A Case study on the successful use of Therapeutic Hypothermia for post-cardiac arrest patient

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
(EMT’s) and 2 respiratory therapists on
duty.

10.  The young woman’s parents at the
bedside provided pertinent history and
background information to the staff.
 The patient’s 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 person’s body temperature
reduces the body’s 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

19. 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 body’s core temperature should be cooled
to 32°C-34°C for 24 hours.
 Cooling blankets, intravenous cold saline, ice
packs, or cooling pads

20. 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.

21. 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)

22.  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.

23. HOW DO YOU MAKE THERAPEUTIC
HYPOTHERMIA WORK IN CURRENT CLINICAL
PRACTICE?

24.  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.

25. 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 4°C 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

26. THERAPEUTIC HYPOTHERMIA
Plan of care
Proceed with Therapeutic
Hypothermia
Transfer to the intensive care unit
(ICU) for management during the
cooling process