CASE PRESENTATION

M Chadi Alraies, MD
Chief Medical Resident
CWRU/SVCH
The case
46 year old Caucasian
gentleman
Found unresponsive by
bystander for unknown
period of time
 HPI
 Found by bystander
 Unresponsive and very cold
 911 called
 EMS report:
 The patient is unresponsive, in mild respiratory
distress.
 V/S 28 rectal, 66, 22, Initial blood pressure could
not be obtained. 92% saturation.
 No history can be obtained.
 Regular rate and rhythm
 Placed on face mask O2 and transferred to SVCH
5
 PMH, PSH, Meds, SH &
FH
 Unknown

6
 What do you think?

What other information

you’d like to know?
Differential diagnosis
 Toxins
 Alcohol
 Trauma / head injury
 Metabolic causes (i.e. Hypoglycemia)
 Neurological

9
 ER course
 V/S:
 Temp: 28.1 C
 BP: 66/56

 HR: 50

 RR: 28

 SpO2: 86%.

10
 ER course
 On exam: (pertinent positives)
 Unresponsive
 GCS (E1, V1, M4) 6/15

 Skin: cold to touch

 Chest: bilateral fine crackles.

 CVS: Sinus bradycardia (matching the

cardiac monitor), RRR, no murmurs or
gallops
 CNS: absent Gag reflex, fixed dilated
pupils.
11
What is your
next step?
 ER course
 ABC
 Patient intubated electively to secure
the airway.
 Basic labs and imaging done.
 Transferred to ICU

13
Which test do
you want and
why?
 CMP  EKG
 CBC  TSH
 ABG  UA
 Coagulation profile  Urine toxicology
 CXR  Lactic acid
 CPP  CT brain
 Accu check

NEXT
15
 CMP
 Na 124  TP 6.0
 K 7.9  ALB 2.8
 CL 93  Ca 8.3
 HCO3 0 !!!  Bili 0.4
 Glucose HIGH  AST 44
 BUN 56  ALT 43
 Cr 3.7  ALKP 125

Glucose 1560
Anion GAP = 31 16
 Corrected Na in
hyperglycemia
 Corrected Na in hyperglycemia=

measured
measured Na + [2.4 x glucose – 100
____________________ ] 100

Na= 159
American Journal of Medicine 1999; 106:399

BACK
17
 Accu check

High
BACK
18
 Coagulation profile
 INR 1.25
 PTT 66.9

BACK
19
 ABG
 PH <5  SAT 93.3%
 PCO2 21.3  A-a 623.4
 PO2 68.3  Hg 11.5
 HCO3 0

BACK
20
 CBC
 WBC 32,000  MCH 31.7
 RBC 4.64  MCHC 30.6
 HGB 14.7  RDW 12.6
 HCT 48.1  PLT 293
 MCV 103.7

BACK
21
 CPP
 CPK 495
 CKmb 18.9
 Troponin I <0.04

BACK
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 LDH
 264

BACK
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 TSH
 0.971

BACK
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 Mild congestive heart failure.
 Bilateral pleural effusion
 Basal infiltrate
 Recommend PA and lateral views.

BACK
26
EKG
28
 EKG changes in
Hypothermia
 Sinus bradycardia.
 J wave “Osborne wave”.
 Atrial and ventricular arrhythmias.
 prolonged PR, QRS, and QT intervals.
 Asystole and ventricular fibrillation.

BACK
29
 Urinalysis
 Pail yellow  Glucose 1000
 Cloudy  Ketones 150
 Specific gravity  Blood 250
1.021  Bacteria moderate
 PH 5.0
 Myoglobinuria -ve

BACK
30
 Urine toxicology
screening

Cocaine
BACK
31
 Lactic acid
 5.5

BACK
32
 CT brain
 Moderate degree of Cerebellar and
cerebral cortical volume loss.
 No acute ischemia.

BACK

33
 ER course
 Patient received 2 liters of warm
normal saline
 Warming blanket placed.
 ICU resident informed and patient
transferred to ICU.

34
ICU team received call at
1:00 EST

35
 ICU course
 Patient intubated
 Transferred gently from stroller to
the ICU bed
 Patient fully assessed again

36
 Vitals
 T 28.1, rectally
emp: 98/50 dinamap
 BP: 50 bpm
 HR: 28/min
 RR: 100% on vent
 S A/C, 100%, 500cc, 0
pO2: PEEP, 20/min
 Vent
:

37
 On examination
 Unresponsive, intubated
 GCS 6/15
 Pupils dilated, fixed and non-
reactive.
 ETT 7.5 cm, secured.
 Cold skin, dry mucus membranes,
poor capillary refill (>4seconds)
 Bilateral chest crackles with
decreased A/E. 38
 On examination
 Distant heart sounds, regular
bradycardia, no JVD no murmurs,
rubs or gallops.
 Abdomen soft, with epigastric
tenderness and rebound without
guarding and absent bowel sounds.
 Cold lower limbs without signs of
trauma and no edema
 Weak (+1) DP and PT pulses.
 Diffuse areflexia, and rigidity.
39
 Temperature monitor
 Electronic thermometer with flexible
probes
 Rectum
 Bladder

 Esophageal

 NGT and Foley catheter inserted.

40
Triple lumen inserted

41
 CVP

3 cm H2O

42
SvO2

68%

43
 Monitors
 Temperature
 A-line
 CVP
 Urine output.
 Core temperature.
 Cardiac monitor (arrhythmias).

44
 Definition of
hypothermia

An unintentional decline in
the core temperature
below 35 °C.

45
 Physiologic Changes Associated with
Hypothermia

Danzl D and Pozos R. N Engl J Med 1994;331:1756-

46
1760
 Risk Factors for Decreased
Thermostability

Danzl D and Pozos R. N Engl J Med 1994;331:1756-1760 47

 Algorithm for Rewarming

Danzl D and Pozos R. N Engl J Med 1994;331:1756-1760

48
 Active external
rewarming
 Immersion,
 Radiant heat,
 Forced air,
 Electric or plumbed heating blankets.

49
 Core-temperature
afterdrop !!!
 Heating the extremities and rapidly
alleviating peripheral
vasoconstriction.
 Continuing decrease in the core
temperature after the initiation of
rewarming.
 Decline in mean arterial pressure and
peripheral vascular resistance.
 Active core rewarming
 Administration of heated humidified
oxygen by ET. (1 to 2 °C per
hour.)
 Peritoneal lavage with heated
dialysate (40 to 45 °C). 2 to 4 °C
per hour.
 Closed pleural irrigation through
large-bore thoracostomy tubes.

51
 Active core rewarming
 Administration of warm NS or any IV
fluids (fluid temperature should be 37
degrees)
 Gastric, colonic, or bladder irrigation is
very restricted
 Extracorporeal rewarming remains the
most efficient means of rewarming. 1 to
2 °C every 3-5 minutes.
 Arterio-venous
 Veno-venous
 Hemodialysis 52
 Hypothermia
consequences
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

54
 Impaired tissue
oxygenation
1. Hypothermia shifts the
LEFT curve
oxyhemoglobin-dissociation
to the…
2. Vasoconstriction, a ventilation-
perfusion mismatch.
3. Increased blood viscosity.
4. Depressed myocardial contractility
decreased tissues
oxygenation
55
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

56
 Metabolic acidosis
1. Lactate generation from
 Shivering
 Decreased tissue perfusion
2. Impaired hepatic metabolism
3. Impaired acid excretion.
4. Dehydration
5. Fluid sequestration
1. Hamlet MP. An overview of medically related problems in the cold environment. Mil Med 1987;152:393-396.
2. Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and hypothermia deaths among Native Americans in New
Mexico: between bar and home. JAMA 1992;267:1345-1348. 57
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

58
 Hypothermia and
hematocrit
 The hematocrit increases 2 percent
per 1 degree C decline in
temperature.
 However, there are no safe clinical
predictors of the changes in
hematologic and electrolyte values
with rewarming.

59
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

60
 Potassium metabolism
 Hypothermia masks potassium-
induced changes in the
electrocardiogram.
 Hyperkalemia can be particularly
dangerous in a patient with…
 Metabolic acidosis,
 Rhabdomyolysis,

 Renal failure.

 Potassium level should be checked

frequently. 61
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

62
 Glycosuria
 Cold-induced renal glycosuria.
 Persistent hyperglycemia suggests
pancreatitis or diabetic ketoacidosis.

63
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

64
 Coagulopathy
 Normal levels of clotting factor.
 Cold directly inhibits the enzymatic
reactions of the coagulation cascade.
 Hypercoagulability also occurs and
may result in thromboembolism.

•Patt A, McCroskey BL, Moore EE. Hypothermia-induced coagulopathies in trauma. Surg Clin North Am
1988;68:775-785.
•Rohrer MJ, Natale AaM. Effect of hypothermia on the coagulation cascade. Crit Care Med 1992;20:1402- 65
1405.
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

66
 Platelets dysfunction
 Platelet activity also declines, since
the production of thromboxane B2 by
platelets is temperature-dependent.
 Cold-induced thrombocytopenia that
results from
 Direct suppression of bone marrow and
 Hepatosplenic sequestration.

•Valeri CR, Feingold H, Cassidy G, Ragno G, Khuri S, Altschule MD. Hypothermia-induced reversible platelet
dysfunction. Ann Surg 1987;205:175-181.
•Rosenkranz L. Bone marrow failure and pancytopenia in two patients with hypothermia. South Med J 1985;78:358-
359. 67
 Hypothermia
consequences
1. Tissue oxygenation
2. Metabolic acidosis
3. Hematocrit changes
4. Potassium metabolism
5. Coagulopathy
6. Platelets dysfunction
7. Glycosuria
8. Dehydration.

68
 Dehydration
1. Decreased oral intake.
2. Fluid sequestration.
3. Increased vascular permeability.
4. Cold-induced diuresis.

69
 ICU team check list
1. Metabolic acidosis, lactic and
ketoacidosis.
2. Respiratory failure.
3. CNS impairment.
4. Hyperglycemia and DKA
5. Hypothermia.
6. Hypovolemia.
7. Hyponatremia/hypernatremia
8. Leukocytosis (underlying infection)
9. Abdominal tenderness!
70
 Rewarming
 Warming blankets.
 Room temperature raised up.
 Warm and humidified oxygen
through vent.
 Warm normal saline.

71
 Rehydration/rewarming
 Warm NS…
 1 L bag microwaved for 3 min.
 37-40 degrees Celsius.

 Patients received 9 liters of warm NS

in 12 hrs.
 Continued @ NS 250 cc/hr.

72
 Metabolic acidosis
management
 Rehydration with normal saline.
Rehydration with normal saline.
 Insulin IV drip started…
 @ 0.1 units/Kg/hour
 We reach as high as 37 units/hour.
 Response to insulin IV improved with
higher core temperature.
 Bicarbonate drip used for 3 hours
only.
 RR increased to 25/min
 Antibiotics: Imipenem 500 mg IV BID
73
 Labs
 BMP q 3 hours x 5 with magnesium.
 ABG q 2 x 3
 CBC q 12 hours
 Amylase / Lipase
 CPP q 6 hours x 3 (including CPK)
 Accu check q 1 hour.
 INR in am
 EKG q 12 hours.

74
 Amylase 430
 Lipase 360
Na 124 130 136 140 149 159 147 139

K 7.9 8 6 4.4 3.9 2.8 3.9 4

CO
0 5 7 15 22 23 22 24
3
BUN 56 50 42 39 34 28 15 8

Cr 3.7 2.7 2.3 1.8 1.3 0.9 0.5 0.6

76
WB 7
C
32k 30k 28k 18k 15k 11k 9k
.5k
HG 1 1 1 1 1 1 1 1
B 4.7 1.4 1.3 1.1 0.9 0.5 0.5 0.6
HCT 48 33 30 34 32 32 31 31

PLT 294 234 269 145 86 99 166 256

1
2 2 5 7 3 1
CK 495 000
060 700 670 0 000 400 800
1 1
Glu 870 677 411 238 176 149
560 000

77
 After 24 hours
 Patient was awake and alert
 Rectal temp 37.8 C
 Pupils were reactive to light and
accommodation
 Extubated
 Off insulin IV
 Started on Insulin Sliding scale and
Lantus
 Start taking PO
 Transferred to floor. 78
 References
1. Mills WJ Jr. Accidental hypothermia: management approach. Alaska Med 1980;22:9-
11. 
2. Paton BC. Accidental hypothermia. Pharmacol Ther 1983;22:331-377. 
3. Hamlet MP. An overview of medically related problems in the cold environment. Mil
Med 1987;152:393-396.
4. Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and hypothermia deaths
among Native Americans in New Mexico: between bar and home. JAMA
1992;267:1345-1348. 
5. Danzl DF, Pozos RS, Auerbach PS, et al. Multicenter hypothermia survey. AnnEmerg
Med 1987;16:1042-1055. 
6. Fischbeck KH, Simon RP. Neurological manifestations of accidental hypothermia. Ann
Neurol 1981;10:384-387. 
7. Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992;10:311-
327. 
8. Patt A, McCroskey BL, Moore EE. Hypothermia-induced coagulopathies in trauma.
Surg Clin North Am 1988;68:775-785. 
9. Reed RL II, Bracey AW Jr, Hudson JD, Miller TA, Fischer RP. Hypothermia and blood
coagulation: dissociation between enzyme activity and clotting factor levels. Circ
Shock 1990;32:141-152. 
10. Rohrer MJ, Natale AM. Effect of hypothermia on the coagulation cascade. Crit Care
Med 1992;20:1402-1405.
11. Valeri CR, Feingold H, Cassidy G, Ragno G, Khuri S, Altschule MD. Hypothermia-
induced reversible platelet dysfunction. Ann Surg 1987;205:175-181. 
12. Rosenkranz L. Bone marrow failure and pancytopenia in two patients with
hypothermia. South Med 1985;78:358-359.
13. Rahn H. Body temperature and acid-base regulation. Pneumonologie 1974;151:87-94. 79
 References
1. Kroncke GM, Nichols RD, Mendenhall JT, Myerowitz PD, Starling JR. Ectothermic
philosophy of acid-base balance to prevent fibrillation during hypothermia. Arch Surg
1986;121:303-304.
2. Delaney KA, Howland MA, Vassallo S, Goldfrank LR. Assessment of acid-base
disturbances in hypothermia and their physiologic consequences. Ann Emerg Med
1989;18:72-82.
3. Swain JA. Hypothermia and blood pH: a review. Arch Intern Med 1988;148:1643-
1646. 
4. Baraka A. Hydrogen ion regulation during hypothermia -- hibernators versus
ectotherms. Middle East J Anesthesiol 1984;7:235-238.
5. White FN. A comparative physiological approach to hypothermia. J Thorac Cardiovasc
Surg 1981;82:821-831.
6. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three
methods of resuscitaton from mild hypothermia. Resuscitation 1984;11:21-33.
7. Webb P. Afterdrop of body temperature during rewarming: an alternative
explanation. J Appl Physiol 1986;60:385-390.
8. Lloyd EL. Equipment for airway warming in the treatment of accidental hypothermia.
J Wilderness Med 1991;2:330-50.
9. Iserson KV, Huestis DW. Blood warming: current applications and techniques.
Transfusion 1991;31:558-571.
10. Moss JF, Haklin M, Southwick HW, Roseman DL. A model for the treatment of
accidental severehypothermia. J Trauma 1986;26:68-74.
11. Otto RJ, Metzler MH. Rewarming from experimental hypothermia: comparison of
heated aerosol inhalation, peritoneal lavage, and pleural lavage. Crit Care Med
1988;16:869-875. 
12. Brunette DD, Biros M, Mlinek EJ, Erlandson C, Ruiz E. Internal cardiac massage and
mediastinal irrigation in hypothermic cardiac arrest. Am J Emerg Med 1992;10:32-34.80
 It's not what I am
inside... What I do
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DKA BUSTERS

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