Cool It Induced Hypothermia Therapy Post Cardiac Arrest Learning Packet

Transcription

1 Cl It Induced Hypthermia Therapy Pst Cardiac Arrest Learning Packet At the cmpletin f this packet the learner will: 1. Understand the rles/respnsibilities utlined in the Abbtt Nrthwestern plicy directing the care f the induced hypthermia therapy patient 2. Be familiar with the hypthermia rder sets (Phase I & II must be implemented) and understand hw t access them 3. Verbalize the cmpnents f a baseline neurlgical assessment 4. Identify the safe use f paralytic agents (neurmuscular blcking agents (NMB) including the use f peripheral nerve stimulatrs fr mnitring 5. Recgnize skin assessment findings that will require reprting, treating, and dcumenting 6. Demnstrate the use f the Medivance Cling device including equipment lcatin, access, measuring fr pads, all cnnectins, peratin f the device, and trubleshting 7. Be able t chart induced hypthermia patient data in Excellian 8. Be able t lcate induced hypthermia resurce binder and unit resurces including the super users Review Plicy #CC0021: Induced Hypthermia fr Cmatse Pst Cardiac Arrest Patients. (lcated n the AKN) Review Order Set #31189 Hypthermia Initiatin Phase One Review Order Set #31190 Hypthermia Initiatin Phase Tw-Admissin *Please nte inclusin and exclusin criteria and the specific respnsibilities fr yur rle. All plicies are subject t change with changes in practice recmmendatins. Why induced hypthermia? Randmized cntrlled trials in the use f induced hypthermia in pst cardiac arrest have demnstrated imprvement in neurlgical utcmes in patients wh remain cmatse pst cardiac arrest.additinally, the American Heart Assciatin endrsed a Class 2A recmmendatin supprting the use f induced hypthermia pst arrest fr unrespnsive patients. A. Inclusin Criteria fr Induced Hypthermia Therapy at ANW Nn-traumatic cardiac arrest (this includes: Vfib/Vtach, PEA, Asystle arrests; Level One STEMI; and cardigenic shck patients) Cardiac arrest lasting less than 60 minutes frm cllapse t return f spntaneus circulatin (ROSC) Unrespnsive pst arrest (unable t fllw a verbal cmmand r state their name) B. Exclusin Criteria fr Induced Hypthermia Therapy at ANW SBP less than 90 fr greater than 30 minutes after return f spntaneus circulatin despite the use f vaspressrs Active bleeding Cmatse r vegetative state befre arrest DNR/DNI C. Ptential Cmplicatins Cling and re-warming are the mst unstable perids fr patients underging hypthermia treatment. They may experience any r all f the fllwing: Hyptensin

2 Bradycardia Tachycardia Arrythmias, EKG changes, ischemia, prlnged QT intervals Fluid and electrlyte shifts (ptassium and glucse) Cagulpathies Skin breakdwn/frstbite Rebund hypthermia D. Nursing Interventins **Our gal is t start cling ASAP withut delay** ST segment elevated MI (Level One) patients will g t the CV lab where treatment will start in cnjunctin with angigraphy and pening the vessel. First respnders may als apply ice packs en rute t the hspital. All ther cardiac arrest patients wh meet the criteria per MD, will begin induced hypthermia therapy immediately pst arrest (See belw fr prcess). Studies demnstrated that the faster the cling prcess begins the better the utcme fr the patient. We want t initiate FAST cling, maintain a target temperature f 33 degrees Celsius fr 24 hurs, and then prvide a SLOW re-warming. FAST COOL then SLOW RE-WARM. 1. Pre-hypthermia phase STEMI (Level One) cardiac arrest patients will g t the CV lab based n the Cardilgist s decisin. The paging system fr Level One and Cl it will be activated if this takes place. Once the cardilgist activates the cl it (therapeutic hypthermia paging system) several pages will g ut t the apprpriate departments at nce. In sme cases the ED physician can activate the Level One and Cl it paging systems in cnjunctin with the cardilgy cnsult. The charge nurse f the receiving unit (typically H4200) is alerted t prepare fr the patient. Pharmacy is paged and makes the necessary medicatins. The ICU charge RN ntifies the Intensivist f the patient. Nn-STEMI cardiac arrest patients g directly t the available ICU bed (H4200 preferred). In huse MD/Resident running cde cntacts Intensivist and Cardilgist t determine inclusin/exclusin, and t manage care if hypthermia elected Out f hspital Nn-STEMI cardiac arrest patients: Cardilgist calls Intensivist t determine inclusin/exclusin and t manage care. Cardilgist may begin hypthermia rders ED cardiac arrest. ANW ED MD cnsults the Intensivist and Cardilgist. Cling may begin in the ED. The Cling device, pads, and a bladder/esphageal cre temperature prbe will be placed prir t transprt fr cntinuus cre temperature mnitring. The gal is t begin treatment ASAP. Ice packs are usually applied in the ambulance r ED. Once ICU receives cl it page: Call RT t bring Ventilatr Obtain cling equipment (Cling device, pads, bladder/esphageal cre temp prbe, line placement cart, peripheral nerve stimulatr, resurce manual, p techs have a list f supplies that they use t stck the rm If indicated, sme patients may prceed t CT t rule ut intracranial bleeding prir t cling r during the cling prcess. 2. Cling Phase Once patient arrives n the unit (assume the patient is intubated): Obtain cnsents if able frm family (bedside prcedure time-ut) Place cre temp prbe (bladder r esphageal-end f prbe shuld be at heart level) If fley in place withut thermistrs place esphageal prbe fr temperature mnitring instead and cnfirm placement by chest xray Dcument this initial temperature Place defib pads under cling pads and attach cling pads t pump alng with temperature prbe (see guide fr apprpriate sizing) 40% f the patient s bdy shuld be cvered by the pads, d nt cver breasts Use the extra paper cvering prvided in the cling pad package t wrk arund chest tubes, G-tubes, clstmies, incisins, etc.

3 Large patients will need an additinal universal pad Begin cling-always use autmatic mde (see belw fr device peratin) Patients receiving paralytics can feel pain and anxiety. Sedatin and analgesia shuld be administered prir t paralyzing patient Give sedatin, paralytics and analgesia (per rders) Maintain paralysis/sedatin/analgesia as rdered. Assess time f paralytic blus and cnsider need t re-blus as sedatin and analgesia are titrated. Cnsider secnd blus dse prir t increasing paralytic drip rate. Obtain and dcument baseline vital signs, TOF, and neur assessment (prir t paralytics if pssible) Prepare fr line placement (if pt. ges t CV lab they shuld cme up with central access) Cardilgist will place central line/pa catheter if patient ges t the CV lab Call Intensivist t manage any issues r t insert lines if the patient des nt cme frm the CV lab Insert ral gastric tube and check with abdminal chest xray 3. Maintenance Phase **Gal is t reach the target temperature f degrees Celsius as quickly as pssible** Once target temperature is reached we will maintain the patient at 33 degrees Celcius fr 24 hurs befre beginning re-warming Maintain cre temp f degrees Celcius with cling device(tape esphageal temperature prbe in place if necessary t avid disldgement and interruptin f cling) Dcument time n Flwsheet and in prgress ntes when gal temperature achieved Maintain paralysis/sedatin/analgesia as rdered. Assess time f paralytic blus and cnsider need t re-blus as sedatin and analgesia are titrated. Cnsider secnd blus dse prir t increasing paralytic drip rate. Pharmacy will manage Heparin prtcl until patient is re-warmed Mnitr and reprt abnrmal vital signs, rhythm, cardiac utput, etc. Cardiac utput t be btained using thermdilutin methd. Fick methd is nt accurate in these patients because it assumes the patient s SVO2 is nrmal and due t paralytics and hypthermia it is nt. Cardiac utputs will decrease and SVR increases with cling. Mnitr labs, weight, I/O, QT interval, additinal meds Initiate VAP bundle Frequently assess skin fr frstbite/breakdwn (minimum f every 2 hurs). The device pads can be pulled back fr assessment then put back in place. The pads cannt be cut. Cnsult wund/stmy RN if needed. If patient has an IABP d nt place cling pads ver the catheter. Fld the pad back against itself and leave the IABP catheter and tubing expsed Pads shuld nt be in cntact with thermistrs fley catheter. Wrap a twel arund the catheter and avid cntact with the pads. Any wunds r pen areas shuld nt have pads adhered t patient. Fld pad inward If the patient needs acute dialysis alert dialysis nurse t turn ff warming system n machine Fllw purging prcedure t purge Cling device pads prir t transprt. Bring the Cling device with t any test/prcedure lasting mre than 30 minutes and re-attach t maintain cling. ***VERY IMPORTANT: 16 hurs after target temperature is reached begin fluid lading as rdered t avid marked hyptensin and further brain injury upn re-warming which is caused by warming assciated vasdilatin*** 4. Re-warming Phase Verify fluid lading(if rdered) is cmplete-gal CVP 8-12, PAWP per rders

4 Stp ptassium (K) supplement 8 hurs prir t re-warming, ntifying physician f ptassium level less than 3.5 because rewarming will cause K t mve frm intracellular t extra cellular spaces Verify patient has been at target temperature fr 24 hurs SLOWLY re-warm per rders using the Cling device Prgram Cling device t re-warm at a rate f 0.5 degrees Celcius which will take apprximately 8 hurs (nte: the device will cunteract by cling if the patient s wn bdy tries t re-warm faster than the set rate) Maintain sedatin/ analgesia Cnsult Intensivist with issues Ech and EP cnsult as rdered 5. Pst Treatment Phase Once re-warming t target temperature is reached, paralytics may be discntinued. Mnitr temperature and maintain at 37 degrees Celcius with the Cling device system. Leave pads n and attached t Cling device with water flwing fr up t 8 hurs t prevent rebund hypthermia Once 8 hurs is up and patient temperature remains stable press PURGE key Always PURGE pads prir t discnnecting them frm the Cling device (this takes apprx. 45 secnds) Clsely mnitr the patient fr reflex hyperthermia Obtain rders fr reductin f sedatin/paralytics when apprpriate Neurlgy will see patient n day 2 Cling device pads are ne-time use and may be discarded when treatment cmplete Cntinue t mnitr fr hemdynamic instability and neurlgical changes E. Neurlgical Assessment A baseline neurlgical assessment shuld be perfrmed by a physician prir t initiating cling. This neurlgical assessment will direct inclusin/exclusin f the patient fr induced hypthermia per prtcl. Nurses shuld be sure t include the fllwing in their assessment: Level f Cnsciusness 1. Arusal-what des it take t wake the patient up? N stimulatin Verbal stimulatin Light tuch Single painful stimulus Repetitive painful stimulus N respnse t stimulus 2. Alertness/Orientatin-what is the patient able t d nce awake? Open eyes r make eye cntact Able t fllw a verbal cmmand such as hlding up 2 fingers Oriented x 4 Carries n a cnversatin Disriented but able t carry n a cherent cnversatin Disriented and cnfused but has a nrmal speech pattern Speaks in nly 1-2 wrd sentences Able t nd but nt verbalize Mumbles r grunts in an incmprehensible way N evidence f wakefulness 3. Onging alertness-what des the patient d when n lnger stimulated by speech r tuch? Maintains alertness withut stimulatin Initiates cnversatin

5 Drifts ff t sleep after a few minutes Becmes quickly unrespnsive withut verbal r tactile stimulatin 4. Decreasing level f cnsciusness is the mst sensitive sign f neurlgical deteriratin and may be subtle at first: Restlessness Irritability Agitatin Cnfusin Lethargy Unrespnsiveness The Glascw Cma Scale (GCS) This tl is used t help determine level f cnsciusness. Assessing a patient using the GCS can help t measure change ver time as well, and can be subjective nurse t nurse. (This scre is dcumented in Excellian). F. Hw d yu assess mtr functin in a patient wh is cmatse? Place the upper extremities in a neutral psitin and apply central stimuli (rub the chest area). Observe the patient fr lcalizatin, withdrawal, r psturing. If the patient des nt respnd t central stimuli then apply peripheral stimuli t the nail beds and bserve fr withdrawal. G. Hw d yu differentiate between altered level f cnsciusness and sedatin? Cmplete neur exam prir t sedatin fr baseline assessment is recmmended If patient is unable t verbalize pain, but appears restless/agitated, assume pain is present and treat with cnservative dse f IV piate first. Use APP with sedated and paralyzed patients during cling and then transitin t nn-verbal pain scale when paralytics are discntinued Remember that repeated dses f narctics and sedatives ften have a cumulative sedating effect If the patient is n a cntinuus infusin f narctic r sedative, cnsider reducing/stpping the dse t determine whether LOC imprves as the drug clears the system (pst-hypthermia treatment) Assess fr ther signs f ver-sedatin: hyptensin, respiratry suppressin (nt breathing abve set rate n vent) Cnsider administering a reversal agent (pst hypthermia treatment) Fllw sedatin vacatin prtcl Sedatin rarely causes restlessness r irritability and usually suppresses agitatin. Decreasing LOC n the ther hand, usually prgresses frm restlessness t agitatin t cnfusin and lethargy Assess GCS t determine if a change has ccurred H. Hw d yu assess ther aspects f neurlgical functin as it relates t the induced hypthermia patient? The MD will perfrm a basic neurlgical assessment prir t treatment, if pssible, that may include the assessment f papillary reactin, crneal reflex, Dll s eye reflex, mtr respnse t nxius stimuli and ther reflexes. This may happen prir t the patient s arrival at ANW. Hw are these assessed? 1. Pupillary reactin tests CNII (ptic) and CNIII (culmtr). CNII testing is cnducted by bserving the reactin f the pupil t direct light and describing cnstrictin as brisk, sluggish, r nn-reactive. Cnsensual reactin t light can als be tested by shining a light in the ppsite eye f the patient. The pupil shuld cnstrict when the ppsite pupil is expsed t direct light. The nrmal reactin shuld be brisk.

6 2. CNIII testing includes reactivity t light as well, but lking at the pupil size, shape and equality. Pupil size shuld be 2-5mm in diameter, shape shuld be rund unless pst cataract surgery, and pupils shuld be equal. 3. Crneal reflex tests CNV and is cnsidered a superficial reflex. It is cnducted by gently and rapidly tuching the patient s crnea with cttn tipped swab and watching fr a reflex r blinking. It is recrded as present (nrmal) r absent (abnrmal). 4. Dll s eyes reflex tests CNIII and is used in patients wh cannt cperate with extracular mvement testing (actively fllwing mvement thrugh 6 cardinal fields). It is cnducted by briskly rtating the head frm ne side t the ther and bserving the eyes. The eyes shuld mve in the directin ppsite the head mvement then slwly return t midline. Absent dll s eyes (abnrmal) reflex is indicated by the eyes staying fixed in the scket, r mving in a discnjugate fashin. 5. Respnse t nxius stimuli tests sensry functin in thse patients wh are unable t verbalize their respnse t sensry stimuli. It is cnducted by squeezing the gastrcneumius (calf muscle) r Achilles tendn and bserving fr withdrawal, grimacing, r ther evidence that the patient is aware f painful stimuli (nrmal). 6. The MD may als cnduct additinal neurlgical testing t include testing f ther reflexes. I. Paralytic Agents/Neurmuscular Blckage: Patients being treated with induced hypthermia will be intubated and sedated prir t paralytic agents being used. Shivering, which is a nrmal cmpensatry mechanism as the bdy is cled, is als a symptm that can be harmful t a patient pst cardiac arrest. Shivering causes a large demand fr xygen as the skeletal muscles cntract in an attempt t re-warm the bdy. This increased xygen demand cmes at a time when the heart cannt affrd t cmpete fr xygen. Cnsequently, we will be utilizing paralytic agents (neurmuscular blcking agents) t eliminate shivering. As with ther patients, when NMB agents are used we must sedate and plan fr pain cntrl as well. NMB agents wrk similarly. Mechanism f Actin: These agents cmpete with acetylchline (ACH) at the chlinergic receptr sites f the skeletal muscle membrane, thereby blcking ACH transmitter actin and preventing muscle membranes frm deplarizing Pharmackinetics: Absrbed parenterally, distributed rapidly thrughut the bdy but dn t crss the bld-brain barrier, therefre DO NOT ALTER CONSCIOUSNESS OR PAIN PERCEPTION (hence the need fr sedatin and pain cntrl). Metablized in the liver and excreted in the urine. Drug Examples: Atracurium besylate (Tacrium) and Cisatracurium besylate (Nimbex), Vecurnium Cntraindicatins: Cntraindicated in patients hypersensitive t the drugs. Use cautiusly in pregnant and breast-feeding wmen Adverse reactins: Apnea, hyptensin, skin reactins, brnchspasms, excessive brnchial r salivary excretins Interactins: Mst drugs, such as antibitics and anesthetics that interact will have an ADDITIVE effect. Antichlinergics (nestigmine, pyridstigmine) are ANTAGONISTIC and are used as antidtes t NMBs Nursing respnsibilities: Mnitr fr adverse reactins Suctin as needed (suppresses cugh reflex and causes increased secretins) Keep meds refrigerated t maintain ptency Mnitr fr level f desired effect (see belw fr use f peripheral nerve stimulatrs) Reductin f neurmuscular blckade is evidenced by increased muscle strength, hand grip, head lift, and ability t cugh J. Peripheral Nerve Stimulatr (PNS)-Adult Use **See ANW Critical Care Plicy #CC0096 n the AKN**

7 Peripheral nerve stimulatrs are used t help mnitr the degree f neurmuscular blckade by stimulating a nerve and measuring a respnse in the patient. Mst peripheral nerve stimulatrs have 2 mdes: TOF (train f fur) and Tetanus. WE USE TOF FOR INDUCED HYPOTHERMIA PATIENTS. See rder set fr specific details. The gal will be t maintain 2 t 4 twitches using TOF t suppress shivering. Althugh there are n studies t supprt using TOF mnitring n induced hypthermia patients it is the best methd we have t measure level f paralysis in these patients Train f Fur Percentage f NMB 4 f 4 twitches 0-75% 3 f 4 twitches 75% 2 f 4 twitches 80% 1 f 4 twitches 90% 0 f 4 twitches 100% Prcedure: Gather equipment: peripheral nerve stimulatr and 2 electrdes Explain prcedure t patient and family Select a prper site (see diagrams in plicy) Clean skin and wipe dry Apply patches (pediatric-d nt trim regular electrdes as this can decrease cnductivity) and change every 24 hurs Set energy level t zer Place negative electrde (black) n mtr pint, distally alng the nerve Slwly increase energy level and press and release the train f fur buttn Lk fr the twitch f thumb tward the hand (ulnar site) OR hld patient s hand and feel fr mvement If n twitches bserved, slwly increase energy level and repeat If still n respnse, decrease NMB dse and recheck in ne hur Repeat this prcess decreasing the dse as needed and rechecking ne hur later until patient demnstrates at least ne twitch (gal with induced hypthermia is 2 t 4 twitches). Cnsult physician if TOF is less than 2 ut f 4 twitches Once a stable energy level is fund, reassess using PNS every 8 hurs Trubleshting PNS Make sure skin is clean and dry D nt use edematus areas will cause decreased respnse Assure battery functin f device befre adjusting NMB dse with a 0 f 4 twitch respnse Make sure gel is mist in patches Avid alligatr clips tuching each ther Assure negative (black) electrde is distal J. Skin Assessment Induced hypthermia can put the patient at risk fr skin breakdwn. Cling causes vascnstrictin, hypthermia treatment can reduce the patient s immune respnse, and the use f cling pads directly against the skin has the ptential t cause frstbite. Assess skin by peeling back the cling device pads every 1-2 hurs (The adhesin f the pads shuld last fr 72 hurs, despite assessment activities). Frstbite can have lng term effects including paresthesias, sensry deficits, lss f nails, cld sensitivity, and intrinsic muscle atrphy and can lead t necrsis and sepsis. Frstbite signs and symptms: Cldness/firmness Stinging, burning, numbness Clumsiness

8 Pain, thrbbing, burning, r electric current-like sensatins n rewarming Degree f Injury: As in thermal burns, frstbite injuries may be classified by degree 1 st degree: erythema, edema, waxy appearance, hard white plaques 2 nd degree: erythema, edema, blister frmatin blisters filled with clear liquid (frm w/in 24 hurs f injury) 3 rd degree: bld-filled blisters which prgress t black eschar within weeks fllwing injury 4 th degree: full-thickness damage affecting muscles, tendns, and bnes *Alert MD and wund stmy nurses if frstbite suspected* K. Dcumenting in Excellian A. Neurlgical Data: ICU flwsheet Add peripheral nerve stimulatr grup t the assessment flwsheet by the keywrd train r nerve B. Skin: Mst skin assessments can be dcumented n the ICU flwsheet C. Device: Add Induced Hypthermia Grup (#107785) n VS Flwsheet Add Rw fr temperature device mnitring and label temperature prbe type (esphageal vs bladder) Dcument cling device water temperature every hur This grup includes device, status, patient temperature, secnd temperature surce, shivering preventative measures, and water temp D. Other: A nursing nte shuld be written at the nset f treatment including starting time, cre temperature, baseline neurlgical data, nursing plan and when gal temperature is achieved A nursing nte shuld als be written when beginning the re-warming prcedure (include fluid lading prir t re-warming) and at cmpletin f treatment as well, in additin t usual charting practices L. Use f Medivance Cling Device: Obtaining equipment: ANW has 4 Cling Devices: 2 in the H4200 clean utility rm, 1 in the ED, and 1 in CV Lab Rm 9. The devices have been set up t include the necessary sterile r distilled water and shuld nt need any water unless purging did nt take place prir t discnnect in the previus use. Please check t ensure water level is sufficient (see device manual n pump). Please see the measuring chart lcated n the device fr the prper size and number f pads needed fr yur patient. Our gal is t make sure the pads cver 40% f the bdy surface area (BSA) t ensure best cling btained. Cnnecting pads: Once the pads are placed, put the cnnectrs frm the patient lines int the manifld blck. Make sure that the white side is aligned t the white tape and the blue side t the blue tape. The cnnectrs shuld fit easily and withut effrt. Avid cutting r puncturing the pads. They can be flded back n themselves t avid cntact with nn-intact skin r wunds. Temperature prbe: Place bladder catheter with thermistr r esphageal prbe in patient and cnnect t Cling device temperature adapter prbe. Then place the adapter prbe int Patient temperature #1 prt lcated n the back f the machine. Cling Prcedure: **SEE ORDERS** Turn the device n (back f machine). During a self-check the message screen will display the water level. If lw, refill per trubleshting sectin in the device guide n the machine. Verify settings per rders. Press the DOWN arrw t Patient Target Temperature 33 degrees Celsius. If the Target Temperature is incrrect, fllw directins n the screen t change the target. Press ENTER t cnfirm. Return t HOME SCREEN nce individual parameters are set.

9 Next press the AUTOMATIC key. The autmatic mde cntrls the patient temperature by cntrlling the water temperature in respnse t actual patient temperature and a preset target temperature. ***DO NOT USE OVERRIDE*** The temperature prbe must be attached t the Cling device fr the autmatic mde t wrk. After ne minute, flw will be shwn in the lwer right crner f the display screen. Verify that the water flw is at least 2.3 LPM (fr 4 pads). If it is nt, check the cnnectins and lines and refer t the trubleshting guide n the device. Trubleshting Device: Rewarming: Verify that 24 hurs at target temperature are cmplete and any vlume lading rdered has ccurred. Press STOP key Press the DOWN arrw t Patient Target Temperature Press ENTER t change Once the number flashes, press the UP arrw t reach the desired temperature Press ENTER t save Press the DOWN arrw key t Warm Max Autmatic Mde Press ENTER t change Press the DOWN arrw until rate f re-warming is achieved (see rders). Check that the crrespnding hurs t reach the Time f Target displayed n the screen is accurate Press ENTER t save Press HOME Press AUTOMATIC mde Check t ensure that the Patient Target Temperature displayed n the screen is crrect **Once the system is turned ff the settings will be lst** Discntinuing Hypthermia Treatment: Discntinue paralytic when patient temperature reaches 37 degrees celcius per rders. Cnsult physician t wean drips ff Leave pads n and attached t Cling device with water flwing fr up t 8 hurs t prevent rebund hypthermia/hyperthermia Once 8 hurs is up and patient temperature remains stable press PURGE key Purge functin will autmatically stp when pads are emptied T discnnect pads frm the manifld, press side clips tgether while pushing the plastic cnnectr int the manifld blck. Pull and remve. Discard pads. Turn pwer OFF then remve plug frm electrical utlet M. Resurces: Device resurces: Each unit will have a resurce manual fr induced hypthermia treatment. See the charge nurse if unsure where t btain the resurce manual. Each device will have permanently secured t the device a chart fr measuring and selecting pads as well as a Quick Reference guide which cntains trubleshting tips and basic device functins Medivance (Device manufacturer) can als be reached 24 hurs per day 7 days per week. See the card printed n the device fr phne numbers (r via internet: Cardilgists, Intensivists, and ED are the three main managing physician grups In-huse nursing super user grup exists including H4200 representatives. These representatives can bring questins/cncerns back t the physician representatives.

10 Self-Learning Verificatin Frm: Induced Hypthermia Pst Cardiac Arrest **Signing belw indicates that yu have read this self-learning packet.** Print Name: Signature: Department: Emplyee Number: Date Cmpleted: Once yu have cmpleted this packet please turn this verificatin frm in t yur unit educatr.