Cardiorespiratory arrest in special circumstances: Hypothermia

The RCEM expect candidates to be aware of special situations causing

cardiac arrest including

 Hypothermia
 Trauma,
 Drug overdose

Hypothermic Cardiac Arrest

Hypothermic cardiac arrest is a rare situation that requires a tailored
approach. Resuscitation is typically prolonged but prognosis in young
previously healthy individuals can be good. Hypothermic cardiac arrest may
be associated with drowning.

Hypothermia Definitions
Hypothermia = core temperature below 35ºC. Hypothermia may be graded
using a number of systems. The below is commonly applied to adults:

Grade Parameter
Mild hypothermia core temperature of 32-35ºC
Moderate hypothermia core temperature of 28-32ºC
Severe hypothermia core temperature below 28ºC
Profound hypothermia core temperature below 20ºC

Pathophysiology of hypothermia
When the core temperature drops basal metabolic rate also falls and cell
signalling between neurones decreases. This results in a number of
physiological features that reduce tissue perfusion. These are shown in box
1 below:

BOX 1: Physiological features of hypothermia leading to reduced

tissue oxygenation:
Depressed myocardial contractility
Left shift of the oxygen dissociation curve
Vasoconstriction
Ventilation-perfusion mismatch
Increased blood viscosity

Signs & symptoms

Initially there is compensatory increase in heart rate and shivering that may
be observed in the patient as tachycardia, tachypnoea and increased SVR.
As core temperature drops into moderate hypothermia territory these
processes cease and the progression of symptoms is as shown in the
infographic below:

Illustration of how symptoms typically progress as core temperature drops in

hypothermia

ECG changes associated with hypothermia

  Bradyarrhythmias
 Osborn waves (= J waves)
 Prolonged PR, QRS and QT intervals
 Shivering artefact
 Ventricular ectopics
 Cardiac arrest (VT, VF or asystole)

Assessment & Management

If hypothermic cardiac arrest occurs ALS should be initiated as per the
standard ALS algorithm but with the following modifications:

 1. Check for signs of life i.e. pulse check for up to 1 minute

 2. Re-warm patient (consider need for cardio-pulmonary bypass)
 3. Consider use of mechanical ventilation due to stiffness of chest wall
 4. Adjust dosing or withhold drugs due to slowed drug metabolism
(see below)
 5. After 3 shocks if defibrillation is not effective not re-attempted until
body temperature above 30ºC
 6. Care correcting electrolyte disturbances

Remember that the resuscitation of hypothermic patients is often

prolonged and may continue for a number of hours!

Pulse check
The patient may have low blood pressure and the pulse can be difficult to
obtain. The pulse check during CPR is prolonged to 1 minute for this
reason.

If there is any doubt about finding the pulse CPR is started as for a
normothermic patient

Drugs in hypothermic cardiac arrest

Drug metabolism is slowed in the hypothermic patient leading to a build up
of potentially toxic plasma concentrations of administered drugs.

There is evidence that the efficacy of several drugs in severe hypothermia is

limited and based mainly on animal studies. Current guidance advises the
following:

 Withhold drugs if core temperature <30ºC

 Double drug interval at core temperatures between 30 and 35ºC e.g.
adrenalineevery 6-10 minutes.

The ED doctor treating the hypothermic patient should be aware that

electrolyte disturbances are common and results need to be interpreted
keeping the setting in mind. Some key points to consider are:

 Hypoglycemia is common and should be treated

 Hypokalaemia will often correct as the patient re-warms so only treat
if hypokalaemia is severe.
 ABG analyzers warm blood samples to 37ºC and give results
'corrected' for normal core temperature. This may not reflect the
reality of the hypothermic patient so use the uncorrected values.
 Hyperkalaemia is seen if there is significant cell death. Severe
hyperkalaemia is a poor prognostic indicator.

Type of
warming Warming measure
External passive Removal of wet clothes
Insulation with blankets
Warm drinks
External active Forced heated air e.g. bear
hugger
External active Hot-water immersion
Internal active Inhalation of warm air
Internal active Warmed intravenous fluids
Internal active Peritoneal lavage
Internal active Haemdiafiltration
Internal active Cardiopulmonary bypass
Effect on core body temperature
Minimal-moderate (0.5-4ºC increase per
hour)
Minimal-moderate (1-2ºC increase per hour)
Moderate (2-4ºC increase per hour)
Minimal (0.7-1.2ºC increase per hour)
Variable
Minimal-moderate(1-3ºC increase per hour)
Moderate(2-3ºC increase per hour)
Maximal (7-10ºC increase per hour)

Outcome
Survival in the UK is around 50% if cardio-pulmonary bypass is used.
Death certification requires:

 The patient has been adequately re-warmed or re-warming has failed

despite instituting optimal warming measures OR
 The patient has another lethal condition or injury identified that
renders resuscitation futile