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M Chadi Alraies, MD
Chief Medical Resident
CWRU/SVCH
The case
46 year old Caucasian
gentleman
Found unresponsive by
bystander for unknown
period of time
HPI
Found by bystander
Unresponsive and very cold
911 called
EMS report:
The patient is unresponsive, in mild respiratory
distress.
V/S 28 rectal, 66, 22, Initial blood pressure could
not be obtained. 92% saturation.
No history can be obtained.
Regular rate and rhythm
Placed on face mask O2 and transferred to SVCH
5
PMH, PSH, Meds, SH &
FH
Unknown
6
What do you think?
9
ER course
V/S:
Temp: 28.1 C
BP: 66/56
HR: 50
RR: 28
SpO2: 86%.
10
ER course
On exam: (pertinent positives)
Unresponsive
GCS (E1, V1, M4) 6/15
13
Which test do
you want and
why?
CMP EKG
CBC TSH
ABG UA
Coagulation profile Urine toxicology
CXR Lactic acid
CPP CT brain
Accu check
NEXT
15
CMP
Na 124 TP 6.0
K 7.9 ALB 2.8
CL 93 Ca 8.3
HCO3 0 !!! Bili 0.4
Glucose HIGH AST 44
BUN 56 ALT 43
Cr 3.7 ALKP 125
Glucose 1560
Anion GAP = 31 16
Corrected Na in
hyperglycemia
Corrected Na in hyperglycemia=
measured
measured Na + [2.4 x glucose – 100
____________________ ] 100
Na= 159
American Journal of Medicine 1999; 106:399
BACK
17
Accu check
High
BACK
18
Coagulation profile
INR 1.25
PTT 66.9
BACK
19
ABG
PH <5 SAT 93.3%
PCO2 21.3 A-a 623.4
PO2 68.3 Hg 11.5
HCO3 0
BACK
20
CBC
WBC 32,000 MCH 31.7
RBC 4.64 MCHC 30.6
HGB 14.7 RDW 12.6
HCT 48.1 PLT 293
MCV 103.7
BACK
21
CPP
CPK 495
CKmb 18.9
Troponin I <0.04
BACK
22
LDH
264
BACK
23
TSH
0.971
BACK
24
Mild congestive heart failure.
Bilateral pleural effusion
Basal infiltrate
Recommend PA and lateral views.
BACK
26
EKG
28
EKG changes in
Hypothermia
Sinus bradycardia.
J wave “Osborne wave”.
Atrial and ventricular arrhythmias.
prolonged PR, QRS, and QT intervals.
Asystole and ventricular fibrillation.
BACK
29
Urinalysis
Pail yellow Glucose 1000
Cloudy Ketones 150
Specific gravity Blood 250
1.021 Bacteria moderate
PH 5.0
Myoglobinuria -ve
BACK
30
Urine toxicology
screening
Cocaine
BACK
31
Lactic acid
5.5
BACK
32
CT brain
Moderate degree of Cerebellar and
cerebral cortical volume loss.
No acute ischemia.
BACK
33
ER course
Patient received 2 liters of warm
normal saline
Warming blanket placed.
ICU resident informed and patient
transferred to ICU.
34
ICU team received call at
1:00 EST
35
ICU course
Patient intubated
Transferred gently from stroller to
the ICU bed
Patient fully assessed again
36
Vitals
T 28.1, rectally
emp: 98/50 dinamap
BP: 50 bpm
HR: 28/min
RR: 100% on vent
S A/C, 100%, 500cc, 0
pO2: PEEP, 20/min
Vent
:
37
On examination
Unresponsive, intubated
GCS 6/15
Pupils dilated, fixed and non-
reactive.
ETT 7.5 cm, secured.
Cold skin, dry mucus membranes,
poor capillary refill (>4seconds)
Bilateral chest crackles with
decreased A/E. 38
On examination
Distant heart sounds, regular
bradycardia, no JVD no murmurs,
rubs or gallops.
Abdomen soft, with epigastric
tenderness and rebound without
guarding and absent bowel sounds.
Cold lower limbs without signs of
trauma and no edema
Weak (+1) DP and PT pulses.
Diffuse areflexia, and rigidity.
39
Temperature monitor
Electronic thermometer with flexible
probes
Rectum
Bladder
Esophageal
40
Triple lumen inserted
41
CVP
3 cm H2O
42
SvO2
68%
43
Monitors
Temperature
A-line
CVP
Urine output.
Core temperature.
Cardiac monitor (arrhythmias).
44
Definition of
hypothermia
An unintentional decline in
the core temperature
below 35 °C.
45
Physiologic Changes Associated with
Hypothermia
48
Active external
rewarming
Immersion,
Radiant heat,
Forced air,
Electric or plumbed heating blankets.
49
Core-temperature
afterdrop !!!
Heating the extremities and rapidly
alleviating peripheral
vasoconstriction.
Continuing decrease in the core
temperature after the initiation of
rewarming.
Decline in mean arterial pressure and
peripheral vascular resistance.
Active core rewarming
Administration of heated humidified
oxygen by ET. (1 to 2 °C per
hour.)
Peritoneal lavage with heated
dialysate (40 to 45 °C). 2 to 4 °C
per hour.
Closed pleural irrigation through
large-bore thoracostomy tubes.
51
Active core rewarming
Administration of warm NS or any IV
fluids (fluid temperature should be 37
degrees)
Gastric, colonic, or bladder irrigation is
very restricted
Extracorporeal rewarming remains the
most efficient means of rewarming. 1 to
2 °C every 3-5 minutes.
Arterio-venous
Veno-venous
Hemodialysis 52
Hypothermia
consequences
Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.
54
Impaired tissue
oxygenation
1. Hypothermia shifts the
LEFT curve
oxyhemoglobin-dissociation
to the…
2. Vasoconstriction, a ventilation-
perfusion mismatch.
3. Increased blood viscosity.
4. Depressed myocardial contractility
decreased tissues
oxygenation
55
Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.
56
Metabolic acidosis
1. Lactate generation from
Shivering
Decreased tissue perfusion
2. Impaired hepatic metabolism
3. Impaired acid excretion.
4. Dehydration
5. Fluid sequestration
1. Hamlet MP. An overview of medically related problems in the cold environment. Mil Med 1987;152:393-396.
2. Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and hypothermia deaths among Native Americans in New
Mexico: between bar and home. JAMA 1992;267:1345-1348. 57
Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.
58
Hypothermia and
hematocrit
The hematocrit increases 2 percent
per 1 degree C decline in
temperature.
However, there are no safe clinical
predictors of the changes in
hematologic and electrolyte values
with rewarming.
59
Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.
60
Potassium metabolism
Hypothermia masks potassium-
induced changes in the
electrocardiogram.
Hyperkalemia can be particularly
dangerous in a patient with…
Metabolic acidosis,
Rhabdomyolysis,
Renal failure.
62
Glycosuria
Cold-induced renal glycosuria.
Persistent hyperglycemia suggests
pancreatitis or diabetic ketoacidosis.
63
Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.
64
Coagulopathy
Normal levels of clotting factor.
Cold directly inhibits the enzymatic
reactions of the coagulation cascade.
Hypercoagulability also occurs and
may result in thromboembolism.
•Patt A, McCroskey BL, Moore EE. Hypothermia-induced coagulopathies in trauma. Surg Clin North Am
1988;68:775-785.
•Rohrer MJ, Natale AaM. Effect of hypothermia on the coagulation cascade. Crit Care Med 1992;20:1402- 65
1405.
Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.
66
Platelets dysfunction
Platelet activity also declines, since
the production of thromboxane B2 by
platelets is temperature-dependent.
Cold-induced thrombocytopenia that
results from
Direct suppression of bone marrow and
Hepatosplenic sequestration.
•Valeri CR, Feingold H, Cassidy G, Ragno G, Khuri S, Altschule MD. Hypothermia-induced reversible platelet
dysfunction. Ann Surg 1987;205:175-181.
•Rosenkranz L. Bone marrow failure and pancytopenia in two patients with hypothermia. South Med J 1985;78:358-
359. 67
Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.
68
Dehydration
1. Decreased oral intake.
2. Fluid sequestration.
3. Increased vascular permeability.
4. Cold-induced diuresis.
69
ICU team check list
1. Metabolic acidosis, lactic and
ketoacidosis.
2. Respiratory failure.
3. CNS impairment.
4. Hyperglycemia and DKA
5. Hypothermia.
6. Hypovolemia.
7. Hyponatremia/hypernatremia
8. Leukocytosis (underlying infection)
9. Abdominal tenderness!
70
Rewarming
Warming blankets.
Room temperature raised up.
Warm and humidified oxygen
through vent.
Warm normal saline.
71
Rehydration/rewarming
Warm NS…
1 L bag microwaved for 3 min.
37-40 degrees Celsius.
72
Metabolic acidosis
management
Rehydration with normal saline.
Rehydration with normal saline.
Insulin IV drip started…
@ 0.1 units/Kg/hour
We reach as high as 37 units/hour.
Response to insulin IV improved with
higher core temperature.
Bicarbonate drip used for 3 hours
only.
RR increased to 25/min
Antibiotics: Imipenem 500 mg IV BID
73
Labs
BMP q 3 hours x 5 with magnesium.
ABG q 2 x 3
CBC q 12 hours
Amylase / Lipase
CPP q 6 hours x 3 (including CPK)
Accu check q 1 hour.
INR in am
EKG q 12 hours.
74
Amylase 430
Lipase 360
Na 124 130 136 140 149 159 147 139
76
WB 7
C
32k 30k 28k 18k 15k 11k 9k
.5k
HG 1 1 1 1 1 1 1 1
B 4.7 1.4 1.3 1.1 0.9 0.5 0.5 0.6
HCT 48 33 30 34 32 32 31 31
77
After 24 hours
Patient was awake and alert
Rectal temp 37.8 C
Pupils were reactive to light and
accommodation
Extubated
Off insulin IV
Started on Insulin Sliding scale and
Lantus
Start taking PO
Transferred to floor. 78
References
1. Mills WJ Jr. Accidental hypothermia: management approach. Alaska Med 1980;22:9-
11.
2. Paton BC. Accidental hypothermia. Pharmacol Ther 1983;22:331-377.
3. Hamlet MP. An overview of medically related problems in the cold environment. Mil
Med 1987;152:393-396.
4. Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and hypothermia deaths
among Native Americans in New Mexico: between bar and home. JAMA
1992;267:1345-1348.
5. Danzl DF, Pozos RS, Auerbach PS, et al. Multicenter hypothermia survey. AnnEmerg
Med 1987;16:1042-1055.
6. Fischbeck KH, Simon RP. Neurological manifestations of accidental hypothermia. Ann
Neurol 1981;10:384-387.
7. Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992;10:311-
327.
8. Patt A, McCroskey BL, Moore EE. Hypothermia-induced coagulopathies in trauma.
Surg Clin North Am 1988;68:775-785.
9. Reed RL II, Bracey AW Jr, Hudson JD, Miller TA, Fischer RP. Hypothermia and blood
coagulation: dissociation between enzyme activity and clotting factor levels. Circ
Shock 1990;32:141-152.
10. Rohrer MJ, Natale AM. Effect of hypothermia on the coagulation cascade. Crit Care
Med 1992;20:1402-1405.
11. Valeri CR, Feingold H, Cassidy G, Ragno G, Khuri S, Altschule MD. Hypothermia-
induced reversible platelet dysfunction. Ann Surg 1987;205:175-181.
12. Rosenkranz L. Bone marrow failure and pancytopenia in two patients with
hypothermia. South Med 1985;78:358-359.
13. Rahn H. Body temperature and acid-base regulation. Pneumonologie 1974;151:87-94. 79
References
1. Kroncke GM, Nichols RD, Mendenhall JT, Myerowitz PD, Starling JR. Ectothermic
philosophy of acid-base balance to prevent fibrillation during hypothermia. Arch Surg
1986;121:303-304.
2. Delaney KA, Howland MA, Vassallo S, Goldfrank LR. Assessment of acid-base
disturbances in hypothermia and their physiologic consequences. Ann Emerg Med
1989;18:72-82.
3. Swain JA. Hypothermia and blood pH: a review. Arch Intern Med 1988;148:1643-
1646.
4. Baraka A. Hydrogen ion regulation during hypothermia -- hibernators versus
ectotherms. Middle East J Anesthesiol 1984;7:235-238.
5. White FN. A comparative physiological approach to hypothermia. J Thorac Cardiovasc
Surg 1981;82:821-831.
6. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three
methods of resuscitaton from mild hypothermia. Resuscitation 1984;11:21-33.
7. Webb P. Afterdrop of body temperature during rewarming: an alternative
explanation. J Appl Physiol 1986;60:385-390.
8. Lloyd EL. Equipment for airway warming in the treatment of accidental hypothermia.
J Wilderness Med 1991;2:330-50.
9. Iserson KV, Huestis DW. Blood warming: current applications and techniques.
Transfusion 1991;31:558-571.
10. Moss JF, Haklin M, Southwick HW, Roseman DL. A model for the treatment of
accidental severehypothermia. J Trauma 1986;26:68-74.
11. Otto RJ, Metzler MH. Rewarming from experimental hypothermia: comparison of
heated aerosol inhalation, peritoneal lavage, and pleural lavage. Crit Care Med
1988;16:869-875.
12. Brunette DD, Biros M, Mlinek EJ, Erlandson C, Ruiz E. Internal cardiac massage and
mediastinal irrigation in hypothermic cardiac arrest. Am J Emerg Med 1992;10:32-34.80
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