Learning Station 3 Environmental Emergency 3 alternate Mysteriously Unresponsive Older Woman

1999 American Heart Association

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Fire-EMS Unit: On Scene

EMS unit arrives on scene after man called stating, Mother is downstairs. I think she is passing on. Contact: 80-something woman, seated on edge of bed, leaning against headboard, unresponsive. Son comments, She looks dead. Quickly but gently moved to floor
Describe your initial approach to this woman.
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Primary ABCD Survey

Airway: pills noted in mouth and cleared Breathing: initially appeared absent but on prolonged auscultation breaths noted at 2 to 3 breaths per minute Circulation: pulse absent Defibrillation: initial rhythm assessment by AED: connect electrodes message repeated multiple times. Resume CPR.
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Secondary ABCD Survey

Airway: ventilations with BVM enter easily Breathing: chest expands with each BVM ventilation Circulation: IV started with NS; blood return thick ECG: sinus bradycardia at 30 bpm Monitor electrodes will not stick; defib pads loose Differential Diagnosis: profound altered mental state with virtual apnea, pulselessness Stroke, intracranial bleed, cardiac collapse; drug overdose, metabolic/endocrine respiratory failure; passing on

Third Quadrad: Further Exam

Patient stiff in joints Stat glucose check: 90 Temp 28C (82F) Intubation considered
What do you think is going on now? Would you attempt intubation?
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Hypothermia

Mild hypothermia 34C to 36C (94F to 98F) Cold diuresis Lethargy, shivering, vasoconstriction Moderate hypothermia 30C to 34C (86F to 94F) Stupor, dilated pupils, bradycardia, decreasing oxygen demand, muscle rigidity Severe hypothermia <30C (<86F) Coma, nonreactive pupils, difficult to detect VS, danger of malignant arrhythmias
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ECG Changes in Hypothermia

Osborne or J waves T-wave inversion Prolonged PR, QRS, QT intervals Arrhythmias

Bradycardias slow AF VF asystole

J Wave or Osborne Wave

a = 26C
b = 28C c = 28.5C

d = 29.5C

Treatment Goals

Prevent further heat loss Oxygen Monitor Rewarming Watch for after-drop phenomenon Prevent ventricular fibrillation

Danger: After-drop Phenomenon

Initial active, external rewarming leads to

Peripheral vasodilation ( BP drops)

Cold blood from peripheral vessels creates acidosis by transport of lactic acid to core circulation Cold acidotic blood causes drop in core temperature Temperature drop and acidosis in core circulation provoke serious arrhythmias

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Handling of Patient

While intubating VF occurred Defibrillate? Limited number? Drugs?

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Hypothermia Algorithm
Initial therapy for all patients Remove wet garments Protect against heat loss and wind chill (use blankets and insulating equipment) Maintain horizontal position Avoid rough movement and excess activity Monitor core temperature Monitor cardiac rhythma

Assess responsiveness, breathing, and pulse

Pulse and breathing present

Pulse and breathing absent

What is core temperature?

Start CPR Defibrillate VF/pulseless VT up to a maximum of

3 shocks (200 J, 200 to 300 J, 360 J or per AED; see VF/VT algorithm, Figure 2, and AED algorithm, Figure 2A) Intubate Ventilate with warm, humid oxygen (42C to 46C)b Establish IV access Infuse warm normal saline (43C)b

34C to 36C (mild hypothermia) Passive rewarming Active external rewarming

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Hypothermia Algorithm

30C to 34C (moderate hypothermia) Passive rewarming Active external rewarming of truncal areas onlyb,c Less than 30C (severe hypothermia) Active internal rewarming sequence (see below)

What is core temperature?

Less than 30C

Greater than 30C

Continue CPR Withhold IV medications Limit shocks for VF/VT to

maximum of 3 Transport to hospital

Continue CPR Give IV medications as

indicated (but space at longer than standard intervals) Repeat defibrillation for VF/VT as core temperature rises

(see next slide)

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Hypothermia Algorithm
Less than 30C Greater than 30C

Current patient: temp. 28C (82F)

Active internal rewarmingb Warm IV fluids (43C) Warm, humid oxygen (42C to 46C) Peritoneal lavage (KCI-free fluid) Extracorporeal rewarming Esophageal rewarming tubesd

Continue CPR Withhold IV medications Limit shocks for VF/VT to Transport to hospital
maximum of 3

Continue CPR Give IV medications as

indicated (but space at longer than standard intervals) Repeat defibrillation for VF/VT as core temperature rises

Continue internal rewarming until Core temperature >35C or Return of spontaneous circulation or Resuscitative efforts cease

a. This may require needle electrodes through the skin. b. Many experts think these interventions should be done only in-hospital, though practice varies. c. Methods include electric or charcoal warming devices, hot water bottles, heating pads, radiant heat sources, and warming beds. d. Esophageal rewarming tubes are widely used internationally and are expected to become available in the United States.

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Treatment

Patient defibrillated 3 Postshock rhythm asystole CPR continues Active internal rewarming (core)
IV, humid oxygen, NG, Foley, enemas, peritoneal lavage, extracorporeal warming
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Clinical Course

Continued rewarming to 31C (88F) Then rhythm returns to sinus bradycardia Rewarming continues while monitoring electrolytes and fluid status

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Summary

Prevent heat loss Avoid rough movement Watch for ECG changes Prevent after-drop Give drugs and defibrillation with caution Remember: Not dead until warm and dead
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