Revised cold injuries and cold water near drowning guidelines
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Revised Cold Injuries and Cold Water Near Drowning Guidelines. Ken Zafren, MD, FACEP EMS Medical Director, State of Alaska. The State of Alaska Cold Injuries and Cold Water Near Drowning Guidelines. Developed in 1988 by an expert panel Revised in 1996 Expert panel revision - Sitka 2002

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Revised cold injuries and cold water near drowning guidelines

Revised Cold Injuries and Cold Water Near Drowning Guidelines

Ken Zafren, MD, FACEP

EMS Medical Director,

State of Alaska

Ken Zafren, MD FACEP Hypothermia Guidelines


The state of alaska cold injuries and cold water near drowning guidelines

The State of Alaska Cold Injuries and Cold Water Near Drowning Guidelines

  • Developed in 1988 by an expert panel

  • Revised in 1996

  • Expert panel revision - Sitka 2002

  • Revised edition in progress

Ken Zafren, MD FACEP Hypothermia Guidelines


Overview of guidelines

Overview of Guidelines

  • General points

  • Hypothermia

  • Cold water near drowning

  • Frostbite

  • New section on avalanche rescue

Ken Zafren, MD FACEP Hypothermia Guidelines


Introduction

Introduction

  • Guidelines - not absolute rules

  • Designed as a reference, not a teaching document

Ken Zafren, MD FACEP Hypothermia Guidelines


Multilevel guidelines

Multilevel guidelines

  • General points

  • General public

  • First Responder / EMT-I

  • EMT-II

  • EMT-III / Paramedic

  • Small/Bush Clinic

  • Hospital

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points

Hypothermia -General Points

  • Core temperature best measured as esophageal temperature if possible

  • Epitympanic temperature second choice

  • Rectal temperature third choice

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points why esophageal temperature

Hypothermia -General PointsWhy esophageal temperature?

  • Best reflection of core temperature

  • Reflects cardiac temperature

  • Relatively non-invasive

  • Technology widely available

  • Patient remains covered

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points epitympanic temperature

Hypothermia -General PointsEpitympanic temperature

  • Reflects carotid artery temperature

  • Non-invasive

  • Technology not yet widely available in USA

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points rectal temperature

Hypothermia -General PointsRectal temperature

  • Does not reflect core temperature very well

  • Lags core temperature during rewarming

  • Requires disrobing patient

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points orthopedic injuries

Hypothermia - General PointsOrthopedic injuries

  • Splint with caution in frostbitten limbs to prevent further damage; frostbitten skin is damaged skin.

  • Align fractures/dislocations in neutral position. This gives the best chance of preserving neurovascular and other structures.

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points orthopedic injuries1

Hypothermia - General PointsOrthopedic injuries

  • Do not reduce frozen extremities to prevent further damage.

  • Splints should not be constrictive in order to allow for postinjury swelling.

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points1

Hypothermia - General Points

  • Warm oral and IV fluids to at least body temperature to prevent further cooling.

  • Give IV fluids as boluses (especially for field use).

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points why iv fluid boluses

Hypothermia - General PointsWhy IV fluid boluses?

  • Less likely to freeze than continuous infusions

  • Better titration to effect

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points2

Hypothermia - General Points

  • Chemical heat packs ineffective for warming

  • Can be used on hands or feet to prevent frostbite

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points3

Hypothermia - General Points

  • Positive attitude is important

  • Assume the patient can be resuscitated even if they appear to be beyond help

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points contraindications to cpr

Hypothermia - General PointsContraindications to CPR

  • New temperature cutoff - core temperature 10°C/50°F

  • Rescuers exhausted or in danger or CPR cannot be maintained throughout transport to a medical facility

  • Transportation available within 3 hours

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points contraindications to cpr new cutoff

Hypothermia - General PointsContraindications to CPR - new cutoff

  • New temperature cutoff - core temperature 10° C / 50° F

  • Survival has now been documented to core temperature of 13.7° C / 56.7° F

  • Routine use of 10° C / 50° F in surgery

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points contraindications to cpr1

Hypothermia - General PointsContraindications to CPR

  • Rescuers exhausted or in danger or CPR cannot be maintained throughout transport to a medical facility

  • If CPR is begun any perfusing rhythm will probably be lost; stopping CPR once begun is therefore likely to be fatal

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points contraindications to cpr2

Hypothermia - General PointsContraindications to CPR

  • Transportation available to critical care within 3 hours

  • Hypothermic patients can survive for up to 3 hours with pulse and blood pressure which are difficult to detect.

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points cpr

Hypothermia - General PointsCPR

  • Apneic pulseless patient - ventilate for 3 minutes before CPR to increase VF threshold

  • Ventilation may increase heart rate, blood pressure

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points cpr1

Hypothermia - General PointsCPR

  • Apneic pulseless patient - decision to start CPR based on time to critical care

  • <3 hours: ventilate (intubate, if possible), prevent heat loss

  • >3 hours: chest compressions and ventilate for 30 minutes, attempt to rewarm

  • CPR cannot be done in a litter

Ken Zafren, MD FACEP Hypothermia Guidelines


Handle hypothermic patients gently to prevent ventricular fibrillation

Handle hypothermic patients gently to prevent Ventricular Fibrillation

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points assessment

Hypothermia - General PointsAssessment

  • Check for cardiac activity for at least 60 seconds

  • Automatic External Defibrillator (AED) may be used to detect cardiac activity - signal to shock indicates V Tach or V Fib

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general points assessment1

Hypothermia - General PointsAssessment

  • New classification for severity of hypothermia

  • Follows International Commission for Alpine Rescue, Winnepeg consensus guidelines

  • Correlates core temperature with observable findings

Ken Zafren, MD FACEP Hypothermia Guidelines


Revised cold injuries and cold water near drowning guidelines

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia stages

Hypothermia stages

  • Mild 32-35°C (90-95°F)

  • Moderate 28-32°C (82-90°F)

  • Severe <28°C (<82°F)

  • Ideally based on esophageal temperature

  • Becoming standard classification worldwide

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public mild hypothermia

Hypothermia - General PublicMild Hypothermia

  • Patient is cold

  • Vigorous shivering

  • Alert

  • May be ambulatory

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public treatment

Hypothermia - General PublicTreatment

  • Remove wet clothes only with shelter

  • Vapor barrier

  • Cover head and neck

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public treatment1

Hypothermia - General PublicTreatment

  • Shivering is an important method to increase heat production

  • Sugar containing fluids are more beneficial than hot drinks

  • Special importance if medical care delayed

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public treatment2

Hypothermia - General PublicTreatment

  • Mild exercise such as walking may be helpful after the patient is dry and has eaten

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public treatment3

Hypothermia - General PublicTreatment

  • Mild exercise such as walking may be helpful after the patient is dry and has eaten. If the patient is exhausted, exercise cannot be maintained and the patient will lose the ability to increase body heat (primarily by shivering)

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public moderate severe treatment

Hypothermia - General Public Moderate-Severe Treatment

  • Handle gently

  • Do not rub or manipulate extremities

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public moderate severe with life signs treatment

Hypothermia - General Public Moderate-Severe (with life signs)Treatment

  • Handle gently

  • Do not rub or manipulate extremities

  • Do not allow to sit or stand

  • Do not put in shower or bath

  • No exercise

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia general public moderate severe without life signs treatment

Hypothermia - General Public Moderate-Severe (without life signs)Treatment

  • Handle gently

  • Check pulse for at least 60 seconds

  • CPR if not contraindicated

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia first responder emt i

Hypothermia -First Responder EMT-I

  • Same as general public with additions

  • Oxygen, if used, should be heated and humidified

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia first responder emt i1

Hypothermia -First Responder / EMT-I

  • Insulate patient - sleeping bag

  • Cover head and neck

  • Rewarming axilla, trunk, groin

  • Hot shower/bath okay only for mild hypothermia

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia emt ii

Hypothermia - EMT-II

  • Same as EMT-I with additions

  • Most patients need volume

  • IV fluid should be normal saline - 250 cc boluses, repeated as needed to treat tachycardia

  • Heat fluid to 104-108°F (40-42°C)

  • Consider glucose, naloxone

Ken Zafren, MD FACEP Hypothermia Guidelines


Emt ii severe hypotherma with signs of life

EMT-IISevere hypothermawith signs of life

  • Measure core temperature (esophageal is preferred)

Ken Zafren, MD FACEP Hypothermia Guidelines


Emt ii severe hypotherma without signs of life

EMT-IISevere hypothermawithout signs of life

  • Ventilate and pre-oxygenate 3 minutes before intubating

  • Intubate

  • Do not hyperventilate

  • One set of defibrillations if core temperature is less than 30°C (86°F)

  • Further attempts above 30°C

Ken Zafren, MD FACEP Hypothermia Guidelines


Emt iii paramedic severe hypotherma without signs of life

EMT-III / ParamedicSevere hypothermawithout signs of life

  • Same as for EMT-II

  • No ACLS drugs

  • No CPR if any rhythm on monitor other than VF/VT

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points

Hypothermia - HospitalGeneral Points

  • Treat to level of ability

  • Transfers follow usual guidelines

  • May be better to bypass community hospital for one with cardiac bypass capability

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points1

Hypothermia - HospitalGeneral Points

  • Consider transfer of patient with core temp <20° C (68° F)

  • Consider bypass if BP<60 systolic

  • Stabilize patient before transport

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points2

Hypothermia - HospitalGeneral Points

Suggestions for evaluation and treatment

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points3

Hypothermia - HospitalGeneral Points

  • Esophageal temperature and end tidal CO2 monitoring

  • IV fluids must be heated.

  • Heated, humidified oxygen, if available

  • Avoid sedation to depress shivering

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points rewarming methods

Hypothermia - HospitalGeneral PointsRewarming methods

  • Passive external rewarming

  • Active external rewarming

  • Active core rewarming

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points active internal rewarming

Hypothermia - HospitalGeneral PointsActive internal rewarming

  • Peritoneal lavage

  • AV Rewarming

  • Cardiopulmonary bypass

  • Venous heat-exchange catheter (possible future technology)

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points active internal rewarming1

Hypothermia - HospitalGeneral PointsActive internal rewarming

  • Slow rewarming prior to adequate ventilation

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points cardiac rhythm disturbances

Hypothermia - HospitalGeneral PointsCardiac rhythm disturbances

  • Supraventricular dysrhythmias are innocent

  • V Tach and V Fib - one round of shocks until 30°C (85°F)

  • Drugs ineffective

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital general points insulin

Hypothermia - HospitalGeneral PointsInsulin

Consider insulin during rewarming.

Ken Zafren, MD FACEP Hypothermia Guidelines


Hypothermia hospital when to stop resuscitation

Hypothermia - HospitalWhen to stop resuscitation?

  • Core temperature not improving despite aggressive rewarming

  • Serum potassium >10 with associated asphyxia (near drowning, avalanche)

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning general points

Cold Water Near DrowningGeneral Points

  • Use of PFDs with thermal protection mandatory for emergency responders

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning general points1

Cold Water Near DrowningGeneral Points

  • Submersion - head under water

  • Immersion - head out of water

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning general points2

Cold Water Near DrowningGeneral Points

  • Hypothermia not the main problem

  • Cardiac, pulmonary and coagulation problems are key

  • Rewarming to raise temperature to make defibrillation more effective

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning general public

Cold Water Near Drowning - General Public

  • Neck protection if possible injury

  • Activate EMS system

  • Start CPR if patient pulseless after pulse check of 60 seconds

  • Heimlich maneuver only for solid foreign body obstruction

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning first responder emt i

Cold Water Near Drowning - First Responder / EMT-I

  • Similar to General Public

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning emt ii

Cold Water Near Drowning - EMT-II

  • Similar to EMT-I

  • Saline lock or TKO (no fluids)

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning emt iii paramedic

Cold Water Near Drowning - EMT-III / Paramedic

  • Similar to EMT-II

  • Assess for possible cardiopulmonary bypass

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning hospital

Cold Water Near Drowning - Hospital

  • IV fluids only if volume depleted

  • Cardiopulmonary bypass no longer recommended

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning hospital1

Cold Water Near Drowning - Hospital

  • Active external rewarming as indicated by core (esophageal) temperature.

  • Keep patients at 32-33° C to protect the brain.

Ken Zafren, MD FACEP Hypothermia Guidelines


Cold water near drowning hospital2

Cold Water Near Drowning - Hospital

  • Agressive cerebral resuscitation (IVP monitoring, diuretics, barbiturates) no longer recommended.

Ken Zafren, MD FACEP Hypothermia Guidelines


Frostbite

Frostbite

  • No significant changes in prehospital care

Ken Zafren, MD FACEP Hypothermia Guidelines


Frostbite1

Frostbite

  • Temperature for thawing 38-40°C (100-107°F). The lower end is preferred.

  • Stop thawing when tips of digits flush.

  • Recommendations for wound care.

Ken Zafren, MD FACEP Hypothermia Guidelines


Frostbite2

Frostbite

  • Fasciotomy guided by compartment pressures (>37-40 mm Hg) and clinical judgment

  • Antibiotics necessary only for deep infection

  • General care recommendations

Ken Zafren, MD FACEP Hypothermia Guidelines


Frostbite3

Frostbite

  • Orthopedic guidelines

  • Guidelines for disposition

  • Sample admitting orders

Ken Zafren, MD FACEP Hypothermia Guidelines


Avalanche rescue

Avalanche rescue

  • Similar to cold water near drowning

  • Importance of asphyxiation

Ken Zafren, MD FACEP Hypothermia Guidelines


Avalanche rescue1

Avalanche Rescue

  • Rapid extrication to 35 minutes to prevent asphyxia

  • Gentle extrication after 35 minutes to prevent ventricular fibrillation in hypothermic patient

  • Check for air pocket

Ken Zafren, MD FACEP Hypothermia Guidelines


Avalanche rescue2

Avalanche Rescue

  • Rapid extrication to 35 minutes to prevent asphyxia

  • Patients extricated in less than 35 minutes are unlikely to be hypothermic, but will die of asphyxia without an adequate air pocket.

  • An air pocket is any space in front of the nose or mouth, no matter how small.

Ken Zafren, MD FACEP Hypothermia Guidelines


Avalanche rescue3

Avalanche Rescue

  • Gentle extrication after 35 minutes to prevent ventricular fibrillation in hypothermic patient

  • Patients extricated after 35 minutes who are still alive will have an air pocket.

  • They are at risk for hypothermia.

Ken Zafren, MD FACEP Hypothermia Guidelines


Avalanche rescue4

Avalanche Rescue

  • Rapid extrication to 35 minutes to prevent asphyxia

  • Gentle extrication after 35 minutes to prevent ventricular fibrillation in hypothermic patient

  • Check for air pocket

Ken Zafren, MD FACEP Hypothermia Guidelines


Avalanche rescue5

Avalanche Rescue

  • CPR/ACLS for 30 minutes for burials less than 35 minutes or core temp >32°C

  • No CPR/ACLS for burials longer than 35 minutes or core temp <32°C if no air pocket

  • CPR/ACLS for burials longer than 35 minutes or core temp <32°C with air pocket

Ken Zafren, MD FACEP Hypothermia Guidelines


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