You're not dead til you're warm and dead? Or are you?

[kat82]

Hi friends- as winter is upon us I wanted to see how you managed severe hypothermia with cardiac arrest. Every year I seem to get a case of a homeless person who was likely intoxicated and froze to death. These people are brought in by EMS with core temps in the 20's (celsius) and we seem to code them forever while trying to rewarm them only to decide a couple hours in that its futile. I had a young guy last month who likely had an arrhythmia while sitting on his front porch and came in with a core temp around 30 but I believe rigor mortis had started to set in so we stopped before we could fully warm him.

Anyway, when is it ok to decide that rewarming is futile? I see many people go on for hours using crazy measures and then eventually give up. We always use the thumper in these cases b/c we cant stand at the bedside doing CPR and let the rest of the dept fall apart.

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[RPedigo]

If the history is that they died and then subsequently got cold, there is no role for resuscitation. There are some case reports of children being able to be cooled quickly enough by falling into ice water and drowning and cooling at the same time (submersion), but in general nobody can cool fast enough after they died in the environment to be salvageable. However, if you think they arrested because they were cold (e.g., an immersion situation, or just from exposure), then I would definitely continue resuscitation. I wrote a little blog post on this topic for EMDocs which can be found here: http://www.emdocs.net/hypothermia-and-drowning-pearls/ which includes the suggested algorithm from the NEJM review which is really nice here: http://www.emdocs.net/wp-content/uploads/2015/04/Hypothermia.jpg

The algorithm above I think is a good guideline, but agree that it is tricky when the history is nebulous and would love the input of others too.

 

[dotcb]

In case you need some motivation...

 

[deleted245139]

Abg and potassium level... Call it over 12 (or 14 depending on resource)

 

[swamprat]

Abg and potassium level... Call it over 12 (or 14 depending on resource)

Was that info from an emrap? This seems familiar but idk where I would have learned it

 

[deleted245139]

Was that info from an emrap? This seems familiar but idk where I would have learned it

A few papers on it. Started lower (historically 10 or somewhere around there) but isolated cases of survival so they nudged it up. Ecmo in capable centers have upped the ante of survival extremes... That said, the patient has to make it to the center. That said, I believe I heard it on emrap too haha. Aug time? Or maybe I was just mowing my lawn at the time haha

 

[deleted109597]

Agree that the rule should be "did they die and get cold, or get cold and then 'die' ".
http://ebmgonewild.com/predicting-survival-avalanches/

Better research shows nobody lives with a K above 7 mEq or mmol/L.
http://ebmgonewild.com/really-warm-dead/

 

[deleted245139]

Anyone on dialysis will show you that >7 is survivable...

Never mind... The article implied >7 in the setting of arrest. . that said, push Ca and see where you get. 10 seems reasonable from all the data I've seen. The hypothermia data suggests slightly higher is tolerated (12) with aggresive measures. The NEJM article above is excellent