MSSM Therapeutic Hypothermia Project
Thank you for filling this form out for all of your comatose survivors of cardiac arrest.
* Required
Your Name
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Medical Record Number
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Does this patient meet ALL inclusion criteria?
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All boxes must be checked or patient is excluded. Remember criteria differ between Sinai and Elmhurst.
Cardiac Arrest due to VF or PVT with ROSC
CPR within 15 minutes of collapse
ROSC within 1 hour of collapse
Initiation of hypothermia within 6 hours of collapse
Comatose: Patient is unresponsive
Initial body temperature must be greater than 30•C
Hemodynamically stable: patient receiving at most a single vasopressor with MAP > 60 mmHg
Does this patient meet ANY exclusion criteria?
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Any box check renders patient ineligible for induced hypothermia
Pre-event considerations: DNR, poor baseline, terminal condition
Coma unrelated to arrest (intox, electrolytes, head trauma, CVA, status)
Uncontrolled Cardiac Arrythmia
Bleeding: Active Bleeding, INR >1.7, PTT >1.5xnormal, PLTs <50,000
Pregnancy
Prolonged pre-protocol Hypoxemia: 02 sat <85% for more than 15 minutes
History of Cryoglobulinemia
Prolonged pre-protocol hypotension: MAP <60 mmHG for >30 min
CCU/Neurology Discussion Time
Our protocol requires an ICU bed and agreement with CCU and Neurology. Please document the time of this discussion here.
CCU/Neurology Disagreement Reason
If a patient is excluded from the protocol based on factors other than inclusion/exclusion criteria, please make note of that here.
Start Time
Please document the time of initiation of any ED hypothermic measures (IV cold saline, Cooling Blankets, Arctic Sun)
Initial Patient Temperature
Total Saline Infused
Time Patient reaches 34•C
This will usually be the time patients are cooled down to 34•C, but should also include the time patients hypothermic between 30-34•C on arrival drift UP to 34•C
Complications
Overshoot (Moderate Hypothermia - Temp <32•C)
Dysrhyhmia
Bleeding
Shivering
Hypotension
Other (document below)
Other Complications
ED Rewarming Time
Occasionally patients will require rewarming in the ED. Please document the time rewarming was begun.
ED Rewarming Reason
Unstable Arrythmia
Severe Bleeding
Persistent Hypotension
Neurological Improvement
Completion of 24 hour protocol
Other
Other ED Rewarming Reason
There should be no other reason to rewarm patients on the protocol in the ED. Be sure to document here the reason when this happens.
Please list any suggestions or operational issues that arose
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