1
|
Dietz N, Blank M, Asaka W, Oxford BG, Ding D, Sieg E, Koenig HM. Emergent Management of Severe Hypothermia, Acidemia, and Coagulopathy in Operative Penetrating Ballistic Cranial Trauma. Cureus 2024; 16:e55630. [PMID: 38586715 PMCID: PMC10995893 DOI: 10.7759/cureus.55630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Hypothermia in a trauma patient has been associated with increased morbidity and mortality and is more frequently seen in those sustaining traumatic brain injuries (TBIs). Acidosis is an important consequence of hypothermia that leads to derangements across the spectrum of the coagulation cascade. Here, we present a case of a 31-year-old male presented after suffering a right parietal penetrating ballistic injury with an associated subdural hematoma and 7 mm midline shift requiring decompressive craniectomy and external ventricular drain (EVD) placement in the setting of severe hypothermia (28°C) and acidosis (pH 7.12). With aggressive rewarming intraoperatively, the use of full-body forced-air warming, warmed IV fluids, and increasing the ambient room temperature, the patient's acidosis and hypothermia improved to pH 7.20 and 34°C. Despite these aggressive attempts to rewarm the patient, he developed coagulopathy in the setting of concurrent hypothermia and acidosis. This case highlights the importance of prompt reversal of hypothermia due to its potentially fatal effects, particularly in the setting of severe TBIs. We discuss the critical aspects of surgical management of the injury and anesthetic management of hypothermia, acidosis, and coagulopathy perioperatively.
Collapse
Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville Hospital, Louisville, USA
| | - Meghan Blank
- Department of Anesthesiology, University of Louisville Hospital, Louisville, USA
| | - William Asaka
- Department of Neurosurgery, University of Louisville Hospital, Louisville, USA
| | - Brent G Oxford
- Department of Neurosurgery, University of Louisville Hospital, Louisville, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville Hospital, Louisville, USA
| | - Emily Sieg
- Department of Neurosurgery, University of Louisville Hospital, Louisville, USA
| | - Heidi M Koenig
- Department of Anesthesiology, University of Louisville Hospital, Louisville, USA
| |
Collapse
|
2
|
Kouchit Y, Canac B, Levraut J, Martis N. Prevalence of hypothermia and its associated clinical and biological features (such as thrombocytopenia) in emergency department patients: a case series. Intern Emerg Med 2023; 18:1595-1598. [PMID: 37395981 DOI: 10.1007/s11739-023-03345-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Yanis Kouchit
- Internal Medicine Department, University Hospital of Nice, Archet 1 Hospital, 151 Route de Saint-Antoine de Ginestière, 06200, Nice, France
- Côte d'Azur University, Nice, France
| | - Benoit Canac
- Côte d'Azur University, Nice, France
- Emergency Medicine Department, University Hospital of Nice, Nice, France
| | - Jacques Levraut
- Côte d'Azur University, Nice, France
- Emergency Medicine Department, University Hospital of Nice, Nice, France
| | - Nihal Martis
- Internal Medicine Department, University Hospital of Nice, Archet 1 Hospital, 151 Route de Saint-Antoine de Ginestière, 06200, Nice, France.
- Côte d'Azur University, Nice, France.
- INSERM U1065, Mediterranean Centre for Molecular Medicine, Team: Control of Gene Expression, Nice, France.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
On-Site Medical Management of Avalanche Victims-A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910234. [PMID: 34639535 PMCID: PMC8507645 DOI: 10.3390/ijerph181910234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/18/2021] [Accepted: 09/19/2021] [Indexed: 12/26/2022]
Abstract
Avalanche accidents are common in mountain regions and approximately 100 fatalities are counted in Europe each year. The average mortality rate is about 25% and survival chances are mainly determined by the degree and duration of avalanche burial, the patency of the airway, the presence of an air pocket, snow characteristics, and the severity of traumatic injuries. The most common cause of death in completely buried avalanche victims is asphyxia followed by trauma. Hypothermia accounts for a minority of deaths; however, hypothermic cardiac arrest has a favorable prognosis and prolonged resuscitation and extracorporeal rewarming are indicated. In this article, we give an overview on the pathophysiology and on-site management of avalanche victims.
Collapse
|
5
|
Saczkowski R, Kuzak N, Grunau B, Schulze C. Extracorporeal life support rewarming rate is associated with survival with good neurological outcome in accidental hypothermia. Eur J Cardiothorac Surg 2021; 59:593-600. [PMID: 33230533 DOI: 10.1093/ejcts/ezaa385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Favourable outcomes have been demonstrated after extracorporeal life support (ECLS) facilitated rewarming for severe accidental hypothermia. The clinical impact of varying rewarming rates however is unclear. We sought to quantify the change in the probability of good neurological outcome with ECLS rewarming rate and identify the optimal rewarming rate threshold. METHODS We performed a secondary analysis of the International ACcidental Hypothermia Extracorporeal Life Support Collaborators, an individual patient data data set (n = 658) for ECLS-assisted rewarming for accidental hypothermia. The independent variable of interest was rewarming rate. The primary outcome was survival with good neurological status. We applied an adjusted marginal effects model to quantify the probability of good neurological outcome over clinically observed rewarming rates. We examined strata defined by sex, initial potassium level and history of asphyxiation. RESULTS Of 658 cases, the median age and initial core temperature were 36 years (22-55) and 24.5°C (22.1-26.2) respectively; 190 (29%) were female, and 547 (83%) had a non-perfusing initial cardiac rhythm. The mean rewarming rate was 7.0°C/h. The median ECLS duration was 5.8 h (range: 0.5-158 h). The overall survival was 46% (n = 303/658), and good neurological outcome was 40% (n = 265/658). The median intensive care unit and hospital length of stay was 5 days (range: 1-35 days) and 18 days (range: 1-106 days), respectively. Marginal effects analysis demonstrated a 1.9% decrease in the probability of survival with good neurological outcome for each 1°C/h increase in rewarming. Across the reported range of rewarming rates (0.05-30.8°C/h), the probability of good neurological outcome declined from 49.6% to 4.1% for an average patient. The relationship was similar within various subgroups. The optimal cut-off threshold for the rate of rewarming to distinguish between a good and poor neurological outcome was ≤5.0°C/h. CONCLUSIONS Among cases with severe accidental hypothermia treated with ECLS, slower rewarming rates are associated with improved survival with good neurological outcomes. Slow rewarming, at rates ≤5.0°C/h, may improve clinical outcomes.
Collapse
Affiliation(s)
- Richard Saczkowski
- Department of Cardiac Sciences, Division of Cardiac Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Nick Kuzak
- Division of Cardiac Anaesthesia, Kelowna General Hospital, Kelowna, BC, Canada.,University of British Columbia, Department of Anesthesiology, Kelowna, BC, Canada.,Department of Emergency Medicine, Kelowna General Hospital, Kelowna, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Costas Schulze
- Department of Cardiac Sciences, Division of Cardiac Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada.,Department of Critical Care Medicine, Kelowna General Hospital, Kelowna, BC, Canada
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Rasmussen JM, Cogbill TH, Borgert AJ, Frankki SM, Kallies KJ, Roberts JC, Cullinane DC, Renier C, Woehrle T, Eyer SD, Zein Eddine SB, Beckman M, Waller CJ. Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care. Am Surg 2020; 88:1062-1070. [PMID: 33375834 DOI: 10.1177/0003134820984869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.
Collapse
Affiliation(s)
- Jessica M Rasmussen
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Thomas H Cogbill
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Susan M Frankki
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Jennifer C Roberts
- Department of Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Daniel C Cullinane
- Department of Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Colleen Renier
- Department of Trauma Surgery, Essentia Health St Mary's Medical Center, Essentia Institute of Rural Health, Duluth, MN, USA
| | - Theo Woehrle
- Department of Trauma Surgery, Essentia Health St Mary's Medical Center, Essentia Institute of Rural Health, Duluth, MN, USA
| | - Steven D Eyer
- Department of Trauma Surgery, Essentia Health St Mary's Medical Center, Essentia Institute of Rural Health, Duluth, MN, USA
| | - Savo Bou Zein Eddine
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marshall Beckman
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christine J Waller
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
| |
Collapse
|
8
|
Petrone P, Marini CP, Miller I, Brathwaite CEM, Howell RS, Cochrane D, Rodríguez-Velandia W, Rahn C, Allegra JR. Factors associated with severity of accidental hypothermia: A cohort retrospective multi-institutional study. Ann Med Surg (Lond) 2020; 55:81-83. [PMID: 32477500 PMCID: PMC7251493 DOI: 10.1016/j.amsu.2020.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/03/2020] [Indexed: 11/17/2022] Open
Abstract
Background Frequently it is difficult to determine illness severity in hypothermic patients. Our goal was to determine if there are factors associated with illness severity of hypothermic emergency department (ED) patients. Methods Multi-hospital retrospective cohort. Consecutive patients in 24 EDs (1-1-2012 to 4-30–2015). Hypothermic patients (≤35 °C) were identified using ICD codes. We used hospital admission as marker of illness severity. Student's t-test was used for differences between mean age and temperature for admitted and discharged patients. We calculated the percent of patients admitted by factor, the difference from overall admission rate and 95% confidence interval (CI) of difference. Results There were 2094 visits with hypothermia ICD code. Of these, 132 patients had initial rectal temperatures ≤35 °C. Females comprised 42%; the mean age was 55 ± 23 years, and overall admission rate was 62%. The percent of patients with alcohol, trauma and found indoors were 39%, 27% and 27%, respectively. For admitted and discharged patients the mean ages were 60 and 48 years, respectively (p = 0.01), and initial mean temperature 32.3 °C vs. 33 °C, respectively (p = 0.07). Found indoors was associated with an 86% admission rate, a 22% increase (95% CI, 3%–34%) compared to overall admission rate. There was no statistically significant difference in admission rates from overall admission rate based on gender, alcohol or trauma. Conclusions For hypothermic ED patients increased severity of illness was associated with older age and found indoors but not associated with initial temperature, gender, alcohol or trauma. These findings may assist physicians in treatment and disposition decisions. Accidental hypothermia is defined as a decrease in core body temperature to less than 35°C (95°F). Secondary hypothermia can occur in healthy and ill persons, even in warm environments, as a result of predisposing factors. Maintenance of a normal core temperature is achieved from a balance between heat production and heat loss. Factors associated with increased severity of illness for hypothermic ED patients were older age and found indoors.
Collapse
Affiliation(s)
- Patrizio Petrone
- Department of Surgery, NYU Langone Health - NYU Winthrop Hospital, NYU Long Island School of Medicine; Mineola, New York, USA
| | - Corrado P Marini
- Department of Surgery, Jacobi Medical Center; Albert Einstein College of Medicine; Bronx, New York, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center; Valhalla, New York, USA
| | - Collin E M Brathwaite
- Department of Surgery, NYU Langone Health - NYU Winthrop Hospital, NYU Long Island School of Medicine; Mineola, New York, USA
| | - Raelina S Howell
- Department of Surgery, NYU Langone Health - NYU Winthrop Hospital, NYU Long Island School of Medicine; Mineola, New York, USA
| | - Dennis Cochrane
- Department of Emergency Medicine, Morristown Medical Center; Morristown, New Jersey, USA
| | - Wilson Rodríguez-Velandia
- Department of Surgery, NYU Langone Health - NYU Winthrop Hospital, NYU Long Island School of Medicine; Mineola, New York, USA
| | - Candela Rahn
- Department of Surgery, NYU Langone Health - NYU Winthrop Hospital, NYU Long Island School of Medicine; Mineola, New York, USA
| | - John R Allegra
- Department of Emergency Medicine, Morristown Medical Center; Morristown, New Jersey, USA
| |
Collapse
|
9
|
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.
Collapse
Affiliation(s)
- Robert Willmore
- Institute of Pre-Hospital Care at London's Air Ambulance, The Royal London Hospital, London, United Kingdom.
| |
Collapse
|
10
|
Shida A, Ikeda T, Tani N, Morioka F, Aoki Y, Ikeda K, Watanabe M, Ishikawa T. Cortisol levels after cold exposure are independent of adrenocorticotropic hormone stimulation. PLoS One 2020; 15:e0218910. [PMID: 32069307 PMCID: PMC7028257 DOI: 10.1371/journal.pone.0218910] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/27/2020] [Indexed: 02/08/2023] Open
Abstract
We previously showed that postmortem serum levels of adrenocorticotropic hormone (ACTH) were significantly higher in cases of hypothermia (cold exposure) than other causes of death. This study examined how the human hypothalamic-pituitary-adrenal axis, and specifically cortisol, responds to hypothermia. Human samples: Autopsies on 205 subjects (147 men and 58 women; age 15-98 years, median 60 years) were performed within 3 days of death. Cause of death was classified as either hypothermia (cold exposure, n = 14) or non-cold exposure (controls; n = 191). Cortisol levels were determined in blood samples obtained from the left and right cardiac chambers and common iliac veins using a chemiluminescent enzyme immunoassay. Adrenal gland tissues samples were stained for cortisol using a rabbit anti-human polyclonal antibody. Cell culture: AtT20, a mouse ACTH secretory cell line, and Y-1, a corticosterone secretory cell line derived from a mouse adrenal tumor, were analyzed in mono-and co-culture, and times courses of ACTH (in AtT20) and corticosterone (in Y-1) secretion were assessed after low temperature exposure mimicking hypothermia and compared with data for samples collected postmortem for other cases of death. However, no correlation between ACTH concentration and cortisol levels was observed in hypothermia cases. Immunohistologic analyses of samples from hypothermia cases showed that cortisol staining was localized primarily to the nucleus rather than the cytoplasm of cells in the zona fasciculata of the adrenal gland. During both mono-culture and co-culture, AtT20 cells secreted high levels of ACTH after 10-15 minutes of cold exposure, whereas corticosterone secretion by Y-1 cells increased slowly during the first 15-20 minutes of cold exposure. Similar to autopsy results, no correlation was detected between ACTH levels and corticosterone secretion, either in mono-culture or co-culture experiments. These results suggested that ACTH-independent cortisol secretion may function as a stress response during cold exposure.
Collapse
Affiliation(s)
- Alissa Shida
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- * E-mail:
| | - Tomoya Ikeda
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka, Japan
| | - Naoto Tani
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka, Japan
| | - Fumiya Morioka
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Yayoi Aoki
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Kei Ikeda
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Miho Watanabe
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Laboratory of Clinical Regenerative Medicine Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Health and Medical Science Innovation laboratory, Tsukuba City, Ibaraki, Japan
| | - Takaki Ishikawa
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka, Japan
| |
Collapse
|
11
|
Watanabe M, Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Ohta B. Impact of rewarming rate on the mortality of patients with accidental hypothermia: analysis of data from the J-Point registry. Scand J Trauma Resusc Emerg Med 2019; 27:105. [PMID: 31771645 PMCID: PMC6880476 DOI: 10.1186/s13049-019-0684-5] [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: 07/29/2019] [Accepted: 11/11/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Accidental hypothermia (AH) is defined as an involuntary decrease in core body temperature to < 35 °C. The management of AH has been progressing over the last few decades, and numerous techniques for rewarming have been validated. However, little is known about the association between rewarming rate (RR) and mortality in patients with AH. METHOD This was a multicentre chart review study of patients with AH visiting the emergency department of 12 institutions in Japan from April 2011 to March 2016 (Japanese accidental hypothermia network registry, J-Point registry). We retrospectively registered patients using the International Classification of Diseases, Tenth Revision code T68: 'hypothermia'. We excluded patients whose body temperatures were unknown or ≥ 35 °C, who could not be rewarmed, whose rewarmed temperature or rewarming time was unknown, those aged < 18 years, or who or whose family members had refused to join the registry. RR was calculated based on the body temperature on arrival at the hospital, time of arrival at the hospital, the documented temperature during rewarming, and time of the temperature documentation. RR was classified into the following five groups: ≥2.0 °C/h, 1.5-< 2.0 °C/h, 1.0-< 1.5 °C/h, 0.5-< 1.0 °C/h, and < 0.5 °C/h. The primary outcome of this study was in-hospital mortality. The association between RR and in-hospital mortality was evaluated using multivariate logistic regression analysis. RESULT During the study, 572 patients were registered in the J-Point registry, and 481 patients were included in the analysis. The median body temperature on arrival to the hospital was 30.7 °C (interquartile range [IQR], 28.2 °C-32.4 °C), and the median RR was 0.85 °C/h (IQR, 0.53 °C/h-1.31 °C/h). The in-hospital mortality rates were 19.3% (11/57), 11.1% (4/36), 14.4% (15/104), 20.1% (35/175), and 34.9% (38/109) in the ≥2.0 °C/h, 1.5-< 2.0 °C/h, 1.0-< 1.5 °C/h, 0.5-< 1.0 °C/h, and < 0.5 °C/h groups, respectively. Multivariate regression analysis revealed that in-hospital mortality rate increased with each 0.5 °C/h decrease in RR (adjusted odds ratio, 1.49; 95% confidence interval, 1.15-1.94; Ptrend < 0.01). CONCLUSION This study showed that slower RR is independently associated with in-hospital mortality.
Collapse
Affiliation(s)
- Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuyoshi 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, Kamigyo-ku, Kyoto, 602-8566, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Centre, 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.,Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, 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
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
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]
|
15
|
Hypothermia-rewarming: A Double-edged sword? Med Hypotheses 2019; 133:109387. [PMID: 31541781 DOI: 10.1016/j.mehy.2019.109387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 01/05/2023]
Abstract
Hypothermia is a condition in which the body's core temperature drops below 35.0 °C. Hypothermia is the opposite of hyperthermia, which the metabolism and body functions are abnormal. Severe hypothermia is a life-threatening problem that may cause atrial and ventricular dysrhythmias, coagulopathy, cardiac, and central nervous system depression. What is worse, it is fatal when untreated or treated improperly. Accidental deaths due to hypothermia resulting from immersion in cold water, especially involving naval fighters and maritime victims have occurred continually in the past years. Currently, the treatment of hypothermia has become a research focus. Rewarming is the only approach that should be considered for hypothermia treatment. However, the treatment is of low efficiency, and few active rewarming cases have been reported. It is well known that timely reperfusion is the best way to save the lives of patients with ischemia. Similarly, reoxygenation is effective for hypoxia. However, several studies have identified that improper reperfusion of ischemic tissues and reoxygenation of hypoxic tissues give rise to further injury. Analogically, this study attempts to propose the hypothesis that hypothermia-rewarming injury may also exist. When suffered from hypothermia, both the blood circulation and the oxygen supply in the body will be affected in a deficient state, an injury may also appear in the improper rewarming process. In a word, hypothermia-rewarming may be a double-edged sword.
Collapse
|
16
|
Rousseau G, Reynier P, Jousset N, Rougé-Maillart C, Palmiere C. Updated review of postmortem biochemical exploration of hypothermia with a presentation of standard strategy of sampling and analyses. Clin Chem Lab Med 2019; 56:1819-1827. [PMID: 29715177 DOI: 10.1515/cclm-2018-0153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/03/2018] [Indexed: 11/15/2022]
Abstract
Hypothermia is defined as a core body temperature below 35°C and can be caused by environmental exposure, drug intoxication, metabolic or nervous system dysfunction. This lethal pathology with medico-legal implications is complex to diagnose because macroscopic and microscopic lesions observed at the autopsy and the histological analysis are suggestive but not pathognomonic. Postmortem biochemical explorations have been progressively developed through the study of several biomarkers to improve the diagnosis decision cluster. Here, we present an updated review with novel biomarkers (such as catecholamines O-methylated metabolites, thrombomodulin and the cardiac oxyhemoglobin ratio) as well as some propositional interpretative postmortem thresholds and, to the best of our knowledge, for the first time, we present the most adapted strategy of sampling and analyses to identify biomarkers of hypothermia. For our consideration, the most relevant identified biomarkers are urinary catecholamines and their O-methylated metabolites, urinary free cortisol, blood cortisol, as well as blood, vitreous humor and pericardial fluid for ketone bodies and blood free fatty acids. These biomarkers are increased in response either to cold-mediated stress or to bioenergetics ketogenesis crisis and significantly contribute to the diagnosis by exclusion of death by hypothermia.
Collapse
Affiliation(s)
- Guillaume Rousseau
- Département de Biochimie et Génétique, Centre Hospitalier Universitaire d'Angers, Angers, France
- Service de Médecine Légale et Pénitentiaire, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Pascal Reynier
- Département de Biochimie et Génétique, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Nathalie Jousset
- Service de Médecine Légale et Pénitentiaire, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Clotilde Rougé-Maillart
- GEROM-LHEA, IRIS-IBS Institut de Biologie en Santé, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Cristian Palmiere
- CURML, Centre Universitaire Romand de Médecine Légale, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| |
Collapse
|
17
|
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.
Collapse
|
18
|
Ghadimi K, Levy JH, Welsby IJ. Perioperative management of the bleeding patient. Br J Anaesth 2018; 117:iii18-iii30. [PMID: 27940453 DOI: 10.1093/bja/aew358] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Perioperative bleeding remains a major complication during and after surgery, resulting in increased morbidity and mortality. The principal causes of non-vascular sources of haemostatic perioperative bleeding are a preexisting undetected bleeding disorder, the nature of the operation itself, or acquired coagulation abnormalities secondary to haemorrhage, haemodilution, or haemostatic factor consumption. In the bleeding patient, standard therapeutic approaches include allogeneic blood product administration, concomitant pharmacologic agents, and increasing application of purified and recombinant haemostatic factors. Multiple haemostatic changes occur perioperatively after trauma and complex surgical procedures including cardiac surgery and liver transplantation. Novel strategies for both prophylaxis and therapy of perioperative bleeding include tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates. Point-of-care patient testing using thromboelastography, rotational thromboelastometry, and platelet function assays has allowed for more detailed assessment of specific targeted therapy for haemostasis. Strategic multimodal management is needed to improve management, reduce allogeneic blood product administration, and minimize associated risks related to transfusion.
Collapse
Affiliation(s)
- K Ghadimi
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - J H Levy
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - I J Welsby
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
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]
|
21
|
Christensen ML, Lipman GS, Grahn DA, Shea KM, Einhorn J, Heller HC. A Novel Cooling Method and Comparison of Active Rewarming of Mildly Hypothermic Subjects. Wilderness Environ Med 2017; 28:108-115. [PMID: 28506514 DOI: 10.1016/j.wem.2017.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 02/14/2017] [Accepted: 02/23/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the effectiveness of arteriovenous anastomosis (AVA) vs heated intravenous fluid (IVF) rewarming in hypothermic subjects. Additionally, we sought to develop a novel method of hypothermia induction. METHODS Eight subjects underwent 3 cooling trials each to a core temperature of 34.8±0.6 (32.7 to 36.3°C [mean±SD with range]) by 14°C water immersion for 30 minutes, followed by walking on a treadmill for 5 minutes. Core temperatures (Δtes) and rates of cooling (°C/h) were measured. Participants were then rewarmed by 1) control: shivering only in a sleeping bag; 2) IVF: shivering in sleeping bag and infusion of 2 L normal saline warmed to 42°C at 77 mL/min; and 3) AVA: shivering in sleeping bag and circulation of 45°C warmed fluid through neoprene pads affixed to the palms and soles of the feet. RESULTS Cold water immersion resulted in a decrease of 0.5±0.5°C Δtes and 1±0.3°C with exercise (P < .01); with an immersion cooling rate of 0.9±0.8°C/h vs 12.6±3.2°C/h with exercise (P < .001). Temperature nadir reached 35.0±0.5°C. There were no significant differences in rewarming rates between the 3 conditions (shivering: 1.3±0.7°C/h, R2 = 0.683; IVF 1.3±0.7°C/h, R2 = 0.863; and AVA 1.4±0.6°C/h, R2 = 0.853; P = .58). Shivering inhibition was greater with AVA but was not significantly different (P = .07). CONCLUSIONS This study developed a novel and efficient model of hypothermia induction through exercise-induced convective afterdrop. Although there was not a clear benefit in either of the 2 active rewarming methods, AVA rewarming showed a nonsignificant trend toward greater shivering inhibition, which may be optimized by an improved interface.
Collapse
Affiliation(s)
- Mark L Christensen
- Department of Emergency Medicine, Stanford University School of Medicine (Drs Christensen, Lipman, and Shea).
| | - Grant S Lipman
- Department of Emergency Medicine, Stanford University School of Medicine (Drs Christensen, Lipman, and Shea)
| | - Dennis A Grahn
- Department of Biology, Stanford University (Drs Grahn and Heller)
| | - Kate M Shea
- Department of Emergency Medicine, Stanford University School of Medicine (Drs Christensen, Lipman, and Shea)
| | - Joseph Einhorn
- Stanford - Kaiser Emergency Medicine Residency, Stanford, CA (Dr Einhorn)
| | - H Craig Heller
- Department of Biology, Stanford University (Drs Grahn and Heller)
| |
Collapse
|
22
|
Endovascular rewarming in the emergency department for moderate to severe accidental hypothermia. Am J Emerg Med 2017; 35:1624-1629. [PMID: 28506506 DOI: 10.1016/j.ajem.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 04/09/2017] [Accepted: 05/08/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Endovascular temperature control catheters can be utilized for emergent rewarming in accidental hypothermia. The purpose of this study was to compare patients with moderate to severe hypothermia rewarmed with an endovascular temperature control catheter versus usual care at our institution. METHODS We conducted a retrospective, observational cohort study of patients with moderate to severe accidental hypothermia (core body temperature less than 32°C) in the Emergency Department of an urban, tertiary care medical center. We identified the rewarming techniques utilized for each patient, including those who had an endovascular temperature control catheter placed (Quattro© or Icy© catheter, CoolGuard© 3000 regulation system, Zoll Medical). Rewarming rates and outcomes were compared for patients with and without the endovascular temperature control catheter. We systematically screened for procedural complications. RESULTS There were 106 patients identified with an initial core temperature less than or equal to 32°C; 52 (49%) patients rewarmed with an endovascular temperature control catheter. Other methods of rewarming included external forced-air rewarming (85, 80%), bladder lavage (17, 16%), gastric lavage (10, 9%), closed pleural lavage (6, 6%), and peritoneal lavage (3, 3%). Rate of rewarming did not differ between the groups with and without catheter-based rewarming (1.3°C/h versus 1.0°C/h, difference 0.3°C, 95% confidence interval [CI] of the difference 0-0.6°C) and neither did survival (70% versus 71%, difference 1%, 95% CI -17 to 20%). We did not identify any significant vascular injuries resulting from endovascular catheter use. CONCLUSION The endovascular temperature control system was not associated with an increased rate of rewarming in this cohort with moderate to severe hypothermia; however, this technique appears to be safe and feasible.
Collapse
|
23
|
Lapostolle F, Couvreur J, Koch FX, Savary D, Alhéritière A, Galinski M, Sebbah JL, Tazarourte K, Adnet F. Hypothermia in trauma victims at first arrival of ambulance personnel: an observational study with assessment of risk factors. Scand J Trauma Resusc Emerg Med 2017; 25:43. [PMID: 28438222 PMCID: PMC5402666 DOI: 10.1186/s13049-017-0349-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 01/13/2017] [Indexed: 11/23/2022] Open
Abstract
Background Hypothermia is common in trauma victims and is associated with increased mortality, however its causes are little known. The objective of this study was to identify the risk factors associated with hypothermia in prehospital management of trauma victims. Methods This was an ancillary analysis of data recorded in the HypoTraum study, a prospective multicenter study conducted by the emergency medical services (EMS) of 8 hospitals in France. Inclusion criteria were: trauma victim, age over 18 years, and victim receiving prehospital care from an EMS team and transported to hospital by the EMS team in a medically equipped mobile intensive care unit. The following data were recorded: victim demographics, circumstances of the trauma, environmental factors, patient presentation, clinical data and time from accident to EMS arrival. Independent risk factors for hypothermia were analyzed in a multivariate logistic regression model. Results A total of 461 trauma patients were included in the study. Road traffic accidents (N = 261; 57%) and falls (N = 65; 14%) were the main causes of trauma. Hypothermia (<35 °C) was present in 136/461 cases (29%). Independent factors significantly associated with the presence of hypothermia were: a low GCS (Odds Ratio (OR) = 0,87 ([0,81-0,92]; p < 0.0001), a low air temperature (OR = 0,93 [0,91-0,96]; p < 0.0001) and a wet patient (OR = 2,08 [1,08-4,00]; p = 0.03). Conclusion The incidence of hypothermia was high on EMS arrival at the scene. Body temperature measurement and immediate thermal protection should be routine, and special attention should be given to patients who are wet. Level of evidence Prospective, multicenter, open, observational study; Level IV.
Collapse
Affiliation(s)
- Frédéric Lapostolle
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France. .,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France.
| | - James Couvreur
- Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
| | | | | | - Armelle Alhéritière
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France.,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
| | - Michel Galinski
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France.,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
| | | | - Karim Tazarourte
- Pôle urgence-réanimation-SAMU 77, Centre hospitalier Marc Jacquet, Melun, France
| | - Frédéric Adnet
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France.,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
| |
Collapse
|
24
|
Abstract
Accidental hypothermia is an unintentional drop in core temperature to 35°C or below. Core temperature is best measured by esophageal probe. If core temperature cannot be measured, the degree should be estimated using clinical signs. Treatment is to protect from further heat loss, minimize afterdrop, and prevent cardiovascular collapse during rescue and resuscitation. The patient should be handled gently, kept horizontal, insulated, and actively rewarmed. Active rewarming is also beneficial in mild hypothermia but passive rewarming usually suffices. Cardiopulmonary resuscitation should be performed if there are no contraindications to resuscitation. CPR may be delayed or intermittent.
Collapse
Affiliation(s)
- Ken Zafren
- Alaska Department of Health and Social Services, State of Alaska, Juneau, AK, USA; International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zürich, Switzerland; Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA; Alaska Native Medical Center, Anchorage, AK, USA.
| |
Collapse
|
25
|
Editorial Comment. Prehosp Disaster Med 2017. [DOI: 10.1017/s1049023x00051475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
26
|
Hatam EM, Cameron A, Petsikas D, Messenger D, Ball IM. A Case of Severe Accidental Hypothermia Successfully Treated with Cardiopulmonary Bypass. Clin Pract Cases Emerg Med 2017; 1:33-36. [PMID: 29849406 PMCID: PMC5965436 DOI: 10.5811/cpcem.2016.11.32919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 10/24/2016] [Accepted: 11/12/2016] [Indexed: 11/21/2022] Open
Abstract
After missing for seven days, a 34-year-old female was found with a rectal temperature of 19.8oC. Instead of attempting aggressive rewarming in the emergency department she was directly transferred to the operating room for extracorporeal rewarming. She received cardiopulmonary bypass (CPB) for 66 minutes at an initial warming rate of 12oC/ hour and warmed to 36.2oC. Her postoperative course was complicated by sepsis, which eventually led to bilateral below-knee amputations after refusing antibiotics. She was discharged 22 days after admission, with full neurologic recovery. This remarkable case highlights the emerging role of CPB as the definitive therapy for severe accidental hypothermia.
Collapse
Affiliation(s)
- Erfun M Hatam
- Western University, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Andrew Cameron
- University of Toronto, Department of Emergency Medicine, Toronto, Ontario, Canada
| | - Dimitri Petsikas
- Queen's University, Kingston General Hospital, Division of Cardiac Surgery, Kingston, Ontario, Canada
| | - David Messenger
- Queen's University, Department of Emergency Medicine & Critical Care Medicine, Kingston, Ontario, Canada
| | - Ian M Ball
- Western University, Department of Epidemiology and Biostatistics, Division of Critical Care Medicine, London, Ontario, Canada
| |
Collapse
|
27
|
Zonnenberg C, Bueno-de-Mesquita JM, Ramlal D, Blom JD. Hypothermia due to Antipsychotic Medication: A Systematic Review. Front Psychiatry 2017; 8:165. [PMID: 28936184 PMCID: PMC5594062 DOI: 10.3389/fpsyt.2017.00165] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/23/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hypothermia is a rare, but potentially fatal adverse effect of antipsychotic drug (APD) use. Although the opposite condition, hyperthermia, has been researched extensively in the context of the malignant antipsychotic syndrome, little is known about hypothermia due to APDs. OBJECTIVE This study aimed to review the literature on hypothermia in the context of APD use, and formulate implications for research and clinical care. METHODS A systematic search was made in PubMed and Ovid Medline. RESULTS The literature search yielded 433 articles, including 57 original case descriptions of hypothermia developed during APD use with non-toxic plasma levels. All cases together indicate that the risk of developing hypothermia is highest during the 7 days following initiation, or increase in dosage, of APDs, especially in the presence of additional predisposing factors, such as advanced age, exposure to cold, adjuvant use of benzodiazepines, and (subclinical) hypothyroidism. In addition, data derived from drug-monitoring agencies suggest that the prevalence of APD-related hypothermia is at least 10 times higher than suggested by the literature. CONCLUSION We conclude that health-care professionals need to monitor the body temperature of patients starting with (an increased dose of) APDs for a duration of 7-10 days to prevent hypothermia, especially in the presence of multiple risk factors. Moreover, systematic studies are needed to establish the actual prevalence of APD-related hypothermia as well as the relative risk for individual APDs.
Collapse
Affiliation(s)
| | | | | | - Jan Dirk Blom
- Parnassia Psychiatric Institute, The Hague, Netherlands.,Faculty of Social Sciences, Leiden University, Leiden, Netherlands.,Department of Psychiatry, University of Groningen, Groningen, Netherlands
| |
Collapse
|
28
|
Khorsandi M, Dougherty S, Young N, Kerslake D, Giordano V, Lendrum R, Walker W, Zamvar V, Yim I, Pessotto R. Extracorporeal Life Support for Refractory Cardiac Arrest from Accidental Hypothermia: A 10-Year Experience in Edinburgh. J Emerg Med 2016; 52:160-168. [PMID: 27884576 DOI: 10.1016/j.jemermed.2016.10.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/14/2016] [Accepted: 10/21/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cardiac arrest caused by accidental hypothermia is a rare phenomenon with a significant mortality rate if untreated. The consensus is that these patients should be rewarmed with extracorporeal life support (ECLS) with the potential for excellent survival and neurologic outcomes. However, given the lack of robust data and clinical trials, the optimal management of such patients remains elusive. OBJECTIVE In this single-center study, we looked at the outcomes of all adult patients undergoing salvage ECLS for cardiac arrest caused by accidental hypothermia over a 10-year period from June 2006 to June 2016. METHODS These data were obtained from the Royal Infirmary of Edinburgh cardiothoracic surgery database. The patients' hard copy case notes, TrakCare (InterSystems Corp, Cambridge, MA), picture archiving and communications system (PACS), and WardWatcher databases were used to cross-check the accuracy of the acquired data. RESULTS Eleven patients met the inclusion criteria. The etiology of hypothermia was exposure to cold air (64%) and cold water immersion (36%). Two (18%) were treated with extracorporeal membrane oxygenation and the rest with cardiopulmonary bypass. The mean age was 51 years (range 32-73), and the mean core body temperature on admission was 20.6°C (range <18-24°C). The overall survival rate to hospital discharge was 72%, with 75% of survivors having no chronic neurologic impairment. CONCLUSION Our case series shows the remarkable salvageability of patients suffering prolonged cardiac arrest caused by accidental hypothermia, particularly in the absence of asphyxia, trauma, or severe hyperkalemia. ECLS is a safe and effective rewarming treatment and should be used to aggressively manage this patient group.
Collapse
Affiliation(s)
- Maziar Khorsandi
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Scott Dougherty
- Department of Internal Medicine, Belau National Hospital, Koror, Republic of Palau
| | - Neil Young
- Department of Critical Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Dean Kerslake
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Vincenzo Giordano
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Robert Lendrum
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - William Walker
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Ivan Yim
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Renzo Pessotto
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
29
|
Outcome After Rewarming From Accidental Hypothermia by Use of Extracorporeal Circulation. Ann Thorac Surg 2016; 103:920-925. [PMID: 27692232 DOI: 10.1016/j.athoracsur.2016.06.093] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Accidental hypothermia with arrested circulation remains a condition associated with high mortality. In our institution, extracorporeal circulation (ECC) rewarming has been the cornerstone in treating such patients since 1987. We here explore characteristics and outcomes of this treatment, to identify significant merits and challenges from 3 decades of experience in ECC rewarming. METHODS Sixty-nine patients rewarmed by ECC during the period from December 1987 to December 2015 were analyzed. One patient was excluded from the analyses because of combined traumatic cerebral injury. The analysis was focused on patient characteristics, treatment procedures, and outcomes were focused. Survivors were evaluated according to the cerebral performance categories scale. Simple statistics with nonparametric tests and χ2 tests were used. Median value and range are reported. RESULTS Median age was 30 years (minimum 1.5, maximum 76), and the cause of accidental hypothermia was cold exposure (27.9%), avalanche (5.9%), and immersion/submersion accidents (66.2%). Eighteen patients survived (26.5%). The survival rate did not improve during the years. Survivors had lower serum potassium (p = 0.002), higher pH (p = 0.03), lower core temperature (p = 0.02), and shorter cardiopulmonary resuscitation time (p = 0.001), but ranges were wide. Although suspected primary hypoxia and hypothermia were associated with lower survival, we observed a 10.5% survival of these victims. Sixteen survivors had good outcome (cerebral performance category 1 or 2), whereas 2 patients with suspected primary hypoxia survived with severe cerebral disability (cerebral performance category 3). CONCLUSIONS Despite extended experience with ECC rewarming, improved handling strategies, and intensive care, no overall improvement in survival was observed. Good outcome was observed even among patients with a dismal prognosis.
Collapse
|
30
|
Paal P, Gordon L, Strapazzon G, Brodmann Maeder M, Putzer G, Walpoth B, Wanscher M, Brown D, Holzer M, Broessner G, Brugger H. Accidental hypothermia-an update : The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med 2016; 24:111. [PMID: 27633781 PMCID: PMC5025630 DOI: 10.1186/s13049-016-0303-7] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/07/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest. METHODS The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review. RESULTS The hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 °C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care. CONCLUSIONS Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.
Collapse
Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, Barts Health NHS Trust, Queen Mary University of London, KGV Building, Office 10, 1st floor, West Smithfield, London, EC1A 7BE UK
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
| | - Les Gordon
- Department of Anaesthesia, University hospitals, Morecambe Bay Trust, Lancaster, UK
- Langdale Ambleside Mountain Rescue Team, Ambleside, UK
| | - Giacomo Strapazzon
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
| | - Monika Brodmann Maeder
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
| | - Beat Walpoth
- Department of Surgery, Cardiovascular Research, Service of Cardiovascular Surgery, University Hospital Geneva, Geneva, Switzerland
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia and Intensive Care 4142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Doug Brown
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregor Broessner
- Department of Neurology, Neurologic Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Hermann Brugger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
| |
Collapse
|
31
|
Perlman R, Callum J, Laflamme C, Tien H, Nascimento B, Beckett A, Alam A. A recommended early goal-directed management guideline for the prevention of hypothermia-related transfusion, morbidity, and mortality in severely injured trauma patients. Crit Care 2016; 20:107. [PMID: 27095272 PMCID: PMC4837515 DOI: 10.1186/s13054-016-1271-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Hypothermia is present in up to two-thirds of patients with severe injury, although it is often disregarded during the initial resuscitation. Studies have revealed that hypothermia is associated with mortality in a large percentage of trauma cases when the patient's temperature is below 32 °C. Risk factors include the severity of injury, wet clothing, low transport unit temperature, use of anesthesia, and prolonged surgery. Fortunately, associated coagulation disorders have been shown to completely resolve with aggressive warming. Selected passive and active warming techniques can be applied in damage control resuscitation. While treatment guidelines exist for acidosis and bleeding, there is no evidence-based approach to managing hypothermia in trauma patients. We synthesized a goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines. This involves the early use of warming blankets and removal of wet clothing in the prehospital phase followed by aggressive rewarming on arrival at the hospital if the patient's injuries require damage control therapy. Future research in hypothermia management should concentrate on applying this treatment algorithm and should evaluate its influence on patient outcomes. This treatment strategy may help to reduce blood loss and improve morbidity and mortality in this population of patients.
Collapse
Affiliation(s)
- Ryan Perlman
- />Department of Anesthesia, Rm M3-200, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- />Trauma, Emergency & Critical Care Research Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Jeannie Callum
- />Department of Laboratory Medicine & Pathobiology, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- />Department of Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Claude Laflamme
- />Department of Anesthesia, Rm M3-200, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Homer Tien
- />Trauma, Emergency & Critical Care Research Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- />Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- />Ornge—Ontario Air Ambulance, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada
| | - Barto Nascimento
- />Trauma, Emergency & Critical Care Research Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- />Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Andrew Beckett
- />Department of Surgery, McGill University, Montreal General Hospital, 1650 Avenue Cedar, Montréal, QC H3G 1A4 Canada
| | - Asim Alam
- />Department of Anesthesia, Rm M3-200, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- />Trauma, Emergency & Critical Care Research Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- />Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| |
Collapse
|
32
|
Li S, Qiu C, Shi W, Huang Y, Gui L. A Survey of Accidental Hypothermia Knowledge among Navy Members in China and the Implications for Training. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E315. [PMID: 26978382 PMCID: PMC4808978 DOI: 10.3390/ijerph13030315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Accidental hypothermia (AH) is a potentially life-threatening condition that can lead to significant morbidity and life-long effects. Navy personnel are always at a greater risk of AH due to frequent outdoor work, wilderness exposure, prolonged immobility and exhaustion. The purpose of the survey was to assess Chinese Navy members' awareness of AH and to make recommendations with regard to better measures for improving it. METHODS 111 Navy members completed a written questionnaire that was subsequently analyzed. RESULTS 30.6% of the respondents have experienced AH and 64.9% rated their knowledge of AH as "low" or "none". Over half of them identified the initial symptom of AH as obvious shivering (69.4%) and apathy (45.0%). As for the aggravate symptoms, 60.9% chose the wrong answer of more obvious shivering instead of the right one-absence of shivering (5.4%). In the case of the treatment of mild AH, more than half of the respondents chose the wrong answers. CONCLUSIONS This study suggests that the basic skills of recognition and treatment of AH are inadequate in the Chinese Navy. Further work is required to develop a systematical, comprehensive and corresponding education method that would promote correct actions during AH.
Collapse
Affiliation(s)
- Shuang Li
- Emergency Nursing Department, School of Nursing, 2nd Military Medical University, Shanghai 200433, China.
| | - Chen Qiu
- Emergency Nursing Department, School of Nursing, 2nd Military Medical University, Shanghai 200433, China.
| | - Wenwen Shi
- Emergency Nursing Department, School of Nursing, 2nd Military Medical University, Shanghai 200433, China.
| | - Yan Huang
- Emergency Nursing Department, School of Nursing, 2nd Military Medical University, Shanghai 200433, China.
| | - Li Gui
- Emergency Nursing Department, School of Nursing, 2nd Military Medical University, Shanghai 200433, China.
| |
Collapse
|
33
|
|
34
|
Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 532] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Skaiaa SC, Brattebø G, Aßmus J, Thomassen Ø. The impact of environmental factors in pre-hospital thermistor-based tympanic temperature measurement: a pilot field study. Scand J Trauma Resusc Emerg Med 2015; 23:72. [PMID: 26400226 PMCID: PMC4581419 DOI: 10.1186/s13049-015-0148-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 09/08/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Few pre-hospital services have the possibility to accurately measure core temperature (T core). Non-invasive estimation of T core will improve pre-hospital decision-making regarding the triage and management of hypothermic patients. Thermistor-based tympanic temperature (T tymp) correlates well with T core in controlled studies; however, little is known about the feasibility of using T tymp under field conditions. This study assessed the impact of pre-hospital environmental factors on the accuracy of T tymp . Deep rectal temperature (T rect) was used as a substitute for T core . METHODS Normothermic volunteers (n = 13) were exposed to four simulated field conditions producing local cooling of the head and ear canal. After exposure, T tymp was recorded every 15 s for 10 min and compared with T rect . Descriptive analysis and Bland-Altman plots were used to assess agreement. RESULTS Immediately after exposure mean T tymp was low, but increased rapidly and reached an apparent steady state after 3-5 min. After 5 and 10 min, the mean temperature difference (∆T rect-tymp) ranged from 1.5-3.2 °C (SD = 0.5) and 1.2-2.0 °C, respectively. T rect remained unchanged throughout the study period. CONCLUSIONS After surface cooling of head and neck, T tymp did not accurately reflect core temperature within the first 10 min of measurement. The variation of ∆T rect-tymp was low after 10 min, regardless of the initial degree of cooling. With the risk of over-triage, T tymp may at this point provide an indication of T core and also exhibit a trend. TRIAL REGISTRATION ClinicalTrials.gov: NCT02274597.
Collapse
Affiliation(s)
- Sven Christjar Skaiaa
- Department of Anaesthesia & Intensive Care, Oslo University Hospital, N 0424, Oslo, Norway.
| | - Guttorm Brattebø
- Department of Anaesthesia & Intensive Care, Haukeland University Hospital, N 5021, Bergen, Norway.
| | - Jörg Aßmus
- Centre for Clinical Research, Haukeland University Hospital, N 5021, Bergen, Norway.
| | - Øyvind Thomassen
- Department of Anaesthesia & Intensive Care, Haukeland University Hospital, N 5021, Bergen, Norway.
| |
Collapse
|
36
|
A Chemical Heat Pack–Based Method For Consistent Heating of Intravenous Fluids. Wilderness Environ Med 2015; 26:412-6. [DOI: 10.1016/j.wem.2015.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 01/22/2015] [Accepted: 02/04/2015] [Indexed: 11/19/2022]
|
37
|
Zafren K, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Weiss EA, Auerbach PS, McIntosh SE, Némethy M, McDevitt M, Dow J, Schoene RB, Rodway GW, Hackett PH, Bennett BL, Grissom CK. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med 2015; 25:S66-85. [PMID: 25498264 DOI: 10.1016/j.wem.2014.10.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
To provide guidance to clinicians, the Wilderness Medical Society (WMS) 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 the balance between benefits and risks/burdens according 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 an updated version of the original Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia published in Wilderness & Environmental Medicine 2014;25(4):425-445.
Collapse
Affiliation(s)
- Ken Zafren
- Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA; International Commission for Mountain Emergency Medicine (ICAR MEDCOM) (Dr Zafren).
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, Canada (Dr Giesbrecht)
| | - Daniel F Danzl
- Department of Emergency Medicine, University of Louisville, School of Medicine, Louisville, KY (Dr Danzl)
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM) (Dr Zafren); European Academy Institute of Mountain Emergency Medicine, Bolzano, Italy (Dr Brugger)
| | - Emily B Sagalyn
- University of Nevada School of Medicine, Reno, NV (Dr Sagalyn)
| | - Beat Walpoth
- Service of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland (Dr Walpoth)
| | - Eric A Weiss
- Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA; Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA (Drs Weiss and Auerbach)
| | - Paul S Auerbach
- Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA; Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA (Drs Weiss and Auerbach)
| | - Scott E McIntosh
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT (Drs McIntosh, Némethy, and McDevitt)
| | - Mária Némethy
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT (Drs McIntosh, Némethy, and McDevitt)
| | - Marion McDevitt
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT (Drs McIntosh, Némethy, and McDevitt)
| | - Jennifer Dow
- Alaska Regional Hospital, Anchorage, AK; Denali National Park and Preserve, AK (Dr Dow)
| | | | - George W Rodway
- Division of Health Sciences, University of Nevada, Reno, NV (Dr Rodway)
| | - Peter H Hackett
- Division of Emergency Medicine, Altitude Research Center, University of Colorado School of Medicine, Denver, CO; Institute for Altitude Medicine, Telluride, CO (Dr Hackett)
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD (Dr Bennett)
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, UT (Dr Grissom)
| | | |
Collapse
|
38
|
Kosiński S, Darocha T, Gałązkowski R, Drwiła R. Accidental hypothermia in Poland – estimation of prevalence, diagnostic methods and treatment. Scand J Trauma Resusc Emerg Med 2015; 23:13. [PMID: 25655922 PMCID: PMC4328070 DOI: 10.1186/s13049-014-0086-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/30/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of hypothermia is difficult to evaluate, and the data concerning the morbidity and mortality rates do not seem to fully represent the problem. The aim of the study was to estimate the actual prevalence of accidental hypothermia in Poland, as well as the methods of diagnosis and management procedures used in emergency rooms (ERs). METHODS A specially designed questionnaire, consisting of 14 questions, was mailed to all the 223 emergency rooms (ER) in Poland. The questions concerned the incidence, methods of diagnosis and risk factors, as well as the rewarming methods used and available measurement instruments. RESULTS The analysis involved data from 42 ERs providing emergency healthcare for the population of 5,305,000. The prevalence of accidental hypothermia may have been 5.05 cases per 100.000 residents per year. Among the 268 cases listed 25% were diagnosed with codes T68, T69 or X31, and in 75% hypothermia was neither included nor assigned a code in the final diagnosis. The most frequent cause of hypothermia was exposure to cold air alongside ethanol abuse (68%). Peripheral temperature was measured in 57%, core temperature measurement was taken in 29% of the patients. Peripheral temperature was measured most often at the axilla, while core temperature measurement was predominantly taken rectally. Mild hypothermia was diagnosed in 75.5% of the patients, moderate (32-28°C) in 16.5%, while severe hypothermia (less than 28°C) in 8% of the cases. Cardiopulmonary resuscitation was carried out in 7.5% of the patients. The treatment involved mainly warmed intravenous fluids (83.5%) and active external rewarming measures (70%). In no case was extracorporeal rewarming put to use. CONCLUSIONS The actual incidence of accidental hypothermia in Polish emergency departments may exceed up to four times the official data. Core temperature is taken only in one third of the patients, the treatment of hypothermic patients is rarely conducted in intensive care wards and extracorporeal rewarming techniques are not used. It may be expected that personnel education and the development of management procedures will brighten the prognosis and increase the survival rate in accidental hypothermia.
Collapse
|
39
|
Hypothermia and low body temperature are common and associated with high mortality in hip fracture patients. Hip Int 2015; 24:237-42. [PMID: 24619871 DOI: 10.5301/hipint.5000124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2013] [Indexed: 02/04/2023]
Abstract
Hip fractures remain one of the commonest injuries treated by orthopaedic surgeons. Despite recent initiatives, the fracture engenders a very high mortality. The UK National Hip Fracture Database reports a 30-day mortality of 8%. The pathophysiology that results in such high mortality remains imperfectly understood. The significance of thermal dysregulation in polytrauma is becoming increasingly recognised. Hypothermia is a common feature of polytrauma and is associated with adverse outcomes. No previous studies have explored the prevalence and outcomes of hip fracture patients with hypothermia and/or low body temperature. We sought to evaluate this. We prospectively collected the demographic details and admission tympanic temperature of all patients presenting to our institution with hip fracture. Patient mortality was also recorded. Seven hundred and eighty-one patients were included. The mean age was 80 years. 38% (300) had a temperature below 36.5°C. 4% (30) presented with a tympanic temperature greater than 37.5°C. The 30-day mortality for patients with a normal admission temperature (between 36.5° and 37.5°C) was 5.1%. This value was 15.3% for those whose admission temperature was less than 36.5°C (p<0.0001). Correcting for potential confounders of age and gender, those with an admission temperature of less than 36.5°C had a 2.8 fold increase in the odds of mortality at 30-days compared with those with an admission temperature of between 36.5° and 37.5°C (p<0.0005). Low body temperature is strongly linked to 30-day mortality in hip fracture patients.
Collapse
|
40
|
Zafren K, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Weiss EA, Auerbach PS, McIntosh SE, Némethy M, McDevitt M, Dow J, Schoene RB, Rodway GW, Hackett PH, Bennett BL, Grissom CK. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia. Wilderness Environ Med 2014; 25:425-45. [PMID: 25443771 DOI: 10.1016/j.wem.2014.09.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 09/05/2014] [Accepted: 09/08/2014] [Indexed: 01/04/2023]
Abstract
To provide guidance to clinicians, the Wilderness Medical Society (WMS) 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 the balance between benefits and risks/burdens according 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.
Collapse
Affiliation(s)
- Ken Zafren
- Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA (Drs Zafren, Weiss, and Auerbach); International Commission for Mountain Emergency Medicine (ICAR MEDCOM) (Drs Zafren and Brugger).
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, Canada (Dr Giesbrecht)
| | - Daniel F Danzl
- Department of Emergency Medicine, University of Louisville, School of Medicine, Louisville, KY (Dr Danzl)
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM) (Drs Zafren and Brugger); European Academy Institute of Mountain Emergency Medicine, Bolzano, Italy (Dr Brugger)
| | - Emily B Sagalyn
- University of Nevada School of Medicine, Reno, NV (Dr Sagalyn)
| | - Beat Walpoth
- Service of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland (Dr Walpoth)
| | - Eric A Weiss
- Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA (Drs Zafren, Weiss, and Auerbach)
| | - Paul S Auerbach
- Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA (Drs Zafren, Weiss, and Auerbach)
| | - Scott E McIntosh
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT (Drs McIntosh, Némethy, and McDevitt)
| | - Mária Némethy
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT (Drs McIntosh, Némethy, and McDevitt)
| | - Marion McDevitt
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT (Drs McIntosh, Némethy, and McDevitt)
| | - Jennifer Dow
- Alaska Regional Hospital, Anchorage, AK (Dr Dow); Denali National Park and Preserve, AK (Dr Dow)
| | | | - George W Rodway
- Division of Health Sciences, University of Nevada, Reno, NV (Dr Rodway)
| | - Peter H Hackett
- Division of Emergency Medicine, Altitude Research Center, University of Colorado School of Medicine, Denver, CO (Dr Hackett); Institute for Altitude Medicine, Telluride, CO (Dr Hackett)
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences Bethesda, MD (Dr Bennett)
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, UT (Dr Grissom)
| |
Collapse
|
41
|
Petrone P, Asensio JA, Marini CP. Management of accidental hypothermia and cold injury. Curr Probl Surg 2014; 51:417-31. [DOI: 10.1067/j.cpsurg.2014.07.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 07/23/2014] [Indexed: 11/22/2022]
|
42
|
Hypothermia in victims of the great East Japan earthquake: a survey in Miyagi prefecture. Disaster Med Public Health Prep 2014; 8:379-89. [PMID: 25215601 DOI: 10.1017/dmp.2014.70] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE A survey was conducted to describe the characteristics of patients treated for hypothermia after the Great East Japan Earthquake. METHODS Written questionnaires were distributed to 72 emergency medical hospitals in Miyagi Prefecture. Data were requested regarding inpatients with a temperature less than 36ºC admitted within 72 hours after the earthquake. The availability of functional heating systems and the time required to restore heating after the earthquake were also documented. RESULTS A total of 91 inpatients from 13 hospitals were identified. Tsunami victims comprised 73% of the patients with hypothermia. Within 24 hours of the earthquake, 66 patients were admitted. Most patients with a temperature of 32ºC or higher were treated with passive external rewarming with blankets. Discharge without sequelae was reported for 83.3% of patients admitted within 24 hours of the earthquake and 44.0% of those admitted from 24 to 72 hours after the earthquake. Heating systems were restored within 3 days of the earthquake at 43% of the hospitals. CONCLUSIONS Hypothermia in patients hospitalized within 72 hours of the earthquake was primarily due to cold-water exposure during the tsunami. Many patients were successfully treated in spite of the post-earthquake disruption of regional social infrastructure.
Collapse
|
43
|
Turtiainen J, Halonen J, Syväoja S, Hakala T. Rewarming a patient with accidental hypothermia and cardiac arrest using thoracic lavage. Ann Thorac Surg 2014; 97:2165-6. [PMID: 24882294 DOI: 10.1016/j.athoracsur.2013.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 07/25/2013] [Accepted: 08/08/2013] [Indexed: 11/15/2022]
Abstract
The optimal treatment for severe accidental hypothermia is cardiopulmonary bypass because this offers the most rapid rate of rewarming. However, cardiopulmonary bypass therapy is not available in every hospital. In these circumstances, rewarming has to be achieved with other methods. We present a patient who was successfully rewarmed with thoracic lavage after he had been found with a core temperature of 21°C and asystole.
Collapse
Affiliation(s)
| | - Jari Halonen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.
| | - Sakari Syväoja
- Department of Anesthesiology, North Karelia Central Hospital, Joensuu, Finland
| | - Tapio Hakala
- Department of Surgery, North Karelia Central Hospital, Joensuu, Finland
| |
Collapse
|
44
|
Boué Y, Payen JF, Brun J, Thomas S, Levrat A, Blancher M, Debaty G, Bouzat P. Survival after avalanche-induced cardiac arrest. Resuscitation 2014; 85:1192-6. [PMID: 24971508 DOI: 10.1016/j.resuscitation.2014.06.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/04/2014] [Accepted: 06/06/2014] [Indexed: 10/25/2022]
Abstract
AIM Criteria to prolong resuscitation after cardiac arrest (CA) induced by complete avalanche burial are critical since profound hypothermia could be involved. We sought parameters associated with survival in a cohort of victims of complete avalanche burial. METHODS Retrospective observational study of patients suffering CA on-scene after avalanche burial in the Northern French Alps between 1994 and 2013. Criteria associated with survival at discharge from the intensive care unit (ICU) were collected on scene and upon admission to Level-1 trauma center. Neurological outcome was assessed at 3 months using cerebral performance category score. RESULTS Forty-eight patients were studied. They were buried for a median time of 43 min (25-76 min; 25-75th percentiles) and had a pre-hospital body core temperature of 28.0°C (26.0-30.7). Eighteen patients (37.5%) had pre-hospital return of spontaneous circulation and 30 had refractory CA. Rewarming of 21 patients (43.7%) was performed using extracorporeal life support. Eight patients (16.7%) survived and were discharged from the ICU, three (6.3%) had favorable neurological outcome at 3 months. Pre-hospital parameters associated with survival were the presence of an air pocket and rescue collapse. On admission, survivors had lower serum potassium concentrations than non-survivors: 3.2 mmol/L (2.7-4.0) versus 5.6 mmol/L (4.2-8.0), respectively (P<0.01). They also had normal values for prothrombin and activated partial thromboplastin compared to non-survivors. CONCLUSIONS Our findings indicate that survival after avalanche burial and on-scene CA is rarely associated with favorable neurological outcome. Among criteria associated with survival, normal blood coagulation on admission warrants further investigation.
Collapse
Affiliation(s)
- Yvonnick Boué
- Pole Anesthésie-Réanimation, Hôpital Michallon, Grenoble F-38043, France; Université Joseph Fourier, Grenoble Institut des Neurosciences, Grenoble F-38043, France; INSERM, U836, Grenoble F-38042, France
| | - Jean-François Payen
- Pole Anesthésie-Réanimation, Hôpital Michallon, Grenoble F-38043, France; Université Joseph Fourier, Grenoble Institut des Neurosciences, Grenoble F-38043, France; INSERM, U836, Grenoble F-38042, France
| | - Julien Brun
- Pole Anesthésie-Réanimation, Hôpital Michallon, Grenoble F-38043, France
| | - Sébastien Thomas
- Pole Anesthésie-Réanimation, Hôpital Michallon, Grenoble F-38043, France
| | - Albrice Levrat
- Service réanimation, Centre Hospitalier Région d'Annecy, Metz-Tessy, F-74370, France
| | - Marc Blancher
- Service Urgences-SAMU-SMUR, Hopital Michallon, Grenoble F-38043, France
| | - Guillaume Debaty
- Service Urgences-SAMU-SMUR, Hopital Michallon, Grenoble F-38043, France
| | - Pierre Bouzat
- Pole Anesthésie-Réanimation, Hôpital Michallon, Grenoble F-38043, France; Université Joseph Fourier, Grenoble Institut des Neurosciences, Grenoble F-38043, France; INSERM, U836, Grenoble F-38042, France.
| |
Collapse
|
45
|
Brändström H, Johansson G, Giesbrecht GG, Ängquist KA, Haney MF. Accidental cold-related injury leading to hospitalization in northern Sweden: an eight-year retrospective analysis. Scand J Trauma Resusc Emerg Med 2014; 22:6. [PMID: 24460844 PMCID: PMC4016575 DOI: 10.1186/1757-7241-22-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 01/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cold injuries are rare but important causes of hospitalization. We aimed to identify the magnitude of cold injury hospitalization, and assess causes, associated factors and treatment routines in a subarctic region. METHODS In this retrospective analysis of hospital records from the 4 northernmost counties in Sweden, cases from 2000-2007 were identified from the hospital registry by diagnosis codes for accidental hypothermia, frostbite, and cold-water drowning. Results were analyzed for pre-hospital site events, clinical events in-hospital, and complications observed with mild (temperature 34.9 - 32°C), moderate (31.9 - 28°C) and severe (<28°C), hypothermia as well as for frostbite and cold-water drowning. RESULTS From the 362 cases, average annual incidences for hypothermia, frostbite, and cold-water drowning were estimated to be 3.4/100,000, 1.5/100,000, and 0.8/100,000 inhabitants, respectively. Annual frequencies for hypothermia hospitalizations increased by approximately 3 cases/year during the study period. Twenty percent of the hypothermia cases were mild, 40% moderate, and 24% severe. For 12%, the lowest documented core temperature was 35°C or higher, for 4% there was no temperature documented. Body core temperature was seldom measured in pre-hospital locations. Of 362 cold injury admissions, 17 (5%) died in hospital related to their injuries. Associated co-factors and co-morbidities included ethanol consumption, dementia, and psychiatric diagnosis. CONCLUSIONS The incidence of accidental hypothermia seems to be increasing in this studied sub-arctic region. Likely associated factors are recognized (ethanol intake, dementia, and psychiatric diagnosis).
Collapse
Affiliation(s)
- Helge Brändström
- Department of Surgical and Perioperative Sciences, Anesthesia and Intensive Care Medicine, Faculty of Medicine, Umeå University, S-901 85 Umeå, Sweden.
| | | | | | | | | |
Collapse
|
46
|
Whelihan MF, Kiankhooy A, Brummel-Ziedins KE. Thrombin generation and fibrin clot formation under hypothermic conditions: an in vitro evaluation of tissue factor initiated whole blood coagulation. J Crit Care 2013; 29:24-30. [PMID: 24331944 DOI: 10.1016/j.jcrc.2013.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 09/06/2013] [Accepted: 10/20/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite trauma-induced hypothermic coagulopathy being familiar in the clinical setting, empirical experimentation concerning this phenomenon is lacking. In this study, we investigated the effects of hypothermia on thrombin generation, clot formation, and global hemostatic functions in an in vitro environment using a whole blood model and thromboelastography, which can recapitulate hypothermia. METHODS Blood was collected from healthy individuals through venipuncture and treated with corn trypsin inhibitor, to block the contact pathway. Coagulation was initiated with 5pM tissue factor at temperatures 37°C, 32°C, and 27°C. Reactions were quenched over time, with soluble and insoluble components analyzed for thrombin generation, fibrinogen consumption, factor (f)XIII activation, and fibrin deposition. Global coagulation potential was evaluated through thromboelastography. RESULTS Data showed that thrombin generation in samples at 37°C and 32°C had comparable rates, whereas 27°C had a much lower rate (39.2 ± 1.1 and 43 ± 2.4 nM/min vs 28.6 ± 4.4 nM/min, respectively). Fibrinogen consumption and fXIII activation were highest at 37°C, followed by 32°C and 27°C. Fibrin formation as seen through clot weights also followed this trend. Thromboelastography data showed that clot formation was fastest in samples at 37°C and lowest at 27°C. Maximum clot strength was similar for each temperature. Also, percent lysis of clots was highest at 37°C followed by 32°C and then 27°C. CONCLUSIONS Induced hypothermic conditions directly affect the rate of thrombin generation and clot formation, whereas global clot stability remains intact.
Collapse
Affiliation(s)
- Matthew F Whelihan
- Departments of Biochemistry and Surgery, College of Medicine, University of Vermont, Burlington, VT.
| | - Armin Kiankhooy
- Departments of Biochemistry and Surgery, College of Medicine, University of Vermont, Burlington, VT.
| | | |
Collapse
|
47
|
Singh T, Hallows KR. Hemodialysis for the Treatment of Severe Accidental Hypothermia. Semin Dial 2013; 27:295-7. [DOI: 10.1111/sdi.12156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tripti Singh
- Renal-Electrolyte Division; Department of Medicine; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Kenneth R. Hallows
- Renal-Electrolyte Division; Department of Medicine; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| |
Collapse
|
48
|
Abstract
Homeostasis refers to the capacity of the human body to maintain a stable constant state by means of continuous dynamic equilibrium adjustments controlled by a medley of interconnected regulatory mechanisms. Patients who sustain tissue injury, such as trauma or surgery, undergo a well-understood reproducible metabolic and neuroendocrine stress response. This review discusses 3 issues that concern homeostasis in the acute care of trauma patients directly related to the stress response: hyperglycemia, lactic acidosis, and hypothermia. There is significant reason to question the "conventional wisdom" relating to current approaches to restoring homeostasis in critically ill and trauma patients.
Collapse
Affiliation(s)
- Patrick J Neligan
- Department of Anaesthesia and Intensive Care, Galway University Hospitals, Galway, Ireland.
| | | |
Collapse
|
49
|
Rahmany MB, Hantgan RR, Van Dyke M. A mechanistic investigation of the effect of keratin-based hemostatic agents on coagulation. Biomaterials 2013; 34:2492-500. [DOI: 10.1016/j.biomaterials.2012.12.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/13/2012] [Indexed: 10/27/2022]
|
50
|
Akzidentelle, tiefe Hypothermie in der Bergrettung. Notf Rett Med 2013. [DOI: 10.1007/s10049-012-1659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|