Author: CNMC Staff

Therapeutic Hypothermia Clinical Presentation Checklist
Patient Name:___________________________________________________________________
Date & Time of Birth: _____/______/_____ ______:_______AM/PM
BABY’S NAME: ______________________________________________________
BABY’S DATE/TIME OF BIRTH: ______________________________________

Clinical Information	Criteria	Instructions
Gestation: _____________weeks	1. > 35 weeks / □ Yes / □ No	Proceed to #2 / STOP, patient ineligible
Birth Weight: __________grams	2. > 1,800 grams / □ Yes / □ No	Proceed to #3 / STOP, patient ineligible
1st blood gas: / ____ Umbilical cord blood gas / ____ 1st baby blood gas (< 1 hour of life): / ___ ___:___ ___ (fill in time) / pH ___.___ ___ / BE ___ ___.___	3a. pH<7.0 or BD≥16 / □ Yes / □ No / 3b. No gas or pH 7.01-7.15 or BD 10-15.9 / □ Yes / □ No	Proceed to exam** / Proceed to #3b / Proceed to #4 / STOP, patient ineligible
Major perinatal events (check all): / ___ Variable/late fetal HR decelerations / ___ Prolapsed, ruptured, or tight nuchal cord / ___ Uterine rupture / ___ Maternal hemorrhage/abruption / ___ Maternal trauma (eg MVA) / ___ Mom received CPR	4. History of major / perinatal event? / □ Yes / □ No	Proceed to #5 / STOP, patient ineligible
Apgar scores: / At 1 minute: ____ / At 5 minutes: ____ / At 10 minutes: ____	5. Apgar <5 at 10 min / □ Yes / □ No	Proceed to exam** / Proceed to #6
Resuscitation after delivery: / ___ PPV/intubated at 10 minutes / ___ CPR / ___ Epinephrine administered	6. PPV/ET at 10 min / □ Yes / □ No	Proceed to exam** / STOP, patient ineligible

**Note: If patient meets above criteria and has a witnessed seizure, the patient is eligible for hypothermia regardless of exam findings Seizure: □ Yes □ No
□ No

NEUROLOGICAL EXAMINATION:
Circle findings for each domain. Patient is eligible for hypothermia if 3 or more domains with findings in columns 2 or 3.

Domain	1	2	3
Level of / consciousness	Normal / Hyperalert	Lethargic (decreased activity in an infant who is aroused and responsive—can be irritable- to external stimuli, i.e. touch)	Stuporous/comatose / (not able to arouse and / unresponsive to external / stimuli)
Spontaneous activity when awake or aroused	Infant is active, / vigorous, doesn’t stay in one position	Less than active, not vigorous	No activity whatsoever
Posture	Moving around and does not maintain only one position	Distal flexion, complete extension, or “frog-legged” position	Decerebrate with or / without stimulation (all / extremities extended)
Tone	Normal, resists passive motion / Hypertonic, jittery	Hypotonic or floppy either focal or general	Completely flaccid like / rag doll
Primitive reflexes	Suck: vigorously sucks finger or ET tube / Moro: normal – / extension of limbs / followed by flexion with stimulus	Suck: weak / Moro: incomplete	Suck: completely / absent / Moro: completely / absent
Autonomic System	Pupils: Normal size (~1/3 iris diameter), react to light / Heart Rate: Normal (>100 bpm) / Respirations: Regular spontaneous breathing	Pupils: Constricted / (< 3 mm est’d), but / react to light / Heart Rate: Bradycardia (<100 bpm, variable up to 120 bpm) / Respirations: Periodic, irregular breathing / effort	Pupils: Skew gaze, fixed dilated, not reactive to light / Heart Rate: Variable, / inconsistent rate, / irregular HR / Respirations: Completely apneac, requiring PPV and/or ET intubation

EXAMINER NAME: ______________________________________________________
DATE: ____/____/_____ TIME: ____ ____: ____ ____ (24:00)

Steps for Initiating Therapeutic Hypothermia:
Call your referral center immediately if patient meets criteria based on clinical presentation checklist and neurological exam
After consultation with cooling center, initiate targeted temperature management
Initiate targeted temperature management:

Document initial axillary temperature

Turn off radiant warmer

Monitor and document axillary temperature every 15 minutes

Baby’s temp < 33˚C

Baby’s temp > 34˚C

Turn on radiant warmer with servo control set min 33˚C and max 35˚C
OR
Add 1 blanket

Consider tepid bath.
Discuss with
cooling center prior to initiating active cooling measures

4. Prepare patient for transfer
5. Request placental pathology (or send placenta with baby upon transfer)

Transfers & Consultations:
Children’s National Neonatal Intensive Care Unit 202-476-5040
Questions about neuroprotection?
Dr. Taeun Chang 202-476-2120 tchang@childrensnational.org
Dr. An Massaro 202-476-5448 anguyenm@.childrensnational.org