Transcript Cold Injuries

Revised Cold
Injuries and Cold
Water Near
Drowning
Guidelines
Ken Zafren, MD, FACEP
EMS Medical Director,
State of Alaska
7/13/2016
Ken Zafren, MD FACEP
Hypothermia Guidelines
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The State of Alaska
Cold Injuries and
Cold Water Near
Drowning Guidelines
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7/13/2016
Developed in 1988 by an expert
panel
Revised in 1996
Expert panel revision - Sitka 2002
Revised edition in progress
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Hypothermia Guidelines
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Overview of
Guidelines
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General points
Hypothermia
Cold water near drowning
Frostbite
New section on avalanche rescue
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Introduction
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Guidelines - not absolute rules
Designed as a reference, not a
teaching document
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Multilevel guidelines
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General points
General public
First Responder / EMT-I
EMT-II
EMT-III / Paramedic
Small/Bush Clinic
Hospital
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Hypothermia General Points
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Core temperature best measured
as esophageal temperature if
possible
Epitympanic temperature second
choice
Rectal temperature third choice
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Hypothermia General Points
Why esophageal
temperature?
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Best reflection of core temperature
Reflects cardiac temperature
Relatively non-invasive
Technology widely available
Patient remains covered
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Hypothermia General Points
Epitympanic
temperature
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Reflects carotid artery temperature
Non-invasive
Technology not yet widely available
in USA
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Hypothermia General Points
Rectal temperature
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Does not reflect core temperature
very well
Lags core temperature during
rewarming
Requires disrobing patient
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Hypothermia General Points
Orthopedic injuries
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Splint with caution in frostbitten
limbs to prevent further damage;
frostbitten skin is damaged skin.
Align fractures/dislocations in
neutral position. This gives the
best chance of preserving
neurovascular and other
structures.
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Hypothermia General Points
Orthopedic injuries
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Do not reduce frozen extremities to
prevent further damage.
Splints should not be constrictive in
order to allow for postinjury
swelling.
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Hypothermia General Points
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Warm oral and IV fluids to at least
body temperature to prevent
further cooling.
Give IV fluids as boluses
(especially for field use).
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Hypothermia General Points
Why IV fluid boluses?
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Less likely to freeze than
continuous infusions
Better titration to effect
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Hypothermia General Points
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Chemical heat packs ineffective for
warming
Can be used on hands or feet to
prevent frostbite
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Hypothermia General Points
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Positive attitude is important
Assume the patient can be
resuscitated even if they appear to
be beyond help
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Hypothermia General Points
Contraindications to
CPR
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New temperature cutoff - core
temperature 10°C/50°F
Rescuers exhausted or in danger
or CPR cannot be maintained
throughout transport to a medical
facility
Transportation available within 3
hours
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Hypothermia General Points
Contraindications to
CPR - new cutoff
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New temperature cutoff - core
temperature 10° C / 50° F
Survival has now been
documented to core temperature of
13.7° C / 56.7° F
Routine use of 10° C / 50° F in
surgery
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Hypothermia General Points
Contraindications to
CPR
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Rescuers exhausted or in danger
or CPR cannot be maintained
throughout transport to a medical
facility
If CPR is begun any perfusing
rhythm will probably be lost;
stopping CPR once begun is
therefore likely to be fatal
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Hypothermia General Points
Contraindications to
CPR
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Transportation available to critical
care within 3 hours
Hypothermic patients can survive
for up to 3 hours with pulse and
blood pressure which are difficult
to detect.
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Hypothermia General Points
CPR
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Apneic pulseless patient - ventilate
for 3 minutes before CPR to
increase VF threshold
Ventilation may increase heart
rate, blood pressure
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Hypothermia General Points
CPR
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Apneic pulseless patient - decision
to start CPR based on time to
critical care
<3 hours: ventilate (intubate, if
possible), prevent heat loss
>3 hours: chest compressions and
ventilate for 30 minutes, attempt to
rewarm
CPR cannot be done in a litter
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Handle hypothermic
patients gently to prevent
Ventricular Fibrillation
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Hypothermia General Points
Assessment
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Check for cardiac activity for at
least 60 seconds
Automatic External Defibrillator
(AED) may be used to detect
cardiac activity - signal to shock
indicates V Tach or V Fib
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Hypothermia General Points
Assessment
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New classification for severity of
hypothermia
Follows International Commission
for Alpine Rescue, Winnepeg
consensus guidelines
Correlates core temperature with
observable findings
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Class ifi cation s of level of hyp ot herm ia
Core temp
Ther moregu latory
status
37 oC
S&S
Classifi cations
Cold sensation
shivering
Normal
35-32 oC
Control and
responses fully
active
Phys ical
im pair ment fine
motor
Gross motor
32-28 oC
Respons es
attenua ted
extingu ished
-30 deg rees
shivering shop s
loss of consc iousnes s
moderate
Below 28 oC
Respons es absen t
Rigidit y
Vit al signs reduced or abs ent
Ris k of VF (rough hand li ng)
Seve re
Below 25 oC
Spontaneou s ven tricular fibrill ation
Cardiac arrest
Mental
im pair ment
Complex
Simple
mil d
Red text are major thresho lds between stages
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Hypothermia stages
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Mild 32-35°C (90-95°F)
Moderate 28-32°C (82-90°F)
Severe <28°C (<82°F)
Ideally based on esophageal
temperature
Becoming standard classification
worldwide
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Hypothermia General Public
Mild Hypothermia
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Patient is cold
Vigorous shivering
Alert
May be ambulatory
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Hypothermia General Public
Treatment
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Remove wet clothes only with
shelter
Vapor barrier
Cover head and neck
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Hypothermia General Public
Treatment
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Shivering is an important method
to increase heat production
Sugar containing fluids are more
beneficial than hot drinks
Special importance if medical care
delayed
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Hypothermia General Public
Treatment
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Mild exercise such as walking may
be helpful after the patient is dry
and has eaten
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Hypothermia General Public
Treatment
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Mild exercise such as walking may
be helpful after the patient is dry
and has eaten. If the patient is
exhausted, exercise cannot be
maintained and the patient will lose
the ability to increase body heat
(primarily by shivering)
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Hypothermia General Public
Moderate-Severe
Treatment
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Handle gently
Do not rub or manipulate
extremities
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Hypothermia General Public
Moderate-Severe
(with life signs)
Treatment
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Handle gently
Do not rub or manipulate
extremities
Do not allow to sit or stand
Do not put in shower or bath
No exercise
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Hypothermia General Public
Moderate-Severe
(without life signs)
Treatment
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Handle gently
Check pulse for at least 60
seconds
CPR if not contraindicated
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Hypothermia First Responder
EMT-I
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Same as general public with
additions
Oxygen, if used, should be heated
and humidified
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Hypothermia First Responder /
EMT-I
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Insulate patient - sleeping bag
Cover head and neck
Rewarming axilla, trunk, groin
Hot shower/bath okay only for mild
hypothermia
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Hypothermia EMT-II
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Same as EMT-I with additions
Most patients need volume
IV fluid should be normal saline 250 cc boluses, repeated as
needed to treat tachycardia
Heat fluid to 104-108°F (40-42°C)
Consider glucose, naloxone
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EMT-II
Severe hypotherma
with signs of life
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Measure core temperature
(esophageal is preferred)
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EMT-II
Severe hypotherma
without signs of life
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Ventilate and pre-oxygenate 3
minutes before intubating
Intubate
Do not hyperventilate
One set of defibrillations if core
temperature is less than 30°C
(86°F)
Further attempts above 30°C
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EMT-III / Paramedic
Severe hypotherma
without signs of life
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Same as for EMT-II
No ACLS drugs
No CPR if any rhythm on monitor
other than VF/VT
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Hypothermia Hospital
General Points
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Treat to level of ability
Transfers follow usual guidelines
May be better to bypass
community hospital for one with
cardiac bypass capability
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Hypothermia Hospital
General Points
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Consider transfer of patient with
core temp <20° C (68° F)
Consider bypass if BP<60 systolic
Stabilize patient before transport
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Hypothermia Hospital
General Points
Suggestions for evaluation and
treatment
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Hypothermia Hospital
General Points
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Esophageal temperature and end
tidal CO2 monitoring
IV fluids must be heated.
Heated, humidified oxygen, if
available
Avoid sedation to depress
shivering
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Hypothermia Hospital
General Points
Rewarming methods
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Passive external rewarming
Active external rewarming
Active core rewarming
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Hypothermia Hospital
General Points
Active internal
rewarming
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Peritoneal lavage
AV Rewarming
Cardiopulmonary bypass
Venous heat-exchange catheter
(possible future technology)
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Hypothermia Hospital
General Points
Active internal
rewarming
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Slow rewarming prior to adequate
ventilation
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Hypothermia Hospital
General Points
Cardiac rhythm
disturbances
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Supraventricular dysrhythmias are
innocent
V Tach and V Fib - one round of
shocks until 30°C (85°F)
Drugs ineffective
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Hypothermia Hospital
General Points
Insulin
Consider insulin during rewarming.
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Hypothermia Hospital
When to stop
resuscitation?
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Core temperature not improving
despite aggressive rewarming
Serum potassium >10 with
associated asphyxia (near
drowning, avalanche)
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Cold Water Near
Drowning
General Points
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Use of PFDs with thermal
protection mandatory for
emergency responders
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Cold Water Near
Drowning
General Points
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Submersion - head under water
Immersion - head out of water
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Cold Water Near
Drowning
General Points
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Hypothermia not the main problem
Cardiac, pulmonary and
coagulation problems are key
Rewarming to raise temperature to
make defibrillation more effective
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Cold Water Near
Drowning General Public
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Neck protection if possible injury
Activate EMS system
Start CPR if patient pulseless after
pulse check of 60 seconds
Heimlich maneuver only for solid
foreign body obstruction
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Cold Water Near
Drowning First Responder /
EMT-I
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Similar to General Public
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Cold Water Near
Drowning EMT-II
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Similar to EMT-I
Saline lock or TKO (no fluids)
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Cold Water Near
Drowning EMT-III / Paramedic
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Similar to EMT-II
Assess for possible
cardiopulmonary bypass
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Cold Water Near
Drowning Hospital
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IV fluids only if volume depleted
Cardiopulmonary bypass no longer
recommended
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Cold Water Near
Drowning Hospital
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Active external rewarming as
indicated by core (esophageal)
temperature.
Keep patients at 32-33° C to
protect the brain.
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Cold Water Near
Drowning Hospital
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Agressive cerebral resuscitation
(IVP monitoring, diuretics,
barbiturates) no longer
recommended.
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Frostbite
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No significant changes in
prehospital care
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Frostbite
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Temperature for thawing 38-40°C
(100-107°F). The lower end is
preferred.
Stop thawing when tips of digits
flush.
Recommendations for wound care.
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Frostbite
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Fasciotomy guided by
compartment pressures (>37-40
mm Hg) and clinical judgment
Antibiotics necessary only for deep
infection
General care recommendations
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Frostbite
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Orthopedic guidelines
Guidelines for disposition
Sample admitting orders
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Avalanche rescue
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Similar to cold water near drowning
Importance of asphyxiation
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Avalanche Rescue
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Rapid extrication to 35 minutes to
prevent asphyxia
Gentle extrication after 35 minutes to
prevent ventricular fibrillation in
hypothermic patient
Check for air pocket
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Avalanche Rescue
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Rapid extrication to 35 minutes to
prevent asphyxia
Patients extricated in less than 35
minutes are unlikely to be hypothermic,
but will die of asphyxia without an
adequate air pocket.
An air pocket is any space in front of the
nose or mouth, no matter how small.
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Avalanche Rescue
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Gentle extrication after 35 minutes to
prevent ventricular fibrillation in
hypothermic patient
Patients extricated after 35 minutes who
are still alive will have an air pocket.
They are at risk for hypothermia.
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Avalanche Rescue
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Rapid extrication to 35 minutes to
prevent asphyxia
Gentle extrication after 35 minutes to
prevent ventricular fibrillation in
hypothermic patient
Check for air pocket
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Avalanche Rescue
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CPR/ACLS for 30 minutes for burials
less than 35 minutes or core temp >32°C
No CPR/ACLS for burials longer than 35
minutes or core temp <32°C if no air
pocket
CPR/ACLS for burials longer than 35
minutes or core temp <32°C with air
pocket
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