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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. 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

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  1. 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

  2. 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

  3. Overview of Guidelines • General points • Hypothermia • Cold water near drowning • Frostbite • New section on avalanche rescue Ken Zafren, MD FACEP Hypothermia Guidelines

  4. Introduction • Guidelines - not absolute rules • Designed as a reference, not a teaching document Ken Zafren, MD FACEP Hypothermia Guidelines

  5. 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

  6. 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

  7. 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

  8. Hypothermia -General PointsEpitympanic temperature • Reflects carotid artery temperature • Non-invasive • Technology not yet widely available in USA Ken Zafren, MD FACEP Hypothermia Guidelines

  9. 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

  10. 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

  11. 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

  12. 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

  13. Hypothermia - General PointsWhy IV fluid boluses? • Less likely to freeze than continuous infusions • Better titration to effect Ken Zafren, MD FACEP Hypothermia Guidelines

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. Handle hypothermic patients gently to prevent Ventricular Fibrillation Ken Zafren, MD FACEP Hypothermia Guidelines

  23. 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

  24. 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

  25. Ken Zafren, MD FACEP Hypothermia Guidelines

  26. 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

  27. Hypothermia - General PublicMild Hypothermia • Patient is cold • Vigorous shivering • Alert • May be ambulatory Ken Zafren, MD FACEP Hypothermia Guidelines

  28. Hypothermia - General PublicTreatment • Remove wet clothes only with shelter • Vapor barrier • Cover head and neck Ken Zafren, MD FACEP Hypothermia Guidelines

  29. 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

  30. 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

  31. 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

  32. Hypothermia - General Public Moderate-Severe Treatment • Handle gently • Do not rub or manipulate extremities Ken Zafren, MD FACEP Hypothermia Guidelines

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. EMT-IISevere hypothermawith signs of life • Measure core temperature (esophageal is preferred) Ken Zafren, MD FACEP Hypothermia Guidelines

  39. 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

  40. 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

  41. 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

  42. 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

  43. Hypothermia - HospitalGeneral Points Suggestions for evaluation and treatment Ken Zafren, MD FACEP Hypothermia Guidelines

  44. 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

  45. Hypothermia - HospitalGeneral PointsRewarming methods • Passive external rewarming • Active external rewarming • Active core rewarming Ken Zafren, MD FACEP Hypothermia Guidelines

  46. Hypothermia - HospitalGeneral PointsActive internal rewarming • Peritoneal lavage • AV Rewarming • Cardiopulmonary bypass • Venous heat-exchange catheter (possible future technology) Ken Zafren, MD FACEP Hypothermia Guidelines

  47. Hypothermia - HospitalGeneral PointsActive internal rewarming • Slow rewarming prior to adequate ventilation Ken Zafren, MD FACEP Hypothermia Guidelines

  48. 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

  49. Hypothermia - HospitalGeneral PointsInsulin Consider insulin during rewarming. Ken Zafren, MD FACEP Hypothermia Guidelines

  50. 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

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