OUT OF THE COLD
RETURN TO CASE
Not knowing the mechanism of injury, your crew places the patient in
a cervical collar and logrolls him onto a long backboard before moving him to the stretcher and loading him into the rig. In the back of
the ambulance, you turn up the heat while your partner places the
patient on high-flow oxygen and connects the patient to the monitor. A quick glance at lead 2 shows atrial fibrillation at a rate of
28 bpm, and you palpate a correspondingly slow carotid pulse.
During the eight-minute transport time to the closest trauma
center, you place an IO in the left tibia and begin to infuse a saline
bolus per protocol. As you offload the patient and the stretcher locks
in the up position, you see on the monitor that the patient’s rhythm
has suddenly changed to v fib. You quickly charge the defibrillator,
deliver a shock, and begin CPR and BVM ventilations as you roll
into the trauma bay.
In the trauma bay, the initial ECG shows asystole and CPR is continued as the patient is intubated. An esophageal probe shows the patient
has a temperature of 84.6 degrees F ( 29. 2 degrees C). The trauma team
places two chest tubes in the patient’s left chest and begins lavage of
the thoracic cavity with warmed saline.
After 65 minutes of CPR and continuous left chest lavage, the
patient re-develops v fib as his core temperature reaches 93.5 degrees
F ( 34. 2 degrees C) and he’s shocked into sinus tachycardia with pulses.
Laboratory testing reveals that his blood ethanol level was four times
the DUI limit at the time of his ED arrival. His head CT scan shows
no intracranial injury and he’s admitted to the ICU.
After a weeklong hospitalization, the patient is discharged to a
rehab facility for intense therapy. He remains moderately cognitively
impaired, but is able to perform normal daily activities such as feeding and bathing himself. JEMS
Daniel Du Pont, BA, EMT, is a fourth-year medical student at the University of Pennsylvania and
an EMT at Radnor Fire Company in Wayne, Pa. Contact him at firstname.lastname@example.org.
Edward T. Dickinson, MD, NRP, FACEP, is interim department chair and a professor of Emergency Medicine at the hospital of the University of Pennsylvania. He serves as the director of
EMS field operations at University of Pennsylvania Department of Emergency Medicine, and
medical director of PennStar Flight Division of Trauma and Critical Care at the Department of
Surgery at the University of Pennsylvania School of Medicine. He also serves as the medical
editor of JEMS and on the JEMS Editorial Board.
Learn more from Edward Dickinson at the EMS Today Conference, Feb. 21-23,
in Charlotte, N.C. EMS Today.com
1. Danzl D: Accidental hypothermia. In Auerbach P (Ed.), Wilderness medicine, 5th edition. Mosby
Elsevier: Philadelphia, pp. 125–160, 2007.
2. Baumgartner EA, Belson M, Rubin C, et al. Hypothermia and other cold-related morbidity emergency department visits: United States, 1995–2004. Wilderness Environ Med. 2008; 19( 4):233–237.
3. Centers for Disease Control and Prevention (CDC): Hypothermia-related deaths: United States,
2003–2004. MMWR Morb Mortal Wkly Rep. 2005; 54( 7):173–175.
4. Lapostolle L, Couvreur J, Koch F, et al. Hypothermia in trauma victims at first arrival of ambulance
personnel: an observational study with assessment of risk factors. Scand J Trauma Resusc Emerg
Med. 2017; 25( 1): 43–48.
5. Centers for Disease Control and Prevention (CDC): Hypothermia-related deaths: United States, 1999-
2002 and 2005. MMWR Morb Mortal Wkly Rep. 2006; 55( 10):282–284.
6. Díaz M, Becker DE. Thermoregulation: Physiological and clinical considerations during sedation and
general anesthesia. Anesth Prog. 2010; 57( 1): 25–32.
7. Crawshaw L, Wallace H, Dasgupta S: Thermoregulation. In Auerbach P (Ed.), Wilderness medicine,
5th edition. Mosby Elsevier: Philadelphia, pp. 110-124, 2007.
8. Marieb E, Hoehn K: Human anatomy and physiology, 8th edition. Pearson Benjamin Cummings:
San Francisco, pp. 953, 2010.
9. Charkoudian N. Mechanisms and modifiers of reflex induced cutaneous vasodilation and vasocon-
striction in humans. J Appl Physiol. 2010;109( 4):1221–1228.
10. Zafren K, Mechem CC. (March 30, 2017.) Accidental hypothermia in adults. Up ToDate. Retrieved
July 16, 2017, from www.uptodate.com/contents/accidental-hypothermia-in-adults.
11. Durrer B, Brugger H, Syme D, et al. The medical on-site treatment of hypothermia: ICAR-MEDCOM
recommendation. High Alt Med Biol. 2003; 4( 1):99.
12. Hanania NA, Zimmerman JL. Accidental hypothermia. Crit Care Clin. 1999; 15( 2):235–249.
13. Mizukami H, Shimizu K, Shiono H, et al. Forensic diagnosis of death from cold. Legal Med.
1999; 1( 4):204–209.
14. Ginsberg M, Globus M, Dietrich W, et al. Temperature modulation of ischemic brain injury: A syn-
thesis of recent advances. Prog Brain Res. 1993;96: 13–22.
15. Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-cardiac arrest care: 2015 American Heart
Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation. 2015;132( 18 Suppl 2):S465–S482.
16. Doshi H, Giudici M. The EKG in hypothermia and hyperthermia. J Electrocardiol. 2015; 48( 2):203–209.
17. Bessen H, Ngo B: Hypothermia. In Tintinalli J, Stapczynski JS, Ma OJ, et al. (Eds.), Tintinalli’s emer-
gency medicine: A comprehensive study guide. McGraw-Hill Education: New York, 2016.
18. Gerecht R. Trauma’s lethal triad of hypothermia, acidosis & coagulopathy create a deadly cycle for
trauma patients. JEMS. 2014; 39( 4): 56–60.
19. Perlman J, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 international consen-
sus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment
recommendations. Circulation. 2015;132( 16 Suppl 1):S204–S241.
20. Lapostolle F, Sebbah JL, Couvreur J, et al. Risk factors for onset of hypothermia in trauma victims:
The Hypo Traum study. Crit Care. 2012; 16( 4):R142-149.
21. Perlman R, Callum J, Laflamme C, et al. A recommended early goal-directed management guideline
for the prevention of hypothermia-related transfusion, morbidity, and mortality in severely injured
trauma patients. Crit Care. 2016; 20( 1):107–117.
22. Brown DJ, Brugger H, Boyd J, et al. Accidental hypothermia. N Engl J Med. 2012;367( 20):1930–1938.
23. Reuler JB. Hypothermia: Pathophysiology, clinical settings, and management. Ann Intern Med.
24. Lexow K. Severe accidental hypothermia: Survival after 6 hours 30 minutes of cardiopulmonary
resuscitation. Arctic Med Res. 1991; 50 Suppl 6:112–114.
25. Dobson J, Burgess J. Resuscitation of severe hypothermia by extracorporeal rewarming in a child.
J Trauma. 1996; 40( 3):483–485.
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