cold man...hypothermia
TRANSCRIPT
?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