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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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Van Tilburg C, Paal P, Strapazzon G, Grissom CK, Haegeli P, Hölzl N, McIntosh S, Radwin M, Smith WWR, Thomas S, Tremper B, Weber D, Wheeler AR, Zafren K, Brugger H. Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update. Wilderness Environ Med 2024; 35:20S-44S. [PMID: 37945433 DOI: 10.1016/j.wem.2023.05.014] [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] [Received: 11/09/2022] [Revised: 04/03/2023] [Accepted: 05/10/2023] [Indexed: 11/12/2023]
Abstract
To provide guidance to the general public, clinicians, and avalanche professionals about best practices, the Wilderness Medical Society convened an expert panel to revise the evidence-based guidelines for the prevention, rescue, and resuscitation of avalanche and nonavalanche snow burial victims. The original panel authored the Wilderness Medical Society Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents in 2017. A second panel was convened to update these guidelines and make recommendations based on quality of supporting evidence.
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Affiliation(s)
- Christopher Van Tilburg
- Occupational Medicine, Mountain Clinic, and Emergency Medicine, Providence Hood River Memorial Hospital, Hood River, OR
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | - Peter Paal
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Giacomo Strapazzon
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Colin K Grissom
- Department of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT
| | | | - Natalie Hölzl
- International Commission for Alpine Rescue
- German Association of Mountain and Expedition Medicine, Munich, Germany
| | - Scott McIntosh
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | | | - William Will R Smith
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
- University of Washington School of Medicine, Seattle, WA
| | - Stephanie Thomas
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | | | - David Weber
- Intermountain Life Flight, Salt Lake City, UT
| | - Albert R Wheeler
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
| | - Ken Zafren
- International Commission for Alpine Rescue
- Himalayan Rescue Association, Kathmandu, Nepal
- Stanford University Medical Center, Palo Alto, CA
| | - Hermann Brugger
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
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Hymczak H, Gołąb A, Kosiński S, Podsiadło P, Sobczyk D, Drwiła R, Kapelak B, Darocha T, Plicner D. The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients-A Literature Review. J Clin Med 2023; 12:6730. [PMID: 37959196 PMCID: PMC10649291 DOI: 10.3390/jcm12216730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.
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Affiliation(s)
- Hubert Hymczak
- Department of Anesthesiology and Intensive Care, St. John Paul II Hospital, 31-202 Krakow, Poland; (H.H.); (R.D.)
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Aleksandra Gołąb
- Faculty of Medicine and Dentistry, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
- Center for Research and Innovative Technology, John Paul II Hospital, 31-202 Krakow, Poland
| | - Sylweriusz Kosiński
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Paweł Podsiadło
- Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland;
| | - Dorota Sobczyk
- Department of Cardiovascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland;
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, 31-202 Krakow, Poland; (B.K.); (D.P.)
| | - Rafał Drwiła
- Department of Anesthesiology and Intensive Care, St. John Paul II Hospital, 31-202 Krakow, Poland; (H.H.); (R.D.)
| | - Bogusław Kapelak
- Department of Anesthesiology and Intensive Care, St. John Paul II Hospital, 31-202 Krakow, Poland; (H.H.); (R.D.)
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, 31-202 Krakow, Poland; (B.K.); (D.P.)
| | - Tomasz Darocha
- Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Dariusz Plicner
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, 31-202 Krakow, Poland; (B.K.); (D.P.)
- Department of Anesthesiology and Intensive Care, Medical University of Silesia, 40-055 Katowice, Poland
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Haddad G, Margius D, Cohen AL, Gorlin M, Jafari D, Li T, Owens C, Becker L, Rolston DM. Doppler ultrasound peak systolic velocity versus end tidal carbon dioxide during pulse checks in cardiac arrest. Resuscitation 2023; 183:109695. [PMID: 36646373 DOI: 10.1016/j.resuscitation.2023.109695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND An accurate, non-invasive measure of return of spontaneous circulation (ROSC) is needed to improve management of cardiac arrest patients. OBJECTIVES During a pulse check in Emergency Department (ED) cardiac arrest patients, we compared the correlation between 1) end tidal carbon dioxide (ETCO2) and systolic blood pressure (SBP), and 2) Doppler ultrasound peak systolic velocity (PSV) and SBP. Additionally, we assessed the accuracy of PSV ≥ 20 cm/sec in comparison to previously suggested ETCO2 ≥ 20 or ≥ 25 mmHg thresholds to predict ROSC with SBP ≥ 60 mmHg. METHODS This was a secondary analysis of a previously published prospective observational study of ED cardiac arrest patients with an advanced airway and femoral arterial line in place. During each pulse check, highest SBP, highest PSV, and ETCO2 at the end of the pulse check were recorded. Spearman correlation coefficients were calculated and compared using a Fisher Z-transformation. Accuracy of previously determined PSV and ETCO2 thresholds for detecting ROSC with SBP ≥ 60 mmHg were compared using McNemar's tests. RESULTS Based on data from 35 patients with 111 pulse checks, we found a higher correlation between PSV and SBP than ETCO2 and SBP (0.71 vs 0.31; p < 0.001). Diagnostic accuracy of PSV ≥ 20 cm/sec for detecting ROSC with SBP ≥ 60 mmHg was 89% (95% CI: 82%-94%) versus 59% (95% CI: 49%-68%) and 58% (95% CI: 48%-67%) for ETCO2 ≥ 20 and ≥ 25 mmHg, respectively. CONCLUSIONS During a pulse check, Doppler ultrasound PSV outperformed ETCO2 for correlation with SBP and accuracy in detecting ROSC with SBP ≥ 60 mmHg.
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Affiliation(s)
- Ghania Haddad
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States.
| | - Deanna Margius
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, United States
| | - Allison L Cohen
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, United States
| | - Margaret Gorlin
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Daniel Jafari
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, United States; Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Timmy Li
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, United States
| | - Casey Owens
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Lance Becker
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, United States; Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Daniel M Rolston
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, United States; Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
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Abrahamowicz AA, Counts CR, Danielson KR, Bulger NE, Maynard C, Carlbom DJ, Swenson ER, Latimer AJ, Yang B, Sayre MR, Johnson NJ. The association between arterial-end-tidal carbon dioxide difference and outcomes after out-of-hospital cardiac arrest. Resuscitation 2022; 181:3-9. [PMID: 36183813 DOI: 10.1016/j.resuscitation.2022.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 02/01/2023]
Abstract
AIM We sought to determine if the difference between PaCO2 and ETCO2 is associated with hospital mortality and neurologic outcome following out-of-hospital cardiac arrest (OHCA). METHODS This was a retrospective cohort study of adult patients who achieved return of spontaneous circulation (ROSC) after OHCA over 3 years. The primary exposure was the PaCO2-ETCO2 difference on hospital arrival. The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurologic status at discharge. We used receiver operating characteristic (ROC) curves to determine discrimination threshold and multivariate logistic regression to examine the association between the PaCO2-ETCO2 difference and outcome. RESULTS Of 698 OHCA patients transported to the hospitals, 381 had sustained ROSC and qualifying ETCO2 and PaCO2 values. Of these, 160 (42%) survived to hospital discharge. Mean ETCO2 was 39 mmHg among survivors and 43 mmHg among non-survivors. Mean PaCO2-ETCO2 was 6.8 mmHg and 9.0 mmHg (p < 0.05) for survivors and non-survivors. After adjustment for Utstein characteristics, a higher PaCO2-ETCO2 difference on hospital arrival was not associated with hospital mortality (OR 0.99, 95% CI: 0.97-1.0) or neurological outcome. Area under the ROC curve or PaCO2-ETCO2 difference was 0.56 (95% CI 0.51-0.62) compared with 0.58 (95% CI 0.52-0.64) for ETCO2. CONCLUSION Neither PaCO2-ETCO2 nor ETCO2 were strong predictors of survival or neurologic status at hospital discharge. While they may be useful to guide ventilation and resuscitation, these measures should not be used for prognostication after OHCA.
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Affiliation(s)
| | - Catherine R Counts
- Seattle Fire Department, Seattle, WA, United States; Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | | | | | - Charles Maynard
- Seattle Fire Department, Seattle, WA, United States; University of Washington School of Public Health, Seattle, WA, United States
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Erik R Swenson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Andrew J Latimer
- Airlift Northwest, Seattle, WA, United States; Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Betty Yang
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Michael R Sayre
- Seattle Fire Department, Seattle, WA, United States; Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States.
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Ellerton JA, Pasquier M, Paal P, Strapazzon G, Darocha T, Brugger H. A Response to "EDCB ET AA: A Mnemonic for Resuscitating Hypothermic Patients Under Extreme Conditions.". Anesth Analg 2022; 135:e40-e41. [PMID: 36269996 DOI: 10.1213/ane.0000000000006202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Mathieu Pasquier
- Department of Emergency Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, St John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
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Venetz P, Luedi MM. In Response. Anesth Analg 2022; 135:e41-e42. [PMID: 36269997 DOI: 10.1213/ane.0000000000006203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,
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Zafren K, Paal P. End-tidal CO2 <10 mm Hg is not a reason to terminate cardiopulmonary resuscitation in hypothermic cardiac arrest. Resuscitation 2022; 174:91-92. [DOI: 10.1016/j.resuscitation.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/08/2022] [Indexed: 11/15/2022]
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