul- for further research before promoting TH in
monary resuscitation is still in progress (Bruel the pediatric population (Hutchison, Doherty,
et al., 2008). Currently the belief is that for Orlowski, & Kissoon, 2008).
TH to be effective, it should be started within Although TH is still debated in the pe-
6 hr of the time of arrest (Green & Howes, diatric population, it is an accepted prac-
2005). However, studies are being conducted tice in newborns with hypoxic ischemic en-
at present to determine whether outcomes cephalopathy. Therapeutic hypothermia has
improve with an extended window of more been shown to reduce mortality and neu-
than 6 hr. rologic deficits. Although there are short-
Studies regarding TH are not limited to term adverse effects, such as thrombocy-
cardiac arrest. One area being explored is topenia, they are greatly outweighed by the
TH for the patient with a severe head injury positive outcomes (Jacobs, Hunt, Tarnow-
(Bernard & Buist, 2003; Clifton et al., 2001). Mordi, Inder, & Davis, 2007).
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October–December 2008 r Vol. 30, No. 4 Therapeutic Hypothermia in the Postresuscitation Patient 329

CONCLUSION Cheung, K. W., Green, R. S., & Magee, K. D. (2006). Sys-


tematic review of randomized controlled trials of ther-
Therapeutic hypothermia after cardiac ar- apeutic hypothermia as a neuroprotectant in post car-
rest with return of spontaneous circulation diac arrest patients. Canadian Journal of Emergency
has been studied extensively throughout the Medicine, 8(5), 329–337.
Clifton, G. L., Miller, E. R., Choi, S. C., Levin, H. S.,
world and the data demonstrate that patients
McCauley, S., Smith, K., et al. (2001). Lack of effect
experience better outcomes when it is imple- of induction of hypothermia after acute brain injury.
mented as soon as possible after arrest, that New England Journal of Medicine, 344(8), 556–563.
is, when the patient reaches 32–34◦ C within Diringer, M. N., Reaven, N. L., Funk, S. E., & Uman,
60 min after initiating TH and stays at this G. C. (2004). Elevated body temperature indepen-
dently contributes to increased length of stay in
temperature, without shivering, for 12–24 hr.
neurologic intensive care unit patents. Critical Care
Emergency departments have an obligation to Medicine, 32(7), 1489–1495.
their patients to not only initiate this proce- Green, R. S., & Howes, D. (2005). Hypothermic modula-
dure but also collaborate with critical care to tion of anoxic brain injury in adult survivors of cardiac
continue the TH protocol. It is the hope of arrest: A review of the literature and an algorithm for
emergency physicians. Canadian Journal of Emer-
NCH that this article will assist others in meet-
gency Medicine, 7(1), 42–47.
ing this goal. Holzer, M., Bernard, S. A., Hachimi-Idrissi, S., Roine, R. O.,
Sterz, F., & Mullner, M. (2005). Hypothermia for neu-
roprotection after cardiac arrest: Systematic review
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