- Количество слайдов: 12
Part 2 Union Hospital, Inc. Emergency Department
UHTH ER Policy • • • Patient must satisfy all of the inclusion criteria and have no exclusion criteria prior to the initiation of cooling. Once criteria decision met, Notify House Supervisor, Bed Control and ICU Charge Nurse of TH patient. Confirm ICU bed assignment. Initiate Induction Therapeutic Hypothermia Post Arrest Routine Order Set per physician orders. 1: 1 staffing will be maintained for this patient by a RN or paramedic that has demonstrated competency. During the cooling phase the patient will be intubated to maintain a patent airway and oxygenation, as well as sedated and paralyzed to prevent shivering. Provide patient’s family education and support. 1. Explain the purpose of hypothermia and the need for pharmacologic paralysis. 2. Encourage the family to continue to talk to the patient. 3. Provide emotional support and answer any questions. 4. Offer pastoral care support to the family. Facilitate communication between the family and the physician.
1: 1 Staffing • Upon notification of the ICU charge nurse that this patient will have Therapeutic Hypothermia induced, ICU charge nurse to come to ER to assist with patient monitoring/transfer.
Determining Inclusion/Exclusion • Patient must meet Criteria • We must have a confirmed ICU Bed Assignment from ICU Charge Nurse
Implement Induction Orders Nursing Protocol • • • Target Temp 33° C Initial Core Temp_____ Time Cooling Initiated_____ Confirm eligibility criteria met. Notify ICU, House Supervisor of TH patient. Patient Monitoring – – – – – Vital Signs Q 15 min X 1 hour, then hourly. Core Temperature Q 15 min until target reached then hourly. Continuous ECG monitoring. BIS Monitoring Glasgow Coma Scale hourly. FSBS hourly. I & O hourly. Assess skin Q 2 hour. Obtain patient weight.
Nursing Protocol-Cont’d. • • NPO Insert NG/OG Tube to low intermittent suction. Insert Thermistor Foley with urometer Insert 2 Lg Bore peripheral IV’s. Preferrably 18 gauge no smaller than 20. • HOB elevated to 30° • Administer sedation and neuromuscular blockade before initiating cooling measures.
Physician Protocol • • Patient meets criteria for Induced Therapeutic Hypothermia Admit Inpatient to ICU. Labs-CBC, CMP, Phos, Mag, PT INR, PTT, Lactate, Amylase/Lipase, ABG, UA, LDH, Troponin, CKMB, BC X 2, Urine Tox, Urine Hcg if indicated. Diagnostics-CXR, 12 Lead EKG Consults: Notify of Post Arrest Induced Therapeutic Hypothermia Protocol-Cardiology, Neurology, or Other Vent-Vent setting per vent orders. Remove heat from ventilator circuit. Arterial Line
Pharmacy Protocol • • Prior to initiating cooling measures Induction Acetaminophen 650 mg per NG/OG Q 6 hr. Buspirone 30 mg per NG/OG Q 8 hr. Midazolam 5 mg IVP once. Cisatracurium 0. 2 mg/kg IV once. Fentanyl 50 mcg IV once.
ED Cooling Measures • • • Fluids-Infuse 2 liters 0. 9% NS chilled to 4° C over 30 minutes- Do Not give if clinical evidence of CHF. Do Not give cold fluid via a jugular or subclavian line. Place each chemical cold pack in stockingette prior to applying to patient. Place 14 chemical cold packs to patient’s neck, axilla, groin and chest. (2) 1 each axilla (4) 1 under neck 1 on top of neck 1 on each side of neck (2) 1 in each groin (2) 2 on the chest (4) 1 on inner and outer thigh Remove cold packs for temps less than 32°C.
Pharmacy Protocol-Maintenance • Midazolam 1 mg/ml IV continuous infusion. May increase by 1 mg/hr every 15 min to maintain sedation. (Maximum 10 mg/hr) • Cisatracurium 3 mcg/kg/min IV • Fentanyl 0. 5 mcg/kg/hr IV
Code Cool Kit • • • Temp sensing Foley with cable BIS electrode 14 Chemical cold packs Stockingette Copy of Induction Order Set
Monitoring Parameters • • Notify MD if: Shivering-notify MD immediately. Seizure-Notify MD immediately. Hypotension SBP< 90 mm. Hg Or bradycardia HR < 50.