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~Cold As Ice~ Case Studies in Hypothermia Brian A. Donaldson Operations Supervisor Western Eagle County Ambulance District Eagle, Colorado 81631 [email protected] 970.390.5373 -Revised 2006- Ground Rules Please place all electronic quiet / vibrate mode, or turn them off if possible. Be an active participant…..you don’t want to listen to me for an hour! If you are easily offended…..please locate the emergency exit nearest your seat. Relax and enjoy yourself! One Final Ground Rule What Happens in St. George Stays in St. George ! Learning Objectives Identify the definition of Hypothermia Identify signs & symptoms commonly associated with Hypothermia Identify appropriate management of the Hypothermic patient What Is Hypothermia? A failure in thermoregulation resulting in a core body temperature of less than 97 F. Classification of Hypothermia Mild Moderate 97 – 95 degrees F 90 – 95 degrees F Severe 75 – 90 degrees F You Can’t Fix Stupid How Is Heat Lost? Conduction Convection 8% Dissipation of Heat into the Surrounding Air Evaporation 2% In Contact with a Cooler Object 30% Transformation of Perspiration and Saliva into Vapor Radiation 60% Transfer of Heat via Electromagnetic Waves Watch for the “Umbles” Stumbles Fumbles Mumbles Grumbles Mild Hypothermia 95 – 97 degrees F Sensation of Being Cold Formation of “Goose Bumps” Mild – Severe Shivering Lack of Sensation in Hands Unable to Perform Complex Tasks with Hands Moderate Hypothermia 93 – 95 degrees F Intense Shivering Obvious Muscle Incoordination Movement Becomes Slow & Labored Stumbling Gait Begins Alert with Mild Disorientation Unable to Successfully Complete Standardized Field Sobriety Testing Moderate Hypothermia 90 – 93 degrees F Violent Shivering Speaking Becomes Difficult Thought Processes Slow Amnesia Begins Gross Muscle Movement Slow Inability to Use Hands Obvious Stumbling Gait Severe Hypothermia 86 - 90 degrees F Shivering Stops Exposed Skin Becomes Cyanotic Profound Muscle Incoordination Unable to Walk Confused with Irrational Behavior May be Able to Maintain Sitting or Standing Position Severe Hypothermia 82 - 86 degrees F Muscles Become Rigid Poorly Responsive to Stimuli Bradycardia Bradypnea Increased Risk of Ventricular Fibrillation Severe Hypothermia 78 - 82 degrees F Unresponsive Loss of Palpable Pulses Irregular Respiratory Patterns Irregular Heart Rhythm Severe Hypothermia 75 - 78 degrees F Profound Pulmonary Edema Cardio-Respiratory Failure Death is Assured…May Occur at Higher Core Body Temperatures Hypothermia Treatment Remove from Cold Environment Place in Warm Environment Remove Wet / Cold Clothing Administer Warmed Humidified Oxygen (105 degrees F) Hypothermia Treatment Administer Warm IV Fluids (105 degrees F) Hot Packs to Neck, Axillae & Groin Neonatal Transport Pack under Torso Burrito Wrap A Little Cold Weather Humor Case Study #1 You and an engine company are dispatched to a local nursing home, near the lake, following a manpower request The time is 0915 hrs It is the middle of April Case Study #1 You arrive at 0920 hrs and are assigned a 1000 ft expanse of lakeshore to search for a missing 76 year old male You are advised the male has been missing since 0630 hrs and is an Alzhiemers patient You and your partner begin to search your assigned area and find the patient at 0957 hrs Case Study #1 The patient is supine with his torso on the riprap and his lower extremities submerged in the water The patient has a 2” laceration on the forehead, an avulsed ® ear, and visible lacerations on both forearms with no active bleeding from any of the wounds The patient is poorly responsive to painful stimuli Case Study #1 What are some special considerations for this patient? What additional information concerning this patient would you like to obtain? What is your differential field diagnosis? What is your care plan for this patient? Special Considerations from Case #1 Under 32 degrees F Exhaustion or Unresponsiveness <15 minute Survival <45 minutes 32.5 – 40 degrees F Exhaustion or Unresponsiveness 15 – 30 min Survival 30 – 90 min 40 – 50 degrees F Exhaustion or Unresponsiveness 30 – 60 min Survival 1 – 3 hours Special Considerations from Case #1 50 – 60 degrees F Exhaustion or Unresponsiveness 1 – 2 hours Survival 1 – 6 hours 60 – 70 degrees F Exhaustion or Unresponsiveness 2 – 7 hours Survival 2 – 40 hours 70 – 80 degrees F Exhaustion or Unresponsiveness 3 – 12 hours Survival 3 hours - Indefinite Hoping for a Little Hypothermia Case Study #2 You and an engine company are dispatched to an outdoor fall The time is 0533 hrs It is early January Case Study #2 You arrive on scene at 0556 hrs Law enforcement is already on scene and states the patient was found by the paper delivery boy shortly before your dispatch The patient appears to be a 60+ yoa female The patient is cyanotic, cold to the touch and without detectable cardio-respiratory effort Case Study #2 What are some special considerations for this patient? What additional information concerning this patient would you like to obtain? What is your differential field diagnosis? What is your care plan for this patient? Special Considerations from Case #2 Hypothermia protects against the effects of cardio-pulmonary arrest Hypothermic patients may have functional cardiac activity without palpable pulses in the field (decreased pulse pressure, bradycardia, environment) Physical stimuli may cause ventricular fibrillation (jostling, chest compressions, intubation) Special Considerations from Case #2 Cardiac tissue is resistant to defibrillation and antidysrhythmic medications in severe hypothermia – withhold until core body temperature is at least 86 degrees F The hypothermic patient is not dead until they are warm and dead Case Study #3 You and an engine company are dispatched to the local Job Corps Center for an unresponsive male The time is 0310 hrs It is March Case Study #3 You arrive to find security with an 18 yoa male patient supine on a concrete walkway in a remote part of the campus The patient is pale, cool and dry The patient has a slow weak radial pulse with slow shallow respirations Your patient responds minimally to painful stimuli and you detect an odor of alcoholic beverage about your patient Case Study #3 What are some special considerations for this patient? What additional information concerning this patient would you like to obtain? What is your differential field diagnosis? What is your care plan for this patient? Special Considerations from Case #3 Alcoholic beverage consumption increases peripheral vasodilation and thus cutaneous circulation by up to 10X Consider poly drug usage with alcohol intoxication Consider blood glucose abnormalities with altered mental states and with alcoholic beverage consumption Thoughts on Hypothermia Often times it is not an isolated event Does not require “Cold” ambient temperatures to occur Be calm & gentle…this is the one instance where time waits for us Thank You for Your Attention! Questions? Comments? Dirty Jokes? Rude Gestures?