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
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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

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Overview of Guidelines

• General points
• Hypothermia
• Cold water near drowning
• Frostbite
• New section on avalanche rescue

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Introduction

• Guidelines - not absolute rules
• Designed as a reference, not a teaching document

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Multilevel guidelines

• General points
• General public
• First Responder / EMT-I
• EMT-II
• EMT-III / Paramedic
• Small/Bush Clinic
• Hospital

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Hypothermia -General Points

• Core temperature best measured as esophageal
  temperature if possible
• Epitympanic temperature second choice
• Rectal temperature third choice

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Hypothermia -General PointsWhy esophageal
temperature?

• Best reflection of core temperature
• Reflects cardiac temperature
• Relatively non-invasive
• Technology widely available
• Patient remains covered

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Hypothermia -General PointsEpitympanic
temperature

• Reflects carotid artery temperature
• Non-invasive
• Technology not yet widely available in USA

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Hypothermia -General PointsRectal temperature

• Does not reflect core temperature very well
• Lags core temperature during rewarming
• Requires disrobing patient

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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.

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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.

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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).

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Hypothermia - General PointsWhy IV fluid
boluses?

• Less likely to freeze than continuous infusions
• Better titration to effect

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Hypothermia - General Points

• Chemical heat packs ineffective for warming
• Can be used on hands or feet to prevent frostbite

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Hypothermia - General Points

• Positive attitude is important
• Assume the patient can be resuscitated even if
  they appear to be beyond help

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Hypothermia - General PointsContraindications to
CPR

• New temperature cutoff - core temperature
  10C/50F
• Rescuers exhausted or in danger or CPR cannot be
  maintained throughout transport to a medical
  facility
• Transportation available within 3 hours

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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

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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

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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.

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Hypothermia - General PointsCPR

• Apneic pulseless patient - ventilate for 3
  minutes before CPR to increase VF threshold
• Ventilation may increase heart rate, blood
  pressure

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Hypothermia - General PointsCPR

• Apneic pulseless patient - decision to start CPR
  based on time to critical care
• lt3 hours ventilate (intubate, if possible),
  prevent heat loss
• gt3 hours chest compressions and ventilate for 30
  minutes, attempt to rewarm
• CPR cannot be done in a litter

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Handle hypothermic patients gently to prevent
Ventricular Fibrillation
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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

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Hypothermia - General PointsAssessment

• New classification for severity of hypothermia
• Follows International Commission for Alpine
  Rescue, Winnepeg consensus guidelines
• Correlates core temperature with observable
  findings

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Hypothermia stages

• Mild 32-35C (90-95F)
• Moderate 28-32C (82-90F)
• Severe lt28C (lt82F)
• Ideally based on esophageal temperature
• Becoming standard classification worldwide

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Hypothermia - General PublicMild Hypothermia

• Patient is cold
• Vigorous shivering
• Alert
• May be ambulatory

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Hypothermia - General PublicTreatment

• Remove wet clothes only with shelter
• Vapor barrier
• Cover head and neck

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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

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Hypothermia - General PublicTreatment

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

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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)

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Hypothermia - General Public Moderate-Severe
Treatment

• Handle gently
• Do not rub or manipulate extremities

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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

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

• Handle gently
• Check pulse for at least 60 seconds
• CPR if not contraindicated

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Hypothermia -First Responder EMT-I

• Same as general public with additions
• Oxygen, if used, should be heated and humidified

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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

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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 104-108F (40-42C)
• Consider glucose, naloxone

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EMT-IISevere hypothermawith signs of life

• Measure core temperature (esophageal is
  preferred)

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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 30C (86F)
• Further attempts above 30C

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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

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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

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Hypothermia - HospitalGeneral Points

• Consider transfer of patient with core temp lt20
  C (68 F)
• Consider bypass if BPlt60 systolic
• Stabilize patient before transport

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Hypothermia - HospitalGeneral Points

• Suggestions for evaluation and treatment

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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

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Hypothermia - HospitalGeneral PointsRewarming
methods

• Passive external rewarming
• Active external rewarming
• Active core rewarming

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Hypothermia - HospitalGeneral PointsActive
internal rewarming

• Peritoneal lavage
• AV Rewarming
• Cardiopulmonary bypass
• Venous heat-exchange catheter (possible future
  technology)

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Hypothermia - HospitalGeneral PointsActive
internal rewarming

• Slow rewarming prior to adequate ventilation

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Hypothermia - HospitalGeneral PointsCardiac
rhythm disturbances

• Supraventricular dysrhythmias are innocent
• V Tach and V Fib - one round of shocks until 30C
  (85F)
• Drugs ineffective

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Hypothermia - HospitalGeneral PointsInsulin

• Consider insulin during rewarming.

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Hypothermia - HospitalWhen to stop
resuscitation?

• Core temperature not improving despite aggressive
  rewarming
• Serum potassium gt10 with associated asphyxia
  (near drowning, avalanche)

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Cold Water Near DrowningGeneral Points

• Use of PFDs with thermal protection mandatory for
  emergency responders

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Cold Water Near DrowningGeneral Points

• Submersion - head under water
• Immersion - head out of water

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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

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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

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Cold Water Near Drowning - First Responder /
EMT-I

• Similar to General Public

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Cold Water Near Drowning - EMT-II

• Similar to EMT-I
• Saline lock or TKO (no fluids)

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Cold Water Near Drowning - EMT-III / Paramedic

• Similar to EMT-II
• Assess for possible cardiopulmonary bypass

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Cold Water Near Drowning - Hospital

• IV fluids only if volume depleted
• Cardiopulmonary bypass no longer recommended

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Cold Water Near Drowning - Hospital

• Active external rewarming as indicated by core
  (esophageal) temperature.
• Keep patients at 32-33 C to protect the brain.

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Cold Water Near Drowning - Hospital

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

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Frostbite

• No significant changes in prehospital care

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Frostbite

• Temperature for thawing 38-40C (100-107F). The
  lower end is preferred.
• Stop thawing when tips of digits flush.
• Recommendations for wound care.

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Frostbite

• Fasciotomy guided by compartment pressures
  (gt37-40 mm Hg) and clinical judgment
• Antibiotics necessary only for deep infection
• General care recommendations

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Frostbite

• Orthopedic guidelines
• Guidelines for disposition
• Sample admitting orders

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Avalanche rescue

• Similar to cold water near drowning
• Importance of asphyxiation

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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

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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.

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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.

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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

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Avalanche Rescue

• CPR/ACLS for 30 minutes for burials less than 35
  minutes or core temp gt32C
• No CPR/ACLS for burials longer than 35 minutes or
  core temp lt32C if no air pocket
• CPR/ACLS for burials longer than 35 minutes or
  core temp lt32C with air pocket