When should the cooling protocol be used as part of ACLS?

“Cooling” is based on the theory that hypothermia can help stabilize patients in cardiopulmonary arrest and improve neurological outcomes.

Cooling should be started as soon as possible when applied (within 6 hours). It should be used in non-traumatic cases of cardiac arrest when ROSC is obtained within 30 minutes. There should be a low GCS and NO purposeful movement. Female patients should not be pregnant.

Parameters to use when titrating temperatures:

  • MAP >65 or 90 when concerned about ICP
  • PCO2 35-45
  • FiO2 > 94%
  • RASS -5
  • EEG monitoring

You should be able to see a J-point on EKG:


Potential complications:

  • Shivering and seizures (can use paralytics if there is concern this is causing respiratory complications. I’ve heard of surgeons using meperidine but haven’t done this myself)
  • Hypo/hyperglycemia
  • Skin injury from the pads
  • Sepsis
  • Rhabdomyolysis
  • Bradycardia refractory to atropine

NB: if there is any question about brain death, you need to wait 72 hours until after someone comes off the cooling protocol to make any determination of prognosis.



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