?Alive?Dead……….Hypothermia

DrWahidAltaf

Ireland

ColdMan

MRN834269J.P.SD.O.B.7/2/1984,25yold

5/3/9

Foundat0722am

collapsed,unconsciousbypasserby inStFinbarr’s(Glasheen)graveyard

Ambulancearrived0728,

Groaninginambulance,GCS3/15,‘pulsepresentbutirregular’Pupilsize4/8bilateral.

ArriveinCUH0747

Smellofalcoholoffbreath,Abrasionsonforehead,leQarm,leQleg

Previously...

RecentlyreleasedfromprisonHistoryofdepression,anxiety

Lastseeneveningbeforeat5.30pm,parentspillsmissing–

aspirin, plavix, lipitor, tritace, emcor, paracetamol.

A&E0747

Unresponsive,pulseless,asystole,

PupilsnonreacVng&dilated

Abrasionsonhead

Rectaltemp20oc

0820rectaltemp22.2oc

9mgadrenalinebetween0755and0835,CPR,

intubaVon,venVlaVon(vomitusnotedinthroat)

2LfluidgiveninA&E

Catheterised

0850totheatreforrewarmingonCPB

Theatre0850‐1230

BloodsinA&E

Na141K 5

Cl 105

Urea6.9

Creat79

Alb33

AST46

Phos2.03

ECGna

TIME 0804

PaO2 3.0

PaCO2 13.4

pH 7.13

Lactate(0.5‐2.0)

3.1

Bic 33

Bdef +4.1

Na(BloodGas) 137

K(BloodGas) 4.7

Cl(BG)(98‐107) 96

CK 2134

Hgb 14.3

Glucose ?

0900100011001200

C

CTbrain5/3/9

(contrast)

ICUbloods

Theatre

R.FemA>VCPBypass

Spontaneousrhythmatnasopharyngealtemp32oC

Rewarmedto35oC

ICUvenVlate

Cefuroxime+metronidazole

R.BasalconsolidaVon

Time 5/3/09

Day01530

6/3/09

Day10620

7/3/09

Hgb 10.6 9.9

WCC 27.4 22

plat 335 242

INR 1.2 1.1

APTT 35 28

Bilirubin 7 6

ALT(4‐45) 145 142

CK(40‐180) 3677 NA

Creat 43 88

5/3/9ICU

Date 5/3/09(day0) 6/3/09(day1)

Time 1300 1400 1600 1800 2000 2200 2400 0200 0400 0600Adrenaline 16 14 14 12 12 12 12 10 6 off

MAP 67 87 69 72 72 70 68 68 84 86

Urineml/hr

500 70 100 320 290 150 100 125 100 120

TempoC 35

ICU

TIME 0804 1315 1500 1700 0047

PaO2 3.0 13.2 14 15.9 14.2

PaCO2 13.4 10.4 6.3 5.5 4.6

pH 7.13 7.19 7.34 7.38 7.48

Lactate(0.5‐2.0)

3.1 1.0 1.3 1.6 1.2

Bic 33 29.8 25.4 24.3 25.3

Bdef +4.1 1.6 ‐0.4 ‐0.8 +1.8

Na(BG) 137 140 139 135 139

K(BG) 4.7 4.4 4.4 4.0 3.7

Cl(BG)(98‐107)

96

CK 2134

Hgb 14.3

Glucose 8.1 8.5

5/3/9cxr

ChestxrayICU6/3/9

Cxr8/3/9

Conundrums

Rewarming passive

acVve

Howtorewarmproblemsencountered

Rateofrewarming

fast

slow‐risksofprolongedCPR

poorcardiacoutput

cerebralhypoxia

#ribs,liver,spleen

Temperatureatwhichtostoprewarming

Whogetshypothermia

induced

accidental

Hypothermia duraVonofexposure

tempatdiscovery

ILCORspecialresuscitaVonsituaVons

Coolingdown‐problems Re‐warming‐problems

SwissstudyNEJM1997

oE

SigaardAnderson1962