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Post-arrest patient? Consider therapeutic hypothermia
Advocate for your patient
Is a cardiac-arrest patient failing to wake up and follow commands? "Therapeutic hypothermia is one of the few therapies we can offer," says Marion Leary, BSN, RN, assistant director of clinical research at the Hospital of the University of Pennsylvania's Center for Resuscitation Science in Philadelphia.
Leary says that all ED nurses should advocate for any post-arrest patient who is not actively following commands, such as nodding yes or no or giving a "thumbs-up." "Moving arms sporadically, or seeming like they are trying to pull out the endotracheal tube, may not actually be following commands," she adds.
In those cases, more than likely the patient would benefit from therapeutic hypothermia, she explains. "Once you decide not to cool, there is no going back if the patient does not wake up in the days following," adds Leary.
Benjamin Abella, MD, MPH, clinical research director of the Center for Resuscitation Science and assistant professor of emergency medicine at the Hospital of the University of Pennsylvania, says that he is somewhat surprised that EDs have been slow to implement therapeutic hypothermia, "as the evidence has been around for almost 10 years."
One reason for this, he says, is that it requires careful coordination of care between the ED, the intensive-care unit, and cardiology. "If a new therapy occurs very much within the ED, it is a lot easier to implement than something that requires that kind of coordination," he explains.
Also, courses and lectures tend to cover the data on therapeutic hypothermia and not the "nuts and bolts" of clinical practice, adds Abella. "If an ED in 2011 wants to start this, there are a lot of details you need to know," he says. "Who do you cool, and who do you not cool, for example?" (For information on therapeutic hypothermia course, see resource box below.)
Abella estimates that about half of EDs are doing therapeutic hypothermia currently. "One of the most important roles for ED nurses is to serve as champions to make the therapy happen," he says. "ED nurses are often the leaders in developing these protocols."
Abella says that when a patient comes into an ED after a cardiac arrest, an attending ED physician may not be aware of the therapy or be comfortable with it. "The ED nurse can say, 'Should we be thinking about hypothermia, for this patient? Have you considered it?'" he says. "It may not be indicated for some patients, but it should at least be considered."
Though the treatment is not as time-sensitive as thrombolytics for stroke patients, says Abella, ideally it should be started within several hours of the arrest. "In most cases, it needs to be started in the ED," he adds. "It's very difficult for ED staff to rationalize that it can be started upstairs, when we all know these patients often take several hours to get where they need to go." (See related stories on preventing skin breakdown and recommended clinical practices, and steps taken by ED nurses, below.)
For more information on therapeutic hypothermia in the ED, contact:
Therapeutic hypothermia? Prevent skin breakdown
Skin breakdown can occur if your patient is undergoing therapeutic hypothermia, warns Marion Leary, BSN, RN, assistant director of clinical research at the Hospital of the University of Pennsylvania's Center for Resuscitation Science in Philadelphia. Always check the patient's skin prior to applying any external cooling wraps, she recommends, and make sure to fill those wraps prior to placing them on the patient.
"If they are placed on the patient before they are filled, they could become tighter when the water is introduced and constrict the patient," explains Leary.
Use these clinical practices when cooling ED patient
When your ED patient is undergoing therapeutic hypothermia, don't underestimate how well the ice cools down the patient, says Louise Anderson, RN, an ED nurse at Abbott Northwestern Hospital in Minneapolis, MN, where ED nurses have utilized a hypothermia protocol since 2006.
"A nurse once told me she was sure the cooling device was 'broken,' because when she applied the device, the patient was being warmed, not cooled," she says. In this instance, explains Anderson, the patient had gone below the target temperature of 33 degrees Celsius, so the device was warming the patient back to the target temperature. Here are other clinical practices to improve care of therapeutic hypothermia patients:
Don't forget about paralyzing and sedating the patient.
"I have been asked before why we cool down the patients before we start the continuous infusions of sedation and paralyzing meds," says Anderson. "Imagine how it might feel as a patient being cold and not able to move."
The key, says Anderson, is to give the patients intravenous push "bumps" of paralyzing and sedation medication until the continuous drips are available. "Of course, you need a doctor's order for these, but don't be afraid to use them," she says. "As long as you have an adequate blood pressure, don't be afraid to maximize the recommended dosage."
Anderson cared for a patient who was hypertensive, and was admitted to the Cardiac Intensive Care Unit after a cardiac procedure. "They were having a difficult time getting his blood pressure within normal range, even using continuous infusions of antihypertensive meds," she recalls.
The patient had no history of hypertension, says Anderson, and the medical team could not figure out why he was so hypertensive. "As it turned out, the patient was under-sedated," says Anderson. "Once the sedation medication was titrated up, the patient's blood pressure came down to within normal range."
Start therapy as soon as possible.
Get the patient to target temperature within four to six hours of return of spontaneous circulation, recommends Marion Leary, BSN, RN, assistant director of clinical research at the Hospital of the University of Pennsylvania's Center for Resuscitation Science in Philadelphia. "When inducing therapeutic hypothermia, paralytics and sedation should be considered to prevent shivering. This will decrease the metabolic work load, which will increase oxygen consumption," she explains.
Use a reliable temperature monitoring source.
Use either a bladder or esophageal probe monitor, says Leary. "A rectal probe is the least reliable of the three modes," she says. "There is a greater temperature lag between that mode and the patient's actual temperature. This could be a concern if the target temperature overshoots."
Take these steps to avoid harmful delays
For the best outcomes with therapeutic hypothermia, patients should be cooled within 30 minutes of the return of spontaneous circulation following a cardiac arrest, according to Louise Anderson, RN, an ED nurse at Abbott Northwestern Hospital in Minneapolis, MN. "The sooner the patient is cooled, the better the outcomes," she says. Abbott's ED nurses take these steps:
All unresponsive, resuscitated arrests have ice placed to their axilla areas and groin areas immediately.
"We receive many patients from outside and out-of-state hospitals," says Anderson. "The staff have been instructed to immediately apply ice to these patients before they are sent to us."
A rectal baseline temperature is obtained on the patient.
"This is not always the priority when you are caring for an acutely ill patient, but it is crucial to have a baseline temperature recorded," says Anderson.
The cooling device is applied to the patient when time allows.
"If the patient needs to go to a test such as a CT scan, don't delay the CT," says Anderson. "They can go with the ice on, and apply the device when they return."
A continuous temperature monitoring device is inserted.
"We use the esophageal probe," says Anderson. "Studies have shown this to be a more accurate core temperature than the rectal or bladder."