Code Cool Post ROSC Induced Hypothermia

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Section 4 - CARDIAC

4.12 CODE COOL – POST ROSC INDUCED HYPOTHERMIA

Indication

ROSC (return of spontaneous circulation) post VF/VT resuscitation (non – trauma)

Utilization:

  • ROSC
  • Age ≥ 18
  • Temperatures > 34°C (Tympanic measurement) repeat measurement for possible change.
  • Unresponsiveness to pain
  • Intubated with EtCO2 > 20 mm Hg
  • Not obviously pregnant

Preparation for Induction – Hypothermia

  • NEURO assessment:
  • Pupils (size, reactivity, equality)
  • Motor Response to Pain
  • Remove clothing, protect modesty
  • Apply cold packs to axilla and groin
  • Goal EtCO2 = 40; NO Hyperventilation
  • Attempt second IV/IO (if not in place)

Transport to the closest hospital with cooling capabilities:

  • Central Florida Regional Hospital
  • Florida Hospital facilities
  • South Seminole Community Hospital

Induction of Paralysis: (prevention of shivering)

  • Administer Versed or Morphine (IV/IO/IN) or Valium (IV/IO) titrated dose to effect.

Saline infusion and Maintenance of Mean Arterial Pressure (MAP)

  • Initiate cold saline bolus through up to two (2) IV or IO access points
  • Infuse cold saline at 30mL/kg to max of 2 Liters
Weight (lbs) Weight (kg)

Volume Target (mL)

88 40 1200
110 50 1500
132 60 1800
≥143 ≥65 2000


  • Target Mean Arterial Pressure (MAP) 90 – 100
  • Check MAP on the LP12, but manually monitor
Systolic Diastolic MAP
110 80 90
120 75-90 90-100
130 70-85 90-100
140 65-80 90-100

MAP = Diastolic Value + 1/3 Pulse Pressure

Target Diastolic: 80 – 90

If chilled saline does not maintain MAP continue to maintenance of MAP with vasopressors

Maintenance of MAP with vasopressors

  • Support B/P with Dopamine as required to Maintain MAP of 90-100

Dopamine 400mg/250mL/NaCl

Weight (lbs) Weight (kg) 5mcg/kg/min 10mcg/kg/min 20mcg/kg/min
88 40 8 15 30
110 50 9 19 38
132 60 11 23 45
154 70 13 26 53
176 80 15 30 60
198 90 17 34 68
220 100 19 38 75
242 110 21 41 83


  • Patient assessment is critical for ongoing care, with any new signs of patient movement (i.e., gasping, eye fluttering, shivering, seizure activity, movement) during ICE therapy, administration of 10mg Versed and 10mg Morphine is required. (Additional may be needed)
  • Reassess patient’s airway frequently and with every movement
  • Cold saline is a strong vasoconstrictor, maintaining cerebral perfusion is essential during the therapeutic hypothermia process. Maintain MAP at 90 – 100 mmHg
  • Monitor EtCO2 frequently and target 40 mm Hg, If EtCO2 falls below 20 mm Hg, consider possible loss of pulses.
  • If there is a loss of ROSC at any time, discontinue cooling and go to appropriate protocol for treatment. Chilled saline infusion should be slowed to KVO rate during the resuscitative process. Upon ROSC (if attained) return chilled saline to wide open infusion.
  • Chilled saline is infused at 30mL/kg to a maximum of 2000 mL.
  • Continue to address specific differentials (H’s and T’s) associated with original dysrhythmia or cause of arrest


Contraindications for “Code Cool”

  • PEA and Asystole
  • Active Bleeding
  • Hemodynamically unstable arrhythmias
  • Sickle Cell Anemia
  • End Stage Terminal Disease
  • Obviously Pregnant

Relative contraindications for “Code Cool”

  • Prolonged QT (consider pacing)
  • Cryoglobulinemia (single or mixed immunoglobulins that undergo reversible precipitation at low temperatures)
  • Raynaud’s Phenomenon