A little confused regarding sever hypothermia.

[ghurty]

I was looking through a PHTLS book, and comparing it to my EMT book and it got me a little confused regarding a severe hypothermic patient in cardiac arrest.

In my EMT book (Brady 10th edition) “Assess the carotid pulse for 30 – 45 seconds. If there is no pulse, start CPR immediately and prepare to apply the AED”

In the PHTLS book it says that you should not start CPR or defib until VF has been verified.

So what does that mean for me as an EMT-B: If I come upon a PT that has an extremely low body temperature and no pulse, do start CPR and hook up an AED or wait to verify that the PT is in VF.

Also in the PHTLS book it states not to stick any airway adjutants. But there is no mention of this in my EMT book. The PHTLS book is from ’94 if that makes any difference.

Thanks

[Ridryder 911]

Okay, if you do not have a AED or monitor you cannot assess for V-fib, so if you can't assess you start CPR. The reason for "no-airway, etc. is vigorous movement and as well as intubating can vagal the patient down (slow down a pulse rate, etc.) so one has to be very cautious on true hypothermic patient on the type of care. I suggest you read the special considerations from American Heart Association Health Care Providers book and that portion of ACLS and the new edition of PHTLS as well. It may be more advanced, but will give you some insight of current treatment and why.

The main point on truly of hypothermic patients .. "their not dead, until they are warm and dead"....

R/r 911

[AZCEP]

The 1994 version of any text should be used as the most general of references. Too many things have changed to make the information that it contains worth following. Current recommendations are to perform 2 minutes of compressions, hypothermia or not.

An AED will also deliver a shock when it is determined a shockable rhythm is present. To the best of my knowledge, AED's do not have hypothermia considerations in their programming. They will work the same way they always do without using the presence of hypothermia as a determinant.

[canadian_ghost]

When we come across a severe hypothermic patient I am suppose to check a carotid pulse for no more than one minute, if no pulse is detected then I am to go into CPR immediately for a minimum of 2 minutes before applying the AED, after that we are only allowed to deliver one shock from the AED, if it is unsuccessful then we just go back to CPR until we either get an ALS intercept or get to the ER. Also no airways are to go in because of movement. Other than that we just get them as warm as possible into the ambulance.

Hope this helped somewhat :?

[DwayneEMTP]

I believe in the new ACLS is says CPR (2min), one shock if indicated, then CPR without further shocks until the body warms to a core temp of 30C. And no adjuncts for the above stated reasons...

Have a great day!

Dwayne

[fiznat]

I think they want you to be really careful with these patients because when the body gets that cold, the heart - if it is not already there - is VERY likely to go into VF. ACLS reminded us to treat these patients as carefully as possible- meaning even avoiding excess jostling and movement. Second, very bradycardic or hypotensive patients with cold, hardened skin may not have a detectable pulse, even if one does in fact exist. Starting CPR in this situation could instigate VF out of a (semi) perfusing rhythm, which is obviously not the thing to do.

Honestly I would not want to ever mess with one of these patients without a monitor so I could actually see what was going on, but I suppose as an EMT I would like to put the AED on first to find out if the rhythm is shockable-- if it is, then shock away and do CPR (30-40 compressions/min), but otherwise... I donno... Be REALLY sure about pulselessness (check carotid/femorally, and anywhere else you can think of, use your scope for heart sounds, anything) before I started CPR.

I forget if they said to shock only once or to continue shocking. Pretty sure they said continue shocking as normal. I do remember though that you are supposed to give only one round of meds, if at all, because the metabolism of the compounds is so much slower when the body is that cold. Our protocols specifically offer the advice that successful resuscitation without CNS complications has been accomplished in patients with a core temperature less than 70*F, so "once you have CPR - do not give up!"

[Just Plain Ruff]

maybe getting a book that is less than 20 years old for your reference.

I'd go out and get the new edition of the book you are reading and review that on instead of the one you have.

Good luck on your learning, shows you are looking outside the box on illness rather than taking at point blank what you read.

Keep up the good work.

[DwayneEMTP]

http://circ.ahajournals.org/cgi/content/fu...24_suppl/IV-136

"For unresponsive patients or those in arrest, endotracheal intubation is appropriate. Intubation serves 2 purposes in the management of hypothermia: it enables provision of effective ventilation with warm, humidified oxygen, and it can isolate the airway to reduce the likelihood of aspiration.

ACLS management of cardiac arrest due to hypothermia focuses on more aggressive active core rewarming techniques as the primary therapeutic modality. The hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation.9 In addition, drug metabolism is reduced. There is concern that in the severely hypothermic victim, cardioactive medications can accumulate to toxic levels in the peripheral circulation if given repeatedly. For these reasons IV drugs are often withheld if the victim’s core body temperature is <30°C (86°F). If the core body temperature is >30°C, IV medications may be administered but with increased intervals between doses.

As noted previously, a defibrillation attempt is appropriate if VF/VT is present. If the patient fails to respond to the initial defibrillation attempt or initial drug therapy, defer subsequent defibrillation attempts or additional boluses of medication until the core temperature rises above 30°C (86°F).9 Sinus bradycardia may be physiologic in severe hypothermia (ie, appropriate to maintain sufficient oxygen delivery when hypothermia is present), and cardiac pacing is usually not indicated. "

Have a great day!

Dwayne

[ccmedoc]

"For unresponsive patients or those in arrest, endotracheal intubation is appropriate. Intubation serves 2 purposes in the management of hypothermia: it enables provision of effective ventilation with warm, humidified oxygen, and it can isolate the airway to reduce the likelihood of aspiration.

ACLS management of cardiac arrest due to hypothermia focuses on more aggressive active core rewarming techniques as the primary therapeutic modality. The hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation.9 In addition, drug metabolism is reduced. There is concern that in the severely hypothermic victim, cardioactive medications can accumulate to toxic levels in the peripheral circulation if given repeatedly. For these reasons IV drugs are often withheld if the victim’s core body temperature is <30°C (86°F). If the core body temperature is >30°C, IV medications may be administered but with increased intervals between doses.

As noted previously, a defibrillation attempt is appropriate if VF/VT is present. If the patient fails to respond to the initial defibrillation attempt or initial drug therapy, defer subsequent defibrillation attempts or additional boluses of medication until the core temperature rises above 30°C (86°F).9 Sinus bradycardia may be physiologic in severe hypothermia (ie, appropriate to maintain sufficient oxygen delivery when hypothermia is present), and cardiac pacing is usually not indicated. "

Have a great day!

Dwayne

Yup! That about covers it. Sounds good... =D>

Hypothermic patients should be handled carefully. In the event of ROSC in a hypothermic full arrest, Jarring movements can initiate v-tach or v-fib until the patient is rewarmed adequately. Right on Fiznat

[AnthonyM83]

Where did this 30-40 compressions per minute number come from? I want to confirm with others it's a rate I should follow