Multisystem - Targeted Temp Management, Toxin/Drug Exposure

Targeted Temperature Management (TTM) - general definition

• a treatment that lowers the patient’s core body temperature in order to prevent the neurological effects of an ischemic injury in the brain of survivors of sudden cardiac death

Targeted Temperature Management (TTM) - Inclusion vs. Exclusion Criteria

• Inclusion Criteria

  • cardiac arrest WITH a return of spontaneous circulation; UNRESPONSIVE/not following commands after arrest; witnessed arrest with downtime of less than 60 minutes

• Exclusion Criteria

  • pregnancy; core temperature less than 35; age <18 or >85; existing DNR or terminal disease; chronic renal failure; sustained refractory ventricular arrhythmias; active bleeding; shock; hemodynamic instability; drug intoxication

Targeted Temperature Management (TTM) - 3 PHASES

• Induction phase - lower the patient’s temperature to 32-36C (as ordered by provider); start this cooling ASAP (RN should initiate this cooling within 90 minutes of the patient going into arrest; the cooling may last for as long as 6 hours after the arrest

• Maintenance phase - keep the patient at the target temperature (32-36C) for 24 hours

• Rewarming phase - slowly increase the patient’s temperature to 36.5-37C (as ordered by provider)

Targeted Temperature Management (TTM) - Induction Phase

• set goal time to target temperature

• monitor core temp (PA catheter, esophageal, bladder, rectal)

• apply device (external pads or internal central venous catheter)

• goal systolic BP generally GREATER than 90; MAP >70

• obtain baseline labs (CMP, CBC, coagulation, serum mag/phosphorous, ABG, blood glucose)

• 12 lead EKG

• initiate deep sedation

• manage shivering by covering head, hands, and feet or by using meperidine (Demerol), an OPIOID ANALGESIC that suppressed shivering; use neuromuscular agent if shivering is NOT controlled by Demerol

• monitor/manage systemic effects of hypothermia

Targeted Temperature Management (TTM) - SYSTEMIC EFFECTS of HYPOTHERMIA

• insulin resistance → HYPERGLYCEMIA

• electrolyte/fluid shifts

• shivering

• skin breakdown

• pupil and corneal reflexes may be absent due to hypothermia

• decreased CO (up to 25%)

• alteration in coagulation (platelet dysfunction)

• increased risk for infection (neutrophil/macrophage functions decrease at temperatures less than 35C)

Targeted Temperature Management (TTM) - Maintenance Phase (duration 24 hours)

• continuously monitor the core temperature (bladder, rectal); the core temp should NOT be lower than the specified goal (32-36C)

• obtain routine bedside blood glucose measurements and initiate insulin drip as needed

• monitor train of four (TOF) every hour IF paralytic is used and ensure a goal of 1-2 twitches to prevent prolonged paralysis

• repeat labs (same as baseline labs) every 8 hours until the patient is rewarmed

Targeted Temperature Management (TTM) - Rewarming Phase

• perform passive rewarming to 36.5-37C

• program cooling unit to increase targeted temperature by 1 degree per hour

• STOP ALL POTASSIUM ADMINISTRATION 8 HOURS PRIOR TO REWARMING (rewarming causes rebound hyperkalemia (*COOLING PUSHES K into CELLS))

• discontinue paralytics (if being used) after the patient is warmed to 36.5C

• repeat labs (same as baseline) when the patient is rewarmed

• perform a close neurological assessment; pupil and corneal reflexes may continue to be absent for a time

toxin/drug exposure - GENERAL POINTS

• INITIAL MANAGEMENT - ALWAYS access ABCs (airway, breathing, circulation)

• patient comatose? → give thiamine 50-100 mg (to support glucose metabolism), 50% dextrose 50 mL (to give brain the glucose supply it needs) and naloxone 2mg IV (if opioid induced)

• to prevent absorption of toxin/drug, give activated charcoal 1 gm/kg via gastric lavage (contraindicated with hydrocarbon/corrosive ingestions; NOT necessary for ingestion of iron, lithium, or alcohols)

• facilitate removal of drugs (urine alkalization, hemodialysis)

• administer antidote (such as naloxone, flumazenil)

• monitor for arrhythmias; urine output

• CHEMICAL exposure? →give antidote (if possible); remove chemical (if a powder, brush away; if liquid, fluid it with saline or water); do NOT rub affected area, and cover with sterile damp dressing

toxin/drug exposure - Acetaminophen (signs/symptoms, management)

• signs/symptoms - N/V, then later RUQ pain, abnormal liver function tests/mental status changes

• management - N-Acetylcysteine!! GI lavage with activated charcoal within 4 hours after ingestion

toxin/drug exposure - Benzodiazepines (signs/symptoms, management)

• signs/symptoms - drowsiness, confusion, slurred speech, respiratory depression, hypotension, aspiration

• management - support the airway; GIVE FLUMAZENIL (remember it has a short half-life → watch for reoccurrence of symptoms); gastric lavage with activated charcoal; fluid resuscitation

toxin/drug exposure - Beta Blockers (signs/symptoms, management)

• signs/symptoms - BRADYCARDIA, HYPOTENSION, CV COLLAPSE

• management -

  • Glucagon (FIRST LINE ANTIDOTE) activates glucagon receptors, which increases cAMP (cyclic adenosine monophosphate), which helps increase intracellular calcium in myocardium to increase HR and contractility

  • epinephrine (increases HR and contractility)

  • insulin + dextrose (insulin drives glucose into myocardial cells to promote more efficient carbohydrate usage, having direct INOTROPIC effects; dextrose prevents hypoglycemia)

  • sodium bicarbonate (for acidosis/QRS widening)

toxin/drug exposure - calcium channel blockers (signs/symptoms, management)

• signs/symptoms - BRADYCARDIA, HYPOTENSION, CV COLLAPSE

• management -

  • CALCIUM GLUCONATE (increases extracellular Calcium to overcome channel blockade, ultimately increasing CONTRACTILITY)

  • epinephrine (help increase HR/contractility/BP)

  • insulin + dextrose (CCBs block insulin release → myocardium is energy starved; insulin increases uptake of glucose into myocardium, increasing ATP production, improving contractility/perfusion; dextrose prevents hypoglycemia)

  • sodium bicarbonate (acidosis)

toxin/drug exposure - Cocaine (signs/symptoms, management)

• signs/symptoms - seizure activity, agitation, hyperthermia, rhabdomyolysis

• management - activated charcoal; fluids/glucose/thiamine IV; benzodiazepines for sedation/seizures; vasopressin preferred over epinephrine in full arrest; vasodilators for HTN; nitrates/calcium channel blockers for ischemia; NO BETA BLOCKERS!!; cooling for hyperthermia

toxin/drug exposure - ethylene glycol (signs/symptoms, management)

• signs/symptoms - intoxication behavior, vomiting, metabolic acidosis/anion gap, renal failure

• management - gastric lavage; sodium bicarb for acidosis, antidotes - ethanol or fomepizole, dialysis

toxin/drug exposure - ETOH (signs/symptoms, management)

• signs/symptoms - stupor, respiratory depression, aspiration risk, intermittent agitation

• management - support/protect airway; fluid resuscitation; multivitamin/thiamine 100 mg IV; electrolyte replacement PRN (magnesium, phosphorous, potassium); prevention of delirium tremens (benzodiazepines, CIWA protocol)

toxin/drug exposure - methamphetamine (signs/symptoms, management)

• signs/symptoms - fever, tachycardia, HTN, seizure, agitation, renal failure

• management - fluids/cooling, benzodiazepines, haloperidol; physical restraints (protect self/others)

toxin/drug exposure - opioids (signs/symptoms, management)

• signs/symptoms - drowsiness, hypoventilation, hypotension, hypothermia, deep sedation, pinpoint pupils

• management - support airway; NARCAN!!; gastric lavage with activated charcoal

toxin/drug exposure - phencyclidine (PCP) (A DISSOCIATIVE AGENT) (signs/symptoms, management)

• signs/symptoms - blank stare, rapid involuntary eye movement, hallucinations, severe mood disorder, flushing, sweating, HTN, tachycardia, seizure/coma

• management - support airway; provide a calm environment; do NOT leave patient alone due to high possibility of harm to self/others; benzos for agitation; fluids, cooling, monitor renal function

toxin/drug exposure - salicylates (Aspirin) (signs/symptoms, management)

• signs/symptoms - vomiting, tinnitus, confusion, hyperthermia, respiratory alkalosis, metabolic acidosis, multiple organ failure

• management - activated charcoal; urine alkalization; dialysis (REGARDLESS of admission renal function to PREVENT AKI)

toxin/drug exposure - tricyclic antidepressants (signs/symptoms, management)

• signs/symptoms - CV signs (arrhythmias, shock); neurological signs (drowsiness, delirium, seizures/coma); anticholinergic signs (blurred vision, fever, twitching)

• management - sodium bicarbonate, activated charcoal, fluids, cardiac monitoring

WHY is activated charcoal indicated for many toxin exposures?

• it can help BIND certain drugs/toxins in the GI tract, keeping them in the gut instead of in the circulation !! it DOES NOT neutralize the toxins