Tag Archives: Environmental

Hypothermia

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Patient presents in cardiac arrest. Found outside on Broadway (all hypothetical). While moving him into EMS truck, patient lost pulse, went into cardiac arrest. Multiple defibrillation and code drugs later, patient maintained to be in v fib. Presents intubated, GCS 3T. On quick secondary survey, patient cold to touch and mottled/cyanotic extremities. ET tube confirmed by auscultation and chest rise. Chem 8 shows nl K, other labs unremarkable. Rectal temp unable to read. Bladder temp reads 75. Go.

We’ve learned some hallmarks of rewarming cardiac arrests. The main point to come is that it will be a slow process that takes a ton of resources. You can find the grading system of hypothermia online; however, here we are specifically talking about severe hypothermia <28C without vitals. Here are my following recommendations:

  1. Have plenty of people in line to do chest compressions, unless you can swipe a Lucas machine from EMS
  2. Start active rewarming early, as it takes a very, very long time. We used the gaymar blanket below the patient, applied the ARCTIC SUN (typically used to cool post cardiac arrest, but can also warm), bear hugger. This sounds like a lot but you will be surprised that this may only warm the body 1-4 C an hour if you are lucky. Keep a temperature sensing foley in or use the one on the Arctic sun. CONTINUE CHEST COMPRESSIONS.
  3. According to Tintinalli’s you can give up to 3 doses of code drugs/defibrillations until above 80. I’ve seen places in the literature to not start shocking again until you have them above 80 degrees and some say as high as 32 C (89F).
  4. Start prepping for more advanced warming. Hypothetically if you were in a place that has ECMO, you would send them straight there as that has the quickest rewarming period of all interventions. However, if you do not have ECMO, then proceed to other means. When doing chest tubes, we preferentially avoided to L side as we were continuing chest compressions and placed 2 on the R side. One anterior mid clavicular line at 2nd intercostal and the other large bore tube on posterior axillary line at 4th/5th. Theoretically I always imagined a closed circuit to continuously reuse and pump warm water in. This was not the case. You can use the rapid transfuser to warm  1L NS and let it run to gravity into the anterior chest tube while clamping the posterior tube, Keep 500cc to 1L in the chest for 15 minutes then let it run into the atrium and bolus another 500cc in. KEEP A TAB ON THE AMOUNT OF FLUIDS GOING IN AS WELL AS OUT. You can also place an NG tube and put war m(40-42C) fluid into the stomach for rewarming. 500cc-1L in the bladder Q15-20 minutes.
  5. Once they get to able 80-ish degrees you may see some change on end tidal or rhythm strip itself. Now begin your regular ACLS, but keep rewarming.
  6. There isn’t much to be found on whether or not to continue with code drugs during the sub 80F. Tintinalli’s is vague on it as well as they note to continue with if it seems to be working. I would opt not to fluid them with epinephrine until you get the body warmed and some warm blood flowing.

Overall: the old adage holds up. “They are not dead until they are warm and dead”

  1. Place a foley for temp
  2. Get Chem 8 to see if resuscitation viable (K>12=not viable)
  3. See if ECMO available
  4. Get med students or a LUCAS machine
  5. Start passive and active rewarming immediately

Sources: Tintinalli’s

Snakebite

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Recently saw at case at ULH (Not mine but posted with permission from resident involved) of a young female (18-20yo) flown from OSH for copperhead bite to L foot. Pt had been hiking in the woods with her boyfriend when she felt a stabbing sensation on her foot, looked down and there was a snake. Pt took a picture of it – sure enough it was a copperhead. Labs at OSH wnl, sent to ULH for concern for possible need for antivenin. I realized – being an urban trauma center – we don’t see a lot of snake bites. If you’re from the area, you may not be familiar with our venomous critters.
There are four species of venomous snakes in KY, all pit vipers (triangular heads, heavy bodies, cat-like pupils) – fw.ky.gov
1. Copperhead – extremely common throughout the state, most common envenomation, mildest venom of the four. (As an acquaintance of mine, Jim Harrison of East KY Venom Extraction lab used to say – no recorded history of death from copperhead envenomation in KY history
2. Timber Rattlesnake – found throughout state, potent venom, relatively docile. Dark coloration, have a rattle (obviously)
3. Pygmy Rattlesnake – found in extreme Western KY. Also have a rattle, potent venom
4. Cottonmouth – found in Western KY, potent venom, can be aggressive. Can be mistaken for Eastern Water Snake (common, non-venomous, aggressive water-dwelling snake found throughout KY)
Best identification – hopefully someone took a picture – otherwise, one to two small puncture wounds with increasing swelling and pain are good signs of envenomation. However, approximately 25% of viper envenomations can be dry bites – where snake gives a warning bite, injects no venom.

Signs and Symptoms of snake bite:
Venomous snakes in KY typically have venoms containing cytotoxins and hemotoxins – they break down tissue and can act on coagulations factors
-puncture wounds (usually paired, can be one)
-erythema and swelling
-intense pain at site and increasing proximally
-systemic symptoms can include nausea, vomiting, abdominal pain, vertigo. Altered mental status and hypotension can present as well

First Aid if bitten:
-Walk slowly – increased activity increases circulation of venom
-Elevate affected part: most bites are on distal extremities: feet, hands. More serious complications are associated with bites involving trunk, neck, face
-Wash with soap and water
DO NOT:
-Apply a tourniquet
-Attempt to suck venom from wound
-Apply ice to wound

Medical Work-up for known or suspected envenomation
-ABCs (always the first step)
-Good H&P – observe amount of swelling, movement of affected area. Mark swelling and erythema with marker to observe for progression
-CBC
-Comp
-Coags
-Total CK
-Fibrinogen
-U/A – to look for myoglobinuria
-Consider ABG and lactic acid if signs of systemic toxicity
-Xray to r/o retained teeth

Severe complications
-Rhabdomyolysis – from muscle breakdown from venom
-Compartment syndrome – cannot be diagnosed on clinical exam alone. Venom can cause tingling and paresthesias. If concerned, consult your surgeon
-Thrombocytopenia and coagulopathy – caused by thrombin-like molecules in venom. Treated with antivenom
-Systemic toxicity – can be life-threatening

Treatment:
-Update Tdap if indicated
-Pain control, elevation
-Antivenom if indicated

Antivenin: Always contact your toxicologist prior to giving
-Recommended for moderate to severe envenomations
(http://www.uptodate.com.echo.louisville.edu/contents/image?imageKey=EM%2F53948&topicKey=EM%2F6595&rank=2%7E39&source=see_link&search=snake+bite&utdPopup=true)
-Dosing: Moderate envenomation – 4 to 6 vials (1g each) over 60 min with repeat dose as needed
Severe envenomation – 6 to 9 vials over 60min with repeat dose prn
-Contraindications: papaya allergy (contains enzyme papain)
-Stop if signs of anaphylaxis

Disposition
-Requires antivenom – admission. Complications can include compartment syndrome, delayed coagulopathy (up to 48hrs). May need redosing of antivenom
-Mild envenomation or no symptoms – can be discharged home if pain controlled and no signs of toxicity at 8-12hrs s/p bite. If bitten by rattlesnake or cottonmouth, recommend CBC, PT, fibrinogen at 2-3d and 5-6d after initial bite