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Chapter 34: Hypothermia and Hyperthermia

A 48-year-old man suddenly collapsed at the mall. An automated external defibrillator was applied, and he was found to have ventricular fibrillation. Advanced Cardiac Life Support was initiated, and ROSC was achieved. He was transferred to the emergency department (ED), and TH was initiated. He was noted to have shivering on his neck, torso, and upper extremities. Which is not an intervention to control shivering?

A. Warm blanket on the face

B. Acetaminophen

C. Buspirone

D. None of the above

D. None of the above

Control of shivering is necessary for affective TH. The Bedside Shivering Assessment Scale (BSAS) is used to gauge the appropriate medication. Scores are 0 = none; 1 = mild with shivering in the neck or thorax; 2 = moderate with shivering in upper extremities, including the neck and thorax; and 3 = gross movements of the truck and upper and lower extremities., An example of the shivering stepwise protocol is derived from Columbia University. Step 1 is for a BSAS score of 2 or 3 despite baseline interventions. Step 2 is used if step 1 is ineffective and so forth. The goal is BSAS of 1 or less. See Table 34-2.

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Table 34-2. Columbia Antishivering Protocol
Step Intervention Dose
0 Baseline



Magnesium sulfate

Skin counterwarming

650–1000 mg every 4–6 h

30 mg every 8 h

0.5–1 mg/h IV goal (3–4 mg/dL)

43°C, maximum temperature

1 Mild sedation




0.2–1.5 mcg/kg/h

Fentanyl starting dose: 25 mcg/h

Meperidine 50–100 mg IM or IV

2 Moderate sedation Dexmedetomidine and opioid Doses as above
3 Deep sedation Propofol 50–75 mcg/kg/min
4 Neuromuscular blockade Vecuronium 0.1 mg/kg IV

IM = intramuscular; IV = intravenous.

Reprinted with permission from Choi HA, Sang-Bae K, Presciutti M, et al. Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol. Neurocrit Care. 2011;1-6.

Skin counterwarming decreases shivering because it provides 20% of hypothalamic input regarding temperature, (choice A). Acetaminophen lowers the hypothalamic setpoint because of prostaglandin synthesis (choice B). Buspirone act of 5-HT1a and lowers the shivering threshold (choice C).

A 45-year-old woman with a history of diabetes mellitus, obesity, and hypotension was admitted after cardiac arrest for ventricular tachycardia. ROSC was achieved, but the patient was not responsive and was subsequently placed on hypothermic protocol. What would be the next step?

A. Initiate tube feeds during the cooling phase.

B. Initiate tube feeds during the warming phase.


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