Bridge Orders For Induced Hypothermia Post-Cardiac Arrest
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2Authorization is hereby given to dispense the generic equivalent unless otherwise indicated by the physician
Bridge Orders for Induced Hypothermia Post-Cardiac Arrest
Code Chill Induction Phase
After Emergency Department provider discussed patient with admitting Hospitalist/Attending:
Dr. __________________________________________ accepted patient at _____________________________ am / pm
In compliance with 42 CFR Section 456.60 Certification/Recertification, I certify that the level of care is based on medical necessity as
documented within this medical record.
Physician Signature ______________________________________ Date _______________ Time _______________
Follow Therapeutic Hypothermia Post-Cardiac Arrest Policy
Keep patient room cool
Goal is to cool patient at 33.0° C (TARGET TEMPERATURE) for 24 hours
Goal to TARGET TEMPERATURE after initiation of therapy is 2 hours
Do NOT cool patient to less than 32.5° C
Upon reaching TARGET TEMPERATURE begin MAINTENANCE PHASE Order Set
Sedation goal during Induction Phase is RASS -3 to -4
Maintain a MAP of 70 to 100 mm Hg for 24 to 48 hours
When ICY™ (femoral) catheter is used, connect patient to CoolGard 3000® Temperature Management System
When using RAP-r™ round blankets, connect to the CSZ Blanketrol® III
Monitor and record esophageal & rectal temperatures every 30 minutes until TARGET TEMPERATURE is reached
Immediately notify Cardiology for continued/prolonged arrhythmias – consider termination of treatment
Level of Care:
Admit Inpatient - CMICU
DATE
TIME
Diagnosis/Medical Reason to support level of care: ______________________
Obtain Active Surveillance Culture (ASC) for patient if he/she is identified as being in a risk group per ASC protocol
Diagnostics/ Lab, Radiology, Other:
1.
Monitor and record vital signs (heart rate, blood pressure, mean arterial pressure (MAP), respiratory rate, CVP,
SPO
):
2
Every 30 minutes until target temperature is met, then hourly if stable
Record esophageal and rectal temperature every 30 minutes until target temperature is met, then hourly if
stable
Notify physician and initiate hypotension management for MAP less than 70 mm Hg and/ or heart rate less
than 40 beats per minute
2.
STAT Labs on admission to CMICU – if not completed in ED:
CBC, Comprehensive metabolic profile (COMPMET), Magnesium, Phosphorus, BNP, Lipase, Amylase,
Coritsol Level, PT/PTT, Lactic Acid, CPK, CK -MB, Troponin I, and Quantitative HCG (females ages 18 to 55)
Paired Blood Cultures
Drug Toxicology Screen (if indicated)
ABG
Urine for urinalysis (U/A) and culture and sensitivity (C&S)
Sputum Culture
MRSA Swab
Other Labs:
_________
3.
Other diagnostic tests:
_________________
4.
EKG on arrival to CMICU
5.
Portable chest x-ray on arrival to CMICU – if not completed in ED
Signature __________________________________________________________ Date _______________ Time _______________
Henrico Doctors’ Hospital
Patient Identification
Bridge Orders for Induced Hypothermia Post-Cardiac Arrest
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HDH.HOSP#167 (11/10)
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