Hypothermia
Content
Treatment Algorithm
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Hypothermia
*
Authors
•The American College
of Surgeons Committee
on Trauma
•Ronald Simon, MD, FACS
•John Hunt, MD, FACS
This publication is designed to offer information suitable for use by an appropriately trained physician.
The information provided is not intended to be comprehensive or to offer a defined standard of care.
The user agrees to release and idemnify the American College of Surgeons from claims arising from use of the publication.
2011 American College of Surgeons
© 2014
Hypothermia
Content
Treatment Algorithm
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Primary
•Due to cold exposure — cold, wind, or water
Secondary
•Occurs when patient becomes cold despite an Primary and Secondary
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Laboratory Evaluation
External Rewarming
Core Rewarming
environmental temperature that normally would not cause hypothermia
––Trauma
––CVA
––Medical conditions
Outcomes
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Content
Treatment Algorithm
page 3 of 11
Stage Core Temp Symptoms
Shivering, tachycardia, tachypnea, dysarthria,
impaired judgment
Passive
II
32–28 C
No shivering, stupor, hypotension,
hypoventilation, brady/atrial arrhythmias,
(j-waves)
Active external,
Active core
III
28–24 C
Coma, apnea, acidosis, coagulopathy, v-fib
Active external,
Active core
IV
24–15 C
Asystole, respiratory arrest
Active external,
Active core
V
15 C
Death
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Laboratory Evaluation
Rewarming Therapy
35–32 C
I
Primary and Secondary
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External Rewarming
Core Rewarming
Outcomes
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Primary and Secondary
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Content
Treatment Algorithm
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•Thiamine deficiency
•Hypothyroidism
•Adrenal insufficiency
Laboratory Evaluation
External Rewarming
Core Rewarming
Outcomes
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Primary and Secondary
Content
Treatment Algorithm
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•Bradycardia
•Ventricular fibrillation
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Laboratory Evaluation
External Rewarming
Core Rewarming
Outcomes
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Content
Treatment Algorithm
Laboratory Evaluation
Primary and Secondary
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Laboratory Evaluation
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Complication of Hypothermia
Basic metabolic profile
Renal failure, hyperkalemia (rhabdomyolsis), hypoglycemia
Coagulation profile
Coagulopathy *
Complete blood count
Thrombocytopenia
EKG/Monitoring
Arrhythmia (atrial, v-fib, j-waves)
Arterial blood gas
Acidosis
Thyroid function tests
Myxedema (possible etiology)
* Clotting abnormalities
Prolongation of clotting times due to inhibition of enzymatic process
Abnormalities in platelet function — reduced production of thromboxane B2
External Rewarming
Core Rewarming
Outcomes
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Primary and Secondary
Content
Treatment Algorithm
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•Warm sheets and blankets
•Forced air warming unit
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Laboratory Evaluation
External Rewarming
Core Rewarming
Outcomes
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Content
Treatment Algorithm
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•Heated inspired gases (1 C/hr)
•Gastric lavage (1.5 C/hr)
•Bladder irrigation (1.5 C/hr)
irrigation (40-42 C infusion solution
•ofWarmed
normal saline) through:
lavage (1-3 C/hr))
––––Peritoneal
Chest tubes (8 C/hr)
•CVVH
•ECMO
•Cardiac bypass (1-3 C/3-5 min)
o
o
o
o
o
o
Primary and Secondary
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Laboratory Evaluation
External Rewarming
Core Rewarming
Outcomes
o
McCullough L, Arora S. Diagnosis and treatment of hypothermia.
American Family Physician. 2004;70(12):2325-2332.
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Content
Treatment Algorithm
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outcomes of hypothermia depend •The
on both duration and etiology.
•Survival of primary hypothermia: 17%
of secondary hypothermia due •Survival
to trauma:
•T > 34 - 40%
•T = 32 - 33 - 69%
•T < 32 - 100%
1
2
o
Primary and Secondary
Definitions
Medical Etiologies of Hypothermia
Cardiac Effects
Laboratory Evaluation
External Rewarming
Core Rewarming
Outcomes
References
o
o
1 Danzl DF, Pozos RS, Auerbach PS, et al. Multicenter
hypothermia survey. Ann Emerg Med. 16:1042, 1987.
2 Jurkovich GJ, Greiser WB, Luterman A, et al. Hypothermia
in trauma victims. An ominous predictor of survival.
J Trauma. 27:1019, 1987.
Algorithm
© 2014 American College of Surgeons
Hypothermia
Content
Treatment Algorithm
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•Danzl DF, Pozos RS. Accidental hypothermia. NEJM. 1994;331:1756-1760.
•Reed RL, Gentillo LM. Temperature-Associated Injuries
and Syndromes. In Trauma: Feliciano DV, ed.
Primary and Secondary
Definitions
Medical Etiologies of Hypothermia
•Haskell RM. Boruta B. Rotondo MF. Frankel HL.
Hypothermia. AACN Clinical Issues. 1997;8(3):368-382.
Cardiac Effects
Laboratory Evaluation
External Rewarming
Core Rewarming
Outcomes
References
Algorithm
© 2014 American College of Surgeons
Hypothermia
Content
Treatment Algorithm
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Hypothermia?
T<35oC
Primary
Secondary
Initiate ABC’s,
EKG,
CXR,
Labs
Status of circulation
Perfusing rhythm
Primary and Secondary
No perfusing rhythm
Definitions
Medical Etiologies of Hypothermia
T≥32oC
T<32oC
Cardiac Effects
Laboratory Evaluation
External Rewarming
Core Rewarming
Outcomes
Active external rewarming
Active external
and
Core rewarming
CPR,
Control surgical bleeding
Active external
and
Core rewarming
References
Algorithm
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2011 American College of Surgeons
© 2014