Hypothermia

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Hypothermia is a medical emergency characterized by a core body temperature below the normal range of 95°F (35°C).

Causes of Hypothermia:

  1. Increased heat loss

    • Homeless population

    • Elderly patients

    • Submersion injuries

    • Drugs, EtOH, CO poisoning can all cause increased vasodilation, leading to increased heat loss

  2. Decreased heat production

    • Endocrine (hypothyroidism, hypoadrenalism, hypoglycemia)

    • Erythrodermas (psoriasis, exfoliative dermatitis, eczema, burns)

    • Impaired shivering

    • Impaired thermoregulation

    • Sepsis

Swiss Hypothermia Staging System:

Stage 1: Mild (32-35°C) - Shivering, mild confusion, awake

Stage 2: Moderate (28-32°C) - Severe shivering, altered mental status

Stage 3: Severe (20-28°C) - Loss of consciousness, bradycardia, shivering may cease

Stage 4: Profound (<20°C) – Unobtainable vital signs

Associated Complications:

  1. Cardiac dysfunction

    1. Dysrhythmias can occur when body temperature drops below 30°C

    2. There is typically a drop in temperature and MAP after rewarming is started due to vasoconstriction

  2. Cold injuries (frostbite, etc. Maybe there will be more on this at a later date)

  3. Coagulopathy (patient may be coagulopathic despite normal labs because the lab rewarms the sample)

    1. Impaired clotting function

    2. Thromboembolism (due to hemoconcentration and poor circulation)

    3. DIC

  4. Impaired pharmacology

    1. Protein binding increases when temperature drops, rendering drugs ineffective

    2. Oral meds are not absorbed well due to decreased GI motility

    3. IM route is impaired due to vasoconstriction

  5. Rhabdomyolysis

General Management:

  1. Airway, Breathing, Circulation (ABCs)

    • Hypothermia causes a leftward shift in oxygen curve so support with oxygen, and prepare for intubation depending on how profound the hypothermia is

  2. ECG Findings

    • Patients usually have sinus bradycardia, can progress to a fib with slow ventricular response

    • Severe cases can develop v fib

    • Osborn or "J" waves (associated with moderate to severe hypothermia)

  3. Remove Wet Clothing - Prevent further heat loss

  4. Passive External Rewarming - Insulate the patient, provide warm blankets

  5. Active External Rewarming (should be done for moderate hypothermia)

    • Use forced warm air blankets or radiant heaters – our ED uses the Bair Hugger

  6. Active Internal Rewarming (for severe hypothermia)

    • Warmed intravenous fluids (warmed to 38-42°C)

    • Heated humidified oxygen

    • Various lavages (Thoracic, peritoneal, bladder, GI)

Management during Cardiac Arrest:

  1. CPR – initiate if patient does not have a pulse (should also assess if patient is still breathing)

    • It is challenging to assess vital signs in hypothermic patients - use end tidal or POCUS to help assist to see if patient is breathing and has cardiac function

    • Starting CPR if the patient does have a pulse may precipitate ventricular rhythms

    • Hypothermic patients have higher chances of improved neurological outcome and survival than normothermic patients that arrest

  2. Defibrillation

    • Use defibrillation if indicated, but note that hypothermic patients may not respond to defibrillation until adequately warmed

  3. ECMO

    • Patients with refractory hypothermia should be considered for ECMO

    • Patients with out-of-hospital-cardiac-arrest that are hypothermic should ideally be transported to an ECMO center

    • If patient is unstable (dysrhythmia, severe hypothermia, etc) ECMO teams should be contacted early in the ED visit

 

Stay warm out there this weekend!

 

Paal P, Pasquier M, Darocha T, Lechner R, Kosinski S, Wallner B, Zafren K, Brugger H. Accidental Hypothermia: 2021 Update. Int J Environ Res Public Health. 2022 Jan 3;19(1):501. doi: 10.3390/ijerph19010501. PMID: 35010760; PMCID: PMC8744717.

Baumgartner EA, Belson M, Rubin C, Patel M. Hypothermia and other cold-related morbidity emergency department visits: United States, 1995-2004. Wilderness Environ Med 2008;19:233-237

Brown et al., Accidental Hypothermia. N Engl J Med 2012; 367:1930-1938

Who to contact after a patient expires

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I wanted to touch on a subject that is important but often not laid out in a concise manner - the protocol after a patient expires. 

I want to break this down into responsibilities of each of the staff. For residents (like myself) this often seems like a seamless process that happens in the background, but the reality is, multiple members of the ED are all coordinating together to progress this process.

Physicians- 

1. Attending physician must pronounce dead.

2. Admitting must be called with time of death, cause of death, whether or not the medical examiner will accept the case (more on that in a bit). Admitting will then process this info, and upload info to NYC Certify. The attending will then have to go into NYC Certify and certify the death.

3. The patient's family must be notified. Hopefully they are in the hospital, as it is more appropriate to have this conversation with the patient's family face to face, in private and to give them time to grieve with the patient.

4. Medical examiner must be notified in certain instances. The ME will take the following types of cases - trauma arrests, homicides, suicides, younger patients that are not terminally ill. Typically the ME will not take older patients with comorbidities. When in doubt, call the ME and they can decide.

5. Finally, the death note needs to be completed. 

Nursing- 

1. Charge nurse will call the expeditor / patient rep (more on that in a bit).

2. NYC LiveOn. This is the organ donor group. In our ED, nursing typically calls them. This requires answering questions about time of death, cause of death, medical comorbidities. 

3. Nursing and PCTs are typically responsible for post mortem care in patients that are not Jewish (more on the Guardians of the Sick in a bit). This involves removing lines, ET tubes, cleaning the patient, etc. This is NOT to be done in ME cases.

4. There is a written nursing protocol, on the MMC intranet site, I have shared the link below.

Expeditor/Patient Rep-

1. If the patient is Jewish, the expeditor will contact the operator, who contacts the Guardians of the Sick, who come and do post mortem care.

2. The patient rep may go to the family and offer support and comfort. Cannot provide suggestions regarding funeral homes (this is a conflict of interest).

3. Contact transport if the patient is going to our morgue (sometimes the family will arrange for the patient to be transported to a funeral home instead). 

Hope this helps outline the process and responsibilities during these stressful situations!

http://intranet.mmc/Main/DocumentLibrary/Post_Mortem_Care_2762.aspx

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Wayne Pneumothorax Tray

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I wanted to do a little blurb about the pigtail kit at Community. I often find that we as providers become pretty comfortable with what we know and uncomfortable with any tools we haven't used before. Back in July, I had to do a chest tube at Community, and the kit was totally different (and rest of the procedure was completely different because of this). This kit is not saldinger technique, and doesn't require use of needles (though you still should use lido obvs). I was initially confused when I was looking at the kit, and so wanted to write this out in case you face the same!


The kit comes with a 14Fr pigtail, trocar, long blade that goes in trocar (looks like a hollow bore needle, but isn't!), 11 blade, tubing, three way stopcock, and one way air valve. The main difference from the pigtail kits that we're used to, is there is no guidewire and no needle! Meaning, you're not going in with the needle first. 


Essentially, you will end up inserting the pigtail with trocar and long blade in one piece, into the incision site. The trocar is placed in a larger fenestrated hole towards the end of the pigtail.


















The steps for the procedure include;

 

  1. Confirm the location, fool (pick the side with the pneumo, and do it in the triangle of safety)

  2. Prep the site with chlorhexadine

  3. Anesthetize the site with lido

  4. Get sterile

  5. Drape and re-prep (you could probably prep once, but I'm a little OCD)

  6. Combine the pigtail, trocar, and long blade as shown in image

  7. Make your incision above the rib with the 11 blade

  8. Taking the combined long blade, in trocar, in pigtail - insert at your incision, aimed towards the lung apex

  9. Remove the long blade once you pass the resistance of the pleura

  10. Advance the trocar and pigtail, before removing the trocar and continuing to advance the pigtail to the desired depth (usually around 15-20 cm)

  11. Suture the pigtail in place and place a dressing over it

  12. Attach the tubing with the one way valve or to a pleurovac



















Now for those of you that may read this and say "omg, I'm not trying to just stab someone," well, you are not alone. Others have commented the same. And if you are so inclined to place this pigtail using saldinger technique, that is still possible. You will need to crack open a central line kit and pillage the needle, syringe, and guidewire. The trocar in the Wayne Pneumothroax tray is hollow bore, and the guidewire can still be fed through that. Hope this was helpful!