1. Hypothermia (Hyperthermia) Dr. Stella Yiu Staff Emergency Physician

2. LMCC objectives List clinical findings of hypothermia Investigate Initiate resuscitation for severe hypothermia

3. 1. Clinical findings of hypothermia

4. Normal temp: 36.5 – 37.5 C

5. Effects By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons Image credit: US public domain

6. Mild (32-35C) By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons Image credit: US public domain

7. Moderate (28-32C) Image credit: US public domain Photo credit: Greg O’Connell, Flickr creative commons

8. Moderate (28-32C) Image credit: James Heilman, MD Photo credit: Greg O’Connell, Flickr creative commons

9. Severe (<28C) Image credit: jer5150, Wikimedia commons, Jeffrey Bary, Flickr creative commons

10. What precipitates hypothermia?

11. Increased heat loss Alcohol Sepsis Burn

12. Impaired thermoregulation Metabolic (Cirrhosis, uremia, DM, Hypothyroid) CNS (stroke, trauma, MS, Parkinson) Drugs (barbituates, TCAs)

13. 2. Investigations

14. CDMQ: 4 investigations

15. Investigations CBC, Cr, Lytes Coag profile (DIC) TSH EKG

16. Osborn J waves

17. 3. Resuscitation

18. Mild (32-35C): Passive external rewarm EM Ottawa 18

19. Mod (28-32C): Active external rewarm EM Ottawa 19 By U.S. Navy photo by Journalist 2nd Class J. Maurer. [Public domain], via Wikimedia Commons

20. Mod (28-32C): Active external rewarm EM Ottawa 20 By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons Warm humidified Oxygen

21. Severe (<28) Warm every cavity but Gentle handling EM Ottawa 21

22. Severe: Arrhythmia VF: CPR, defib x 1 If defib x 1 does not work, no defib (continue CPR) until >30C Not dead until warm and dead

23. CDMQ: What cavities for rewarming? (6)

24. Airway Warm humidified oxygen

25. Circulation Warm intravenous fluids

26. Pleural space By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

28. Bladder By User:Lennert B [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0 (http://creativecommons.org/licenses/by- sa/3.0/) or CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

29. Dialysis By National Kidney and Urologic Diseases Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA [Public domain], via Wikimedia Commons Photo credit: becre8tv, CC by 2.0, via Flickr Creative commons

30. Bypass By Van Meurs, K, Lally, KP, Peek, G, Zwischenberger, Extracorporeal Life Support Organization, Ann Arbor 2005. [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

31. MCQ 3: Patient is confused and bradycardic. Most appropriate warming method? A. Pleural lavage B. Bladder irrigation C. Intubation D. Peritoneal dialysis E. Warm humidified oxygen

32. MCQ 4: 12 yo found in the snow. After 2hrs CPR and warming, asytolic and core temp is 27.5C. What is the most appropriate step? A. Stop resuscitation B. Defibrillation C. Continue CPR and warming D. Warm water immersion E. Stop warming

33. Not dead until warm (>30-32) and dead

34. Hyperthermia

35. LMCC objectives List predisposing illnesses List clinical findings Select investigations Manage patient by various cooling methods

36. Causes Environment Decreased heat dissipation Metabolic heat

37. 1. Predisposing illness

38. Metabolic causes: Heat production Metabolic heat Thyroid, pheochromocytoma Malignant hyperthermia NMS Sepsis

39. Decreased heat loss: Drugs Decreased heat dissipation Obesity Drugs (anticholinergics, serotonin, sympathomimetics)

40. 2. Clinical findings

41. Case: The rave girl

42. Heat stroke: Hot + confused T> 40 Orthostatic BP,  HR CNS: Confusion, ataxic, cerebral edema, seizure CVS: CHF, pulmonary edema, CV collapse

43. Lab findings: Liver, Renal Liver: necrosis Rhabdomyolysis DIC

44. 3. Cooling methods

45. Basic cooling: Photo credit: Kenneth Lu, Flickr creative commons

46. Photo credit: yellowcloud, flickr creative commons

47. More aggressive cooling Tub immersion GI/Peritoneal lavage Cardiac bypass

48. Stop cooling when temp < 40

49. LMCC objectives List predisposing illnesses List clinical findings Select investigations Manage patient by various cooling methods