HYPOTHERMIA Alcohol Related Illness. Hypothermia - Alcohol Hypothermia Hypothermia Epidemiology...

HYPOTHERMIAHYPOTHERMIAAlcohol Related IllnessAlcohol Related Illness

Hypothermia - AlcoholHypothermia - Alcohol

HypothermiaHypothermia EpidemiologyEpidemiology Physiology of Temperature ControlPhysiology of Temperature Control Etiology of HypothermiaEtiology of Hypothermia Pathophysiology/TreatmentPathophysiology/Treatment Hypothermia and TraumaHypothermia and Trauma

AlcoholAlcohol Ethanol IntoxicationEthanol Intoxication Pathophysiology/TreatmentPathophysiology/Treatment Alcohol AbuseAlcohol Abuse

HypothermiaHypothermia

EpidemiologyEpidemiology Defined as temp <35Defined as temp <35OO C (<95 C (<95OO F) F) >700 die each year in US from >700 die each year in US from

hypothermiahypothermia ½ of those are 65+ years old½ of those are 65+ years old Individuals at age extremes and those Individuals at age extremes and those

with AMS are at greatest riskwith AMS are at greatest risk

Physiology of Temperature Physiology of Temperature ControlControl

ConductionConduction Transfer of heat by direct contact down Transfer of heat by direct contact down

temperature gradient.temperature gradient. ConvectionConvection

Transfer of heat by movement of heated Transfer of heat by movement of heated material. (i.e. wind)material. (i.e. wind)

RadiationRadiation Loss of heat from non-insulated areasLoss of heat from non-insulated areas

HH22O EvaporationO Evaporation Loss of heat through exhalationLoss of heat through exhalation

Temperature HomeostasisTemperature Homeostasis Opposition of Heat LossOpposition of Heat Loss

HypothalamusHypothalamus Stimulation of sympathetic nervous system if temp Stimulation of sympathetic nervous system if temp

below ‘set point’below ‘set point’ Behavioral responsesBehavioral responses

Wearing clothes when it’s coldWearing clothes when it’s cold Leaving cold environmentLeaving cold environment

Heat GainHeat Gain ShiveringShivering ““Non-shivering thermogenesis”Non-shivering thermogenesis”

Etiology of HypothermiaEtiology of Hypothermia AccidentalAccidental

Immersion and non-immersion cold Immersion and non-immersion cold exposureexposure

MetabolicMetabolic Hypoendocrine states (hypothyroid, Hypoendocrine states (hypothyroid,

hypoadrenalism, hypopituitarism)hypoadrenalism, hypopituitarism) HypoglycemiaHypoglycemia

Head traumaHead trauma TumorTumor

Etiology of Hypothermia Etiology of Hypothermia (cont.)(cont.)

Wernicke’s disease.Wernicke’s disease. Drug inducedDrug induced

Alcohol (majority of hypothermic pt’s in Alcohol (majority of hypothermic pt’s in US are intoxicated)US are intoxicated)

SedativesSedatives PhenothiazinesPhenothiazines InsulinInsulin

SepsisSepsis

Etiology of Hypothermia Etiology of Hypothermia (cont.)(cont.)

Severe dermal diseaseSevere dermal disease BurnsBurns Exfoliative dermatitisExfoliative dermatitis

Acute incapacitating illnessAcute incapacitating illness Severe infectionsSevere infections DKADKA Psychotic disordersPsychotic disorders Other conditions causing impaired Other conditions causing impaired

thermoregulatory functionthermoregulatory function Resuscitation with room temperature fluidResuscitation with room temperature fluid

PathophysiologyPathophysiology Mild Hypothermia 34-36H C (93.2-96.8̊H F)Mild Hypothermia 34-36H C (93.2-96.8̊H F)

ExcitationExcitation Physiologic adjustments to retain heatPhysiologic adjustments to retain heat

Moderate Hypothermia 32-34H C (8̊9.6-93.2H Moderate Hypothermia 32-34H C (8̊9.6-93.2H F)F) AdynamicAdynamic

Metabolism slowsMetabolism slows Decreased ODecreased O22 demand demand Decreased CODecreased CO22 production production

Severe Hypothermia <32H 9 (8̊9.6H F)Severe Hypothermia <32H 9 (8̊9.6H F) Shivering ceasesShivering ceases

Pathophysiology Pathophysiology (cont.)(cont.)

ExcitationExcitation Sympathetic response (HR, BP, and Sympathetic response (HR, BP, and

Cardiac Output all rise).Cardiac Output all rise). AdynamicAdynamic

HR, CO, BP decrease due to negative HR, CO, BP decrease due to negative ino/chrono tropic effects of hypothermiaino/chrono tropic effects of hypothermia


Hypothermic EKG changesHypothermic EKG changes Osborne or J wavesOsborne or J waves T-wave inversionT-wave inversion Prolonged PR, QRS, QT intervalsProlonged PR, QRS, QT intervals Arrhythmias may include bradycardia, Arrhythmias may include bradycardia,

slow AF, slow AF, VFVF, or asystole, or asystole

Example

26°C

28°C28°C

28.5°C28.5°C

29.5°C29.5°C

a

b

c

d



Systemic Effects of Progressing Systemic Effects of Progressing HypothermiaHypothermia Pulmonary:Pulmonary:

Tachypnea Tachypnea RR & TV RR & TV Bronchorrhea, Bronchorrhea, gag/cough reflex gag/cough reflex

CNSCNS Discoordination Discoordination confusion confusion lethargy lethargy coma coma

Further deterioration may be cerebro-protectiveFurther deterioration may be cerebro-protective

RenalRenal ““Cold Diuresis” due to renal hypoperfusionCold Diuresis” due to renal hypoperfusion 33rdrd spacing spacing hemoconcentration hemoconcentration embolic embolic

complications complications rhabdomyolysis, etc. rhabdomyolysis, etc. CoagulopathyCoagulopathy

TreatmentTreatment

Stop further heat lossStop further heat loss Begin warming Begin warming

processprocess Passive external Passive external

warmingwarming Active external Active external

warmingwarming Active internal Active internal

rewarmingrewarming Warmed oxygen and IV Warmed oxygen and IV

fluidsfluids

Treatment Treatment (cont.)(cont.)

Maintain horizontal position Maintain horizontal position Vertical position may compromise Vertical position may compromise

cerebral and systemic perfusioncerebral and systemic perfusion Avoid rough movements and Avoid rough movements and

activitiesactivities Handle victim gently during CPR, Handle victim gently during CPR,

intubation, BVM ventilation, vascular intubation, BVM ventilation, vascular accessaccess


Cardiac ArrestCardiac Arrest If VF present:If VF present:

Defibrillate x 3 prnDefibrillate x 3 prn ETT w/ warmed, humidified OETT w/ warmed, humidified O22

Warmed IV fluids (avoid overhydration)Warmed IV fluids (avoid overhydration) If temp <30 H C (8̊6 H F)If temp <30 H C (8̊6 H F)

CPR, limit shocks x 3CPR, limit shocks x 3 Withhold IV medsWithhold IV meds Continue rewarmingContinue rewarming


Cardiac Arrest (cont.)Cardiac Arrest (cont.) If temp >30 H CIf temp >30 H C

CPRCPR Defib prn as core temp risesDefib prn as core temp rises IV meds as indicated (longer than normal IV meds as indicated (longer than normal

intervals)intervals) Continue rewarming during transportContinue rewarming during transport

Other Treatment ConsiderationsOther Treatment Considerations AMSAMS

Narcan 2mg IVNarcan 2mg IV Thiamine 100mg IVThiamine 100mg IV D50/W 25gm IV if D50/W 25gm IV if BGLBGL


Passive RewarmingPassive Rewarming Removal from environmentRemoval from environment InsulationInsulation

Active Core Active Core RewarmingRewarming Inhalation rewarmingInhalation rewarming Heated IV fluidsHeated IV fluids GI tract lavageGI tract lavage Bladder lavageBladder lavage Peritoneal lavagePeritoneal lavage Pleural lavagePleural lavage Extracorporeal rewarmingExtracorporeal rewarming Mediastinal lavageMediastinal lavage

Active External Active External RewarmingRewarming Warm HWarm H22O ImmersionO Immersion Heating blanketsHeating blankets Heated objectsHeated objects Radiant HeatRadiant Heat Forced airForced air

Rewarming Caution

After-drop PhenomenonAfter-drop Phenomenon

Temperature drop and acidosis provoke serious arrhythmias

Cold acidotic blood causes drop in core temp

Cold blood from dilated peripheral vessels carries high lactic acid levels to core vessels

Peripheral vasodilation (BP drops)

Initial active external rewarming leads to

Hypothermia – Trauma Pt.Hypothermia – Trauma Pt.

Three mechanisms that contribute toThree mechanisms that contribute tohypothermia-induced coagulopathy inhypothermia-induced coagulopathy in

trauma include:trauma include:

1.1. Platelet DysfunctionPlatelet Dysfunction2.2. Enhanced Fibrinolytic ActivityEnhanced Fibrinolytic Activity3.3. Alteration In Enzyme Alteration In Enzyme

FunctionsFunctions


Platelet DysfunctionPlatelet Dysfunction Inhibition of Thromboxane B2 Inhibition of Thromboxane B2

production causes the normal response production causes the normal response of platelet aggregation to decrease. The of platelet aggregation to decrease. The plateletsplateletsare therefore stored in the spleen and are therefore stored in the spleen and liver, and left unavailable for useliver, and left unavailable for use..


Enhanced Fibrinolytic ActivityEnhanced Fibrinolytic Activity Trauma-induced hypothermia causes a Trauma-induced hypothermia causes a

heparin-like substance to be released, heparin-like substance to be released, thus causing a disseminated intravascular thus causing a disseminated intravascular clotting (DIC)-like syndrome.clotting (DIC)-like syndrome.

This is marked by an increase in This is marked by an increase in prothrombin (PT) and partial prothrombin (PT) and partial thromboplastin times (PTT), and an thromboplastin times (PTT), and an increase in fibrin split products.increase in fibrin split products.


Alteration In Enzyme FunctionsAlteration In Enzyme Functions Hageman factor and Thromboplastin are Hageman factor and Thromboplastin are

needed to form clots at the site of needed to form clots at the site of injured endothelium.injured endothelium.

Hypothermia alters the function of these Hypothermia alters the function of these enzymes and others, therefore enzymes and others, therefore increasingincreasingbleeding and clotting times.bleeding and clotting times.

Hypothermia – Trauma Pt.Hypothermia – Trauma Pt. Coagulopathy – PerpetuatedCoagulopathy – Perpetuated

Blood transfusions/fluid resuscitation Blood transfusions/fluid resuscitation may lead to or exacerbate hypothermia.may lead to or exacerbate hypothermia.

Silbergleit et al report that room (or ambient)Silbergleit et al report that room (or ambient)temperature IV fluids, used in resuscitation,temperature IV fluids, used in resuscitation,increase hypothermia or may actually causeincrease hypothermia or may actually causesecondary hypothermia in trauma patients.secondary hypothermia in trauma patients.

Crystalloids dilute the availability of Crystalloids dilute the availability of coagulationcoagulationfactorsfactors

Banked blood is low in platelets and clottingBanked blood is low in platelets and clottingfactors, especially Factors V and VIIIfactors, especially Factors V and VIII

Hypothermia – Near Hypothermia – Near DrowningDrowning

Cerebral ProtectionCerebral Protection Protective Hypothermia (HProtective Hypothermia (H22O O

<5 H C) core body temp <28̊ H C<5 H C) core body temp <28̊ H C Water must be icy.Water must be icy. Heat loss must occur rapidly to Heat loss must occur rapidly to

metabolic rate before metabolic rate before significant hypoxemia begins.significant hypoxemia begins.

Very unlikely for this to happenVery unlikely for this to happen

More commonly, More commonly, hypothermic near drowning hypothermic near drowning have higher mortality rate.have higher mortality rate.

Acute Ethanol IntoxicationAcute Ethanol Intoxication EthanolEthanol

Most frequently used and abused Most frequently used and abused intoxicantintoxicant

¾ of adult Americans will consume at ¾ of adult Americans will consume at least one drink per yearleast one drink per year

36% will smoke a fag36% will smoke a fag Beer is number 4 on the most consumed Beer is number 4 on the most consumed

beverage list (pop, milk, coffee)beverage list (pop, milk, coffee) Average American pounded 2 gallons of Average American pounded 2 gallons of

pure ethanol 1997pure ethanol 1997 Down from 2.77 in 198̊1Down from 2.77 in 198̊1

EthanolEthanol

Distilled spiritsDistilled spirits 40-50% (8̊0-100 40-50% (8̊0-100

proof)proof) Some as high as Some as high as

75%75% WineWine

10-20%10-20% Beer Beer

2-6%2-6%

Other StuffOther Stuff Mouthwash (up to Mouthwash (up to

75%)75%) Cologne (40-60%)Cologne (40-60%) Medicinal Medicinal

preparations (as preparations (as high as 65%)high as 65%)

Pathophysiology - EthanolPathophysiology - Ethanol

CNS depressantCNS depressant Stimulant effect may occur @ Stimulant effect may occur @

concentrationconcentration Absorbed mainly in small bowelAbsorbed mainly in small bowel

Also occurs in mouth, esophagus, stomach, Also occurs in mouth, esophagus, stomach, and large boweland large bowel

Majority metabolized by liverMajority metabolized by liver Small % excreted by lungs, in urine, or Small % excreted by lungs, in urine, or

sweatsweat

Pathophysiology - EthanolPathophysiology - Ethanol Alcohol and WomenAlcohol and Women

More prone to alcohol related health More prone to alcohol related health problemsproblems

Smaller volume of distributionSmaller volume of distribution No first pass metabolism capabilityNo first pass metabolism capability

Alcohol dehydrogenaseAlcohol dehydrogenase Alcohol and PregnancyAlcohol and Pregnancy

Low birth weight infantsLow birth weight infants Fetal alcohol syndromeFetal alcohol syndrome

Facial dysmorphology Facial dysmorphology Mental/growth retardationMental/growth retardation

Ethanol IntoxicationEthanol Intoxication

Signs and SymptomsSigns and Symptoms Disinhibited behaviorDisinhibited behavior CNS depressionCNS depression NystagmusNystagmus Slurred speechSlurred speech motor coordination/controlmotor coordination/control

Ethanol IntoxicationEthanol Intoxication

Signs and Symptoms (cont.)Signs and Symptoms (cont.) BP BP hypotension hypotension

Due to Due to PVR and/or volume loss PVR and/or volume loss TachycardiaTachycardia

Respiratory depressionRespiratory depression Usually in unhabituated usersUsually in unhabituated users

Morbidity/MortalityMorbidity/Mortality Usually due to impaired judgment Usually due to impaired judgment

sequelaesequelae

TreatmentTreatment

SupportiveSupportive ABC’sABC’s Prepare to support respirationsPrepare to support respirations

Altered Mental StatusAltered Mental Status 25 gm D50/W prn25 gm D50/W prn Narcan 2 mgNarcan 2 mg Thiamine 100 mgThiamine 100 mg

Effects of Alcohol AbuseEffects of Alcohol Abuse Trauma and AlcoholTrauma and Alcohol

4th highest cause of death, after coronary 4th highest cause of death, after coronary disease, cerebro-vascular accidents and cancer. disease, cerebro-vascular accidents and cancer.

Main cause of death before the age of 40 years. Main cause of death before the age of 40 years. 40-50% of traffic deaths40-50% of traffic deaths 25-35% of non fatal car accidents25-35% of non fatal car accidents 64% of fires and burns64% of fires and burns 48̊% of cases of hypothermia and freezing48̊% of cases of hypothermia and freezing ~20% of suicides~20% of suicides

Implicated in 40% of falls and 50 % of murders Implicated in 40% of falls and 50 % of murders (victims or criminals).(victims or criminals).

Effects of Alcohol AbuseEffects of Alcohol Abuse CNSCNS

Acute IntoxicationAcute Intoxication Alcohol withdrawalAlcohol withdrawal

SeizuresSeizures HallucinationsHallucinations

Wernicke’s encephalopathyWernicke’s encephalopathy Korsakoff’s psychosisKorsakoff’s psychosis DementiaDementia Depression/antisocial/suicidalDepression/antisocial/suicidal

Effects of Alcohol AbuseEffects of Alcohol Abuse

GastrointestinalGastrointestinal Esophageal varicesEsophageal varices

Erosive gastritisErosive gastritis Hepatitis/liver failureHepatitis/liver failure Peptic ulcer diseasePeptic ulcer disease PancreatitisPancreatitis Oropharyngeal, esophageal, gastric, Oropharyngeal, esophageal, gastric,

hepatic and pancreatic malignancieshepatic and pancreatic malignancies

Effects of Alcohol AbuseEffects of Alcohol Abuse CardiovascularCardiovascular

HypertensionHypertension CardiomyopathyCardiomyopathy StrokeStroke Dysrhythmic events (intoxication or Dysrhythmic events (intoxication or

withdrawal)withdrawal) Endocrine/MetabolicEndocrine/Metabolic

Testicular atrophyTesticular atrophy Alcoholic ketoacidosisAlcoholic ketoacidosis Folic acid and thiamine deficienciesFolic acid and thiamine deficiencies

Effects of Alcohol AbuseEffects of Alcohol Abuse Challenges of Evaluation and TreatmentChallenges of Evaluation and Treatment

Obtaining reliable historyObtaining reliable history Obtaining cooperative care and evaluationObtaining cooperative care and evaluation

Difficult to reason with ‘the intoxicated’Difficult to reason with ‘the intoxicated’ Evaluating underlying disorderEvaluating underlying disorder

Often overlooked due to intoxicated stateOften overlooked due to intoxicated state Comorbid complications of underlying organ Comorbid complications of underlying organ

system dysfunction in chronic alcoholicsystem dysfunction in chronic alcoholic Affects pt. presentation and response to treatmentAffects pt. presentation and response to treatment


HypothermiaHypothermia Most cases related Most cases related

to ETOH useto ETOH use Contributes to Contributes to

cooling via:cooling via: Depressing central Depressing central

thermoregulationthermoregulation VasodilitationVasodilitation Depressed shiveringDepressed shivering

Sedative effects Sedative effects ability to remove ability to remove oneself from a cold oneself from a cold environment.environment.

Police in Poland say that about half of the 270 people who have frozen to death so far this winter were drunk. British Broadcasting

Corporation © 2001-2002


WithdrawalWithdrawal Peak sx usually ~48̊hrs after last drinkPeak sx usually ~48̊hrs after last drink

Autonomic hyperactivityAutonomic hyperactivity Cardiac dysrhythmiasCardiac dysrhythmias

Tremor/anxietyTremor/anxiety AgitationAgitation Visual disturbancesVisual disturbances SeizuresSeizures


Withdrawal TreatmentWithdrawal Treatment Supportive (ABC’s prn)Supportive (ABC’s prn) AMSAMS

Thiamine, D50/W, NarcanThiamine, D50/W, Narcan If seizing/tremorsIf seizing/tremors

Versed 2.5-10 mgVersed 2.5-10 mg Magnesium 2 gmMagnesium 2 gm

HYPOTHERMIA Alcohol Related Illness. Hypothermia - Alcohol Hypothermia Hypothermia Epidemiology...

Documents

Transcript of HYPOTHERMIA Alcohol Related Illness. Hypothermia - Alcohol Hypothermia Hypothermia Epidemiology...