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Falat C. Environmental Hypothermia. Emerg Med Clin North Am 2024; 42:493-511. [PMID: 38925770 DOI: 10.1016/j.emc.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Although a rare diagnosis in the Emergency Department, hypothermia affects patients in all environments, from urban to mountainous settings. Classic signs of death cannot be interpreted in the hypothermic patient, thus resulting in the mantra, "No one is dead until they're warm and dead." This comprehensive review of environmental hypothermia covers the clinical significance and pathophysiology of hypothermia, pearls and pitfalls in the prehospital management of hypothermia (including temperature measurement techniques and advanced cardiac life support deviations), necessary Emergency Department diagnostics, available rewarming modalities including extracorporeal life support, and criteria for termination of resuscitation.
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Affiliation(s)
- Cheyenne Falat
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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2
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Wyatt CR, Brown LH. Outcomes in hypothermic cardiac arrest without evidence of abrupt cooling. Am J Emerg Med 2024; 79:201-203. [PMID: 38538508 DOI: 10.1016/j.ajem.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 04/16/2024] Open
Affiliation(s)
- Christopher R Wyatt
- Division of Emergency Medicine, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, TX, USA; US Acute Care Solutions, Canton, OH, USA.
| | - Lawrence H Brown
- Division of Emergency Medicine, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, TX, USA; US Acute Care Solutions, Canton, OH, USA
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3
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Prekker ME, Rischall M, Carlson M, Driver BE, Touroutoutoudis M, Boland J, Hu M, Heather B, Simpson NS. Extracorporeal membrane oxygenation versus conventional rewarming for severe hypothermia in an urban emergency department. Acad Emerg Med 2023; 30:6-15. [PMID: 36000288 DOI: 10.1111/acem.14585] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/28/2022] [Accepted: 08/19/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Severe hypothermia (core body temperature < 28°C) is life-threatening and predisposes to cardiac arrest. The comparative effectiveness of different active internal rewarming methods in an urban U.S. population is unknown. We aim to compare outcomes between hypothermic emergency department (ED) patients rewarmed conventionally using an intravascular rewarming catheter or warm fluid lavage versus those rewarmed using extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective cohort analysis of adults with severe hypothermia due to outdoor exposure presenting to an urban ED in Minnesota, 2007-2021. The primary outcome was hospital survival. We also calculated the rewarming rate in the 4 h after ED arrival and compared these data between patients rewarmed with ECMO (the extracorporeal rewarming group) versus without ECMO (the conventional rewarming group). We repeated these analyses in the subgroup of patients with cardiac arrest. RESULTS We analyzed 44 hypothermic ED patients: 25 patients in the extracorporeal rewarming group (median temperature 24.1°C, 84% with cardiac arrest) and 19 patients in the conventional rewarming group (median temperature 26.3°C, 37% with cardiac arrest; 89% received an intravascular rewarming catheter). The median rewarming rate was greater in the extracorporeal versus conventional group (2.3°C/h vs. 1.5°C/h, absolute difference 0.8°C/h, 95% confidence interval [CI] 0.3-1.2°C/h) yet hospital survival was similar (68% vs. 74%). Among patients with cardiac arrest, hospital survival was greater in the extracorporeal versus conventional group (71% vs. 29%, absolute difference 42%, 95% CI 4%-82%). CONCLUSIONS Among ED patients with severe hypothermia and cardiac arrest, survival was significantly higher with ECMO versus conventional rewarming. Among all hypothermic patients, ECMO use was associated with faster rewarming than conventional methods.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Megan Rischall
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Michelle Carlson
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | | | - Jessica Boland
- Department of Critical Care Medicine, Allina Health, Minneapolis, Minnesota, USA
| | - Michael Hu
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Beth Heather
- Critical Care Nursing and the Extracorporeal Life Support Program, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Hennepin Emergency Medical Services, Minneapolis, Minnesota, USA
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Bjertnæs LJ, Næsheim TO, Reierth E, Suborov EV, Kirov MY, Lebedinskii KM, Tveita T. Physiological Changes in Subjects Exposed to Accidental Hypothermia: An Update. Front Med (Lausanne) 2022; 9:824395. [PMID: 35280892 PMCID: PMC8904885 DOI: 10.3389/fmed.2022.824395] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/28/2022] [Indexed: 12/01/2022] Open
Abstract
Background Accidental hypothermia (AH) is an unintended decrease in body core temperature (BCT) to below 35°C. We present an update on physiological/pathophysiological changes associated with AH and rewarming from hypothermic cardiac arrest (HCA). Temperature Regulation and Metabolism Triggered by falling skin temperature, Thyrotropin-Releasing Hormone (TRH) from hypothalamus induces release of Thyroid-Stimulating Hormone (TSH) and Prolactin from pituitary gland anterior lobe that stimulate thyroid generation of triiodothyronine and thyroxine (T4). The latter act together with noradrenaline to induce heat production by binding to adrenergic β3-receptors in fat cells. Exposed to cold, noradrenaline prompts degradation of triglycerides from brown adipose tissue (BAT) into free fatty acids that uncouple metabolism to heat production, rather than generating adenosine triphosphate. If BAT is lacking, AH occurs more readily. Cardiac Output Assuming a 7% drop in metabolism per °C, a BCT decrease of 10°C can reduce metabolism by 70% paralleled by a corresponding decline in CO. Consequently, it is possible to maintain adequate oxygen delivery provided correctly performed cardiopulmonary resuscitation (CPR), which might result in approximately 30% of CO generated at normal BCT. Liver and Coagulation AH promotes coagulation disturbances following trauma and acidosis by reducing coagulation and platelet functions. Mean prothrombin and partial thromboplastin times might increase by 40-60% in moderate hypothermia. Rewarming might release tissue factor from damaged tissues, that triggers disseminated intravascular coagulation. Hypothermia might inhibit platelet aggregation and coagulation. Kidneys Renal blood flow decreases due to vasoconstriction of afferent arterioles, electrolyte and fluid disturbances and increasing blood viscosity. Severely deranged renal function occurs particularly in the presence of rhabdomyolysis induced by severe AH combined with trauma. Conclusion Metabolism drops 7% per °C fall in BCT, reducing CO correspondingly. Therefore, it is possible to maintain adequate oxygen delivery after 10°C drop in BCT provided correctly performed CPR. Hypothermia may facilitate rhabdomyolysis in traumatized patients. Victims suspected of HCA should be rewarmed before being pronounced dead. Rewarming avalanche victims of HCA with serum potassium > 12 mmol/L and a burial time >30 min with no air pocket, most probably be futile.
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Affiliation(s)
- Lars J. Bjertnæs
- Department of Clinical Medicine, Faculty of Health Sciences, Anesthesia and Critical Care Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Cardiovascular Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Department of Clinical Medicine, Faculty of Health Sciences, Anesthesia and Critical Care Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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5
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Fukuda M, Nozawa M, Okada Y, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Matsuyama T. Clinical relevance of impaired consciousness in accidental hypothermia: a Japanese multicenter retrospective study. Acute Med Surg 2022; 9:e730. [PMID: 35169485 PMCID: PMC8836211 DOI: 10.1002/ams2.730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 11/09/2022] Open
Abstract
Aim This study aimed to investigate the association between level of impaired consciousness and severe hypothermia (<28°C) and to evaluate the association between level of impaired consciousness and inhospital mortality among accidental hypothermia patients. Methods This was a multicenter retrospective study using the J‐Point registry database, which includes data regarding patients whose core body temperature was 35.0°C or less and who were treated as accidental hypothermia in emergency departments between April 1, 2011 and March 31, 2016. We estimated adjusted odds ratios of the level of impaired consciousness for severe hypothermia less than 28°C and inhospital mortality using a logistic regression model. Results The study included 505 of 572 patients in the J‐Point registry. Relative to mildly impaired consciousness (Glasgow Coma Scale [GCS] 13–15), the adjusted odds ratios for severe hypothermia less than 28°C were: moderate (GCS 9–12), 3.26 (95% confidence interval [CI], 1.69–6.25); and severe (GCS < 9), 4.68 (95% CI, 2.40–9.14). Relative to mildly impaired consciousness (GCS 13–15), the adjusted odds ratios for inhospital mortality were: moderate (GCS9–12), 1.65 (95% CI, 0.95–2.88); and severe (GCS < 9), 2.10 (95% CI, 1.17–3.78). Conclusion The level of impaired consciousness in patients with accidental hypothermia was associated with severe hypothermia and inhospital mortality.
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Affiliation(s)
- Masahiro Fukuda
- Department of Emergency and Critical Care Medicine Saiseikai Shiga Hospital Ritto Japan
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine Saiseikai Shiga Hospital Ritto Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine Japanese Red Cross Society Kyoto Daini Hospital Kyoto Japan
- Department of Primary Care and Emergency Medicine Graduate School of Medicine Kyoto University Kyoto Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Japan
| | - Naoki Ehara
- Department of Emergency Medicine Japanese Red Cross Society Kyoto Daiichi Red Cross Hospital Kyoto Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine Rakuwa‐kai Otowa Hospital Kyoto Japan
| | - Takaaki Jo
- Department of Emergency Medicine Uji‐Tokushukai Medical Center Uji Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine North Medical Center Kyoto Prefectural University of Medicine Kyoto Japan
| | - Nobunaga Okada
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
- Department of Emergency and Critical Care Medicine National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Makoto Watanabe
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine Kyoto Min‐Iren Chuo Hospital Kyoto Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital Osaka Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine Fukuchiyama City Hospital Fukuchiyama Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences Department of Social and Environmental Medicine Graduate School of Medicine Osaka University Osaka Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
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Swol J, Darocha T, Paal P, Brugger H, Podsiadło P, Kosiński S, Puślecki M, Ligowski M, Pasquier M. Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review. ASAIO J 2022; 68:153-162. [PMID: 34261875 PMCID: PMC8797003 DOI: 10.1097/mat.0000000000001518] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.
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Affiliation(s)
- Justyna Swol
- From the Deparment of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Severe Accidental Hypothermia Center, Medical University of Silesia, Katowice, Poland
| | - Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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7
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Paal P, Pasquier M, Darocha T, Lechner R, Kosinski S, Wallner B, Zafren K, Brugger H. Accidental Hypothermia: 2021 Update. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:501. [PMID: 35010760 PMCID: PMC8744717 DOI: 10.3390/ijerph19010501] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/13/2022]
Abstract
Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.
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Affiliation(s)
- Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
| | - Mathieu Pasquier
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Medical University of Silesia, 40-001 Katowice, Poland;
| | - Raimund Lechner
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Military Hospital, 89081 Ulm, Germany;
| | - Sylweriusz Kosinski
- Faculty of Health Sciences, Jagiellonian University Medical College, 34-500 Krakow, Poland;
| | - Bernd Wallner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK 99508, USA
- Department of Emergency Medicine, Stanford University Medical Center, Stanford University, Palo Alto, CA 94304, USA
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
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Hymczak H, Podsiadło P, Kosiński S, Pasquier M, Mendrala K, Hudziak D, Gocoł R, Plicner D, Darocha T. Prognosis of Hypothermic Patients Undergoing ECLS Rewarming-Do Alterations in Biochemical Parameters Matter? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189764. [PMID: 34574690 PMCID: PMC8468166 DOI: 10.3390/ijerph18189764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/07/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
Background: While ECLS is a highly invasive procedure, the identification of patients with a potentially good prognosis is of high importance. The aim of this study was to analyse changes in the acid-base balance parameters and lactate kinetics during the early stages of ECLS rewarming to determine predictors of clinical outcome. Methods: This single-centre retrospective study was conducted at the Severe Hypothermia Treatment Centre at John Paul II Hospital in Krakow, Poland. Patients ≥18 years old who had a core temperature (Tc) < 30 °C and were rewarmed with ECLS between December 2013 and August 2018 were included. Acid-base balance parameters were measured at ECLS implantation, at Tc 30 °C, and at 2 and 4 h after Tc 30 °C. The alteration in blood lactate kinetics was calculated as the percent change in serum lactate concentration relative to the baseline. Results: We included 50 patients, of which 36 (72%) were in cardiac arrest. The mean age was 56 ± 15 years old, and the mean Tc was 24.5 ± 12.6 °C. Twenty-one patients (42%) died. Lactate concentrations in the survivors group were significantly lower than in the non-survivors at all time points. In the survivors group, the mean lactate concentration decreased −2.42 ± 4.49 mmol/L from time of ECLS implantation until 4 h after reaching Tc 30 °C, while in the non-survivors’ group (p = 0.024), it increased 1.44 ± 6.41 mmol/L. Conclusions: Our results indicate that high lactate concentration is associated with a poor prognosis for hypothermic patients undergoing ECLS rewarming. A decreased value of lactate kinetics at 4 h after reaching 30 °C is also associated with a poor prognosis.
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Affiliation(s)
- Hubert Hymczak
- Department of Anesthesiology and Intensive Care, John Paul II Hospital, 31-202 Krakow, Poland;
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Paweł Podsiadło
- Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland;
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, University of Lausanne, 1015 Lausanne, Switzerland;
| | - Konrad Mendrala
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, 40-055 Katowice, Poland; (K.M.); (T.D.)
| | - Damian Hudziak
- Department of Cardiac Surgery, Medical University of Silesia, 40-055 Katowice, Poland; (D.H.); (R.G.)
| | - Radosław Gocoł
- Department of Cardiac Surgery, Medical University of Silesia, 40-055 Katowice, Poland; (D.H.); (R.G.)
| | - Dariusz Plicner
- Unit of Experimental Cardiology and Cardiac Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
- Correspondence:
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, 40-055 Katowice, Poland; (K.M.); (T.D.)
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9
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Walpoth BH, Maeder MB, Courvoisier DS, Meyer M, Cools E, Darocha T, Blancher M, Champly F, Mantovani L, Lovis C, Mair P. Hypothermic Cardiac Arrest - Retrospective cohort study from the International Hypothermia Registry. Resuscitation 2021; 167:58-65. [PMID: 34416307 DOI: 10.1016/j.resuscitation.2021.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/01/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Abstract
AIM The International Hypothermia Registry (IHR) was created to increase knowledge of accidental hypothermia, particularly to develop evidence-based guidelines and find reliable outcome predictors. The present study compares hypothermic patients with and without cardiac arrest included in the IHR. METHODS Demographic, pre-hospital and in-hospital data, method of rewarming and outcome data were collected anonymously in the IHR between 2010 and 2020. RESULTS Two hundred and one non-consecutive cases were included. The major causeof hypothermia was mountain accidents, predominantly in young men. Hypothermic Cardiac Arrest (HCA) occurred in 73 of 201 patients. Core temperature was significantly lower in the patients in cardiac arrest (25.0 vs. 30.0 °C, p < 0.001). One hundred and fifteen patients were rewarmed externally (93% with ROSC), 53 by extra-corporeal life support (ECLS) (40% with ROSC) and 21 with invasive internal techniques (71% with ROSC). The overall survival rate was 95% for patients with preserved circulation and 36% for those in cardiac arrest. Witnessed cardiac arrest and ROSC before rewarming were positive outcome predictors, asphyxia, coagulopathy, high potassium and lactate negative outcome predictors. CONCLUSIONS This first analysis of 201 IHR patients with moderate to severe accidental hypothermia shows an excellent 95% survival rate for patients with preserved circulation and 36% for HCA patients. Witnessed cardiac arrest, restoration of spontaneous circulation, low potassium and lactate and absence of asphyxia were positive survival predictors despite hypothermia in young, healthy adults after mountaineering accidents. However, accidental hypothermia is a heterogenous entity that should be considered in both treatment strategies and prognostication.
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Affiliation(s)
- Beat H Walpoth
- Dept. of Cardiovascular Surgery, University Hospitals, Geneva, Switzerland (Emeritus).
| | - Monika Brodmann Maeder
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland; Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | | | - Marie Meyer
- Dept. of Anesthesia, University Hospital, Lausanne, Switzerland
| | - Evelien Cools
- Division of Anesthesia, University Hospitals, Geneva, Switzerland
| | - Tomasz Darocha
- Dept. Anesthesiology & Intensive Care, Medical University of Silesia, Katowice, Poland
| | | | | | | | - Christian Lovis
- Division of Medical Information Sciences, University Hospitals, Geneva, Switzerland
| | - Peter Mair
- Dept. of Anesthesia, University Hospitals, Innsbruck, Austria
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10
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Horioka K, Tanaka H, Okaba K, Yamada S, Ishii N, Motomura A, Inoue H, Alkass K, Druid H, Yajima D. Hypothermia causes platelet activation in the human spleen. Thromb Res 2021; 205:47-55. [PMID: 34247097 DOI: 10.1016/j.thromres.2021.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/08/2021] [Accepted: 06/30/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Accidental hypothermia results in various dysfunctions in the human body. Additionally, coagulation disorder can lead to a life-threatening condition. We previously demonstrated that platelets stored in the spleen were activated and thus triggered coagulation disorder in a mouse model of hypothermia. In the present study, we wanted to investigate if this phenomenon in mice also occurs in humans as a reaction to hypothermia. METHODS We analyzed splenic tissue collected from 22 deceased subjects who have died from hypothermia. These samples were compared with 22 control cases not exposed to cold environment. We performed immunohistochemical staining for CD61 (a marker of all platelets) and CD62P (a marker of activated platelets). We also evaluated the morphology of platelets in the spleen with scanning electron microscopy. RESULTS Immunohistochemical analysis revealed no significant changes in the amounts of CD61-positive platelets between the hypothermia and control cases. However, the hypothermia cases contained abundant CD62P-positive platelets compared with those of the control cases. Immunohistochemical analysis also revealed that the activated platelets formed aggregates and adhered to splenic sinusoidal endothelial cells in the hypothermia cases. However, we observed no significant fibrin formation around the activated platelets. CONCLUSIONS Hypothermia resulted in splenic platelet activation, which may be used as a postmortem marker of hypothermia. The release of activated platelets from the spleen into to circulation upon rewarming may promote coagulation disturbances.
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Affiliation(s)
- Kie Horioka
- Department of Legal Medicine, International University of Health and Welfare, Japan; Department of Oncology-Pathology, Karolinska Institutet, Sweden.
| | - Hiroki Tanaka
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University, Japan
| | - Keisuke Okaba
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Shinnosuke Yamada
- Department of Anatomy, International University of Health and Welfare, Japan
| | - Namiko Ishii
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Ayumi Motomura
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Hiroyuki Inoue
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Kanar Alkass
- Department of Oncology-Pathology, Karolinska Institutet, Sweden
| | - Henrik Druid
- Department of Oncology-Pathology, Karolinska Institutet, Sweden
| | - Daisuke Yajima
- Department of Legal Medicine, International University of Health and Welfare, Japan
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11
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Wiberg S, Mortensen AF, Kjaergaard J, Hassager C, Wanscher M. Accidental hypothermia in Denmark: A nationwide cohort study of incidence and outcomes. BMJ Open 2021; 11:e046806. [PMID: 34059513 PMCID: PMC8169477 DOI: 10.1136/bmjopen-2020-046806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate the incidence of accidental hypothermia (AH) in a nationwide registry and the associated outcomes. DESIGN Nationwide retrospective cohort study PARTICIPANTS AND SETTINGS: All patients at least 18 years old, admitted to hospitals in Denmark with a diagnosis of AH, with an International Classification of Diseases, 10th edition code of T689, from January 1996 to November 2016. Other recorded diagnoses were included in the analyses. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was 1-year mortality. RESULTS During the inclusion period, 5242 patients were admitted with a diagnosis of AH, corresponding to a mean annual incidence of 4.4±1.2 (range by calendar year: 2.9-6.4) per 100 000 inhabitants. A total of 2230 (43%) had AH recorded as the primary diagnosis without any recorded secondary diagnoses (primary AH), 1336 (25%) had AH recorded as the primary diagnosis with other recorded secondary diagnoses (AH+2° diagnosis), and 1676 (32%) had AH recorded as a secondary diagnosis with another recorded primary diagnosis (1° diagnosis+AH). Alcohol intoxication was the most common diagnosis associated with AH. Overall 1-year mortality was 27%. In patients with primary AH, 1-year mortality was 22%, compared with 26% in patients with secondary AH type I, and 35% in patients with secondary AH type II (plog-rank<0.001). CONCLUSIONS The present study investigated the incidence of AH, associated comorbidities and mortality after AH in Denmark from 1995 to 2016. The diagnosis is associated with a high comorbidity burden and a considerable 1-year mortality. In the high proportion of patients with associated comorbidities, establishing whether AH or the comorbidities are the drivers of mortality remains difficult. This complicates our understanding of AH and makes it difficult to find modifiable factors associated with both AH and outcomes. Future prospective studies are needed elucidate the causal relationship between AH and associated comorbidities.
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Affiliation(s)
| | - Asmus Friborg Mortensen
- Department of Anaesthesiology and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael Wanscher
- Department of CardioThoracic Anaesthesiology, Rigshospitalet, Copenhagen, Denmark
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12
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Bjertnæs LJ, Hindberg K, Næsheim TO, Suborov EV, Reierth E, Kirov MY, Lebedinskii KM, Tveita T. Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:641633. [PMID: 34055829 PMCID: PMC8155640 DOI: 10.3389/fmed.2021.641633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/04/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: This systematic review and meta-analysis aims at comparing outcomes of rewarming after accidental hypothermic cardiac arrest (HCA) with cardiopulmonary bypass (CPB) or/and extracorporeal membrane oxygenation (ECMO). Material and Methods: Literature searches were limited to references with an abstract in English, French or German. Additionally, we searched reference lists of included papers. Primary outcome was survival to hospital discharge. We assessed neurological outcome, differences in relative risks (RR) of surviving, as related to the applied rewarming technique, sex, asphyxia, and witnessed or unwitnessed HCA. We calculated hypothermia outcome prediction probability score after extracorporeal life support (HOPE) in patients in whom we found individual data. P < 0.05 considered significant. Results: Twenty-three case observation studies comprising 464 patients were included in a meta-analysis comparing outcomes of rewarming with CPB or/and ECMO. One-hundred-and-seventy-two patients (37%) survived to hospital discharge, 76 of 245 (31%) after CPB and 96 of 219 (44 %) after ECMO; 87 and 75%, respectively, had good neurological outcomes. Overall chance of surviving was 41% higher (P = 0.005) with ECMO as compared with CPB. A man and a woman had 46% (P = 0.043) and 31% (P = 0.115) higher chance, respectively, of surviving with ECMO as compared with CPB. Avalanche victims had the lowest chance of surviving, followed by drowning and people losing consciousness in cold environments. Assessed by logistic regression, asphyxia, unwitnessed HCA, male sex, high initial body temperature, low pH and high serum potassium (s-K+) levels were associated with reduced chance of surviving. In patients displaying individual data, overall mean predictive surviving probability (HOPE score; n = 134) was 33.9 ± 33.6% with no significant difference between ECMO and CPB-treated patients. We also surveyed 80 case reports with 96 victims of HCA, who underwent resuscitation with CPB or ECMO, without including them in the meta-analysis. Conclusions: The chance of surviving was significantly higher after rewarming with ECMO, as compared to CPB, and in patients with witnessed compared to unwitnessed HCA. Avalanche victims had the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high s-K+ were factors associated with low surviving chances.
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Affiliation(s)
- Lars J. Bjertnæs
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hindberg
- K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Cardiovascular Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Federation Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University Named After I. I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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13
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Friess JO, Gisler F, Kadner A, Jenni H, Eberle B, Erdoes G. The use of minimal invasive extracorporeal circulation for rewarming after accidental hypothermia and circulatory arrest. Acta Anaesthesiol Scand 2021; 65:633-638. [PMID: 33529359 DOI: 10.1111/aas.13790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 01/04/2021] [Accepted: 01/16/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation has become a recommended treatment option for patients with severe hypothermia with cardiac arrest. Minimal invasive extracorporeal circulation (MiECC) may offer advantages over the current standard extracorporeal membrane oxygenation (ECMO). METHODS Retrospective cohort analysis of hospital database for patients with accidental hypothermia and extracorporeal rewarming with MiECC admitted between 2010 and 2019. RESULTS Overall, six of 17 patients survived to hospital discharge. Eleven patients suffered accidental hypothermia in an alpine and six in an urban setting. Sixteen patients arrived at the hospital under ongoing cardiopulmonary resuscitation (CPR). CPR time was 90 minutes (0-150). Four patients survived from an alpine setting and two from an urban setting with CPR duration of 90 minutes (0-150) and 85 minutes (25-100), respectively. Asphyctic patients tended to have lower survival (one of seven patients). Two patients of six with major trauma survived. CONCLUSION MiECC for extracorporeal rewarming from severe accidental hypothermia is a feasible alternative to ECMO, with comparable survival rates.
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Affiliation(s)
- Jan O. Friess
- Department of Anaesthesiology and Pain Medicine InselspitalBern University HospitalUniversity of Bern Bern Switzerland
| | - Fabian Gisler
- Department of Cardiovascular Surgery, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - Alexander Kadner
- Department of Cardiovascular Surgery, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - Hansjoerg Jenni
- Department of Cardiovascular Surgery, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - Balthasar Eberle
- Department of Anaesthesiology and Pain Medicine InselspitalBern University HospitalUniversity of Bern Bern Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine InselspitalBern University HospitalUniversity of Bern Bern Switzerland
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14
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Podsiadło P, Smoleń A, Kosiński S, Hymczak H, Waligórski S, Witt-Majchrzak A, Drobiński D, Nowak E, Barteczko-Grajek B, Toczek K, Skowronek R, Darocha T. Impact of rescue collapse on mortality rate in severe accidental hypothermia: A matched-pair analysis. Resuscitation 2021; 164:108-113. [PMID: 33930504 DOI: 10.1016/j.resuscitation.2021.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/26/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022]
Abstract
AIM To assess the impact of the occurrence of cardiac arrest associated with initial management on the outcome of severely hypothermic patients who were rewarmed with Extracorporeal Life Support (ECLS). METHODS We collected the individual data of patients in a state of severe accidental hypothermia who were found with spontaneous circulation and rewarmed with ECLS, from cardiac surgery departments. Patients were divided into two groups: those with a subsequent cardiac arrest (RC group); and those with the retained circulation (HT3 group), and compared by using a matched-pair analysis. The mortality rates and the neurological status in survivors were compared as the main outcomes. The difference in the risk of death between the HT3 and RC groups was calculated. RESULTS A total of 124 patients were included into the study: 45 in the HT3 group and 79 in the RC group. The matched cohorts consisted of 45 HT3 patients and 45 RC patients. The mortality rate in both groups was 24% and 49% (p = 0.02) respectively; the relative risk of death was 2.0 (p = 0.02). ICU length of stay was significantly longer in the RC group (p < 0.001). Factors associated with survival in the HT3 group included patient age, rewarming rate, and blood BE; while in the RC group, patient age and lactate concentration. CONCLUSIONS The occurrence of rescue collapse is linked to a doubling of the risk of death in severely hypothermic patients. Procedures which are known as potential triggers of rescue collapse should be performed with special attention, including in conscious patients.
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Affiliation(s)
- Paweł Podsiadło
- Institute of Medical Sciences, Jan Kochanowski University, Kielce, Poland
| | - Agata Smoleń
- Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Hubert Hymczak
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Szymon Waligórski
- Department of Cardiosurgery, Pomeranian Medical University, Szczecin, Poland
| | - Anna Witt-Majchrzak
- Department of Cardiac Surgery Provincial Specialist Hospital, Olsztyn, Poland
| | - Dominik Drobiński
- Cardiosurgery Clinic and Department of Cardiac Anaesthesia, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Ewelina Nowak
- Institute of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Barbara Barteczko-Grajek
- Department and Clinic of Anaesthesiology and Intensive Care, Wrocław Medical University, Wrocław, Poland
| | - Krzysztof Toczek
- Department of Cardiac Surgery, 4th Military Hospital, Wrocław, Poland
| | - Radomir Skowronek
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland.
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15
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Accidental hypothermia: Factors related to a prolonged hospital stay - A nationwide observational study in Japan. Am J Emerg Med 2021; 47:169-175. [PMID: 33831783 DOI: 10.1016/j.ajem.2021.03.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/26/2021] [Accepted: 03/26/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The incidence of accidental hypothermia (AH) is low, and the length of hospital stay in patients with AH remains poorly understood. The present study explored which factors were related to prolonged hospitalization among patients with AH using Japan's nationwide registry data. METHODS The data from the Hypothermia STUDY 2018, which included patients ≥18 years old with a body temperature ≤ 35 °C, were obtained from a multicenter registry for AH conducted at 89 institutions throughout Japan, collected from December 1, 2018, to February 28, 2019. The patients were divided into a "short-stay patients" group (within 7 days) and "long-stay patients" group (more than 7 days). A logistic regression analysis after multiple imputation was performed to obtain odds ratios (ORs) for prolonged hospitalization with age, frailty, location, causes underlying the hypothermia, temperature, pH, potassium level, and disseminated intravascular coagulation (DIC) score as independent variables. RESULTS In total, 656 patients were included in the study, of which 362 were eligible for the analysis. The median length of hospital stay was 17 days. Of the 362 patients, 265 (73.2%) stayed in the hospital for more than 7 days. The factors associated with prolonged hospitalization were frailty (OR, 2.11; 95% confidence interval [CI], 1.09-4.10; p = 0.027), the occurrence of indoor (OR, 3.20; 95% CI, 1.58-6.46; p = 0.001), alcohol intoxication (OR, 0.17; 95% CI, 0.05-0.56; p = 0.004), pH (OR, 0.07; 95% CI, 0.01-0.76; p = 0.029), potassium level (OR, 1.36; 95% CI, 1.00-1.85; p = 0.048), and DIC score (OR, 1.54; 95% CI, 1.13-2.10; p = 0.006). CONCLUSIONS Frailty, indoor situation, alcohol intoxication, pH value, potassium level, and DIC score were factors contributing to prolonged hospitalization in patients with AH. Preventing frailty may help reduce the length of hospital stay in patients with AH. In addition, measuring the pH value and potassium level by an arterial blood gas analysis at the ED is recommended for the early evaluation of AH.
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16
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Mittermair C, Foidl E, Wallner B, Brugger H, Paal P. Extreme Cooling Rates in Avalanche Victims: Case Report and Narrative Review. High Alt Med Biol 2021; 22:235-240. [PMID: 33761270 DOI: 10.1089/ham.2020.0222] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Mittermair, Christof, Eva Foidl, Bernd Wallner, Hermann Brugger, and Peter Paal. Extreme cooling rates in avalanche victims: case report and narrative review. High Alt Med Biol. 22: 235-240, 2021. Background: We report a 25-year-old female backcountry skier who was buried by an avalanche during ascent. A cooling rate of 8.5°C/h from burial to hospital is the fastest reported in a person with persistent circulation. Methods: A case report according to the CARE guidelines is presented. A literature search with the keywords "avalanche" AND "hypothermia" was performed and yielded 96 results, and the last update was on October 25, 2020. A narrative review complements this work. Results: A literature search revealed four avalanche patients with extreme cooling rates (>5°/h). References of included articles were searched for further relevant studies. Nineteen additional pertinent articles were included. Overall, 32 studies were included in this work. Discussion: An avalanche patient cools in different phases, and every phase may have different cooling rates: (1) during burial, (2) with postburial exposure on-site, and (3) during transport. It is important to measure the core temperature correctly, ideally with an esophageal probe. Contributing factors to fast cooling are sweating, impaired consciousness, no shivering, wearing thin monolayer clothing and head and hands uncovered, an air pocket, and development of hypercapnia, being slender. Conclusions: Rescuers should be prepared to encounter severely hypothermic subjects (<30°C) even after burials of <60 minutes. Subjects rescued from an avalanche may cool extremely fast the more contributing factors for rapid cooling exist. After avalanche burial (≥60 minutes) and unwitnessed cardiac arrest, chances of neurologically intact survival are small and depend on rapid cooling and onset of severe hypothermia (<30°C) before hypoxia-induced cardiac arrest.
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Affiliation(s)
- Christof Mittermair
- Department of Surgery, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Eva Foidl
- Department of Anaesthesiology and Intensive Care Medicine, Kufstein Hospital, Kufstein, Austria
| | - Bernd Wallner
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
| | - Peter Paal
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland.,Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
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17
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Miraglia D, Ayala JE. Extracorporeal cardiopulmonary resuscitation for adults with shock-refractory cardiac arrest. J Am Coll Emerg Physicians Open 2021; 2:e12361. [PMID: 33506232 PMCID: PMC7813516 DOI: 10.1002/emp2.12361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/28/2020] [Accepted: 12/23/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation has increasingly emerged as a feasible treatment to mitigate the progressive multiorgan dysfunction that occurs during cardiac arrest, in support of further resuscitation efforts. OBJECTIVES Because the recent systematic review commissioned in 2018 by the International Liaison Committee on Resuscitation Advanced Life Support task did not include studies without a control group, our objective was to conduct a review incorporating these studies to increase available evidence supporting the use of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest patients, while waiting for high-quality evidence from randomized controlled trials (RCTs). METHODS MEDLINE, Embase, and Science Citation Index (Web of Science) were searched for eligible studies from database inception to July 20, 2020. The population of interest was adult patients who had suffered cardiac arrest in any setting. We included all cohort studies with 1 exposure/1 group and descriptive studies (ie, case series studies). We excluded RCTs, non-RCTs, and observational analytic studies with a control group. Outcomes included short-term survival and favorable neurological outcome. Short-term outcomes (ie, hospital discharge, 30 days, and 1 month) were combined into a single category. RESULTS Our searches of databases and other sources yielded a total of 4302 citations. Sixty-two eligible studies were included (including a combined total of 3638 participants). Six studies were of in-hospital cardiac arrest, 34 studies were of out-of-hospital cardiac arrest, and 22 studies included both in-hospital and out-of-hospital cardiac arrest. Seven hundred and sixty-eight patients of 3352 (23%) had short-term survival; whereas, 602 of 3366 (18%) survived with favorable neurological outcome, defined as a cerebral performance category score of 1 or 2. CONCLUSIONS Current clinical evidence is mostly drawn from observational studies, with their potential for confounding selection bias. Although studies without controls cannot supplant case-control or cohort studies, several ECPR studies without a control group show successful resuscitation with impressive results that may provide valuable information to inform a comparison.
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Affiliation(s)
- Dennis Miraglia
- Department of Emergency MedicineSan Francisco HospitalSan JuanPuerto RicoUSA
| | - Jonathan E. Ayala
- Department of Emergency MedicineGood Samaritan HospitalAguadillaPuerto RicoUSA
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18
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Miraglia D, Miguel LA, Alonso W. Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resusc Plus 2020; 4:100045. [PMID: 34223320 PMCID: PMC8244502 DOI: 10.1016/j.resplu.2020.100045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used as extracorporeal cardiopulmonary resuscitation (ECPR) to support further resuscitation efforts in patients with cardiac arrest, yet its clinical effectiveness remains uncertain. OBJECTIVES This study reviews the role of ECPR in contemporary resuscitation care compared to no ECPR and/or standard care, e.g. conventional CPR, and quantitatively summarize the rates of long-term neurologically intact survival after adult in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). METHODS We searched the following databases on January 31 st, 2020: CENTRAL, MEDLINE, Embase, and Web of Science. We followed PRISMA guidelines and used PICO format to summarize the research questions. Risk of bias was assessed using the ROBINS-I tool. Pooled risk ratios (RRs) for each outcome of interest were calculated. Quality of evidence was evaluated according to GRADE guidelines. RESULTS Six cohort studies were included, totaling 1750 patients. Of these, 530 (30.3%) received the intervention, and 91 (17.2%) survived with long-term neurologically intact survival. ECPR compared to no ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest in any setting (risk ratio [RR] 3.11, 95% confidence interval [CI] 2.06-4.69; p < 0.00001) (GRADE: Very low quality). Similar results were found for long-term neurologically intact survival after IHCA (RR 3.21, 95% CI 1.74-5.94; p < 0.0002) (GRADE: Very low quality) and OHCA (RR 3.11, 95% CI 1.50-6.47; p < 0.002) (GRADE: Very low quality). Long-term time frames for neurologically intact survival (three months to two years) were combined into a single category, defined a priori as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1 or 2. CONCLUSIONS VA-ECMO used as ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest. Future evidence from randomized trials is very likely to have an important impact on the estimated effect of this intervention and will further define optimal clinical practice. Review registration: PROSPERO CRD42020171945.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Lourdes A. Miguel
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Wilfredo Alonso
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
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19
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Chau T, Joseph M, Ledesma J, Hsu DWH. Case of Severe Accidental Hypothermia Cardiac Arrest in a Subtropical Climate and Review of Management. Open Access Emerg Med 2020; 12:399-404. [PMID: 33235527 PMCID: PMC7680251 DOI: 10.2147/oaem.s245398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 10/15/2020] [Indexed: 11/23/2022] Open
Abstract
A patient was brought to the hospital with severe accidental hypothermia due to cold exposure associated with acute alcohol intoxication. Initial bladder core temperature was 21°C (70°F). The patient was agitated and combative with altered mental status and suffered rescue collapse during transport. Initial rhythm was ventricular fibrillation and we initiated a standard advanced cardiac life support (ACLS) protocol with rewarming measures. The patient received 28 mg of epinephrine and 13 shocks. Active and passive rewarming were initiated without extracorporeal rewarming. The patient achieved return of spontaneous circulation (ROSC) at a core temperature of 23.8°C (74.8°F). Patient was discharged 15 days later neurologically intact with no organ damage. The clinical management and implications for further research in severe accidental hypothermia management are discussed. In patients with severe accidental hypothermia (defined as <30°C or <86°F) in cardiac arrest, the optimal rewarming technique, use of epinephrine, and time when defibrillation should be attempted remain controversial. In our patient, the patient achieved ROSC in less than 2 hours with standard ACLS procedures despite a minimal increase in core temperature (21°C to 23.8°C or 70°F to 73.9°F).
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Affiliation(s)
- Terence Chau
- Department of Pharmacy, Cooper University Hospital, Camden, NJ, 08103, USA
| | - Merlyn Joseph
- Texas A&M University, Irma Lerma Rangel College of Pharmacy, Houston, TX 77030, USA
| | - Jesus Ledesma
- Emergency Department, Memorial Hermann Memorial City Medical Center, Houston, TX, 77024, USA
| | - David Wei Hau Hsu
- Emergency Department, Memorial Hermann Memorial City Medical Center, Houston, TX, 77024, USA
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20
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Podsiadło P, Darocha T, Svendsen ØS, Kosiński S, Silfvast T, Blancher M, Sawamoto K, Pasquier M. Outcomes of patients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: A systematic review. Artif Organs 2020; 45:222-229. [PMID: 32920881 DOI: 10.1111/aor.13818] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/12/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022]
Abstract
Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients' cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non-asphyxia-related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.
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Affiliation(s)
- Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Øyvind S Svendsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Tom Silfvast
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marc Blancher
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble Alps, Grenoble, France
| | - Keigo Sawamoto
- Department of Emergency Medicine, Sapporo Medical University, Sapporo, Japan
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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21
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Fujimoto Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Okumura Y, Kitamura T, Takegami T. Indoor Versus Outdoor Occurrence in Mortality of Accidental Hypothermia in Japan: The J-Point Registry. Ther Hypothermia Temp Manag 2020; 10:159-164. [DOI: 10.1089/ther.2019.0017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yoshihiro Fujimoto
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Yosa-gun, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Yosa-gun, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center, Kyoto Min-iren Chuo Hospital, Kyoto, Japan
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tetsurou Takegami
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
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22
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Okada Y, Kiguchi T, Irisawa T, Yoshiya K, Yamada T, Hayakawa K, Noguchi K, Nishimura T, Ishibe T, Yagi Y, Kishimoto M, Shintani H, Hayashi Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Nakamura F, Nishioka N, Matsuyama T, Matsui S, Shimazu T, Koike K, Kawamura T, Kitamura T, Iwami T. Predictive accuracy of biomarkers for survival among cardiac arrest patients with hypothermia: a prospective observational cohort study in Japan. Scand J Trauma Resusc Emerg Med 2020; 28:75. [PMID: 32758271 PMCID: PMC7404926 DOI: 10.1186/s13049-020-00765-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022] Open
Abstract
Background There is limited information on the predictive accuracy of commonly used predictors, such as lactate, pH or serum potassium for the survival among out-of-hospital cardiac arrest (OHCA) patients with hypothermia. This study aimed to identify the predictive accuracy of these biomarkers for survival among OHCA patients with hypothermia. Methods In this retrospective analysis, we analyzed the data from a multicenter, prospective nationwide registry among OHCA patients transported to emergency departments in Japan (the JAAM-OHCA Registry). We included all adult (≥18 years) OHCA patients with hypothermia (≤32.0 °C) who were registered from June 2014 to December 2017 and whose blood test results on hospital arrival were recorded. We calculated the predictive accuracy of pH, lactate, and potassium for 1-month survival. Results Of the 34,754 patients in the JAAM-OHCA database, we included 754 patients from 66 hospitals. The 1-month survival was 5.8% (44/754). The areas under the curve of the predictors and 95% confidence interval were as follows: pH 0.829 [0.767–0.877] and lactate 0.843 [0.793–0.882]. On setting the cutoff points of 6.9 in pH and 120 mg/dL (13.3 mmol/L) in lactate, the predictors had a high sensitivity (lactate: 0.91; pH 0.91) and a low negative likelihood ratio (lactate: 0.14; pH 0.13), which are suitable to exclude survival to 1 month. Furthermore, in additional analysis that included only the patients with potassium values available, a cutoff point of 7.0 (mmol/L) for serum potassium had high sensitivity (0.96) and a low negative likelihood ratio (0.09). Conclusion This study indicated the predictive accuracy of serum lactate, pH, and potassium for 1-month survival among adult OHCA patients with hypothermia. These biomarkers may help define a more appropriate resuscitation strategy.
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Affiliation(s)
- Yohei Okada
- Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, 606-8501, Japan.,Department of Primary care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeyuki Kiguchi
- Kyoto University Health Services, Kyoto, Japan.,Critical Care and Trauma Center, Osaka General Medical Center, Osaka, Japan
| | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazuhisa Yoshiya
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoki Yamada
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Koichi Hayakawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Takii Hospital, Moriguchi, Japan
| | - Kazuo Noguchi
- Department of Emergency Medicine, Tane General Hospital, Osaka, Japan
| | - Tetsuro Nishimura
- Department of Critical Care Medicine, Osaka City University, Osaka, Japan
| | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine, Kinki University School of Medicine, Osaka-Sayama, Japan
| | - Yoshiki Yagi
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Center of Acute Medicine, Higashi-Osaka, Japan
| | | | - Yasuyuki Hayashi
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Taku Sogabe
- Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takaya Morooka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Haruko Sakamoto
- Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
| | - Keitaro Suzuki
- Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, 606-8501, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kaoru Koike
- Department of Primary care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Kawamura
- Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, 606-8501, Japan.,Kyoto University Health Services, Kyoto, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Taku Iwami
- Department of Preventive Services, School of Public Health, Kyoto University, Kyoto, 606-8501, Japan. .,Kyoto University Health Services, Kyoto, Japan.
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23
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Lumbard DC, Lacey AM, Endorf FW, Gayken JR, Fey RM, Schmitz KR, Deisler RF, Calcaterra D, Prekker M, Nygaard RM. Severe Hypothermia and Frostbite Requiring ECMO and Four Limb Amputations. J Burn Care Res 2020; 41:1301-1303. [PMID: 32663261 DOI: 10.1093/jbcr/iraa113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Severe hypothermia and frostbite can result in significant morbidity and mortality. We present a case of a patient with severe hypothermia and frostbite due to cold exposure after a snowmobile crash. He presented in cardiac arrest with a core temperature of 19°C requiring prolonged cardiopulmonary resuscitation, active internal rewarming, venoarterial extracorporeal membrane oxygenation, and subsequently amputations of all four extremities. Although severe hypothermia and frostbite can be a fatal condition, the quick action of Emergency Medical Services, emergency physicians, trauma surgeons, cardiothoracic surgeons, intensivists, and the burn team contributed to a successful recovery for this patient including a good neurological outcome. This case highlights the importance of a strong interdisciplinary team in treating this condition.
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Affiliation(s)
| | | | | | | | - Ryan M Fey
- Department of Surgery, Minneapolis, Minnesota
| | | | | | | | - Matthew Prekker
- Division of Pulmonary and Critical Care Medicine, Hennepin Healthcare, Minneapolis, Minnesota
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24
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Willmore R. Cardiac Arrest Secondary to Accidental Hypothermia: Who Should We Resuscitate? Air Med J 2020; 39:205-211. [PMID: 32540113 DOI: 10.1016/j.amj.2019.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/03/2019] [Indexed: 06/11/2023]
Abstract
Cardiac arrest with a degree of concurrent hypothermia is not a rare presentation. This presentation, often in remote areas, poses a challenge for the prehospital physician because the cause of the arrest will significantly alter decision making and prognostication. Survival from cardiac arrest secondary to accidental hypothermia is significantly greater than that of normothermic arrests when appropriate triage and management decisions are made. The complexity of this decision benefits from a specific algorithm to follow in the event of such a casualty presenting. This article systematically reviews the literature on cardiac arrest secondary to accidental hypothermia and provides recommendations in addition to a novel algorithm to aid the responding prehospital clinician in deciding if a hypothermic resuscitation standard operating procedure should be implemented.
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Affiliation(s)
- Robert Willmore
- Institute of Pre-Hospital Care at London's Air Ambulance, The Royal London Hospital, London, UK.
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25
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Willmore R. Cardiac Arrest Secondary to Accidental Hypothermia: The Physiology Leading to Hypothermic Arrest. Air Med J 2020; 39:133-136. [PMID: 32197691 DOI: 10.1016/j.amj.2019.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
Cardiac arrest secondary to accidental hypothermia is rare in the United Kingdom. However, some evidence suggests that it is under-reported; furthermore, recognizing hypothermia as the cause of death is difficult in the postmortem setting. Urban and rural residents are exposed to cold winter conditions both at home and while undertaking recreational activities. Understanding the physiology underpinning hypothermic cardiac arrest is crucial in order to make informed clinical decisions in regard to triage and management by air ambulance services and in prevention of this rare presentation. This article discusses the epidemiology and pathophysiology of accidental hypothermic to explain how personnel can survive after 8 hours 40 minutes of cardiac arrest.
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Affiliation(s)
- Robert Willmore
- Institute of Pre-Hospital Care at London's Air Ambulance, The Royal London Hospital, London, United Kingdom.
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26
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Pasquier M, Blancher M, Buse S, Boussat B, Debaty G, Kirsch M, de Riedmatten M, Schoettker P, Annecke T, Bouzat P. Intra-patient potassium variability after hypothermic cardiac arrest: a multicentre, prospective study. Scand J Trauma Resusc Emerg Med 2019; 27:113. [PMID: 31842931 PMCID: PMC6916106 DOI: 10.1186/s13049-019-0694-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/03/2019] [Indexed: 12/24/2022] Open
Abstract
Background To date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests. Methods Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL). Results Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were − 1.6 to + 1.7 mmol/L; − 1.18 to + 2.7 mmol/L and − 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium. Conclusions We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement. Trial registration ClinicalTrials.gov Identifier: NCT03096561.
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Affiliation(s)
- M Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland.
| | - M Blancher
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble Alps, Grenoble, France
| | - S Buse
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble Alps, Grenoble, France
| | - B Boussat
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble Alps, Grenoble, France
| | - G Debaty
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble Alps, Grenoble, France
| | - M Kirsch
- Department of Cardiac Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | | | - P Schoettker
- Department of Anesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - T Annecke
- Klinik für Anästhesiologie und Operative Intensivmedizin, University Hospital of Cologne, Köln, Germany
| | - P Bouzat
- Department of anesthesiology and critical care, Grenoble Alps Trauma Center, University Hospital of Grenoble, Grenoble, France
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27
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Dow J, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Auerbach PS, McIntosh SE, Némethy M, McDevitt M, Schoene RB, Rodway GW, Hackett PH, Zafren K, Bennett BL, Grissom CK. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med 2019; 30:S47-S69. [PMID: 31740369 DOI: 10.1016/j.wem.2019.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 01/16/2023]
Abstract
To provide guidance to clinicians, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and a balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations. This is the 2019 update of the Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2014 Update.
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Affiliation(s)
- Jennifer Dow
- Alaska Regional Hospital Anchorage, Anchorage, AK; National Park Service: Alaska Region, Anchorage, AK.
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, Canada
| | - Daniel F Danzl
- Department of Emergency Medicine, University of Louisville, School of Medicine, Louisville, KY
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Bolzano, Italy; Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | | | - Beat Walpoth
- Service of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Paul S Auerbach
- Departments of Emergency Medicine and Surgery, Stanford University School of Medicine, Stanford, CA
| | - Scott E McIntosh
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | | | | | - George W Rodway
- School of Nursing, University of California, Davis, Sacramento, CA
| | - Peter H Hackett
- Division of Emergency Medicine, Altitude Research Center, University of Colorado School of Medicine, Denver, CO; Institute for Altitude Medicine, Telluride, CO
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Bolzano, Italy; Departments of Emergency Medicine and Surgery, Stanford University School of Medicine, Stanford, CA
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, UT
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28
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Kandori K, Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Iiduka R. Prognostic ability of the sequential organ failure assessment score in accidental hypothermia: a multi-institutional retrospective cohort study. Scand J Trauma Resusc Emerg Med 2019; 27:103. [PMID: 31718708 PMCID: PMC6849316 DOI: 10.1186/s13049-019-0681-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/31/2019] [Indexed: 12/05/2022] Open
Abstract
Background Severe accidental hypothermia (AH) is life threatening. Thus, prognostic prediction in AH is essential to rapidly initiate intensive care. Several studies on prognostic factors for AH are known, but none have been established. We clarified the prognostic ability of the Sequential Organ Failure Assessment (SOFA) score in comparison with previously reported prognostic factors among patients with AH. Methods The J-point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients who were treated at the intensive care unit (ICU) in various critical care medical centers. In-hospital mortality was the primary outcome. We investigated the discrimination ability of each candidate prognostic factor and the in-hospital mortality by applying the logistic regression models with areas under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI). Results Of the 572 patients with AH registered in the J-point registry, 220 were eligible for the analyses. The in-hospital mortality was 23.2%. The AUROC of the SOFA score (0.80; 95% CI: 0.72–0.86) was the highest among all factors. The other factors were serum potassium (0.65; 95% CI: 0.55–0.73), lactate (0.67; 95% CI: 0.57–0.75), quick SOFA (qSOFA) (0.55; 95% CI: 0.46–0.65), systemic inflammatory response syndrome (SIRS) (0.60; 95% CI: 0.50–0.69), and 5A severity scale (0.77; 95% CI: 0.68–0.84). Discussion Although serum potassium and lactate had relatively good discrimination ability as mortality predictors, the SOFA score had slightly better discrimination ability. The reason is that lactate and serum potassium were mainly reflected by the hemodynamic state; conversely, the SOFA score is a comprehensive score of organ failure, basing on six different scores from the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. Meanwhile, the qSOFA and SIRS scores underestimated the severity, with low discrimination abilities for mortality. Conclusions The SOFA score demonstrated better discrimination ability as a mortality predictor among all known prognostic factors in patients with AH.
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Affiliation(s)
- Kenji Kandori
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan. .,Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society, Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kyoto Min-Iren Chuo Hospital, Kyoto, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ryoji Iiduka
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
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29
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Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H. Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study. Resuscitation 2019; 144:27-32. [DOI: 10.1016/j.resuscitation.2019.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/17/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022]
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30
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Horioka K, Tanaka H, Isozaki S, Okuda K, Asari M, Shiono H, Ogawa K, Shimizu K. Hypothermia-induced activation of the splenic platelet pool as a risk factor for thrombotic disease in a mouse model. J Thromb Haemost 2019; 17:1762-1771. [PMID: 31237986 PMCID: PMC6851562 DOI: 10.1111/jth.14555] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/19/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hypothermia, either therapeutically induced or accidental (ie, an involuntary decrease in core body temperature to <35°C), results in hemostatic disorders. However, it remains unclear whether hypothermia enhances or inhibits coagulation, especially in severe hypothermia. The present study evaluated the thrombocytic and hemostatic changes in hypothermic mice. METHODS C57Bl/6 mice were placed at an ambient temperature of -20°C under general anesthesia. When the rectal temperature decreased to 15°C, 10 mice were immediately euthanized, while another 10 mice were rewarmed, kept in normal conditions for 24 hours, and then euthanized. These treatments were also performed in 20 splenectomized mice. RESULTS The hypothermic mice had adhesion of CD62P-positive platelets with high expression of von Willebrand factor (vWF) in their spleens, while the status of the peripheral platelets was unchanged. Furthermore, the plasma levels of platelet factor 4 (PF4) and pro-platelet basic protein (PPBP), which are biomarkers for platelet degranulation, were significantly higher in hypothermic mice than in control mice, indicating that hypothermia activated the platelets in the splenic pool. Thus, we analyzed these biomarkers in asplenic mice. There was no increase in either PF4 or PPBP in splenectomized hypothermic mice. Additionally, the plasma D-dimer elevation and microthrombosis were caused in rewarmed mice, but not in asplenic rewarmed mice. CONCLUSIONS Our results indicate that hypothermia leads to platelet activation in the spleen via the upregulation of vWF, and this activation causes hypercoagulability after rewarming.
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Affiliation(s)
- Kie Horioka
- Department of Legal MedicineAsahikawa Medical UniversityAsahikawaJapan
| | - Hiroki Tanaka
- Department of Legal MedicineAsahikawa Medical UniversityAsahikawaJapan
| | - Shotaro Isozaki
- Division of Gastroenterology and Hematology/OncologyAsahikawa Medical UniversityAsahikawaJapan
| | - Katsuhiro Okuda
- Department of Legal MedicineAsahikawa Medical UniversityAsahikawaJapan
| | - Masaru Asari
- Department of Legal MedicineAsahikawa Medical UniversityAsahikawaJapan
| | - Hiroshi Shiono
- Department of Legal MedicineAsahikawa Medical UniversityAsahikawaJapan
| | - Katsuhiro Ogawa
- Department of PathologyAsahikawa Medical UniversityAsahikawaJapan
| | - Keiko Shimizu
- Department of Legal MedicineAsahikawa Medical UniversityAsahikawaJapan
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31
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Abstract
L’hypothermie accidentelle est définie comme une baisse non intentionnelle de la température centrale du corps en dessous de 35 °C. La prévention de l’hypothermie est essentielle. La mesure de la température centrale est nécessaire au diagnostic d’hypothermie et permet d’en juger la sévérité. En présence de signes de vie, et en présence d’une hypothermie pure, l’instabilité hémodynamique apparente ne devrait en principe pas faire l’objet d’une prise en charge spécifique. Un risque d’arrêt cardiaque (AC) est présent si la température chute en dessous de 30–32 °C. En raison du risque d’AC, un patient hypotherme devrait bénéficier de l’application d’un monitoring avant toute mobilisation, laquelle devra être prudente. En cas d’AC, seule la mesure de la température oesophagienne est fiable. Si l’hypothermie est suspectée comme étant potentiellement responsable de l’AC du patient, celui-ci doit être transporté sous réanimation cardiopulmonaire vers un hôpital disposant d’une méthode de réchauffement par circulation extracorporelle (CEC). La valeur de la kaliémie ainsi que les autres paramètres à disposition (âge, sexe, valeur de la température corporelle, durée du low flow, présence d’une asphyxie) permettront de décider de l’indication d’une CEC de réchauffement. Le pronostic des patients victimes d’un AC sur hypothermie est potentiellement excellent, y compris sur le plan neurologique.
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Gibbison B, Reeves BC. Forecasting HOPE: Risk prediction in rare events. Resuscitation 2019; 139:361-362. [PMID: 31005589 DOI: 10.1016/j.resuscitation.2019.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/10/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Ben Gibbison
- Dept. of Cardiac Anaesthesia and Intensive Care, Bristol Heart Institute, Bristol, UK; NIHR Bristol Biomedical Research Centre, University of Bristol, UK.
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, UK; NIHR Bristol Biomedical Research Centre, University of Bristol, UK
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Forcey DS, FitzGerald MP, Burggraf MK, Nagalingam V, Ananda-Rajah MR. 'Cold and lonely': emergency presentations of patients with hypothermia to a large Australian health network. Intern Med J 2019; 50:54-60. [PMID: 30963670 DOI: 10.1111/imj.14308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extreme heat is a public health priority in Australia with the health effects of cold poorly studied. A record-breaking cold winter prompted an institutional investigation into the epidemiology and outcomes of hypothermic presentations. AIMS To describe the clinical and epidemiological characteristics of hypothermic emergency presentations including patient outcomes as well as gaps in practice. METHODS This was a retrospective cohort observational study of hypothermic emergency presentations between 7 July 2009 and 1 September 2016 with a temperature of ≤35°C. Independent predictors for inpatient mortality and characteristics of exposure versus non-exposure presentations were evaluated. RESULTS There were 217 patients with 226 presentations comprising male gender in 54%, median age 76.5 years (interquartile range (IQR) 53-88) and median initial temperature 33.3°C (IQR 31.2-34.3°C). Non-exposure presentations being found indoors, accounted for 78% overall, with elderly persons ≥65 years (P = 0.002) and multimorbidity (Charlson comorbidity index ≥4, P = 0.013) overrepresented in this subgroup. Among the non-exposure cohort, 55% were pensioners and 42% lived alone. Inpatient mortality was 11% overall and significantly higher in non-exposure versus exposure cohorts (16 vs 2%, P = 0.01). Independent predictors of inpatient mortality included heart failure (P = 0.04), metastatic malignancy (P < 0.01), chronic kidney disease (P < 0.05) and sepsis (P < 0.01). In contrast, exposure-related presentations were characterised by younger patients with intoxication due to alcohol and/or illicit drugs and psychiatric comorbidity. CONCLUSIONS Hypothermia is a marker of clinical and socioeconomic vulnerability. The dominant presentation of the elderly patient with multimorbidity, and few social supports being found indoors, raises broader questions around the social determinants of health.
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Affiliation(s)
- Dana S Forcey
- General Medical Unit, Alfred Health, Melbourne, Victoria, Australia
| | | | - Millicent K Burggraf
- General Medical Unit, Alfred Health, Melbourne, Victoria, Australia.,Central and Eastern Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Vathy Nagalingam
- General Medical Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Michelle R Ananda-Rajah
- General Medical Unit, Alfred Health, Melbourne, Victoria, Australia.,Central and Eastern Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Frei C, Darocha T, Debaty G, Dami F, Blancher M, Carron P, Oddo M, Pasquier M. Clinical characteristics and outcomes of witnessed hypothermic cardiac arrest: A systematic review on rescue collapse. Resuscitation 2019; 137:41-48. [DOI: 10.1016/j.resuscitation.2019.02.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 11/27/2022]
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Mazur P, Kosiński S, Podsiadło P, Jarosz A, Przybylski R, Litiwnowicz R, Piątek J, Konstanty-Kalandyk J, Gałązkowski R, Darocha T. Extracorporeal membrane oxygenation for accidental deep hypothermia-current challenges and future perspectives. Ann Cardiothorac Surg 2019; 8:137-142. [PMID: 30854323 DOI: 10.21037/acs.2018.10.12] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of accidental hypothermia (core temperature ≤35 °C) is difficult to estimate, as the affected population is heterogeneous. Both temperature and clinical presentation should be considered while determining severity, which is difficult in a prehospital setting. Extracorporeal rewarming is advocated for all Swiss Staging System class IV (hypothermic cardiac arrest) and class III (hypothermic cardiac instability) patients. Veno-arterial extracorporeal membrane oxygenation (ECMO) is the method of choice, as it not only allows a gradual, controlled increase of core body temperature, but also provides respiratory and hemodynamic support during the unstable period of rewarming and reperfusion. This poses difficulties with the coordination of patient management, as usually only cardiac referral centers can deliver such advanced treatment. Further special considerations apply to subgroups of patients, including drowning or avalanche victims. The principle of ECMO implantation in severely hypothermic patients is no different from any other indication, although establishing vascular access in a timely manner during ongoing resuscitation and maintaining adequate flow may require modification of the operating technique, as well as aggressive fluid resuscitation. Further studies are needed in order to determine the optimal rewarming rate and flow that would favor brain and lung protection. Recent analysis shows an overall survival rate of 40.3%, while additional prognostic factors are being sought for determining those patients in whom the treatment is futile. New cannulas, along with ready-to-use ECMO sets, are being developed that would enable easy, safe and efficient out-reach ECMO implantation, thus shortening resuscitation times. Moreover, national guidelines for the management of accidental hypothermia are needed in order that all patients that would benefit from extracorporeal rewarming would be provided with such treatment. In this perspective article, we discuss burning problems in ECMO therapy in hypothermic patients, outlining the important research goals to improve the outcomes.
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Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Cracow, Poland
| | - Paweł Podsiadło
- Emergency Medicine Department, Jan Kochanowski University, Kielce, Poland
| | - Anna Jarosz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Radosław Litiwnowicz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Jacek Piątek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Janusz Konstanty-Kalandyk
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Robert Gałązkowski
- Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Silesia, Katowice, Poland
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36
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Beyond the limits - ECPR in putative fatal circumstances. CAN J EMERG MED 2018; 20:S70-S73. [DOI: 10.1017/cem.2018.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThe eligibility criteria for applying extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiac arrest are currently unclear. For those patients with hypothermic cardiac arrest, the European Resuscitation Council (ERC) Guidelines recommend considering ECPR only for patients with potassium <8 mmol/L and a body temperature below 32°C, whereas the American Heart Association Guidelines (AHA) do not express this in a specific manner.We report the case of an urban unwitnessed out-of-hospital cardiac arrest patient found with her head immersed in water at a temperature of 23°C. The patient presented an unclear history and a dire combination of clinical and laboratory parameters (asystole, arterial blood gas: pH 6.8, potassium 8.3 mmol/L, lactate 16.0 mmol/L). Despite these poor prognostic indicators, ECPR was initiated after 95 minutes of CPR and the patient survived with a good neurological outcome.This case highlights the uncertainty in ECPR eligibility and prognostication, especially in those with hypothermia and water immersion for whom aggressive therapies may be warranted. Further data and improved strategies are required to delineate candidacy for this resource-intensive procedure better.
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Beyea MM, Tillmann BW, Iansavichene AE, Randhawa VK, Van Aarsen K, Nagpal AD. Neurologic outcomes after extracorporeal membrane oxygenation assisted CPR for resuscitation of out-of-hospital cardiac arrest patients: A systematic review. Resuscitation 2018; 130:146-158. [PMID: 30017957 DOI: 10.1016/j.resuscitation.2018.07.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation-assisted CPR (ECPR) is an evolving adjunct for resuscitation of OHCA patients. The primary objective of this systematic review was to assess survival-to-hospital discharge with good neurologic recovery after OHCA among patients treated with ECPR compared to conventional CPR (CCPR). METHODS A systematic search of MEDLINE® and EMBASE® electronic databases was performed from inception until July 2016 to identify studies reporting ECPR use in adults with OHCA and survival outcomes. RESULTS Of the 1512 citations identified, 75 studies met our inclusion criteria (63 case series and 12 cohort studies). Among case series, 0 to 71.4% of patients treated with ECPR survived to discharge with a good neurologic outcome. Subgroup analysis of the cohort studies demonstrated survival-to-hospital discharge with good neurologic recovery in the ECPR group ranging from 8.3 to 41.6% compared to 1.5 to 9.1% in the CCPR group. Five cohort studies adjusted for confounders, 3 of which demonstrated significantly increased adjusted odds ratios of survival among the ECPR-treated patients. Due to significant heterogeneity (I2 = 63%, p = 0.03), pooling of outcomes and a meta-analysis were not conducted. CONCLUSION Although a trend towards improved survival with good neurologic outcome was reported in controlled, low-risk of bias cohort studies, a preponderance of low quality evidence may ascribe an optimistic effect size of ECPR on survival among OHCA patients. Our confidence in a clinically relevant difference in outcomes compared to current standards of care for OHCA remains weak. In this state of equipoise, high quality RCT data is urgently needed.
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Affiliation(s)
- Michael M Beyea
- Division of Emergency Medicine, London Health Sciences Centre, Western University, London, ON, Canada; Critical Care Medicine, London Health Sciences Centre, Western University, London, ON, Canada.
| | - Bourke W Tillmann
- Department of Critical Care Medicine, Sunnybrook Health Sciences, Toronto, ON, Canada
| | - Alla E Iansavichene
- Health Science Library, London Health Sciences Centre, Victoria Campus, London, ON, Canada
| | - Varinder K Randhawa
- Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Kristine Van Aarsen
- Division of Emergency Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - A Dave Nagpal
- Critical Care Medicine, London Health Sciences Centre, Western University, London, ON, Canada
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Paal P, Rauch S. Indoor accidental hypothermia in the elderly: an emerging lethal entity in the 21st century. Emerg Med J 2018; 35:667-668. [PMID: 30158146 DOI: 10.1136/emermed-2018-207804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Simon Rauch
- Institute of Mountain Emergency Medicine, EURAC research, Bolzano, Italy.,Department of Anaesthesiology, University Hospital LMU, Munich, Germany.,Department of Sports Science, Medical Section, University of Innsbruck, Innsbruck, Austria
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Morita S, Matsuyama T, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Hayashi Y. Prevalence and outcomes of accidental hypothermia among elderly patients in Japan: Data from the J-Point registry. Geriatr Gerontol Int 2018; 18:1427-1432. [PMID: 30094918 DOI: 10.1111/ggi.13502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/11/2018] [Accepted: 07/02/2018] [Indexed: 12/01/2022]
Abstract
AIM We aimed to evaluate the prevalence and outcomes of accidental hypothermia (AH) among elderly patients in Japan. METHODS This was a multicenter chart review study of patients with AH (Japanese accidental hypothermia network registry; J-Point registry) that included patients with a body temperature ≤35 °C and those aged ≥18 years who visited the emergency department of 12 institutions in Japan from 1 April 2011 to 31 March 2016. The patients were classified into three groups: adult (aged 18-64 years), young-old (aged 65-79 years) and old-old (aged ≥80 years). The association between each age category and in-hospital mortality from AH was examined through a multivariable logistic regression analysis. RESULTS In total, 572 patients were registered in the J-Point registry database, of which 537 were included. The proportion of individuals who developed AH in an indoor setting was higher in the old-old group than in the adult group (86.9% [226/260] vs 61.1% [87/113]). The in-hospital mortality rates of the adult, young-old and old-old groups were 15.0% (17/113), 21.3% (35/164) and 30.4% (79/260), respectively. In the multivariable analysis, the in-hospital mortality rate was higher in the young-old and old-old groups than in the adult group (young-old vs adult, adjusted odds ratio: 2.31 and 95% confidence interval 1.16-4.64; old-old vs adult, adjusted odds ratio: 2.91 and 95% confidence interval 1.41-6.02). CONCLUSIONS Approximately 80% of patients with AH were aged ≥65 years. The in-hospital mortality rate of patients aged ≥65 years was significantly higher than that of those aged <65 years. Geriatr Gerontol Int 2018; 18: 1427-1432.
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Affiliation(s)
- Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga 23 Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center, Kyoto Min-iren Chuo Hospital, Kyoto, Japan.,Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yasuyuki Hayashi
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
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Podsiadło P, Kosiński S, Darocha T, Sałapa K, Sanak T, Brugger H. The Use of E-Learning in Medical Education for Mountain Rescuers Concerning Hypothermia. High Alt Med Biol 2018; 19:272-277. [PMID: 30010429 PMCID: PMC6157343 DOI: 10.1089/ham.2018.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Podsiadło, Paweł, Sylweriusz Kosiński, Tomasz Darocha, Kinga Sałapa, Tomasz Sanak, and Hermann Brugger. The use of e-learning in medical education for mountain rescuers concerning hypothermia. High Alt Med Biol 19:272–277, 2018. Objective: Victims of mountain accidents are often exposed to wet and cold environments which may increase the risk of hypothermia. Mountain rescuers should be able to recognize and manage hypothermia. We aimed to assess relevant knowledge in professional and volunteer mountain rescuers, as well as to evaluate the efficacy of an e-learning platform for continuing medical education. Methods: An e-learning platform was developed to provide access to updated information about hypothermia. Volunteer and professional mountain rescuers participated in an e-learning course. Pretest, post-test, and specific lesson test scores were compared. After 1 year, a follow-up course was performed. Results: In total, 187 rescuers, comprising 136 (72.7%) volunteers and 51 (27.3%) professionals, were enrolled. Ahead of the course, no difference in knowledge was found between professionals and volunteers. After the course, one's knowledge of hypothermia increased significantly (p < 0.001). The scores achieved in the field management of hypothermia were better among professional rescuers than among volunteer rescuers (p = 0.003), whereas in post-traumatic hypothermia half of the results were insufficient in both groups. Moreover, 57 rescuers repeated the course after 12 months. While professionals partially retained the achieved level of knowledge, the volunteers had dropped back to their initial level. Conclusions: The e-learning course increased the knowledge of hypothermia among mountain rescuers. The poor retention after 1 year indicates that the interval between lectures should be reduced. An e-learning platform is an effective tool for the medical education of mountain rescuers.
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Affiliation(s)
- Paweł Podsiadło
- 1 Department of Emergency Medicine, Jan Kochanowski University , Kielce, Poland .,2 Polish Medical Air Rescue , Warsaw, Poland
| | - Sylweriusz Kosiński
- 3 Faculty of Health Sciences, Jagiellonian University Medical College , Kraków, Poland .,4 Tatra Mountain Rescue Service , Zakopane, Poland
| | - Tomasz Darocha
- 2 Polish Medical Air Rescue , Warsaw, Poland .,5 Department of Anesthesiology and Intensive Care, Medical University of Silesia , Katowice, Poland
| | - Kinga Sałapa
- 6 Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College , Kraków, Poland
| | - Tomasz Sanak
- 7 Department of Disaster Medicine and Emergency Care, Jagiellonian University Medical College , Kraków, Poland
| | - Hermann Brugger
- 8 Institute of Mountain Emergency Medicine , EURAC Research, Bolzano, Italy .,9 Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck , Innsbruck, Austria
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Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Kitamura T, Iiduka R. Prognostic factors for patients with accidental hypothermia: A multi-institutional retrospective cohort study. Am J Emerg Med 2018; 37:565-570. [PMID: 29950275 DOI: 10.1016/j.ajem.2018.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION In cases of severe accidental hypothermia (AH) in urban areas, the prognostic factors are unknown. We identified factors associated with in-hospital mortality in patients with moderate-to-severe AH in urban areas of Japan. METHOD The J-Point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients whose core body temperature was 32 °C or less on admission. In-hospital death was the primary outcome of this study. We investigated the association between each candidate prognostic factor and in-hospital death by applying the multivariate logistic regression analyses with adjusted odds ratios (AORs) and their 95% confidence interval [CI] as the effect variables. RESULTS Of 572 patients registered in the J-point registry, 358 hypothermic patients were eligible for analyses. Median body temperature was 29.2 °C (interquartile range, 27.0 °C-30.8 °C). In-hospital deaths comprised 26.3% (94/358) of all study patients. Factors associated with in-hospital death were age ≥ 75 years (AOR, 3.09; 95% CI, 1.31-7.27), need for assistance with activities of daily living (ADL; AOR, 3.06; 95% CI, 1.68-5.59), hemodynamic instability (AOR, 2.49; 95% CI, 1.32-4.68), and hyperkalemia (≥5.6 mEq/L; AOR, 2.65; 95% CI, 1.13-6.21). CONCLUSION The independent prognostic factors associated with in-hospital mortality of patients with moderate-to-severe AH in urban areas of Japan were age ≥ 75 years, need for assistance with ADL, hemodynamic instability, and hyperkalemia.
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Affiliation(s)
- Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, SaiseikaiSenri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Ryoji Iiduka
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Japan
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Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Ohta B. Characteristics and outcomes of accidental hypothermia in Japan: the J-Point registry. Emerg Med J 2018; 35:659-666. [PMID: 29886414 DOI: 10.1136/emermed-2017-207238] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 05/12/2018] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Accidental hypothermia (AH) has higher incidence and mortality in geriatric populations. Japan has a rapidly ageing population, and little is known about the epidemiology of hypothermia in this country. METHODS We created an AH registry based on retrospective review of patients visiting the ED of 12 institutions with temperature ≤35°C between April 2011 and March 2016. The severity of AH was classified as mild (≤35, ≥32°C), moderate (<32, ≥28°C) or severe (<28°C). The relationship between in-hospital mortality and severity of AH was assessed using a multivariable logistic regression analysis. RESULTS A total of 572 patients were registered in this registry and 537 patients were eligible for our analysis. The median age was 79 (IQR 66-87) years and the proportion of men was 51.2% (273/537). AH was more likely to occur in elderly patients aged ≥65 years (424/537, 80.0%) and in indoor settings (418/537, 77.8%). The condition most frequently associated with AH, irrespective of severity, was acute medical illness. A lower mean outside temperature was associated with a higher prevalence of AH, and particularly severe AH (p for trend <0.001). The overall proportion of cases resulting in in-hospital death was 24.4% (131/537), with no significant difference between severity levels observed in a multivariable logistic regression analysis (severe group (37/118, 31.4%) vs mild group (42/192, 21.9%), adjusted OR (AOR) 1.01, 95% CI 0.61 to 1.68; and moderate group (52/227, 22.9%) vs mild group, AOR 1.11, 95% CI 0.58 to 2.14). CONCLUSION Active prevention and intervention should occur for this important public health issue.
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Affiliation(s)
- Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Department of Emergency and Critical Care Medicine, Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Yosa-gun, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center, Kyoto Min-iren Chuo Hospital, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Division of Environmental Medicine and Population Sciences, Graduate School of Medicine, Osaka University, Suita City, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
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43
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Saczkowski RS, Brown DJ, Abu-Laban RB, Fradet G, Schulze CJ, Kuzak ND. Prediction and risk stratification of survival in accidental hypothermia requiring extracorporeal life support: An individual patient data meta-analysis. Resuscitation 2018; 127:51-57. [DOI: 10.1016/j.resuscitation.2018.03.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 10/17/2022]
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44
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Brunet J, Valette X, Daubin C. Place de l’assistance circulatoire extracorporelle dans l’arrêt cardiaque réfractaire. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le bénéfice d’une réanimation cardiopulmonaire (RCP) extracorporelle en comparaison d’une réanimation conventionnelle sur la survie et le pronostic neurologique à long terme des patients victimes d’un arrêt cardiaque réfractaire reste encore incertain. Il pourrait être très différent selon que la RCP soit considérée dans les arrêts cardiaques extrahospitaliers ou intrahospitaliers, d’origine cardiaque ou pas, en contexte toxicologique ou d’hypothermie. L’objectif de cet article est une mise au point sur l’apport de l’assistance circulatoire extracorporelle dans la prise en charge des arrêts cardiaques réfractaires à partir des recherches cliniques les plus récentes. Ainsi, l’apport d’une RCP extracorporelle dans les arrêts cardiaques réfractaires extrahospitaliers d’origine cardiaque est probablement limité, même au sein de populations hautement sélectionnées. En revanche, son intérêt est probablement plus important dans les arrêts cardiaques réfractaires intrahospitaliers d’origine cardiaque sous réserve d’une bonne sélection des patients. Enfin, si des résultats encourageants ont été rapportés dans les cas d’arrêt cardiaque réfractaire de cause toxique ; en revanche, ils sont plus contrastés concernant les arrêts cardiaques réfractaires associés à une hypothermie profonde suite à une exposition accidentelle au froid, à une noyade ou une avalanche. Des recherches bien conduites sont encore nécessaires pour préciser les contextes et les indications pour lesquels les patients seraient en droit d’attendre un bénéfice médical d’une RCP extracorporelle.
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Pasquier M, Hugli O, Paal P, Darocha T, Blancher M, Husby P, Silfvast T, Carron PN, Rousson V. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: The HOPE score. Resuscitation 2018; 126:58-64. [DOI: 10.1016/j.resuscitation.2018.02.026] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/15/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
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Brunet J, Valette X, Daubin C. Place de l’assistance circulatoire extracorporelle dans l’arrêt cardiaque réfractaire. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le bénéfice d’une réanimation cardiopulmonaire (RCP) extracorporelle en comparaison d’une réanimation conventionnelle sur la survie et le pronostic neurologique à long terme des patients victimes d’un arrêt cardiaque réfractaire reste encore incertain. Il pourrait être très différent selon que la RCP soit considérée dans les arrêts cardiaques extrahospitaliers ou intrahospitaliers, d’origine cardiaque ou pas, en contexte toxicologique ou d’hypothermie. L’objectif de cet article est une mise au point sur l’apport de l’assistance circulatoire extracorporelle dans la prise en charge des arrêts cardiaques réfractaires à partir des recherches cliniques les plus récentes. Ainsi, l’apport d’une RCP extracorporelle dans les arrêts cardiaques réfractaires extrahospitaliers d’origine cardiaque est probablement limité, même au sein de populations hautement sélectionnées. En revanche, son intérêt est probablement plus important dans les arrêts cardiaques réfractaires intrahospitaliers d’origine cardiaque sous réserve d’une bonne sélection des patients. Enfin, si des résultats encourageants ont été rapportés dans les cas d’arrêt cardiaque réfractaire de cause toxique ; en revanche, ils sont plus contrastés concernant les arrêts cardiaques réfractaires associés à une hypothermie profonde suite à une exposition accidentelle au froid, à une noyade ou à une avalanche. Des recherches bien conduites sont encore nécessaires pour préciser les contextes et les indications pour lesquels les patients seraient en droit d’attendre un bénéfice médical d’une RCP extracorporelle.
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Zhou F, Jong R, Heroux A, Dubrowski A. Hypothermia in a Rural Setting: An Emergency Medicine Simulation Scenario. Cureus 2017; 9:e1998. [PMID: 29511605 PMCID: PMC5837320 DOI: 10.7759/cureus.1998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Patients presenting with hypothermia in a rural emergency department can be quite challenging to manage without significant mortality and morbidity. Standard medical school curricula do not fully prepare trainees for the unique aspects of practice in northern rural and remote communities. Training opportunities on site may provide a solution to this lack of experience. However, these communities often have limited simulation-based resources and expertise for conducting and developing simulation scenarios. In this technical report, we outline a hypothermia simulation that utilizes only basic resources and is, thus, practical for rural and remote facilities. The aim of this report is to better equip trainees, clinicians, and emergency department staff who may encounter such a scenario in their practice. While the simulation is specifically designed for medical students, resident doctors, and emergency department staff, it could also be applicable in other low-resource settings, such as military bases, search and rescue stations, and arctic travel and tourism infirmaries.
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Affiliation(s)
- Felix Zhou
- Medical Education, Memorial University of Newfoundland
| | - Robert Jong
- Medicine, Memorial University of Newfoundland/Janeway
| | | | - Adam Dubrowski
- Emergency Medicine, Pediatrics, Memorial University of Newfoundland
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Pirnes J, Ala-Kokko T. Accidental hypothermia: factors related to long-term hospitalization. A retrospective study from northern Finland. Intern Emerg Med 2017; 12:1225-1233. [PMID: 27677616 DOI: 10.1007/s11739-016-1547-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 09/20/2016] [Indexed: 10/20/2022]
Abstract
Accidental hypothermia has a low incidence, but is associated with a high mortality rate. Knowledge about concomitant factors, complications, and length of hospital stay is limited. A retrospective cohort study on patients with accidental hypothermia admitted to Oulu University Hospital in Finland, over a 5-year period. Patients were categorized as short-stay patients (7 days or less) and long-stay patients (more than 7 days) according to their length of stay in hospital. From a total of 105 patients, 67 patients were included in the analyses. Alcohol abuse was the most common concomitant factor (54 %). Median length of hospital stay was 4 days, and 16 patients (24 %) stayed in hospital over 7 days (median 15 days). Thirty-day mortality was low (14/105, 13 %). Patients with long-term hospitalization had a lower initial temperature (28.4 versus 31.2 °C, p = 0.011), a lower level of consciousness (GCS score 8.4 versus 12.8, p = 0.003), more severe acidosis (pH 7.08 versus 7.28, p = 0.005, and lactate 7.2 versus 3.9, p = 0.043), and a lower level of platelets (183 versus 242, p = 0.041) on admission compared with short-stay patients. Thirty-six patients (54 %) had at least one complication, and this prolonged median hospital treatment for 2.5 days (p < 0.001). Alcohol is the most common concomitant factor and every fourth patient spends more than 7 days in hospital. Long-term hospitalization is related to a lower core temperature, lower consciousness, more severe lactic acidosis, lower platelet level and infections, rhabdomyolysis, and renal failure.
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Affiliation(s)
- Jari Pirnes
- Division of Intensive Care Medicine, and Medical Research Center Oulu, Department of Anaesthesiology, Oulu University Hospital and Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Faculty, University of Oulu, Box 21, OUH, 90029, Oulu, Finland.
| | - Tero Ala-Kokko
- Division of Intensive Care Medicine, and Medical Research Center Oulu, Department of Anaesthesiology, Oulu University Hospital and Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Faculty, University of Oulu, Box 21, OUH, 90029, Oulu, Finland
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Podsiadło P, Darocha T, Kosiński S, Sałapa K, Ziętkiewicz M, Sanak T, Turner R, Brugger H. Severe Hypothermia Management in Mountain Rescue: A Survey Study. High Alt Med Biol 2017; 18:411-416. [PMID: 28968162 PMCID: PMC5743028 DOI: 10.1089/ham.2017.0090] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Podsiadło, Paweł, Tomasz Darocha, Sylweriusz Kosiński, Kinga Sałapa, Mirosław Ziętkiewicz, Tomasz Sanak, Rachel Turner, and Hermann Brugger. Severe hypothermia management in mountain rescue: A survey study. High Alt Med Biol 18:411–416, 2017. Introduction: Severe hypothermia is a rare but demanding medical emergency. Although mortality is high, if well managed, the neurological outcome of survivors can be excellent. The aim of the study was to assess whether mountain rescue teams (MRTs) are able to meet the guidelines in the management of severe hypothermia, regarding their equipment and procedures. Methods: Between August and December 2016, an online questionnaire, with 24 questions to be completed using Google Forms, was sent to 123 MRTs in 27 countries. Results: Twenty-eight MRTs from 10 countries returned the completed questionnaire. Seventy-five percent of MRTs reportedly provide advanced life support (ALS) on-site and 89% are regularly trained in hypothermia management. Thirty-two percent of MRTs transport hypothermic patients in cardiac arrest to the nearest hospital instead of an Extracorporeal Life Support facility; 39% are equipped with mechanical chest compression devices; 36% measure core body temperature on-site and no MRT is equipped with a device to measure serum potassium concentration on-site in avalanche victims. Conclusions: Most MRTs are regularly trained in the treatment of severe hypothermia and provide ALS. The majority are not equipped to follow standard procedural guidelines for the treatment of severely hypothermic patients, especially with cardiac arrest. However, the low response rate—23% (28/123)—could have induced a bias.
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Affiliation(s)
- Paweł Podsiadło
- 1 Polish Society for Mountain Medicine and Rescue , Szczyrk, Poland .,2 Polish Medical Air Rescue , Warsaw, Poland
| | - Tomasz Darocha
- 2 Polish Medical Air Rescue , Warsaw, Poland .,3 Department of Anaesthesiology and Intensive Care, Medical University of Silesia , Katowice, Poland
| | - Sylweriusz Kosiński
- 4 Department of Anesthesiology and Intensive Care, Pulmonary Hospital , Zakopane, Poland .,5 Tatra Mountain Rescue Service , Zakopane, Poland
| | - Kinga Sałapa
- 6 Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College , Kraków, Poland
| | - Mirosław Ziętkiewicz
- 7 Department of Anaesthesiology and Intensive Care, Jagiellonian University Medical College , Kraków, Poland
| | - Tomasz Sanak
- 8 Department of Disaster Medicine and Emergency Care, Jagiellonian University Medical College , Kraków, Poland
| | - Rachel Turner
- 9 EURAC Institute of Mountain Emergency Medicine , Bolzano, Italy
| | - Hermann Brugger
- 9 EURAC Institute of Mountain Emergency Medicine , Bolzano, Italy .,10 Medical University of Innsbruck , Innsbruck, Austria
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