Cardiac arrest for a hypothermic patient

KevinEMT

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Regarding test questions if I had a patient in cardiac arrest in the snow I would probably bring them into a warm environment ie the ambulance then perform CPR instead of doing CPR in a cold environment? They ain't dead til they're warm.
 

VentMonkey

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Are you asking us, or telling us, Kev? What would you do? Why would you do it? Is there a threshold (time frame) to take into account with this patient population, or any other special considerations?
 

DesertMedic66

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What he said
 

cprted

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If someone has been in the snow and has a core temp in the 20s (Celsius), how much do you think being in the back of a warm ambulance will actually impact their core body temperature? Not at all. If we think they're in cardiac arrest secondary to hypothermia (they're in arrest because they're cold, not they arrested and got cold afterward), this is a viable patient, even with a prolonged down time. They should be transported to an ECMO capable facility.
 

E tank

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If someone has been in the snow and has a core temp in the 20s (Celsius), how much do you think being in the back of a warm ambulance will actually impact their core body temperature? Not at all. If we think they're in cardiac arrest secondary to hypothermia (they're in arrest because they're cold, not they arrested and got cold afterward), this is a viable patient, even with a prolonged down time. They should be transported to an ECMO capable facility.
Had a drunk co-ed pass out on a hiking trail in jeans and a tank top and was found in the morning, asystolic, literally frozen to the ground by some hikers ('magine that). Core temp hi teens. Dead dead. Brought to us and put on cardiopulmonary bypass and rewarmed until she fibrillated. Defib'd once, returned to 36.5, taken off of bypass and sent home the next day.
 

VFlutter

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Had a drunk co-ed pass out on a hiking trail in jeans and a tank top and was found in the morning, asystolic, literally frozen to the ground by some hikers ('magine that). Core temp hi teens. Dead dead. Brought to us and put on cardiopulmonary bypass and rewarmed until she fibrillated. Defib'd once, returned to 36.5, taken off of bypass and sent home the next day.
Just like patients in DHCA. It is amazing what the body can tolerate when hypothermic.
 

VentMonkey

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This is all good stuff guys, but perhaps a bit over the OP's head; still fascinating though.
 

VFlutter

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It's totally fine to move the patient into the ambulance before initiating CPR/ACLS. I wouldn't want to do CPR in the snow. You will never get ROSC while they are cold, no point in working them outside.
 

EpiEMS

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It's totally fine to move the patient into the ambulance before initiating CPR/ACLS.
Just curious...why* is this the case? ECC guidelines indicate "If the hypothermic victim has no signs of life, begin CPR without delay." Not to imply that ECC guidlines are state of the art science, or anything. Indeed, I found one paper (here's a PPT summary) which suggested that CPR can be delayed for a couple of minutes in such cases, with the time delay dependent on the profundity of hypothermia. (Also, here's a nice review.)

*I'm presuming more or less that brain oxygen demand falls so we don't worry so much about hypoxic (or anoxic) brain injury? Or something along these lines?
 

Summit

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How far is the ambulance? Did you drive up to someone in the snow on the side of the road where they passed out drunk walking home from the bar last night?
OK we can take 2 minutes to move them carefully to the ambulance before pounding them.

Did you respond 2 miles up the trail for someone who passed out in an OD suicide attempt and was found by hikers?
Let's do CPR now and during transport. Did anyone bring an Autopulse and some extra batteries?

Avalanche victim?
Totally different algorithm to decide if we work them or not

Anyway... transport to ECMO/CPB center
 

VFlutter

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Just curious...why* is this the case? ECC guidelines indicate "If the hypothermic victim has no signs of life, begin CPR without delay." Not to imply that ECC guidlines are state of the art science, or anything. Indeed, I found one paper (here's a PPT summary) which suggested that CPR can be delayed for a couple of minutes in such cases, with the time delay dependent on the profundity of hypothermia. (Also, here's a nice review.)

*I'm presuming more or less that brain oxygen demand falls so we don't worry so much about hypoxic (or anoxic) brain injury? Or something along these lines?
Profoundly hypothermic patients tolerate being pulseless for extended periods of time because of what you mentioned, lower metabolic demands. Hypoythermia is neuro-protective. This is why we hear about people being down for long periods of time outside without neurological deficits and why we induce hypothermia post cardiac arrest. I mentioned DHCA to show that in the OR we put people into complete circulatory arrest for up to an hour.

Having said that, there is no way you are going to get ROSC on a hypothermic patient until they are rewarming. Taking the few minutes to quickly move the patient into a controlled environment is not going to harm them and doing CPR during that time will have little if any benefit. If you have ever done CPR on a frozen patient with a rigid chest it is extremely difficult and tiring along with being outside in the cold there is nothing effective about it. Get them to a warmer enviroment, for both you and the patient, and being your treatment and rewarming. Just my opinion, may not be what the guidelines say.
 

EpiEMS

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@Chase, thanks for the clarification.

I haven't yet dealt with a profoundly hypothermic arrest patient, but it makes sense that it'd be quite effortful!
 

VentMonkey

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OP, if you're still lurking hopefully you took down some of these wicked-sweet notes and looked into them yourself.

While some might be a bit beyond the basic EMT course material, you have zero excuses to no longer not understand physiologic differences in a hypothermic cardiac arrest from here on out.
 

NysEms2117

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The one and only hypothermic patient i ever "treated" (im not the primary provider) got buried by a snow plow. was an older man(late 60's), he had a boot on for a broken foot(why he couldn't get out i think). Very first thing we did, get him out and into the rig, exact opposite of what your "told", but patient success>protocols in my book any day.
 

DrParasite

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serious question: so if you find a frozen person down, do you do CPR on them while they go to the hospital? or just let the ER know you are bringing in a frozen body with L&S and let them know they are going to be dethawed when they get there? Are there any interventions that you could or should do that would be a positive benefit to the patient?
 

VFlutter

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serious question: so if you find a frozen person down, do you do CPR on them while they go to the hospital? or just let the ER know you are bringing in a frozen body with L&S and let them know they are going to be dethawed when they get there? Are there any interventions that you could or should do that would be a positive benefit to the patient?
IRRC body temp < 30 Celsius you limit all interventions until above 35. So Epi x 1, no other medications. Minimal defibrillation until above 35. Longer intervals between meds. Monitor and treat hyperkalemia and hypoglycemia. I'll link an actual protocol.
 

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