Hypothermia its that season again

1
Hypothermiaits that season again
2
Homeothermic

• Man is homeothermic
• Mans metabolism is exothermic
• Man is a temperate organism
• Metabolism most efficient at 98.6 F/37 C

3
/- 2 c/4 F
4
(No Transcript)
5
When Heat loss gt gain

• Metabolism increases heat generated dependent
  on Hypothalamic recognition Thymic
  triggers receptive cells adequate
  glucose cellular activity
• Shunt heat/circulation to priority
  areas dependent on Hypothalamic
  recognition intact nervous system reactive
  cardiovasculature

6
Hypothermia

• When
• Heat loss exceeds
  Heat production/gain

7
Hypothermia

• Definition core temperature less than 35 C
  or 95 F
• Levels Mild 32-35 C Moderate 28-32 C
  Severe gt28 C
• Primary Hypothermia Exposure or
  environmental usually acute
• Secondary metabolic or nutritional usua
  lly chronic circumstance

8
Causes of Hypothermia

• Excessive heat loss Exposure ,elderly,
  infants, debilitated Immersion Drugs
  Alcohol Dermal Dysfunction
• Inadequate heat production Metabolic
  dysfunction all the hypos CNS dysfunction
  Sepsis

9
At Risk Groups

• Alcoholics CNS depression vaso-dilation poor
  nutrition hepatic/endocrine
• Geriatric Decrease activity medications nut
  rition/ Isolation/ MS

• Endocrine /Metabolic Nutrition all
  hypos medications physiology
• Neonatal
• EMS Induced

10
(No Transcript)
11
Neuromuscular Signs of Hypothermia

• Amnesia,dysarthria,poor judgment (34 C)
• Loss of coordination,appearing drunk (33 C)
• Shivering ceases (32 C)
• Progressive decrease in LOC (29 C)
• Pupils Dilate/ Loss constrictive reflex (29 C)
• Loss of deep tendon reflexes (27 C)

12
Cardiovascular Signs of Hypothermia

• Sinus Bradycardia (lt35 C)
• Atrial Fibrillation (30 C)
• Progressive decrease in BP (29 C)
• Progressive slowing of pulse (29 C)
• Ventricular irritability (28 C)
• Cardiovascular collapse (24 C)

13
Respiratory Signs of Hypothermia

• Initial Hyperventilation 34 C
• Progressive decrease rate/volume lt34 C
• Non cardiac pulmonary edema 25 C

14
GU signs of Hypothermia

• Gastrointestinal - ileus
• Renal - cold diuresis hypovolemia hemocon
  centration
• Hematologic lactic acidosis hyperglycem
  ia

15
Suggestive electro-cardiograph patterns

• Rate slows
• QRS widens
• P waves ? Presence
• Baseline artifact
• T wave inversion
• ST segments Osburn Wave

16
(No Transcript)
17
(No Transcript)
18
Two Quick Changes

• Ventricular Fibrillation
• After Warming Drop

19
(No Transcript)
20
(No Transcript)
21
Hypothermic Pitfalls

• FTR hypothermia lack of suspicion
• FTR normal treatments(chemical electrical)
  ineffective below 28 C
• Airway,ventilation ,invasive and movement
  techniques precipitate arrhythmia's/ VF
• Failure to continue resuscitation to/past 32 C
• Failure to adequately volume resuscitate
• Failure to monitor/ watch out for afterdrop

22
Initial Rx Hypothermia

• ABCs Protect from further heat loss
• Airway- prevent gag
• Ventilation avoid hyperventilation
  10-12/min warmed humidified Oxygen
• Circulation assure absence or presence of
  pulse Defibrillation x3 max..(200-300-360
  ws) Volume expansion 250cc bolus 40-42
  C NB meds ineffective below 28 C
• Careful movement and manipulation

23
(No Transcript)
24
Cold Induced Tissue Injury

• Freezing near freezing

25
Cold Induced Tissue Injury

• Cold/Freezing of cellular fluid reduction
  cellular metabolism expansion of
  volume formation of ice crystals hypoxi
  a/acidosis dehydration/ concentration c
  ellular ischemia
• Incipient - 1st Degree -Frost Nip
• Superficial-2nd Degree-Frostbite
• Deep- 3rd Degree-Frozen

26
(No Transcript)
27
Sporadic in Civilian Life Endemic in military
history

• Napoleon's Disastrous Russian Campaign
  1812 Larrey described 250,000 cold injuries
• Crimean War 1852-1856 52,150 cases
  frostbite out of 309,000 troops Sevastapol
  2,880 (900 fatalities) in 2 nights
• World War I 1914-1918 British lost 115,000
  troops frostbite/trenchfoot Dardenelles 15,000
  troops lost to cold
• World War II Dec 41 to Jan 42 German
  army lost 100,000/15K amps 10 all American
  casualties
• Recent Falkland's Trenchfoot major
  issue Argentine amputations all combat
  related deaths 200

28
Frostbite/Post In From the Cold
29
Initial Presentation Management

• Careful handling
• Remove constrictions rings watches
• Careful Remove socks
• Immersion
• Elevation
• Pain Management

30
Treatment Dont(s) No matter what Hollywood Says

• Dont rub with snow dry massage use
  radiant heat rupture blisters apply
  ointments no tight bandages allow to
  re-freeze handle roughly allow
  smoking, alcohol

31
(No Transcript)
32
Management of Cold Injury

• Wet Thaw/immersion water 100-110 F (40-42
  C) end point sensation pliability
• Watch for concurrent Hypothermia
• Dont overlook related disorders
• Anticipate precipitated problems

33
Post Thaw Treatment

• Dont Not Allow Re-freeze
• Elevation
• Pain Management
• Wound Management Sepsis control Bandaging

34
Frostbiteevaluation management review

• Careful history, conditions, risk factors
• Remember concurrent or precipitating
  hypothermia systemic hypothermia treated first
• Remove adherent,constricting clothing materials
• Rapid Re-warming water bath 40-42 C
  15-20 min. End point sensation and/or
  pliability
• Be watch out for post-thaw edema pain

35
14 -21 Days

• Tissue Necrosis
• Viability Demarcation
• Physiologic Amputation

36
Immersion/ Trench Foot
37
Immersion/ Trench Footthe scent that lingers
with you forever

• Caused by prolonged cold exposure 30-40
  F localized non-freezing commonly wet
• Symptoms associated leg cramping Early
  cool,pallor,insensitive edema late
  cyanotic,erythema/mottled blisters/ulcers
  macerated with infection
• Management Recognition,elevation,avoidance
  pressure, Tissue management

38
Do not attempt thawing in the field if any chance
of re-freezing exists
39
The temperature in the water bath must be kept
between 38-42 C
40
DO NOT SPEND TIME IN THE FIELD TRYING TO REWARM
SEVERLY HYPOTHERMIC PATIENT
41
The hypothermic patient isnt dead until he is
warm and dead
42
Watch out for rewarming shock/arrest
43
(No Transcript)
44
(No Transcript)
45
Cold Water Immersion

• Always Two Problems

46
DrowningBad label a form of Death

• Drowning death by water related suffocation
  within 24 hr. of submersion
• Hear Drowning non lethal anoxic event due
  to submersion
• 14,000 cases/year predominantly young
  males seasonal location
• Remember not always an inability to swim Often
  multiple problems at once

47
(No Transcript)
48
Po2gt50 PcPCO2 lt50
49
(No Transcript)
50
Cold Water Immersion

• Water conducts heat away x32
• USCG definition water gt 70F/21 C universal in
  North America year round issue
• 50/50/50 Rule
• Remember the Titanic 2,201 passengers 712
  Survivors all in lifeboats 1,489 deaths most
  wearing lifejackets

51
(No Transcript)
52
Factors Affecting Heat Loss

• Water Temperature
• Victims body fat,nutrition,overall health
• Protective clothing
• Victims activity
• Water activity
• Amount/portions of body immersed

53
(No Transcript)
54
(No Transcript)
55
Drownproofing H.E.L.P Position
Wind-chill not as important as out of water
56
(No Transcript)
57
(No Transcript)
58
Cold water ImmersionResuscitation

• Remember both problems near drowning-
  asphyxia hypothermia
• Airway- watchful for aspiration
• Ventilation-IPPV high FiO2 evaluate for
  Bronchospasm
• Circulation- supportive
• Hypothermia-prevent/passive reheat watch out
  for re-warming shock/arrest

59
Presentation donated by

• Jon F Levine REMT-p I/C
• Superintendent Boston EMS
• Training Quality Improvement
• 30 year paramedic and instrucor with City of
  Boston