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 CBC ABG Coagulation profile CXR CPP Accu check

     

EKG TSH UA Urine toxicology Lactic acid CT brain

NEXT
15

CMP
      

Na 124 K 7.9 CL 93 HCO3 0 !!! Glucose HIGH BUN 56 Cr 3.7

      

TP 6.0 ALB 2.8 Ca 8.3 Bili 0.4 AST 44 ALT 43 ALKP 125

Glucose 1560
Anion GAP = 31
16

Corrected Na in hyperglycemia

Corrected Na in hyperglycemia=

measured glucose – 100 measured Na + [2.4 x ____________________ ] 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 PCO2 21.3 PO2 68.3 HCO3 0

  

SAT 93.3% A-a 623.4 Hg 11.5

BACK

20

CBC
    

WBC 32,000 RBC 4.64 HGB 14.7 HCT 48.1 MCV 103.7

   

MCH 31.7 MCHC 30.6 RDW 12.6 PLT 293

BACK

21

CPP
  

CPK 495 CKmb 18.9 Troponin I <0.04

BACK

22

LDH

264

BACK

23

TSH

0.971

BACK

24

   

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 Cloudy Specific gravity 1.021 PH 5.0 Myoglobinuria -ve

   

Glucose 1000 Ketones 150 Blood 250 Bacteria moderate

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 emp: BP: HR: RR: S pO2: Vent :

28.1, rectally 98/50 dinamap 50 bpm 28/min 100% on vent A/C, 100%, 500cc, 0 PEEP, 20/min

37

On examination
  

 

Unresponsive, intubated GCS 6/15 Pupils dilated, fixed and nonreactive. 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;331:17561760

46

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. 2. 3. 4. 5. 6. 7. 8.

Tissue oxygenation Metabolic acidosis Hematocrit changes Potassium metabolism Coagulopathy Platelets dysfunction Glycosuria Dehydration.
54

Impaired tissue oxygenation
1.

2.

3. 4.

Hypothermia shifts the oxyhemoglobin-dissociation curve LEFT to the… Vasoconstriction, a ventilationperfusion mismatch. Increased blood viscosity. Depressed myocardial contractility
decreased tissues oxygenation

55

Hypothermia consequences
1. 2. 3. 4. 5. 6. 7. 8.

Tissue oxygenation Metabolic acidosis Hematocrit changes Potassium metabolism Coagulopathy Platelets dysfunction Glycosuria Dehydration.
56

Metabolic acidosis
1.

Lactate generation from
 

Shivering Decreased tissue perfusion

2. 3. 4. 5.
1. 2.

Impaired hepatic metabolism Impaired acid excretion. Dehydration Fluid sequestration

Hamlet MP. An overview of medically related problems in the cold environment. Mil Med 1987;152:393-396. 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. 2. 3. 4. 5. 6. 7. 8.

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

Tissue oxygenation Metabolic acidosis Hematocrit changes Potassium metabolism Coagulopathy Platelets dysfunction Glycosuria Dehydration.
60

Potassium metabolism

Hypothermia masks potassiuminduced 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. 2. 3. 4. 5. 6. 7. 8.

Tissue oxygenation Metabolic acidosis Hematocrit changes Potassium metabolism Coagulopathy Platelets dysfunction Glycosuria Dehydration.
62

Glycosuria
 

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

63

Hypothermia consequences
1. 2. 3. 4. 5. 6. 7. 8.

Tissue oxygenation Metabolic acidosis Hematocrit changes Potassium metabolism Coagulopathy Platelets dysfunction Glycosuria 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;20:14021405.
65

Hypothermia consequences
1. 2. 3. 4. 5. 6. 7. 8.

Tissue oxygenation Metabolic acidosis Hematocrit changes Potassium metabolism Coagulopathy Platelets dysfunction Glycosuria 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;78:358359. 67

Hypothermia consequences
1. 2. 3. 4. 5. 6. 7. 8.

Tissue oxygenation Metabolic acidosis Hematocrit changes Potassium metabolism Coagulopathy Platelets dysfunction Glycosuria Dehydration.
68

Dehydration
1. 2. 3. 4.

Decreased oral intake. Fluid sequestration. Increased vascular permeability. Cold-induced diuresis.

69

ICU team check list
1. 2. 3. 4. 5. 6. 7. 8. 9.

Metabolic acidosis, lactic and ketoacidosis. Respiratory failure. CNS impairment. Hyperglycemia and DKA Hypothermia. Hypovolemia. Hyponatremia/hypernatremia Leukocytosis (underlying infection) 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 CO 3
BUN

7.9 0 56

8 5 50

6 7 42

4.4 3.9 2.8 3.9 15 39 22 34 23 28 22 15

4 24 8

Cr

3.7 2.7 2.3 1.8 1.3 0.9 0.5 0.6

76

WB 32k 30k 28k 18k 15k 11k C HG B HCT

7 9k .5k 1 1 1 1 1 1 1 1 4.7 1.4 1.3 1.1 0.9 0.5 0.5 0.6 48 33 30 34 32 86 32 31 31

PLT 294 234 269 145

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. 2. 3. 4.

5. 6. 7. 8. 9.

10. 11. 12. 13.

Mills WJ Jr. Accidental hypothermia: management approach. Alaska Med 1980;22:911.  Paton BC. Accidental hypothermia. Pharmacol Ther 1983;22:331-377.  Hamlet MP. An overview of medically related problems in the cold environment. Mil Med 1987;152:393-396. 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.  Danzl DF, Pozos RS, Auerbach PS, et al. Multicenter hypothermia survey. AnnEmerg Med 1987;16:1042-1055.  Fischbeck KH, Simon RP. Neurological manifestations of accidental hypothermia. Ann Neurol 1981;10:384-387.  Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992;10:311327.  Patt A, McCroskey BL, Moore EE. Hypothermia-induced coagulopathies in trauma. Surg Clin North Am 1988;68:775-785.  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.  Rohrer MJ, Natale AM. Effect of hypothermia on the coagulation cascade. Crit Care Med 1992;20:1402-1405. Valeri CR, Feingold H, Cassidy G, Ragno G, Khuri S, Altschule MD. Hypothermiainduced reversible platelet dysfunction. Ann Surg 1987;205:175-181.  Rosenkranz L. Bone marrow failure and pancytopenia in two patients with hypothermia. South Med 1985;78:358-359. Rahn H. Body temperature and acid-base regulation. Pneumonologie 1974;151:87-94. 79

References
1. 2.

3. 4. 5. 6. 7. 8. 9. 10. 11.

12.

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. 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. Swain JA. Hypothermia and blood pH: a review. Arch Intern Med 1988;148:16431646.  Baraka A. Hydrogen ion regulation during hypothermia -- hibernators versus ectotherms. Middle East J Anesthesiol 1984;7:235-238. White FN. A comparative physiological approach to hypothermia. J Thorac Cardiovasc Surg 1981;82:821-831. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three methods of resuscitaton from mild hypothermia. Resuscitation 1984;11:21-33. Webb P. Afterdrop of body temperature during rewarming: an alternative explanation. J Appl Physiol 1986;60:385-390. Lloyd EL. Equipment for airway warming in the treatment of accidental hypothermia. J Wilderness Med 1991;2:330-50. Iserson KV, Huestis DW. Blood warming: current applications and techniques. Transfusion 1991;31:558-571. Moss JF, Haklin M, Southwick HW, Roseman DL. A model for the treatment of accidental severehypothermia. J Trauma 1986;26:68-74. 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.  Brunette DD, Biros M, Mlinek EJ, Erlandson C, Ruiz E. Internal cardiac massage and 80 mediastinal irrigation in hypothermic cardiac arrest. Am J Emerg Med 1992;10:32-34.

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