Running head: THERAPEUTIC HYPOTHERMIA

Therapeutic Hypothermia with Cardiac Arrest

Angel Jacobs, LPN
Hondros College School of Nursing
NUR 296
August 17, 2014

THERAPEUTIC HYPOTHERMIA

Therapeutic Hypothermia with Cardiac Arrest

The use of therapeutic hypothermia following cardiac arrest has been an area of interest
for cardiologist and clinicians since the 1950s (CCJM, 2011). The interest was rekindled in the
1990s following positive results in a study involving animals. There have been numerous trials
since that time which suggest there is a significant benefit to utilizing therapeutic hypothermia in
cardiac arrest patients. Most notably is the 2010 recommendation by the American Heart
Association (AHA). The AHA guideline for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care states that therapeutic hypothermia has been shown to improve outcomes
for comatose adult victims of witnessed out-of-hospital cardiac arrest due to ventricular
fibrillation (CTAF, 2011).
Therapeutic hypothermia involves cooling the internal body temperature of a cardiac
arrest patient to 32C to 34C in an effort to preserve the bodys energy and oxygen supplies.
This reduces the risk of brain damage following a cardiac arrest by basically leaving more
oxygen supply for the brain. The primary criterion for this intervention is the adult patient who
has a cardiac arrest with a returned heartbeat but remains unresponsive. If the patient is
responsive then this indicates brain activity after the arrest. Compromising this state would be
contraindicated (CMJ, 2011).
Absolute contraindications include hemorrhagic stroke (which must be proved by
computed tomography) and cardiac arrest due to trauma. Other major contraindications are a
Glasgow Coma Scale score of 8 or higher before the initiation of therapeutic hypothermia,
cardiac arrest due to drug overdose, and preexisting hypothermia when first-responders arrive
(CCJM, 2011). Relative contraindications include baseline coagulopathy and severe hypotension
that is not correctable by fluid infusion, vasopressors, or invasive hemodynamic support.

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As with any type of intervention, there are risks and benefits. Some risks include adverse
effects such as hypokalemia, bradyarrhythmia, ventricular tachycardia, hypotension, seizures,
hyperglycemia, a transient decrease in the glomerular filtration rate, abnormal coagulation
studies, and an increased incidence of pneumonia and sepsis (CCJM, 2011). Careful monitoring
of the patients vital signs, labs, and most importantly, core body temperature is essential.
Once a patient has been identified as a candidate for therapeutic hypothermia, the quick
action of the emergency department team of physicians, cardiologists, and nurses is crucial.
Rapid cooling over the course of 1-3 hours is the goal of phase one or the induction phase.
During this time a triple lumen central venous line is accessed. Sedatives, pain management, and
neuromuscular blockers (NMB) are started. The preferences for sedatives are Ativan, Versed, or
Propofol. Fentanyl is the pain management of choice. Norcuron is the preferred NMB (CCJM,
2011). Additionally, deep vein thrombosis prophylaxis is initiated by using SCDs, Heparin,
Lovenox, or Arixtra. A Foley catheter should be inserted and a bladder probe is used to measure
core body temperature. Some clinicians administer cold IV fluids in addition to surface cooling
pads. In this event, the patient should be closely monitored for fluid volume overload. Lactated
Ringers or Normal Saline 0.9% is the fluids of choice. Cooling pads should be placed on the
patients legs and torso. It is recommended that the cooling pads cover 40% of the patients total
body surface (CCJM, 2011). Phase two or the maintenance phase involves maintaining the core
body temperature at 32C to 34C. By this point, the patient should be admitted into the
intensive care unit (ICU). Phase three or the rewarming phase involves the slow controlled
rewarming of the patients core body temperature to 36.5C to 37.5C. Most cases take 17-20
hours to achieve this. Phase four or the normothermia maintenance phase involves maintaining
normothermia. Avoiding rebound hyperthermia for the next 24 hours during this phase is

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essential in recovery. Aggressively managing shivering and fever is crucial. During phase four,
the patient is titrated off of the NMB.
Throughout all four phases, the nurse must closely monitor the patients electrolytes,
especially potassium, magnesium, and phosphate. The patients blood sugar levels, CMP, CBC,
and ABGs should be closely monitored as well. The patients skin under the cooling pads should
be assessed every 4 hours due to vasoconstriction and decreased perfusion at the skins pressure
points.
Dr. Sanju Varghese, Chief of Staff at Springfield Regional Medical Center (SRMC), was
recently interviewed by Allison Wichie, staff writer for the Springfield News Sun, regarding the
hospitals use of therapeutic hypothermia (Springfield News Sun, 2014). Varghese states that
SRMC has treated eight patients with therapeutic hypothermia following cardiac arrest. He
claims that eight out of the eight patients treated have had successful recoveries (Springfield
News Sun, 2014).
Overall, the research that I have found suggests positive recovery in cardiac arrest
patients when utilizing therapeutic hypothermia. The benefits appear to outweigh the risks
provided the proper evidenced based practice guidelines are upheld and carried out. As time
goes on, I would suspect that there will be additional data to support the use of therapeutic
hypothermia in cardiac arrest patients. This will undoubtedly raise awareness to the benefits and
increase the use of this intervention among healthcare providers.

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References

Oommen, S., & Menon, V. (July, 2011). Review. Retrieved from Cleveland Clinic Journal of
Medicine: http://ccjm.org
Tice, J. (July, 2011). CTAF. Retrieved from Medscape: http://www.medscape.com
Wichie, A. (2014, June 5). Springfield News Sun. Retrieved from Springfield News Sun:
http://www.springfieldnewssun.com