Treatment for patient with Moderate hypothermia and Major Frostbite

johnrsemt

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I had a patient last week with Moderate hypothermia: 91.0 tympanic (ear); and major frostbite: both legs knees down.

He was picked up by the State Police for walking on the freeway (started walking fully clothed including boots) in the dark, about 15 deg. F, in slush at approx. 0500. Picked up at approx. 0730 15 miles away, walking in heavy fog, dark, against traffic (not a lot thankfully).

VS: B/P: 138/88, RR 36, HR 136. SpO2 94 room air.

We are supposed to actively warm up hypothermic patients, but not actively warm up frostbitten limbs.

Approx. 2 hour transport to closest hospital by ground. No chance at flying him due to weather

Thoughts, comments?
 

luke_31

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Passive rewarming and if you have warm saline I’d give a liter and monitor the temperature rectally if possible.
 

Peak

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In stable patients with mild hypothermia (32 - 35 C) the current recommendations are to allow for passive rearming with a goal of 0.5 to 2 C per hour.
 

Bishop2047

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This has a pretty good First Aid/Prehospital treatment plan. Also runs through the best care in hospital.

I have been ordered by a few OLMC to give ASA and Ibuprofen (Prostaglandin Effects) and this paper mentions that in the Prehospital world also.

I work in the arctic regions of Canada on an air-amb so frostbite is pretty common. Most important thing is that once you begin to warm the patient do not allow them to become cold again. Sounds easy but can be difficult on some of those remote rescue situations.

Keep those limbs dry and dressed if need be and as others have stated passive warming is better than hot packs.
 
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Gurby

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2 hours is plenty of time to call medical control and see if they have any comments/questions/concerns.
 

Summit

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To the burn center!
 
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johnrsemt

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We called the hospital that we were transporting to; tried to keep the limbs wrapped (patient was uncooperative on that, although he did keep a blanket on them for the most part)
Pt was picked up in socks and nothing else by troopers, and when we got there 10 minutes later they had him in blankets and he kept his groin covered (again for the most part). He was telling us and the troopers he was trying to get ran over by traffic to die.
ED doc told us to try for a liter of warm NS; keep the heat on in the back until he stopped shivering, then turn the heat down, try to keep the lower legs covered (which he ripped off as soon as we wrapped them {he was convinced we were going to cut them off}).
We got about 300mL of NS into him is all over about 2 hour transport. He laid fairly calmly as long as we didn't mess with him too much.

He admitted to Cocaine, Marijuana and alcohol use (lived in a state that Marijuana is legal).
Tox screen came back at the hospital with Meth and Opiates also, which from having transported him multiple times was more believable.

We got him to the hospital at approx. 1130, his feet and calves were purple; and I called them at 1740 for a patient update: the nurse said they had just released him to his mother and his feet and calves were black with large blisters; but he had a follow up appointment with a podiatrist for the following Monday and Friday.
I asked her why they released him when he was suicidal; and she said that he told the social worker that he didn't want to hurt himself. I reminded her that we told them he was walking into traffic trying to get hit. She said it didn't matter what we said, it mattered what she said.

2 days later he stabbed himself in the stomach, trying to kill himself because the pain in his legs was so bad, and he was out of the 10 days worth of pain meds that the 1st hospital given him. The crew from that night got him to another hospital by ground after a 130 transport alive. I don't know if he is out yet or not. He may have talked his way out, because he wasn't trying to kill himself, he just wanted the pain to stop.
 

Tigger

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To the burn center!
Yarp. But why can't we have any burn care in COS :(.

I had a similar patient last year. The events leading up to the frostbite are just too good to withhold, but entirely irrelevant. Which isn't stopping me from writing them.

A few times a year, the patient and his (I really hope step) sister would make a foray from the boons where I was working to Hotel Elegante in Colorado Springs. As you can guess, this hotel is not elegant. Once a room had been secured, the two of them would embark on a meth and alcohol fueled bender during which time some "great" relations of a more biblical nature would occur. After about three days, the patient tells me they would run out of drugs and money and skulk back to the boons and go about their separate lives at the family homestead.

This fateful night, the patient discovers some leftover meth, smokes it, and then according to his father "takes a pass at his sister." Rightfully perturbed, he calls the constabulary but of course this is nowhereville so the response takes over an hour. During this intermission, the patient takes the opportunity to down a bottle of bourbon and set out into the night. A pretty good winter storm has blown in, not a blizzard persay but a good'un.

Hours later, the patient returns to the residence. He's cold, drunk, and a little agitated. The sheriffs return to make peace, during which time they note some blood leaking out of the patient's pants leg. As they attempt to ascertain the source of bleeding by removing the patient's pants, they tear all of the skin off both legs from the kneecaps down to his ankles. Right down to the last level of dermis was my guess as his legs just sort of wept blood. He was also weeping, as you may have imagined.

In any case we were summoned and in addition to the above issues, he has actual frostbite to the periphery of the wounds. Oh and there are just piles of skin frozen into his pants laying next to him. I ended up wrapping his legs up with burn sheets, cranking the heat, and giving him a bit fentanyl along with some warmed fluids. He was immediately transferred to the burn center and I understand ended up doing ok.

Turns out, he got tangled in barbed wire fence and was too intoxicated to get out of a kneeling position. He eventually passed out in that position, woke up, realized he was cold, and walked home.
 

Peak

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He was telling us and the troopers he was trying to get ran over by traffic to die.
...
He admitted to Cocaine, Marijuana and alcohol use (lived in a state that Marijuana is legal).
Tox screen came back at the hospital with Meth and Opiates also, which from having transported him multiple times was more believable.
...
I asked her why they released him when he was suicidal; and she said that he told the social worker that he didn't want to hurt himself. I reminded her that we told them he was walking into traffic trying to get hit. She said it didn't matter what we said, it mattered what she said.

2 days later he stabbed himself in the stomach, trying to kill himself because the pain in his legs was so bad, and he was out of the 10 days worth of pain meds that the 1st hospital given him. The crew from that night got him to another hospital by ground after a 130 transport alive. I don't know if he is out yet or not. He may have talked his way out, because he wasn't trying to kill himself, he just wanted the pain to stop.
The role of inpatient psychiatric care is either med stabilize or provide a safe environment to those who fit emergency mental health hold or are certified by the state.

Patients who got high and then clear in the ED or inpatient medical environment and who do not at that time fit those criteria cannot be admitted. Not only would inpatient hospitalization not be appropriate, but it would be a violation of their constitutional rights.

If a patient is now competent to determine their care, what they were doing when they were high has no or very little impact on their competency. Often in the ED you will hear terms like drunk-icidal, meth-icidal, metabolize to freedom, metabolize to evaluation, and so on.

Likely the patient was offered options like admission to a burn center, admission to see plastic therapy, et cetera but refused. The doc probablt did the only thing they could with a now competent patient and discharge with return precautions and give follow up resources.
 
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