Name: STATUS POST CARDIAC ARREST ORDERS (PG 1 OF 5) Date f Birth: Rm: Inclusin Criteria Nn Traumatic Cardiac Arrest with Return f Spntaneus Circulatin (ROSC) Cre Temperature greater than (34 C) at presentatin Time t initiatin f hypthermia is less than 6 hurs Cmatse after ROSC : GCS less than 8 and n purpseful mvements t pain Exclusin Criteria Uncntrlled GI bleeding Severe CHF knwn t be present at baseline (NY Heart Assciatin class III r IV) Knwn terminal illness r pre-arrest impaired cgnitive status (unable t perfrm ADL independently) Cnflict with Advanced Directives r DNR status Cardivascular instability as evidenced by : Uncntrllable arrhythmias Refractry hyptensin (unable t achieve target MAP f 75 mm Hg despite interventins) Sepsis as suspected cause f cardiac arrest Suspected intracranial hemrrhage Majr intracranial, intrathracic r intrabdminal surgery within 14 days Gravid pregnancy Check bx t activate desired rders. ORDERS AND PHYSICIAN S SIGNATURE This is nt a stand alne rder set; MUST be used in cnjunctin with unit specific admissin rders) DATE : TIME : (TIME f ROSC : ) ADMIT STATUS : Admit t CCU Admit t ICU DIAGNOSIS : S/P Cardiac Arrest. ADMITTING Allergies/Intlerances/Nature f reactin : PHYSICIAN : CONSULTS : LINE PLACEMENT : PHASE : TIME STARTED : VITAL SIGNS : IV : Critical Care/Pulmnary Neurlgy n all patients Other Arterial line placement (MUST have Arterial line placed) Cling device set up unless placed in ED CVP catheter needed Place temperature - sensing fley t mnitr temp ( 1/4-1/8" adapter fr cling device) (GOAL is t get cre temp t 32-34 C within 6 hrs f nset f arrest) If cre temperature is greater than (34 C) at initiatin f prtcl, blus with refrigerated (4 C) 0.9% NaCl until patient s cre temperature is (34 C). Blus at 100mL/min with a maximum f 2 liters ttal; this is t include ED and EMS vlume. May btain cld saline frm ED. (Omit if 2 L already given by EMS r ED). Place ice packs arund head, neck, axillary areas, and grin fr 20-25 min (include EMS time). Initiate cling device prtcl fr 24 hurs with machine t 33 C, unless t cath lab, start prtcl after lab. Place fley; temperature prbe t cling device. Place rectal prbe t cardiac mnitr fr secndary surce f temperature Crrelate and recrd secndary temp every 2 hurs. Dcument surce f secndary temp (may be rectal r central catheter). IF patient has recurring arrhythmias, discntinue active cling, begin re-warming & call MD STAT. IF unable t btain target cre temperature cnsult MD fr further cling rders BP, MAP, HR, O2 sat, and cardiac rhythm every 15 min x 4, every 30 min x 4 then hurly and prn. Check CVP every hur. Recrd fley temperature every 15 minutes until (32-34 C) is achieved. Then every 30 minutes until rewarming cmpleted. D nt cl less than (32 C) 0.9% Sdium Chlride at ml/hr If pssible, fluids shuld be dextrse free with the exceptin f standard infusins r Rx f hypglycemia.
Name: STATUS POST CARDIAC ARREST ORDERS (PG 2 OF 5) BP & VOLUME MANAGEMENT : ANALGESIA Date f Birth: Rm: Gal is MAP > 75 and < 120 mm Hg Replace urine utput every 1 hur with : 0.9% NaCl 0.45% NaCl Lactated Ringers using : 0.5 ml / 1 ml IVF replacement t urine utput 1 ml / 1 ml IVF replacement t urine utput Observe clsely fr fluid verlad. CVP gal f 6-10 mmhg Additinal IV vlume supprt : Nrepinephrine IV start at 0.5 mcg/min and titrate as needed t keep MAP greater than 75. Other pressr agent : Nitrglycerin IV, start if MAP ver 120 r. Start at 5 mcg/min, increase by 5 mcg/min increments every 3-5 min unitl a BP respnse is nted. Use nnverbal pain scale t assess fr pain/discmfrt prir t administering a Neurmuscular Blcking Agent Gal fr analgesia : less than 3, n the 1-10 Nnverbal Pain Scale, r minimal pain behavirs. APP scale will be used fr patients receiving Neurmuscular Blcking Agent r prpfl. Fentanyl mcg/hr (range: 0.5-2 mcg/kg/hr) cntinuus infusin. (Cnsider if patient is hemdynamically unstable r has renal insufficiency, r if GFR < 30 ml/min.) OR : 0-2 n pain 3-6 mderate pain 7-10 severe pain - use app Mrphine mg (0.1 mg/kg lad; typically 5-10 mg), then mg/hr IV cntinuus infusin (range: 0.8-10 mg/hr IV) If piate verdse in differential (small pupils, unrespnsive and/r track marks), cnsider : Nalxne : 0.4 mg IV ; (may rder every 2-3 min as needed up t 2 mg; d nt cl further if awakens and neurlgic deficit reslves) SEDATION Lrazepam : mg IV x 1 (range 1-2 mg) Midazlam : mg/hr (range 2-5 mg/hr) NEUROMUSCULAR BLOCKING AGENT (Fr preventin f shivering) DVT PROPHYLAXIS STRESS ULCER PROPHYLAXIS Prpfl Infusin : mcg/kg/min (5 mcg/kg/min initially) cntinuus infusin, titrate every 5 minutes until at gal (range : 5-50 mcg/kg/min IV). Mnitr triglycerides after 48 hurs. Dsing nt t exceed 80 mcg/kg/min. Vial and tubing must be changed every 12 hurs. Cnsider discntinuing prpfl after 2 days; cnsult with MD fr further sedatin requirements. Befre starting neurmuscular blcking agent, verify that the patient is adequately medicated with analgesic and sedative agents at gal and receiving mechanical ventilatin. Obtain baseline "train f fur" then every 1 hur. Adjust degree f neurmuscular blcking agent t achieve 2/4. If unable t btain train f fur, titrate neurmuscular blcking agent t prevent shivering. Vecurnium : mg (0.1 mg/kg) IV blus x 1 (unless full neurmuscular blcking agent blus given by ED r EMS) Vecurnium : mcg/min (range : 0.8-1.2 mcg/kg/min) cntinuus infusin. (Standard pharmacy slutin). Avid in significant renal r hepatic impairment. If significant renal (GFR < 30) r hepatic dysfunctin, cnsider: Cisatracurium : mg (0.2 mg/kg) IV blus x 1 (unless full neurmuscular blcking agent blus given by ED r EMS) Cisatracurium : mcg/min (range : 2.5-3 mcg/kg/min) cntinuus infusin Sequential cmpressin devices (SCDs). Use Ft Pumps if unable t use SCDs Heparin 5000 units subcutaneusly every 8 hurs OR : Enxaparin 40 mg subcutaneusly daily (autmatic adjustment fr GFR < 30 ml/min) Famtidine 20mg IV every 12 hurs stress ulcer prphylaxis (autmatic substitutin permissable) If GFR < 30 ml/min, give Famtidine (Pepcid) 20 mg IV every 24 hurs.
STATUS POST CARDIAC ARREST ORDERS (PG 3 OF 5) OTHER MEDICATIONS Date f Birth: Rm: Lacrilube t bth eyes every 4 Hurs and PRN while n neurmuscular blcking agent. Fr intubated/trached patients : Fllw ICU Oral Care Plicy NURSING : VENT MANAGEMENT : Insert NG/OGT t lw cntinuus wall suctin Intake and utput hurly; Call MD if urine utput is less than 0.5 ml/kg/hr despite abve vlume given Mnitr CVP and A-line; use saline flush nly fr pressure line D NOT bathe patient during hypthermic r rewarming perid Vent Settings : N warm humidified air ABG every (maintain PaCO2 35-45) IF NOT DONE IN ED : STAT LABS : STAT DIAGNOSTICS LABS EVERY 6 HOURS X 24 HRS BMP Trpnin UA PCXR CBC, BMP and ABG CBC PT/PTT Serum & Urine Tx Serum Albumin PCXR 12 lead ECG BMP PT/PTT 12 HOURS Bld Culture x 2 AFTER START OF PROTOCOL DAILY Ca/Magnesium/Phs CBC with diff Ca/Magnesium/Phs Lactate Type & Screen Ntify MD if Hgb < 10 ABG (temp crrected) Urine HCG Female (Age 10-55) OTHER LABS OR DIAGNOSTICS ELECTROLYTE REPLACEMENT Trpnin every 8 hurs x 24 hurs CK s every hurs x D nt replace ptassium unless serum ptassium is less than 3mEq/L during cling phase. Call MD fr specific replacement dse. Make sure time t rewarm phase is cmmunicated. DO NOT USE PRE-EXISTING ELECTROLYTE REPLACEMENT ORDERS
STATUS POST CARDIAC ARREST ORDERS (PG 4 OF 5) Date f Birth: Rm: **************** PHASE: A. TIME STARTED: B. TIME STARTED IN ED: C. TIME FINISHED: ********************************************************************************************************** Target Temperature (36.1-37 C) Begin rewarming 24 hurs frm time cling was started Target temperature t be btained in apprximately 18 hurs; STOP re-warming nce (36 C) is reached t prevent versht. Rewarming gal f 0.17 C/hr. Remve warming garments frm patient. Empty fley at start f rewarming. Strict I & O (see vlume relacement sectin) Activate re-warming (prgram warming device fr 0.17 C/hr and 36 C). Call MD if warming > 0.5 C/hr. If external cling devices used, remve cl packs. May place warm blankets (d NOT use Bair Hugger) if needed Mnitr temp/vs/rhythm clsely every 30 minutes until target temp is reached, then every 1 hur x 12 additinal hurs, fllwed by temp/vs every 4 hurs IF patient remains nrmthermic r mre if cnditin warrants Cntinue sedatin and neurmuscular blcking agent until temperature is equal t r greater than 36 C. (Discntinue neurmuscular blcking agent first, then wean sedatin.) D nt permit temperature greater than 37 C in first 24 hurs after cling phase. IF temp greater than (37 C) administer acetaminphen Cntinue labs as rdered (anticipate increase in ptassium) Cntinue mnitring I & O every 1 hur (anticipate hypvlemia) Once nrmthermic gal reached at end f 48 hurs, cnsult with MD service fr D/C f femral line if present. Acetaminphen : Rute 650 mg abve 37 C X 48 hurs. per feeding NG tube PR If given via tube, clamp x 30 min. Dsage nt t exceed 4 gm / 24 hurs every 4 hurs PRN temp SHIVERING : Observe fr shivering every 1 hur If ff neurmuscular blckade, and shivering ccurs during rewarming phase apply warm blankets. Hydrmrphne 1 mg IV, may repeat in 5 minutes x 1 IF abve methds(s) ineffective, call MD STAT fr further rders (may need t restart neurmuscular blcking agent and sedatin). Physician signature required : Transcribed by : Checked by (Nurse) : Beeper # : ---
1) 2) STATUS POST CARDIAC ARREST ORDERS (PG 5 OF 5) Date f Birth: Rm: Physician Infrmatin (Guidelines - d nt replace physician judgment) Ptassium less than 3.4 meq/l early in cling (first 12 hurs) - replace Ptassium Chlride with 40 meq by NG Ptassium less than 3.0 meq/l late in cling (12-24 hurs) - replace Ptassium Chlride with 40 meq by NG (Ptassium tends t rise n rewarming) 3) 4) 5) 6) 7) Hgb less than 10 - Transfuse PRBCs Platelets less than 30,000 - transfuse 2 packs Platelets 30,000-50,000 with bleeding transfuse 2 packs During rewarming there is an smtic diuresis - replace vlume slightly greater than 1 : 1 t urine utput Treatment f Hyperglycemia (nn-diabetic) : glucse 200-249 - 2 units reg insulin, 250-299 - 3 units reg insulin, 300-349 - 4 units reg insulin, 350-400 - 5 units reg insulin 8) 9) INR > 2 crrect with FFP 2-4 units + vitamin K (if n Warfarin) Temp < 31 C - cnsider 250 ml blus f warmed 0.9% nrmal saline and warming blanket 10) Unable t cl t temp 32-34 C - cnsider 250-500 ml 4 degree 0.9% sdium chlride 11) Magnesium < 1.7-2 grams Magnesium Sulfate IV 12) Crrected Calcium < 8.4 - Calcium Chlride 1 gram IV (Calcium level shuld be crrected fr decreased albumin : Crrected calcium (mg/dl) = measured ttal Ca (mg/dl) + 0.8 (4.0 - serum albumin [g/dl]), where 4.0 represents the average albumin level) ** NOTIFY MD IF : Magnesium < 1.7 Crrected Calcium < 8.4 Ptassium < 3.4 Hgb < 10 Platelets < 30,000 Platelets 30,000-50,000 with bleeding Glucse > 200 Temperature Cnversin Chart C F 31 32 87.8 89.6 33 91.4 34 93.2 35 95 36 96.8 36.1 96.98 37 38 98.6 100.0 39 102.2