Rapid Treatment of Hypothermia. Rebecca Carman, MSN, ACNP-BC

Transcription

1 Rapid Treatment of Hypothermia Rebecca Carman, MSN, ACNP-BC Nurse Practitioner, Trauma Services, Intermountain Medical Center, Intermountain Healthcare; Salt Lake City, Utah Objectives: Describe hypothermia and physiologic effects on trauma patients Discuss rapid rewarming methods Describe ongoing management of hypothermic patients

2 Rapid Treatment of Accidental Hypothermia Rebecca Carman, MSN, ACNP BC Trauma NP Intermountain Medical Center, SLC, UT September 20, 2014

3 Trivia 1. What is the lowest recorded temperature in a patient with full neurologic recovery? a) 25 C (77 F) b) 20 C (68 F) c) 17 C (63 F) d) 14 C (57 F) 2. Which vasopressor drug is most effective in patients with hypothermia? a) epinephrine b) dopamine c) dobutamine d) levophed 3. What is a common EKG finding in a hypothermic patient? a) Osborn wave b) third degree heart block c) junctional rhythm d) sinus rhythm with PACs

4 Trivia 4. Which answer is a contraindication for resuscitation of a hypothermic patient? a) hyperkalemia K + >10 b) apnea c) fixed and dilated pupils d) pulseless 5. What is the end of resuscitation core temperature goal? a) 30 C (86 F) b) 37 C (98.6 F) c) 32 C (89 F) d) 31 C (88 F)

5 Accidental Hypothermia Definition: Core Body Temperature below 35 C (95 F) Typically happens in areas of the world with severe winters but also happens in the U.S. Happens in the winter AND summer Incidence in trauma patients 10 43% with about 1.9% severe hypothermia In hospital mortality of patients with moderate to severe accidental hypothermia have been reported at 40% 1,500 patients/year have hypothermia on death certificate Inconsistent treatments between and within trauma centers One hospital 84 cases of accidental hypothermia (14 different treatment methods)

6 Degree of Hypothermia Stages Mild hypothermia temperature C (89 95 F) Moderate hypothermia temperature C (86 89 F) Severe hypothermia temperature <30 C (<86 F)

7 Pathophysiology Body temperature reflects balance between heat production and heat loss Body strives to maintain homeostasis or thermoregulation The hypothalamus attempts to stimulate heat production through shivering and increased thyroid, catecholamine and adrenal activity vasoconstriction Environmental exposure and medical conditions can disrupt thermoregulation

8 Biem J et al. CMAJ 2003;168:

9 Trauma Triad of Death Deadly combination of hypothermia, coagulopathy and metabolic acidosis Seen in patients who have sustained severe traumatic injuries Significant rise in mortality

10 Risk Factors Environmental exposure Trauma (exposure, IVF, meds/paralytics, blood loss) Elderly Children Homelessness Psychiatric disease Alcohol abuse Post operative and ICU patients Medical Conditions Hypothyroidism Adrenal insufficiency Sepsis Neuromuscular disease Malnutrition Thiamine deficiency Hypoglycemia

11 Mild Hypothermia Temperature C (89 95 F) Excitation phase Shivering Tachypnea Tachycardia Early CNS depression

12 Moderate Hypothermia Temperature Slowing phase Hypoventilation Bradycardia Loss of shivering Further CNS depression (hyporeflexia, stupor and dilated pupils) Cardiac arrhythmias(sinus bradycardia, slow A fib) C (86 89 F)

13 Severe Hypothermia Temperature < 30 C (< 86 F) Cardiopulmonary failure Hypotension Pulmonary edema Apnea V. fib Profound CNS depression Areflexia Dilated, unreactive pupils Coma

14 Resuscitation YOU ARE NOT DEAD UNTIL YOU ARE WARM AND DEAD True in patients who suffer cardiac arrest as result of hypothermia Neuro and cardiac protective and may allow recovery despite prolonged arrest End Point of resuscitation is to rewarm to temp of 32 C 35 C

15 Exceptions to the Rule Anoxic event while still normothermic who has no pulse or respiration. Serum potassium level >than 10 mmol/l. Reflects cell lysis and predicts failed resuscitation Signs of irreversible death Frozen chest wall Burial in avalanche > 35 min Airway packed with snow and asystole

16 Primary Survey Assessment Airway and Protection of Spinal Cord Breathing and Ventilation Circulation Disability Exposure and Control of the Environment Do not delay transfer to critical care setting

17 Primary Survey in Hypothermia Vital Signs Don t forget temperature! Often missed vital sign. Temperature probe preferably esophageal. Insert thermistor probe into the lower third of esophagus. Bladder temp can be falsely elevated with peritoneal lavage Severe Depression of RR and HR listen/feel at least 60 sec Avoid rough movements and activity v.fibs

18 Common EKG Abnormalities Osborn Waves prominent in V2 V5 Suggests hypothermia, but can be present in other conditions (SAH) Misinterpreted as injury or infarct

19 Cardiovascular Management Pearls Organized Cardiac Rhythm?? If present sufficient circulation is likely present no CPR No rhythm ini ate CPR and con nue un l rewarmed Femoral venous catheters preferred access (cardiac irritability with SC and IJ) Treat hypotension with warmed crystalloids Pressors? Give Dopamine only inotropic agent that has some degree of action in hypothermia

20 Cardiovascular Management Pearls cont. Arrhythmias may persist until rewarmed Ignore atrial arrhythmias with slow ventricular response Cardiac drugs and defibrillation NOT effective with acidosis, hypoxia and hypothermia Avoid rough handling v.fib Use caution with ACLS drugs, including epinephrine and lidocaine while hypothermic When temp is > C follow ACLS guidelines

21 Lab studies Check CBC, CMP, BG, ETOH, toxins, amylase, TSH and blood cultures Clinical coagulopathy with normal coag times HCT increases 2 % for every 1 drop in temp ABGs best interpreted uncorrected that is blood warmed to 37 C with the values used as guides for administering sodium bicarbonate and adjusting ventilation parameters

22 Overview of Treatment Hypothermia Technique Mild Passive external rewarming Moderate Active external rewarming Severe Active internal rewarming

23 Rapid Treatment Mild Hypothermia Passive External Remove from cold Remove wet clothing Cover with warm blankets Don t delay transport

24 Rapid Treatment Moderate Hypothermia Active External Rewarming and Internal Rewarming All passive interventions AND Warmed humidified oxygen; warmed IV fluids Forced air warming systems Rewarm the trunk first to minimize risk of core temperature after drop* Increase temp at least 2 C/hr *Paradoxical drop in core temperature due to return of cold blood from extremities to core

25 Rapid Treatment of Severe Hypothermia Warmed humidified oxygen Warmed IV fluids Pleural and peritoneal irrigation with warm saline Extracorporeal options: Continuous intravascular rewarming, Hemodialysis, Continuous arteriovenous rewarming and Cardiopulmonary bypass (CPB) *Avoid GI irrigation due to fluid and electrolyte fluctuations. Surface area of bladder is too small to be of much benefit.

26 Continuous Intravascular Rewarming Central line placement Minimally invasive Available quick (used for heating and cooling) Practical Portable temp 2 3 C/hr

27 Pleural and Peritoneal Lavage Thoracic insert two right sided CTsanterior used to infuse warmed saline; posterior to drain fluid Peritoneal insert two catheters infuse saline leave in abd. cavity for 20 min. drain

28 Cardiopulmonary Bypass (CPB) Who is it for? Reserved for patients who are: 1. Potentially salvageable 2. HD instability or arrest 3. Do not rewarm with less invasive rewarming Transthoracic cannulation in OR Used for hours NOT days 47% survival in pts with severe hypothermia and cardiac arrest Rewarm at 9.5 C/hr

29 Extracorporeal Membrane Oxygenation (ECMO) Preferred to CPB because it prolongs oxygenation and can treat noncardiogenic pulmonary edema Use it for 3 10 days Cervical/femoral cannulation (preferred to transthoracic cannulation used in CPB) *Consider that heparin is required with more invasive rewarming

30 Complications of Rewarming Patients may get worse before they get better! Arrhythmias may persist until rewarmed Hypotension Rhabdomyolysis Bleeding Acid Base Balance Hypoglycemia Paralytic ileus Electrolyte abnormalities (hyperkalemia, low phos)

31 Failure to Rewarm Continue rewarming techniques! Consider the following differential and tx: Sepsis ABX broad spectrum Urban pts with hypothermia, infection is major cause Adrenal Insufficiency single dose of glucocorticoid (dexamethasone 4 mg IV not measured in cortisol assays when measuring adrenal function) Hypoglycemia D 5 W IV drip Severe Hypothyroidism levothyroxine 250 mcg IV after labs are drawn for thyroid function

32 Accidental hypothermia 13.7 C with circulatory arrest History Norway May 20, 1999 at y.o. female skier fell down a waterfall. Wedged between rocks and ice with flowing icy water. Struggled under ice for 40 min. EMS assessment 80 min post fall: clinically dead with dilated and unresponsive pupils CPR started immediately Flown to hospital, taken to the OR. Still NO signs of life. Interventions and Outcome Cardiopulmonary bypass for 179 minutes Rewarmed vfib, bleeding subclavian artery, cardiopulmonary insufficiency Started on ECMO continued x 5 days Multi organ dysfunction 60 days later d/c to rehab 5 months later returned to work with normal neuro exam Residual nerve damage of upper and lower extremities but able to hike and ski

33 Risk factors same as systemic hypothermia Most frequently ears, nose, cheeks, chin, fingers and toes Ice crystals form within or between tissue cells freezing tissue and causing cell death May auto amputate Initially depth of injury is difficult to recognize Clear blister=superficial Blood filled blisters=deeper damage Frostbite

34 Classification of Frostbite Injuries 1 st degree: superficial, central pallor and edema 2 nd degree: superficial blisters, edema, may form eschar but later sloughs off and no tissue loss 3 rd degree: full thickness blisters smaller, hemorrhagic and proximal. Black eschar. 4 th degree: full thickness involves muscle and bone and complete tissue necrosis

35 Non Freezing Cold Injuries (NFCI) Wet Trenchfoot (described in WW1) Swollen, edematous, numb foot Initially red then becomes pale and cyanotic Increased sensitivity to pain and infections Nerve and vascular injuries

36 Non Freezing Cold Injuries Dry Chilblains or Pernio Bare skin exposed to dry or damp environment Edematous, red or purple, tender, swollen, itchy and painful After rewarming inflamed, red and hot to the touch for hours

37 Local Injury Treatments Do not rub Avoid dry heat Passive Rewarm: Remove wet clothes, wrap in warm blankets Actively rewarm ASAP: Place injured tissue into 40 C water bath Leave minutes Until area appears flushed with good circulation Keep wound uncovered, clean, dry and elevated

38 Local Injury Treatments cont. Tetanus and IV antibiotics (penicillin). If gangrene use broad spectrum abx. Intra arterial tpa for pts high risk for life altering amputations Within 24 hours of injury Narcotic Pain Relief Very painful! May need debridement and or amputation Observe demarcation for weeks or months May have neuropathic pain indefinitely

39 Summary Remember ABCDEs You are not dead until you are warm and dead. A few exceptions. Resuscitation goal is C Appropriate warming techniques depend on degree of hypothermia If hypotension give warmed crystalloids consider dopamine CPR should continue until rewarmed; then renewed attempts at ACLS Patient may get worse before they get better Local injuries: Rewarm ASAP. Give tetanus, Abx and consider tpa Thank You!

40 References Advanced Trauma Life Support. The American College of Surgeons Beilman, G., Blondet, J., Nelson, T., Nathens, A, Moore, F. et al. Early Hypothermia in Severely Injured Trauma Patients is a Significant Risk Factor for Multiple Organ Dysfunction Syndrome but Not Mortality. Annals of Surgery 2009; 249 (5): Biem, J, Koehnck, N, Classen, D., Dosman, J. Out of the cold: management of hypothermia and frostbite. CMAJ FEB. 4, 2003; 168 (3) 309 Brown, D., Brugger, H, Boyd, J and Paal, P. Accidental Hypothermia. NEJM 2012; 367: Byrne, Mark. Severe Hypothermia. Critical Care Conference Online PPP. Fukudome, E. Alam, H. Hypothermia in Multisystem Trauma. Critical Care Medicine 2009; 37 (7): s265 s272. Gilbert, M., Busund, R., Skagseth, A., Nilsen, P., Solbo, J. Resuscitation from Accidental Hypothermia of 13.7 degrees C with Circulatory Arrest. The Lancet 2000; vol 355; Gordon, Les, Ellerton, J, Paal, P, Giles, J and Barker, J. Severe Accidental Hypothermia. BMJ 2014; 348: g1675

41 References continued Ireland, S., Edacott, R., Cameron, P., Fitzgerald, M., Paul, E. The Incidence and significance of accidental hypothermia in major trauma A prospective observational study. Resuscitation 2011; 82: Laupland, K., Zahar, J., Adrie, C., Minet, C. Vesin, A. et al. Severe Hypothermia Increases the Risk for Intensive Care Unit Acquired Infection. Clinical Infectious Disease 2012; 54 (8): Mechem, C. and K. Zafren. Accidental hypothermia in adults. Up to date, Mechem, C and K. Zafren. Frostbite. Up to date, Protocol. Treatment of hypothermia in trauma patients. Intermountain Medical Center Trauma Program. Soreide, Kjetil. Clinical and translational aspects of hypothermia in major trauma patients. From pathophysiology to prevention, prognosis and potential preservation. Injury 2014; 45: Trentzsch, H., Huber Wagner, S., Hildebrand, F., Kanz, K., Faist, E. et al. Hypothermia for predication of death in severely injured blunt trauma patients. Shock 2012; 37: Vassal, T, Benoit Gonin, B, Carrat, F. et al. Severe accidental hypothermia treated in an ICU: prognosis and outcome. Chest 2001; 120: 1998.