NCM 103 FLUIDS AND ELECTROLYTES

HYPOTHERMIA
Pathophysiology and Management

Submitted by: ASIS, ANGELICA P. BSN 219

Conduction and Convection Respiration and Evaporation Circulating Air

Heat Loss

Dry Conditions and Radiation Direct transfer of heat to another object Drowning/ Immersion of water

Stimulation of Hypothalamus Thermoregulation

Increase Heat Production

Shivering

Thyroxine and Epinephrine

O2 consumption and caloric demands

Vasoconstriction

Overwhelmed mechanism for heat preservation Drop of core temperature HYPOTHERMIA

Depolarization of cardiac pacemakers

CNS Depression

Bradycardia

Atrial and Ventricular arrhythmia

Abnormal Electrical Activity Brain Death

MANAGEMENT Gentle rewarming of the patient.

To perform this, three main techniques are available. These are passive rewarming, active external rewarming and active internal rewarming. In passive rewarming, wet clothing should be removed and the patient well insulated at room temperature, including the head, to prevent further heat loss while the bodys natural thermogenesis is relied upon to restore body temperature. Proponents of this method argue that it is the most physiological and it is thought that it reduces the incidence of rewarming shock. However, failure to rewarm or the presence of dysrhythmias are not good prognostic signs and indicate that a more aggressive approach is required.

Active external rewarming relies on a heat source applied to the body and therefore depends on the conduction of heat through the skin. Methods currently used are warming blankets, heating pads or immersion of the patient in a bath maintained at a temperature around 40C. Caution must be taken with heating pads as skin injury can occur while monitoring is made virtually impossible by submersion in water. Hence the later technique should only be used for those who are conscious, shivering, uninjured and able to get in and out of the bath unaided. Nevertheless, the advantage of active external rewarming is that rewarming occurs more rapidly than with passive rewarming, particularly if the patient has impaired thermoregulatory function.

In active internal rewarming heated fluid or humidified gas is delivered internally. Humidified and warmed oxygen can be given, thereby warming and effectively insulating the patients airways. Heated peritoneal lavage warms the heart through the diaphragm and blood returning via the inferior vena cava, stabilising cardiac conduction. It is a relatively safe and simple technique, although it is contraindicated in intra-abdominal trauma and cases of severe intra-abdominal sepsis and disseminated intravascular coagulation have been reported. Fluids, including blood, can be warmed and given intravenously, although the risk of fluid overload and cardiac failure must be considered. Finally, heated cardiopulmonary bypass provides extracorporeal rewarming and circulatory support, with this technique providing the most rapid and physiological method of internal rewarming as the core is rewarmed first. However, an experienced team is required and it has been argued that this technique is unnecessarily invasive. In practice, extracorporeal warming is usually adopted only if other methods have failed.

While rewarming occurs, a number of supportive measures may require implementation and patients should have their vital signs monitored to detect any possible complications. If the gag reflex or ventilation is inadequate, endotracheal intubation may be required. However, in an attempt to avoid dysrhythmias, the hypothermic patient should be handled gently and the ECG continuously monitored. Consequently, chest compressions should only be commenced by rescuers prior to hospital admission if there is no carotid pulse palpable for at least one minute and it will be possible to continue the compressions until hospital or other location.

If hypothermia has been prolonged, patients may be hypovolaemic and therefore warmed fluids should be given and the bladder catheterised. Blood glucose may initial be high but falls as rewarming progresses, so 50% glucose solution may be necessary. In this situation, glucagon is not usually effective as the majority of patients will have depleted their glycogen stores. As many hypothermic patients are alcoholics, vitamin B, particularly thiamine, should be given to avoid the complication of acute Wernicke's encephalopathy. Acidosis is not normally corrected with bicarbonate as the patients metabolic picture changes rapidly throughout the rewarming process and over vigorous correction results in alkalaemia, which may predispose to arrhythmias. Finally, if gastric dilatation and poor gastric mobility exist, the insertion of a nasogastric tube is an option.

The use of drugs should be avoided as they are ineffective at lower temperatures and may cause unwanted side effects as the patient is rewarmed. Exceptions to this are oxygen, dextrose, naloxone and thiamine.

Bloods should be taken for full blood count, urea and electrolytes, amylase, clotting and, in severe hypothermia, blood gases. Toxicology screens may be appropriate. A chest x-ray is also essential to exclude a subsequent pneumonia or adult respiratory distress syndrome.2