Field Care Audit presented at St. Joseph's Hospital

1. A Buffalo Squirrels Production

2. Case #1
78 y.o. female brought in by EMS for
weakness and altered mental status

3. Case #2
28 y.o. male picked up by law enforcement
after being found walking along the highway
at 2 in the morning

4. Case #3
16 y.o. male brought in with altered mental
status the morning after partying all night
with friends

5. Case #4
54 y.o. male with witnessed cardiac arrest,
brought in by EMS now with pulses after
AED used

6. Cases
78 y.o. female brought in by EMS for weakness
and altered mental status
28 y.o. male picked up by law enforcement after
being found walking along the highway at 2 in the
morning
16 y.o. male brought in with altered mental status
the morning after partying all night with friends
54 y.o. male with witnessed cardiac arrest, brought
in by EMS now with pulses after AED used

7. Case #1
78 y.o. female brought in by EMS for
weakness and altered mental status

8. Case #1
78 y.o. female brought in by EMS for
weakness and altered mental status
Found to have urosepsis, with a temperature
of 34.8o C

9. Case #2
28 y.o. male picked up
by law enforcement
after being found
walking along the
highway at 2 in the
morning

10. Case #2
28 y.o. male picked up
by law enforcement
after being found
walking along the
highway at 2 in the
morning

11. Case #3
16 y.o. male brought in with altered mental
status the morning after partying all night
with friends

12. Case #3
16 y.o. male brought in with altered mental
status the morning after partying all night
with friends
Blood sugar of 25 when found, with body
temperature of 36o C

13. Case #4
54 y.o. male with
witnessed cardiac
arrest, brought in by
EMS now with pulses
after AED used

14. Case #4
54 y.o. male with
witnessed cardiac
arrest, brought in by
EMS now with pulses
after AED used

15. Falling Temperatures
Veronica Bonales, M.D.
CEPAmerica, Emergency Medicine

16. Hypothermia

17. Hypothermia
States with highest death rates
Alaska
New Mexico
North Dakota
Montana

18. Hypothermia
Case distribution - Greatest number
Urban areas
Environmental exposure
EtOH
Illicit Drug Use
Mental illness
All exacerbated by homelessness

19. Physiology

20. Thermoregulation
Regulatory center
Temp between
36.5 - 37.5C
Peripheral
thermoreceptors
Central
thermoreceptors

21. Thermoregulation
Regulatory center
Temp between
36.5 - 37.5C
Peripheral
thermoreceptors
Central
thermoreceptors

22. Thermoregulation
Body temperature can be increased or
decreased in two ways:
Regulation of heat production
(thermogenesis)
Regulation of heat loss (thermolysis)

23. Regulating Heat Production
Muscular Fats
Proteins
Baseline muscular
activity Glycogen Stores
Exertion Endocrine
Shivering Role of hormones
in setting basal
Metabolic metabolic rate -
Processing of food thyroxine and epi
and nutrients
Carbohydrates –
sugars and starches

24. Regulating Heat Loss
Heat is lost from the body to the external
environment through the skin, lungs, and
excretions
The skin is most important in regulating
heat loss
Radiation, conduction, convection, and
evaporation are the major sources of heat
loss

25. Heat Loss Mechanisms

26. Maintenance of
Thermoregulation
Hypothermic compensation
Decreased heat loss
Peripheral vasoconstriction
Reduction of surface area by body position (or clothing)
Piloerection (not effective in humans)
Increased heat production
Shivering (last resort to maintain temperature)
Increased voluntary activity
Increased hormone secretion
Increased appetite

27. External Environmental
Factors
External environmental factors that may
contribute to a medical emergency
Climate
Season
Weather
Atmospheric pressure
Terrain

28. Predisposing Factors
Patient’s age
Predisposing medical conditions
Use of prescription and over-the-counter
medications
Use of alcohol or recreational drugs
Previous rate of exertion

29. “Indoor” Hypothermia
Occurs with significant medical comorbidities
Alcoholism
Sepsis
Hypothyroid/hypopituitary
Worse outcome than exposure

30. Hypothermia

31. Hypothermia
Hypothermia (CBT less than 95º F [35º
C]) may result from:
A decrease in heat production
An increase in heat loss
A combination of these factors

32. Hypothermia
Progression of clinical signs and symptoms
may be divided into three classes
Mild (core temperature between 93.2º
and 96.8º F [34º and 36º C])
Moderate (core temperature between 86º
and 93º F [30º and 34º C])
Severe (core temperature below 86
degrees F [30º C])

33. Hypothermia
Heart and brain most affected
Bradycardia, arrhythmias as get colder
CNS depression, abnormal EEG at temps
<30 degrees C, EEG shows signal similar to
brain death 19 - 20 degrees C

34. Frostbite

35. Frostbite
A localized injury that results from
environmentally induced freezing of body
tissues
Pathophysiology
Predisposing factors

36. Frostbite Classifications/Symptoms
A common classification separates cold
injury into three categories
Frostnip (the mildest form of cold
exposure) may be treated without loss of
tissue
In superficial frostbite, there is at least
some minimal tissue loss
With deep frostbite, there is significant
tissue loss even with appropriate therapy

37. Superficial Frostbite
Some freezing of epidermal tissue
Initial redness followed by blanching
Diminished sensation

38. Deep Frostbite
Freezing of epidermal and subcutaneous layers
White appearance
Hard (frozen) to palpation
Loss of sensation

39. Frostbite
Edema and blister formation 24 hours after
frostbite injury in area covered by tightly
fitted boot

40. Frostbite
Gangrenous necrosis 6 weeks after frostbite
injury

41. Frostbite
Remove wet clothing
Do not rub extremities
Wrap in blanket
Rapid re-warming in tub of
water (40o C) or warm, wet
packs
Thaw 20 - 40 minutes - distal
tip flushes
Auto-amputation (1 - 2 months)

42. Submersion

43. Submersion
Hypothermic considerations
Common concomitant syndrome
May be organ protective in cold-water
submersion
Always treat hypoxia first
Treat all submersion patients for
hypothermia

44. Factors That Affect Clinical
Outcome
Factors that can affect clinical outcome
after a submersion incident
Temperature of the water
Length of submersion
Cleanliness of the water
Age of the victim

45. Submersion Incident
Management
ABCs
Trauma considerations
Immersion episode of unknown etiology warrants
trauma management
Post-resuscitation complications
Adult respiratory distress syndrome (ARDS) or
renal failure often occur post-resuscitation
Symptoms may not appear for 24 hours or more
post-resuscitation
All submersion patients should be transported
for evaluation

46. The stickmen face a horrible choice
Questions...?

47. Cases

48. Case #1
78 y.o. female brought in by EMS for
weakness and altered mental status
Found to have urosepsis, with a temperature
of 34.8o C

49. Case #1
Usually elderly with low reserves
Vasodilation secondary to infection
Poorly functioning CNS and endocrine system
Independent predictor of mortality

50. Case #2
28 y.o. male picked up
by law enforcement
after being found
walking along the
highway at 2 in the
morning

51. Case #2
Treat frostbite
... But, severe
hypothermia....
Bair hugger
IV, peritoneal,
bladder, chest
rewarming
Cordis, DPL, foley,
chest tubes

52. Case #3
16 y.o. male brought in with altered mental
status the morning after partying all night
with friends
Blood sugar of 25 when found, with body
temperature of 35o C, (spent night outdoors
in barn)

53. Case #3
Pediatric livers have low glycogen stores
Alcohol causes starvation state
Glycemic stores used
No gluconeogenesis
Leads to clinical triad of: coma,
hypoglycemia, hypothermia

54. Case #4
54 y.o. male with
witnessed cardiac
arrest, brought in by
EMS now with pulses
after AED used

55. Case #4
Therapeutic
hypothermia
Should start with
EMS
Keep on for 24
hours
Improved neuro
status on discharge

56. Things to Remember
Can have “indoor” hypothermia
Triad of coma, hypoglycemia and
hypothermia
Rapid rewarming of extremities with no
rubbing

57. Thank you!
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