Cold man...Hypothermia

?Alive ?Dead……….Hypothermia

Dr Wahid AltafIreland

Cold Man

MRN 834269 J. P. SD. O. B. 7/2/1984, 25 y old

5/3/9

Found at 0722 am

collapsed, unconscious by passer by in St Finbarr’s (Glasheen) graveyard

Ambulance arrived 0728,

Groaning in ambulance, GCS 3/15,‘pulse present but irregular’Pupil size 4/8 bilateral.

Arrive in CUH 0747

Smell of alcohol off breath,Abrasions on forehead, left arm, left leg

Previously ...

Recently released from prisonHistory of depression, anxiety

Last seen evening before at 5.30 pm, parents pills missing –

aspirin, plavix, lipitor, tritace, emcor, paracetamol.

A&E 0747

Unresponsive, pulseless, asystole, Pupils non reacting & dilatedAbrasions on headRectal temp 20oc0820 rectal temp 22.2oc9 mg adrenaline between 0755 and 0835, CPR, intubation, ventilation(vomitus noted in

throat)2 L fluid given in A&ECatheterised

0850 to theatre for rewarming on CPBTheatre 0850 - 1230

Bloods in A&E

Na 141K 5Cl 105Urea 6.9Creat 79Alb 33AST 46Phos 2.03

ECG na

TIME 0804

PaO2 3.0

PaCO2 13.4

pH 7.13

Lactate(0.5-2.0)

3.1

Bic 33

B def +4.1

Na(Blood Gas) 137

K (Blood Gas) 4.7

Cl(BG) (98-107) 96

CK 2134

Hgb 14.3

Glucose ?

0900 1000 1100 1200

C

CT brain 5/3/9(contrast)

ICU bloods

Theatre

R. Fem A > V CP Bypass

Spontaneous rhythm at nasopharyngeal temp 32oCRewarmed to 35oC

ICU ventilateCefuroxime + metronidazoleR.Basal consolidation

Time 5/3/09Day 01530

6/3/09Day 10620

7/3/09

Hgb 10.6 9.9

WCC 27.4 22

plat 335 242

INR 1.2 1.1

APTT 35 28

Bilirubin 7 6

ALT(4-45) 145 142

CK (40-180) 3677 NA

Creat 43 88

5/3/9 ICU

Date 5/3/09 (day 0) 6/3/09 (day 1)

Time 1300 1400 1600 1800 2000 2200 2400 0200 0400 0600Adrenaline 16 14 14 12 12 12 12 10 6 off

MAP 67 87 69 72 72 70 68 68 84 86

Urine ml/hr

500 70 100 320 290 150 100 125 100 120

Temp oC 35

ICU

TIME 0804 1315 1500 1700 0047

PaO2 3.0 13.2 14 15.9 14.2

PaCO2 13.4 10.4 6.3 5.5 4.6

pH 7.13 7.19 7.34 7.38 7.48

Lactate(0.5-2.0)

3.1 1.0 1.3 1.6 1.2

Bic 33 29.8 25.4 24.3 25.3

B def +4.1 1.6 - 0.4 - 0.8 +1.8

Na(BG) 137 140 139 135 139

K(BG) 4.7 4.4 4.4 4.0 3.7

Cl(BG)(98-107)

96

CK 2134

Hgb 14.3

Glucose 8.1 8.5

5/3/9 cxr

Chest x ray ICU 6/3/9

Cxr 8/3/9

Conundrums

Rewarming passiveactive

How to rewarmproblems encountered

Rate of rewarmingfastslow - risks of prolonged CPR

poor cardiac output

cerebral hypoxia# ribs, liver, spleen

Temperature at which to stop rewarming

Who gets hypothermiainducedaccidental

Hypothermia duration of exposuretemp at discovery

ILCOR special resuscitation situations

Cooling down - problems Re-warming - problems

Swiss study NEJM 1997

oE

Sigaard Anderson 1962