Hypothermia 4 ways & What can we do to save more lives?

Posted on by DrM@WildernessEMC

I’m honoured and excited to have been asked to do  a presentation on 22 August 2018 for  the Canterbury & West Coast Emergency Care Coordination Team.

This is how they explain on their website what they do:

“The Emergency Care Co-ordination Team (ECCT) is a clinical network group that works across all pre-hospital and in-hospital emergency services to help resolve these challenges.  ECCT aims to ensure the patient receives the right care, at the right time, in the right place and from the right person.  The focus is to share knowledge and build relationships to provide a coordinated response for the patient.  An example is addressing issues relating to inter-hospital transfer of patients by air ambulance.  The team works together to provide a patient-focused, seamless service which will enable all New Zealanders to gain timely and appropriate access to emergency services required to manage:

  • Trauma
  • Medical and surgical emergencies
  • Complicated births”

 

Thus “Hypothermia 4 ways” means Hypothermia of patients indoors, patients outdoors, patients who have sustained trauma and who develop trauma induced coagulopathy (TIC) where mild hypothermia aggravate the situation and lastly, hypothermia caused by avalanche burial.

The resources and references I referred to in my presentation are posted below.

 

I thoroughly enjoyed the opportunity to share my research as well as  the practical things, like costing of equipment,  with a highly invested and forward planning audience.

Best of all for me, both the environmental temperature and the lights in the room were OK.It is always good not to paralyse  ( I have  unpredictable Hypo Kalaemic Periodic Paralysis ) or get expressive aphasia as a prodrome to an episode,  during a presentation! My plan B was to just refer to this web site post if I had become incapacitated.

 

My research paper:   NZ Accidental Hypothermia:Who freezes to death and what can we do to save more lives? (fully referenced)

 

Hypothermia 4 ways: Slides of presentation

Additional references for slide 10:

1)DanzlD. Accidental hypothermia. In: AuerbachPS, ed. Wilderness Medicine 6th ed. Philadelphia, PA: Elsevier; 2012:116–142.

WMS consensus guidelines for the treatment of hypothermia – 2015

2)JurkovichG, GreiserW , Luterman:Hypothermia in trauma victims: an ominous predictor of survval  J Trauma 1987 (link lower down on page)

3)Accidental hypothermia in severe trauma Fanny Vardon,  SegoleneMrozek, Thomas Geeraerts, Olivier Fourcade,  ACCPM 141 2016 ( link lower down on page)

4) Preventing post injury prehospital hypothermia 2002 prehospital and disaster medicine Husum et al (tropical combat)

Reference for slide 11:

5) Battlefield Trauma Induced Hypothermia ( link  lower down on this page)

Hypothermia 4 ways: Transcript of slideshow

 

I haven’t covered Trauma Induced Coagulopathy  (TIC) in any great detail in previous blog posts, so here is a whole bunch of relevant references. The first 3 are just about TIC, good introductions if it is a new concept to you.

Mechanisms of Trauma Induced Coagulopathy

This is a 2013 article which can be read as a good introduction to the several interconnected mechanisms introducing the role of the endothelium.

 

Acute traumatic coagulopathy and trauma-induced coagulopathy: an overview

Tis is a straightforward 2017 article which clearly defines endogenous and exogenous influences in the coagulopathy pathways. Table 1 is great as is diagram 2 .It mentions overall increased mortality but nothing specific to hypothermia

 

Advances in the understanding of trauma-induced coagulopathy

This is a 2106 article with a more complex, really good diagram. It mentions Tranexamic acid and the CRASH-2 trial

 

The next three articles are Hypothermia specific:

Accidental Hypothermia in severe trauma

This is a very easy to read 2016 article. It includes, cardiac, immunosuppressive and other effects of hypothermia on the trauma patient. Mortality statistics on page 4, haemostasis  page 8 . It also mentions the ROTEM/ TEG  clot strength testing procedure. For TEG (which Christchurch Operating Theatre suite has) the analysis needs to be done at the patient core temp rather than at the standard testing temp of 37*C. (Much harder to change temperature for ROTEM analysis and is therefore less ideal)

 

Hypothermia in Trauma

2012 article, very easy to read. Some of the  coagulation details are a little out of date now but overall pretty good.

Battlefield Trauma-Induced Hypothermia: Transitioning the Preferred Method of Casualty Rewarming

This is a 2017 article, it has several very good mortality statistics on  page 84. and the introduction is good.

However,  the benefits of the chemical heating pads with a vapour barrier  marketed as the HPMK (hypothermia Prevention and management kit) might easily be misunderstood: It is not capable of actively rewarming a hypothermic patient. However , it can help to reduce further cooling and development of trauma induced  hypothermia ( i.e. injured but normothermic to start with ). As long as the difference is understood, I am happy. ( also see video  posted just below KPI of BritishMilitary Trauma)

Hypothermia in Trauma Victims:An Ominus Predictor of Survival

This is a 1987 paper which is widely cited with regards to survival rates

 

Evolving beyond the vicious triad: Differential mediation of traumatic coagulopathy by injury, shock, and resuscitation

2015 article discussing endogenous coagulopathy factors. Really good list of references.

 

Other items of possible interest

Key performance Indicators of British Military Trauma

Note : Pre Hospital hypothermia prevention and core temp 36*C or above on arrival

Tactical Field Care Trauma Hypothermia Prevention video

This June 2018 video is pretty good, 1 min 30 seconds in they stress the most salient point. You can buy these kits  for US$ 100 online or NZ$274 from Pharmaco (price correct as of  9 August 2018)

 

Bloodwarmer Buddy Lite

There are many other small ,portable devices which are not licensed for use in NZ.THis one is and is currently in use by Auckland HEMS

 

Braun Thermostat 6000 pro specifications& manual

This is a low reading ( core temp 20*C) epitympanic infrared thermometer which removes the errors caused by environmental temperature by measuring the ambient temperature separately and using an algorithm to reach the actual core temp. Pretty cool ,sold in NZ by Welch Allen and costs about NZ$ 350.

 

Geratherm Resc+ portable electric patient torso warming blanket

This is currently being used by Christchurch Westpac Rescue Helicopter with very good results. I strongly believe every rescue helicopter and road ambulance should be equipped with these or similar devices.

 

Austrian man survives after being buried by avalanche for 10 hours

I also referred to the ICAR checklist and my LandSAR flowchart, they are both posted on my  “Avalanche  SARex”  post, just scroll down and you will find it.

The Polish Accidental Hypothermia Cardiac Arrest video showing the chain of rescue and use of ECMO which I referred to in my presentation  is on the “Christchurch ED post”, scroll down a little further.

I hope today’s meeting will open the channels for  further discussion and collaboration  with regards to management of accidental hypothermia in NZ in general and the West Coast and Canterbury in particular , please do not hesitate to get in touch with me.

Cheers, Malin

malinzachau@yahoo.com