Hypothermia(Hyperthermia)Dr. Stella YiuStaff Emergency Physician

LMCC objectives

List clinical findings of hypothermia

Investigate

Initiate resuscitation for severe hypothermia

1. Clinical findings of hypothermia

Normal temp: 36.5 – 37.5 C

Effects

By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

Image credit: US public domain

Mild (32-35C)

By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

Image credit: US public domain

Moderate (28-32C)

Image credit: US public domain Photo credit: Greg O’Connell, Flickr creative commons

Moderate (28-32C)

Image credit: James Heilman, MD Photo credit: Greg O’Connell, Flickr creative commons

Severe (<28C)

Image credit: jer5150, Wikimedia commons, Jeffrey Bary, Flickr creative commons

What precipitates hypothermia?

Increased heat lossAlcohol

Sepsis

Burn

Impaired thermoregulation

Metabolic (Cirrhosis, uremia, DM, Hypothyroid)

CNS (stroke, trauma, MS, Parkinson)

Drugs (barbituates, TCAs)

2. Investigations

CDMQ: 4 investigations

InvestigationsCBC, Cr, Lytes

Coag profile (DIC)

TSH

EKG

Osborn J waves

3. Resuscitation

EM Ottawa

Mild (32-35C): Passive external rewarm

18

EM Ottawa

Mod (28-32C): Active external rewarm

19By U.S. Navy photo by Journalist 2nd Class J. Maurer. [Public domain],

via Wikimedia Commons

EM Ottawa

Mod (28-32C): Active external rewarm

20By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

Warm humidified Oxygen

EM Ottawa

Severe (<28)Warm every cavity

butGentle handling

21

Severe: ArrhythmiaVF: CPR, defib x 1

If defib x 1 does not work, no defib (continue CPR) until >30C

Not dead until warm and dead

CDMQ: What cavities for rewarming? (6)

AirwayWarm humidified oxygen

CirculationWarm intravenous fluids

Pleural space

By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

Bladder

By User:Lennert B [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or CC-BY-2.5

(http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

Dialysis

By National Kidney and Urologic Diseases Information Clearinghouse, National Institute of Diabetes and Digestive

and Kidney Diseases, National Institutes of Health, USA [Public domain], via Wikimedia Commons

Photo credit: becre8tv, CC by 2.0, via Flickr Creative commons

Bypass

By Van Meurs, K, Lally, KP, Peek, G, Zwischenberger, Extracorporeal Life Support Organization, Ann Arbor 2005. [CC-BY-2.5

(http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

MCQ 3: Patient is confused and bradycardic. Most appropriate warming method?

A. Pleural lavageB. Bladder irrigationC. IntubationD. Peritoneal dialysisE. Warm humidified oxygen

MCQ 4: 12 yo found in the snow. After 2hrs CPR and warming, asytolic and core temp is 27.5C. What is the most appropriate step?A. Stop resuscitation B. DefibrillationC. Continue CPR and warmingD. Warm water immersionE. Stop warming

Not dead until warm (>30-32) and dead

Hyperthermia

LMCC objectivesList predisposing illnesses

List clinical findings

Select investigations

Manage patient by various cooling methods

CausesEnvironm

ent Decreased heat dissipation

Metabolic heat

1. Predisposing illness

Metabolic causes: Heat production

Metabolic heatThyroid, pheochromocytomaMalignant hyperthermiaNMSSepsis

Decreased heat loss: Drugs

Decreased heat dissipation

ObesityDrugs (anticholinergics, serotonin, sympathomimetics)

2. Clinical findings

Case: The rave girl

Heat stroke: Hot + confusedT> 40Orthostatic BP, HR

CNS: Confusion, ataxic, cerebral edema, seizureCVS: CHF, pulmonary edema, CV collapse

Lab findings: Liver, RenalLiver: necrosis

Rhabdomyolysis

DIC

3. Cooling methods

Basic cooling:

Photo credit: Kenneth Lu, Flickr creative commons

Photo credit: yellowcloud, flickr creative commons

More aggressive coolingTub immersion

GI/Peritoneal lavage

Cardiac bypass

Stop cooling when temp < 40

LMCC objectivesList predisposing illnesses

List clinical findings

Select investigations

Manage patient by various cooling methods