Hypothermia FCA 1211

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Field Care Audit presented at St. Joseph's Hospital

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  • Hypothermia FCA 1211

    1. 1. A Buffalo Squirrels Production
    2. 2. Case #178 y.o. female brought in by EMS forweakness and altered mental status
    3. 3. Case #228 y.o. male picked up by law enforcementafter being found walking along the highwayat 2 in the morning
    4. 4. Case #316 y.o. male brought in with altered mentalstatus the morning after partying all nightwith friends
    5. 5. Case #454 y.o. male with witnessed cardiac arrest,brought in by EMS now with pulses afterAED used
    6. 6. Cases78 y.o. female brought in by EMS for weaknessand altered mental status28 y.o. male picked up by law enforcement afterbeing found walking along the highway at 2 in themorning16 y.o. male brought in with altered mental statusthe morning after partying all night with friends54 y.o. male with witnessed cardiac arrest, broughtin by EMS now with pulses after AED used
    7. 7. Case #178 y.o. female brought in by EMS forweakness and altered mental status
    8. 8. Case #178 y.o. female brought in by EMS forweakness and altered mental statusFound to have urosepsis, with a temperatureof 34.8o C
    9. 9. Case #228 y.o. male picked upby law enforcementafter being foundwalking along thehighway at 2 in themorning
    10. 10. Case #228 y.o. male picked upby law enforcementafter being foundwalking along thehighway at 2 in themorning
    11. 11. Case #316 y.o. male brought in with altered mentalstatus the morning after partying all nightwith friends
    12. 12. Case #316 y.o. male brought in with altered mentalstatus the morning after partying all nightwith friendsBlood sugar of 25 when found, with bodytemperature of 36o C
    13. 13. Case #454 y.o. male withwitnessed cardiacarrest, brought in byEMS now with pulsesafter AED used
    14. 14. Case #454 y.o. male withwitnessed cardiacarrest, brought in byEMS now with pulsesafter AED used
    15. 15. Falling Temperatures Veronica Bonales, M.D. CEPAmerica, Emergency Medicine
    16. 16. Hypothermia
    17. 17. HypothermiaStates with highest death rates Alaska New Mexico North Dakota Montana
    18. 18. HypothermiaCase distribution - Greatest number Urban areas Environmental exposure EtOH Illicit Drug Use Mental illness All exacerbated by homelessness
    19. 19. Physiology
    20. 20. ThermoregulationRegulatory center Temp between 36.5 - 37.5C Peripheralthermoreceptors Centralthermoreceptors
    21. 21. ThermoregulationRegulatory center Temp between 36.5 - 37.5C Peripheralthermoreceptors Centralthermoreceptors
    22. 22. Thermoregulation Body temperature can be increased ordecreased in two ways: Regulation of heat production (thermogenesis) Regulation of heat loss (thermolysis)
    23. 23. Regulating Heat Production Muscular Fats Proteins Baseline muscular activity Glycogen Stores Exertion Endocrine Shivering Role of hormones in setting basal Metabolic metabolic rate - Processing of food thyroxine and epi and nutrients Carbohydrates – sugars and starches
    24. 24. Regulating Heat Loss Heat is lost from the body to the externalenvironment through the skin, lungs, andexcretions The skin is most important in regulating heat loss Radiation, conduction, convection, and evaporation are the major sources of heat loss
    25. 25. Heat Loss Mechanisms
    26. 26. Maintenance of ThermoregulationHypothermic compensation Decreased heat loss Peripheral vasoconstriction Reduction of surface area by body position (or clothing) Piloerection (not effective in humans) Increased heat production Shivering (last resort to maintain temperature) Increased voluntary activity Increased hormone secretion Increased appetite
    27. 27. External Environmental Factors External environmental factors that may contribute to a medical emergency Climate Season Weather Atmospheric pressure Terrain
    28. 28. Predisposing FactorsPatient’s agePredisposing medical conditions Use of prescription and over-the-countermedicationsUse of alcohol or recreational drugsPrevious rate of exertion
    29. 29. “Indoor” HypothermiaOccurs with significant medical comorbidities Alcoholism Sepsis Hypothyroid/hypopituitaryWorse outcome than exposure
    30. 30. Hypothermia
    31. 31. Hypothermia Hypothermia (CBT less than 95º F [35ºC]) may result from: A decrease in heat production An increase in heat loss A combination of these factors
    32. 32. Hypothermia Progression of clinical signs and symptomsmay be divided into three classes Mild (core temperature between 93.2º and 96.8º F [34º and 36º C]) Moderate (core temperature between 86º and 93º F [30º and 34º C]) Severe (core temperature below 86 degrees F [30º C])
    33. 33. HypothermiaHeart and brain most affected Bradycardia, arrhythmias as get colder CNS depression, abnormal EEG at temps <30 degrees C, EEG shows signal similar to brain death 19 - 20 degrees C
    34. 34. Frostbite
    35. 35. Frostbite A localized injury that results fromenvironmentally induced freezing of bodytissuesPathophysiologyPredisposing factors
    36. 36. Frostbite Classifications/Symptoms A common classification separates cold injury into three categories Frostnip (the mildest form of cold exposure) may be treated without loss of tissue In superficial frostbite, there is at least some minimal tissue loss With deep frostbite, there is significant tissue loss even with appropriate therapy
    37. 37. Superficial FrostbiteSome freezing of epidermal tissueInitial redness followed by blanchingDiminished sensation
    38. 38. Deep FrostbiteFreezing of epidermal and subcutaneous layersWhite appearanceHard (frozen) to palpationLoss of sensation
    39. 39. Frostbite Edema and blister formation 24 hours afterfrostbite injury in area covered by tightlyfitted boot
    40. 40. Frostbite Gangrenous necrosis 6 weeks after frostbiteinjury
    41. 41. FrostbiteRemove wet clothingDo not rub extremitiesWrap in blanketRapid re-warming in tub ofwater (40o C) or warm, wetpacksThaw 20 - 40 minutes - distaltip flushesAuto-amputation (1 - 2 months)
    42. 42. Submersion
    43. 43. SubmersionHypothermic considerations Common concomitant syndrome May be organ protective in cold-water submersion Always treat hypoxia first Treat all submersion patients for hypothermia
    44. 44. Factors That Affect Clinical Outcome Factors that can affect clinical outcomeafter a submersion incident Temperature of the water Length of submersion Cleanliness of the water Age of the victim
    45. 45. Submersion Incident ManagementABCsTrauma considerations Immersion episode of unknown etiology warrants trauma managementPost-resuscitation complications Adult respiratory distress syndrome (ARDS) or renal failure often occur post-resuscitation Symptoms may not appear for 24 hours or more post-resuscitation All submersion patients should be transportedfor evaluation
    46. 46. The stickmen face a horrible choiceQuestions...?
    47. 47. Cases
    48. 48. Case #178 y.o. female brought in by EMS forweakness and altered mental statusFound to have urosepsis, with a temperatureof 34.8o C
    49. 49. Case #1Usually elderly with low reservesVasodilation secondary to infectionPoorly functioning CNS and endocrine systemIndependent predictor of mortality
    50. 50. Case #228 y.o. male picked upby law enforcementafter being foundwalking along thehighway at 2 in themorning
    51. 51. Case #2Treat frostbite... But, severehypothermia.... Bair hugger IV, peritoneal, bladder, chest rewarming Cordis, DPL, foley, chest tubes
    52. 52. Case #316 y.o. male brought in with altered mentalstatus the morning after partying all nightwith friendsBlood sugar of 25 when found, with bodytemperature of 35o C, (spent night outdoorsin barn)
    53. 53. Case #3Pediatric livers have low glycogen stores Alcohol causes starvation state Glycemic stores used No gluconeogenesis Leads to clinical triad of: coma, hypoglycemia, hypothermia
    54. 54. Case #454 y.o. male withwitnessed cardiacarrest, brought in byEMS now with pulsesafter AED used
    55. 55. Case #4Therapeutichypothermia Should start with EMS Keep on for 24 hours Improved neuro status on discharge
    56. 56. Things to RememberCan have “indoor” hypothermiaTriad of coma, hypoglycemia andhypothermiaRapid rewarming of extremities with norubbing
    57. 57. Thank you!Slides can be reviewed: www.slideshare.net/docmontey

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