1. NURSING GRAND ROUNDS: COMING BACK FROM THE BRINK OF DEATH THERAPEUTIC HYPOTHERMIA Spotlight on the Emergency Department and Intensive Care Unit Geraldine M. Harris, BSN, RN, CEN

2. OBJECTIVES At the conclusion of this presentation, the participant will be able to: Define therapeutic hypothermia (TH). Describe how and when is the appropriate time to initiation therapeutic hypothermia in post- cardiac arrest care. Describe effects of therapeutic hypothermia on the cardiovascular and neurological systems. Understand inclusion and relative exclusion criteria for initiation of therapeutic hypothermia. 3. On Feb 24, 2014, 9:53 PM, Miami-Dade FR unit 72 received a call reporting a young woman with convulsions and not breathing. On duty Paramedics Webb, Aubi and Gutierrez were dispatched to the scene. 4. 29 year-old female unresponsive, pulseless and not breathing. Father reports he heard a thud, and after 2 minutes, he went into the bathroom to investigate. He found his daughter in the bathtub submerged in water. The family pulled her out of the tub and initiated cardiopulmonary resuscitation, most well-known as CPR. 5. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used for anyone who has stopped breathing or whose heart has stopped beating. It is a combination of mouth-to-mouth breathing and chest compressions to help the heart circulate oxygenated blood to the body. According to the American Heart Association (2014), immediate CPR can double or even triple persons chances of survival. 6. Paramedics continued CPR, as the young woman still had no pulse. The cardiac monitor revealed she had dangerous rhythm known as Ventricular Fibrillation. With this rhythm, the lower chambers of the heart are quivering, but no blood is being delivered to the body. Within minutes, this quickly changed to Asystole, meaning the heart completely stopped beating. 7. Endotracheal tube for mechanical support with breathing 8. Return of spontaneous circulation with ECG rhythm Sinus Tachycardia. Her heart was beating; she now had a stable organized rhythm and a palpable pulse. En route to Homestead Hospital Emergency Department for further stabilization and continuation of care. 9. Emergency Severity Index priority One in critical condition. Upon arrival she was receiving assisted ventilations with 100% oxygen, cardiac rhythm remained stable sinus tachycardia with rate of 124, and Blood pressure was stable 114/88. Care team consisted of the primary nurse, Emergency Physician Weinstein, the ED patient care supervisor, several other ED nurses, Emergency Medical Technicians (EMTs) and 2 respiratory therapists on duty. 10. The young womans parents at the bedside provided pertinent history and background information to the staff. The patients name was C. Mesa. She is active and healthy young woman with a past medical history of seizure disorder. Home medications: Tegretol and Lamictal for seizure disorder 11. EMERGENCY DEPARTMENT CARE Placed on the continuous cardiac monitor to detect if there any recurrent arrhythmias. The primary ED physician placed a central venous catheter for medication administration and to obtain blood samples for laboratory diagnostics. A Foley catheter was placed to monitor for urinary output. Nasogastric tube was placed to prevent aspiration of stomach contents. 12. Several medications were initiated to ensure her comfort and stability through the invasive and much needed interventions Intravenous Fentanyl infusions helped reduce experiences of pain. Propofol was administered for Sedation. Nimbex a neuromuscular blocking agent. Intravenous 0.9% Normal Saline Levophed, a vasoactive drug was started to maintain a stable blood pressure. 13. Brain injury and cardiovascular instability are the major determinants of survival after cardiac arrest. Based on current recommendations from the American Heart Association (AHA) Advance Cardiac Life support guidelines Ms. Mesa was a good candidate for post- cardiac arrest Therapeutic Hypothermia (TH). 14. THERAPEUTIC HYPOTHERMIA The initial objectives of post cardiac arrest care are to optimize cardiopulmonary function, vital organ perfusion and obtain good neurological outcomes. The process of lowering a persons body temperature reduces the bodys oxygen demand to reduce the risk of tissue injury from lack of blood flow. 15. THERAPEUTIC HYPOTHERMIA For protection of the brain and other organs, hypothermia is indicated in patients who remain comatose after return of spontaneous circulation. Targets reperfusion injury associated with cardiac arrest or 16. HISTORY OF THERAPEUTIC HYPOTHERMIA In 1950, Bigelow introduced hypothermia as a means of cerebral protection during cardiac surgery. The first reported use of TH for neurologic injury after cardiac arrest was in 1958 in four patients. Between 1997 and 2000, prospective, randomized, controlled clinical trials were conducted in Australia and Europe. (BERNARD, 2006) 17. American Heart Association 2010 Guidelines Therapeutic Hypothermia is now a Class I intervention for out-of-hospital VF arrest 18. THERAPEUTIC HYPOTHERMIA Time of initiation should be less than 4-6 hours from return of spontaneous circulation (ROSC). The sooner it is started, the better the outcome The bodys core temperature should be cooled to 32C-34C for 24 hours. Cooling blankets, intravenous cold saline, ice packs, or cooling pads 19. THERAPEUTIC HYPOTHERMIA Indications and inclusion criteria Cardiac arrest with return of spontaneous circulation (ROSC) Men and Women age 18 and older Endotracheal intubation with mechanical ventilation Glasgow Coma Scale of 8 or less, with no purposeful movement Optimal initiation time should be less than 4 hours from ROSC. 20. THERAPEUTIC HYPOTHERMIA Relative exclusions to therapeutic hypothermia include: Active Do Not Resuscitate Order Minimal Pre-arrest cognitive/neurological status Pulseless for time greater than 60 minutes Significant trauma such as intra-abdominal, spleen or liver laceration major surgery within 14 days or active systemic infection/sepsis (hypothermia my inhibit immune function) Head trauma, stroke, intracranial hemorrhage or uncontrolled bleeding (hypothermia may impair clotting system) 21. A non-contrasted Cat scan of the brain was completed on Ms. Mesa to rule out the possibility of bleeding in the brain. Results were Normal. 22. HOW DO YOU MAKE THERAPEUTIC HYPOTHERMIA WORK IN CURRENT CLINICAL PRACTICE? 23. Therapeutic hypothermia, is managed through collaborative efforts between EMS, clinical staff in the emergency department and intensive care unit. TH can be initiated by trained fire rescue paramedics on the field (chilled NS). The ED team can also initiate the process under direction of physician. ICU addresses management issues of cooling as well as rewarming. 24. THERAPEUTIC HYPOTHERMIA The process begins Within an hour of arrival to emergency department, the cooling process was initiated. Rapid IV infusion of 2 liters of 4C crystalloid fluid was given over 20 -30 minutes to reduce the core temperature. Ice packs placed on axilla and groin. An esophageal thermometer was placed to monitor core body temperature. Water-based Gel Cooling pads were obtained and placed on Ms. Mesa torso and thighs 25. THERAPEUTIC HYPOTHERMIA Plan of care Proceed with Therapeutic Hypothermia Transfer to the intensive care unit (ICU) for management during the cooling process