Accidental Hypothermia. Peter Paal, MD, Associate Professor DESA, EDIC

Transcription

1 Accidental Hypothermia Peter Paal, MD, Associate Professor DESA, EDIC

2 Conflict of interest Ambu Covidien Genericon Jolife Laerdal Larnygeal Mask Company Ratiopharm VBM 2

3 Innsbruck 3

4 Innsbruck 4

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6 Innsbruck 6

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8 Innsbruck 8

9 Tyrol 9

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14 Content Pathophysiology Therapy Prevention Outlook 14

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16 Thermoregulation Glucose dependent Central regulation Peripheral regulation via shivering Glucose depletion faster cooling Sakakibara I et al. Cell Metab 2009;9: Young AJ et al. Comp Biochem Physiol A Mol Integr Physiol 2001;128:

17 Acute hypothermia Setting Hypothermia induced cardiac arrest Pathophysiology Water immersion/snow burial Cold overwhelmes heat production Cooling before glucose depletion catecholamines/corticosteroids grossly stimulated, CPR Glucose level supranormal Beiser DG et al. Resuscitation Jun;80(6): van den Berghe G et al. N Engl J Med Nov 8;345(19): Skrifvars MB et al. Resuscitation Dec;59(3):

18 Subacute hypothermia Setting Exhaustion, exposure to moderate cold Immersion in relatively warm water Pathophysiology Moderate cold Cooling when glucose is depleted No spontaneous rewarming Glucose level low Young A et al. Appl Physiol Nutr Metab 2007 Aug;32(4):

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20 Wind-Chill-Index Temperature effect on skin: frost bites below -35 C within 10min, below -60 C within two minutes (Defence R&D Canada 2001)

21 Deadly triad in trauma 21

22 Blood loss 1 C cooling intraoperative bleeding 10-15% packed red blood cells transfusion 12% Rajagopalan S et al. Anesthesiology 2008;108(1):

23 Head and multiple trauma Pain Shivering Hypovolaemia Reduced perfusion CNS and muscle O 2 and glucose Shivering central and peripheral thermogenesis Hypothermia Sakakibara I et al. Cell Metab 2009;9: Young AJ et al. Comp Biochem Physiol A Mol Integr Physiol 2001;128:

24 Diminished O 2 metabolism O 2 -consumption 7% /1 C Lexow K. Arctic Med Res 1991;50 Suppl 6: Soar J, Paal P et al. Resuscitation 2010;81:

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26 Institute of Mountain Emergency Medicine Bozen 44y male skier 255 min (4:15h) complete burial 60 cm burial depth Patent airway & air pocket No pulse, no breathing No visible injuries No temperature measurement No ECG Declared dead on site Strapazzon G, Brugger H, et al. Circulation

27 Institute of Mountain Emergency Medicine Bozen The day after found a Multifunction sport watch Wireless chest belt Continuous monitoring of altitude, temperature and heart rate Avalanche Time (h) Strapazzon G et al.circulation Jan 31;125(4):

28 Institute of Mountain Emergency Medicine Bozen Ascent Avalanche Burial Extrication Heart rate (bpm) Time (h) Strapazzon G et al.circulation Jan 31;125(4):646-7 Strapazzon G et al. 28

29 Pre-hospital therapy Splinting and immobilization bleeding Ellerton J, Paal P et al. High Alt Med Biol Winter;10(4): Insulation and heating Avoid wind and wetness Warming pack Warm transport vehicle 29

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31 Non invasive rewarming Advantages No bleeding No risk of infection Efficiency Röggla M et al. Wien Klin Wochenschr. 2002; 114(8-9): van der Ploeg GJ et al. Resusciation 2010 Nov;81(11):

32 Forced air warming blankets Outside layer Forced Air 42 C Inside layer 32

33 Non-invasvie rewarming Different therapy approaches Increasing evidence that it is safe and efficient Standard therapy in hypothermic patients with sufficient perfusing rhythm Widely practiced, also in smaller hospitals Brown D, Brugger H, Boyd J, Paal P. N Engl J Med N Engl J Med. 2012;367(20):

34 Invasive Rewarming Body cavity lavage Stomach Urinary bladder Peritoneum Pleura Röggla M et al. Wien Klin Wochenschr. 2002; 114(8-9):

35 Extracorporeal Rewarming Haemofiltration Haemodialysis Cardiopulmonary bypass Extracorporeal membrane oxygenation (ECMO) 2-4 C/h Walpoth BH et al. N Engl J Med 1997;337: Ruttmann E et al. J Thorac Cardiovasc Surg Sep;134(3):

36 Brown D, Brugger H, Boyd J, Paal P. N Engl J Med N Engl J Med. 2012;367(20):1930-8

37 Cold Patient, Conscious

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39 Cold Patient, Unconscious with Vital Signs

40 hypotension or arrhythmia? transport to ECMO/CPB hospital careful handling and attempt rewarming

41 Cold Patient, No Signs of Life

42 start CPR? patient cooled BEFORE cardiac arrest? ~50% Survivial ~50

43 Who is Cold & Dead? Frozen solid (chest not compressible) History of arrest prior to cooling Major trauma and cardiac arrest Avalanche burial>35min, airway packed with snow K>12mmol L -1

44 Near-infrared spectroscopy during CPR in hypothermic cardiac arrest Putzer G et al. Resuscitation 2012 Jan;83(1):e

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65 Avalanche survival in Canada vs. Switzerland Probability of survival (%) Period: Sample size: Activities: Burial time: Burial depth: Survival overall: Switzerland % BC 30% OB 34 min (12-120) 80 cm (50-130) 47% Canada % BC 22% Mech 22% SM 8% OB 18 min (5-60) 100 cm (50-180) 46% Time buried in avalanche (min) Haegeli P, Brugger H, et al. CMAJ 2011 Apr 19;183(7):

66 Avalanche survival in Canada vs. Switzerland Probability of survival (%) Influence of trauma on survival phase 2. Influence of snow climate on asphyxia phase Switzerland Canada 3. Influence of local rescue regime on long-term survival Time buried in avalanche (min) Haegeli P, Brugger H, et al. CMAJ 2011 Apr 19;183(7):

67 Avalanche Rescue Algorithm ICAR MEDCOM Brugger B, Paal P, Boyd J et al. Resuscitation 2013, in press

68 Open issues Prognostic criteria Glucose? Ideal rewarming Snow density Austria, France, Germany, Italy, Netherlands, Norway, Spain, Switzerland, UK, USA 68

69 Conclusions Trauma patients cool fast Hypothermia increases morbidity and mortality Insulation Rewarming Non invasive Invasive

70 Thank you