We're back with more chilly sauce from Doug and Mel. That guy in the woods who's got no vitals? Forget him, we dealt with him in the last segment. We're talking about the guy next to him with hardly a pulse. Doug gives you the skinny.
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David W. - January 1, 2014 2:09 PM
I wanted to thank EMRAP of another very good presentation of information, insight and depth.
I have a silly question.
Is there any difference or value one way or the other to utilizing an IO rather than an IV in this case?
My thoughts would be to attempt to establish an EJ if possible, at my level as just a paramedic, however should that option not be available the question of IV vs. IO is one that I was wondering about.
Any further insights would be appreciated.
Thank you again!
David W. - January 1, 2014 5:16 PM
One final follow up question.
With the hypothermia induced patient, there is slower progression to temperature change.
- Is there a similar recommendation to the rewarming of the accidental hypothermic patients?
- And, is there a limit to the amount of fluid that can be given, or what rate would be best to aim for to improve the patients temperature?
Again, thank you for the information.
brendan c. - January 7, 2014 8:57 AM
At our shop we use an endovascular cooling device, Cool Guard, for our post-cardiac arrest patients.
Last year I had a profoundly hypothermic pt with a carotid and femoral pulse a fib, rate =30. We used to the Cool Guard to give pressors and rapidly re-warm the patient.
Just another idea for those with these catheters who want to avoid a traditional invasive approach. It works really well. It is 2 degrees and I am off to my next shift, if it happens again I'll record how long it takes to get them back to normal temp.
Thanks EM-RAP for the timely pod-cast!
Brendan in Bethesda, MD
David K. - January 10, 2014 7:38 AM
Thanks for the great talk, and hi from Winnipeg.
A clinical scenario I want to ask about, one that I've seen discussed a couple times in the last month.
Patient comes in hypothermic around 28-29 degrees Celsius. Monitor shows organized activity but no pulses palpable.
I have had a couple colleagues say they won't start CPR if there is an organized rhythm because it will likely irritate the myocardium, and the lack of pulses is from the vasoconstriction. I would think to lay the ultrasound probe on and see if there is any mechanical organized activity.
Anyone's thoughts on management when electrical activity on monitor but no pulse?
John D. S., MD - January 14, 2014 6:22 AM
I disagree with the position of your colleagues. No central pulse = inadequate perfusion and CPR should be started. Dr. Brown states the same recommendation in this interview with Mel.
IO is a last resort rescue access technique with a list of disadvantages over IV access, be it peripheral, EJ or central. I would always go for IV of IO unless time or speed of access became a barrier to IV access.
Patient rewarming is accomplished by ECMO or CPBP, the rate of which is limited by the modality, not therapeutics to the best of my knowledge. Warm IV fluids and other non invasive or minimally invasive techniques only limit further heat loss; they do not warm the patient.
Quantity of IVF should be tailored to the clinical situation. Clearly, as these patients are warmed, they are going to require significant volume resuscitation as they third space and go into hypovolemic shock.
GHS, MD - January 15, 2014 7:26 AM
Is there a protocol or recommendation for microwaving fluids to use during rewarming? It is mentioned as an option in the podcast but how to determine you don't overwarm the fluid and cause additional issues
Aaron A. - January 20, 2014 3:58 PM
David W., IO is a rescue but I don't see significant disadvantages versus an IV. We usually hang fluids via pressure bag if going through an IO, as there is some resistance even with an initial push of 10 cc of NS on placement, but you can deliver blood, fluid, or pressors through an IO just like you can through an IV. I'd be interested to hear John D's 'list'; it's a good extra tool if you need quick access.
That said, neither is as reliable as a good central line. I was always taught to use low lines in hypothermia, but a femoral line is usually a pretty quick procedure, and a venous re-warming catheter could achieve a lot more than an IO or peripheral IV until the patient gets to ECMO.
Aaron A. - January 28, 2014 8:16 PM
Just used an intravascular temp device that had a patient who came in at 80F up to 85F prior to transport to the ICU; these are a viable alternative if ECMO is not indicated (this patient was 'stable' with slow a fib and expected hypotension). Great lecture, really helped get my mind around this patient.
Kevin E., M.D. - May 31, 2014 10:23 AM
i practice at a level 2 trauma center in montana with cool/ cold water and every spring there is 1-3 drownings in the local rivers. we routinely face the decision tree of whether to initiate the whole rewarming protocol or not. it seems to me that our spring run off is never cold enough to cool someone fast enough before they are killed by drowning. it sounds like from this segement that submersion/ drowning + hypothermia, if no signs of life/ rhythm is 100% fatal. does anyone have a drowning protocol regarding when if at all to initiate any resuscitation?