Code Chill Tracking Sheet
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15-Hole 1/4 1 3/8 c-to-c
Code Chill Tracking Sheet
RES-500 (08/12)
RES1
Code Tracking
CPC Scale prior to Collapse: _______
Chilling prior to ICU:
Yes
No
Method of Pre-ICU Chilling:
Ice Packs
CPC Scale 48 Hours
Chilled Fluids
(Check as many as necessary)
Prior to D/C:
Intravascular Catheter
Other
Date/Time CPC Done:
Location of Pre-ICU Chilling:
Field
ED
Nursing Unit
(Check as many as necessary)
Assessing Physician:
Cath Lab
Other
Date / Time Chilling Initiated:
Cerebral Performance Category Scale
Formal Hypothermia initiated at another hospital via:
(Neuro Baseline/Outcome)
Arctic Sun
Ice Packs
Chilled Fluids
Intravascular Catheter
CPC 1:
Good cerebral performance: conscious, alert, able
Other
to work, might have mild neurologic or psychologic defect.
Time Initiated at other facility:
CPC 2:
Moderate cerebral disability: conscious, suffi cient cerebral
function for independent activities of daily life. Able to work in
sheltered environment.
Formal Induced Hypothermia: See Order Set for
CPC 3:
Severe cerebral disability: conscious, dependent on others
Inclusion / Exclusion Criteria
for daily support because of impaired brain function. Ranges
from ambulatory state to severe dementia or paralysis.
Potential Code Chill Issued Date / Time:___________________
CPC 4:
Coma or vegetative state: any degree of coma without the
Intensivist Concurs:
Yes
No
presence of all brain death criteria. Unawareness, even if
appears awake without interaction with environment; may
Hypothermia ICU Orders Initiated Date/Time:_______________
have spontaneous eye opening and sleep/awake cycles.
Cerebral unresponsiveness.
Method ICU Chilling:
Arctic Sun
Cooling blankets, Fluids, Ice Packs
CPC 5:
Brain death: apnea, arefl exia, EEG silence, etc.
Intravascular Catheter
Pre-Hospital/Pre-ICU
Comments:
Date / Time:
Date / Time of Collapse:
Witnessed By:
@
Last Seen prior to Discovery:
CPR Initiated At:
Call to 911/Code Blue Team:
EMS/Code Blue Team Contacted:
ROSC Sustained > 20 Min:
Cath Lab
Patient Label
Date of Cath:
Time in Cath Lab
Time out of Cath Lab
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