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Accidental Hypothermia

Accidental Hypothermia. The Basics Clinical Questions Treatment. Who gets hypothermia?. Case: 25 M Ice climber… Temp: 31 degrees. How would you classify this pt’s hypothermia?. 31 degrees C. Mild: Core temp. 32 to 35ºC Moderate: Core temp. 28 to 32ºC Severe: Core temp. below 28ºC.

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Accidental Hypothermia

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  1. AccidentalHypothermia

  2. The BasicsClinical QuestionsTreatment

  3. Who gets hypothermia?

  4. Case:25 M Ice climber…Temp: 31 degrees

  5. How would you classify this pt’s hypothermia? 31 degrees C

  6. Mild:Core temp. 32 to 35ºCModerate:Core temp. 28 to 32ºCSevere:Core temp. below 28ºC

  7. Mild:34 - amnesia and dysarthria begin33 - ataxia and apathy developModerate:32 - stupor31 - shivering stops30 - dysrhythmias, CO drops, insulin ineffectiveSevere:28 - high risk for VF27 - lose reflexes and voluntary movement26 - major A/B disturbanceProfound:19 - flat EEG18 - asystole

  8. Pretend there is no history of exposure…why else could this patient be hypothermic?

  9. Differential Diagnosis Increased Heat Loss Impaired Heat Regulation Decreased Heat Production

  10. What mechanisms contribute to heat loss in our patient?

  11. Evaporation, radiation, conduction, convection….

  12. How is the cold affecting this patient?At the body level?At the organ system level?

  13. Increase HRProgressive bradycardiaVentricular ArrhythmiasAsystole

  14. The J Wave

  15. Cold diuresisReduced renal flow

  16. Progressive depressionperfusion maintained until 25 degrees19 degrees flat EEG

  17. Initial stimulationProgressive decreaseCO2 retention and Acidosis

  18. Case continued….

  19. What is the most accurate method of measuring his temperature?

  20. Rectal temperature (insert to 15 cm)- ? Accurately reflect brain/heart temperature- Influenced by adjacent frozen stool- lags behind core temperature changesOral- Often do not measure below 34 degrees C.Tympanic- accurately reflect hypothalamus if true tympanicAxilla- easily affected by external factorsEsophogeal (insert to 24 cm)-can be affected by warm airway temperature in tubed patient

  21. Blood Work ChemstripElectrolytesCreatinine, BUNHg, WBC, PltLactateEKGABGOther: CK, fibrinogen, INR, cortisol, thyroid

  22. Blood Work Chemstrip:-Insulin ineffective below 30 degrees -persistent elevation despite rewarming signals secondary causeHct:-Increases 2% for every drop by 1 degree C-Beware of the hypothermic patient with a normal/low hematocritABG:-Historically controversial-Use uncorrected values

  23. How can you rewarm him?

  24. Passive External Rewarming (PER) • Providing blankets • Moving to a warm environment • Heated IV fluids/oral fluids **pt must be able to produce their own heat ***slow rise in temperature

  25. Active External Rewarming • Applying heat to the skin: • Warm blankets • Bear Hugger • Immersion warming • Brokeback Hug?

  26. Active Internal Rewarming • Peritoneal dialysis • Bladder, gastric, or colonic lavage • Heated intravenous fluids • Heated humidified oxygen • Thoracic cavity lavage • Extracorporeal blood rewarming • Hemodialysis

  27. Recipe: Warmed NS • Place 1L NS in 650 W microwave • Cook on high for 120s, turning and shaking it once at midcycle • Agitate before infusion

  28. Inhaled warmed O2 • Use warmed air at 45 degrees celcius • Up to 2 degrees/hr*

  29. Peritoneal Lavage • Use Arrow peritoneal lavage kit • Up to 3 degrees C/hour

  30. GI and bladder rewarming • 1.5-2.0 degrees/hour

  31. Thoracic Cavity Lavage Up to 6 or 7 degrees/hour reported

  32. Cardiac Bypass • Need to consult CV surgery • Up to 2 degrees/5 mins

  33. Hemodialysis • Up to 4.5 degrees/hour

  34. Comparison of Rewarming Rates

  35. Case Continued

  36. Why has this patient become more hypothermic despite your warming measures?

  37. Approach to rewarming Mild Hypothermia Passive External Rewarming +/- Active External Rewarming

  38. Approach to rewarming Moderate Hypothermia Active External Rewarming Active Internal Rewarming

  39. Approach to Rewarming Severe Hypothermia Level 1 callout If Stable, treat as moderate but be prepared for ecmo If Unstable, ACLS and prepare for ecmo

  40. ACLS guidelines? BLS: -prevent heat loss, rewarm -mild AH = passive rewarming -moderate AH = AER -Severe + Stable = AER or AIR -Severe + Unstable = bypass or AIR -Do not withhold ABC’s to rewarm ACLS: -If in VF or pulseless VT, attempt defibrillation -“Might be reasonable to perform further defibs -“Might be reasonalbe to administer vasopressor”

  41. Cold and Dead? “Patients with severe accidental hypothermia and cardiac arrest may benefit from resuscitation even in cases of prolonged downtime and prolonged cpr”

  42. The Obvious:-Decapitation-Non-compressible chest-Ice in mouth and nose-DNR orderThe Unreliable:-rigor or livor mortis-fixed pupils-tissue deterioration

  43. Rosens:“Significant predictors of outcome”asphyxia, prehospital arrest, low or no BP, high BUN, need for intubation in ERLiterature:Mt. Hood: only survivors had signs of life on scene, temps were above 20 degrees, K < 7 Mair et al. 1994: K > 10, pH < 6.5, Others: fibrinogen <50mg/dL, ammonia >250mmol/L

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