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HYPOTHERMIAAlcoholRelatedIllnessHypothermia-AlcoholHypothermiaEpidemiologyPhysiologyofTemperatureControlEti

ologyofHypothermiaPathophysiology/TreatmentHypothermiaandTraumaAlcoholEthanolIntoxicationPathophysiology/TreatmentAlco

holAbuseHypothermiaEpidemiologyDefinedastemp<35OC(<95OF)>700dieeachyearinUSfromhypothermia½ofthoseare65+yearsoldIndi

vidualsatageextremesandthosewithAMSareatgreatestriskPhysiologyofTemperatureControlConductionTransferofheatbydirectcont

actdowntemperaturegradient.ConvectionTransferofheatbymovementofheatedmaterial.(i.e.wind)RadiationLossofheat

fromnon-insulatedareasH2OEvaporationLossofheatthroughexhalationTemperatureHomeostasisOppositionofHeatLossHypothalamusSt

imulationofsympatheticnervoussystemiftempbelow„setpoint‟BehavioralresponsesWearingclotheswhenit‟scoldLeavingcoldenvironmentHeatGa

inShivering“Non-shiveringthermogenesis”EtiologyofHypothermiaAccidentalImmersionandnon-immersioncoldexposureMetabolicHypoendocrinestate

s(hypothyroid,hypoadrenalism,hypopituitarism)HypoglycemiaHeadtraumaTumorEtiologyofHypothermia(cont.)Wernicke‟sdisease.Dr

uginducedAlcohol(majorityofhypothermicpt‟sinUSareintoxicated)SedativesPhenothiazinesInsulinSepsisEtiologyofHypothermia(cont.)Severedermaldisea

seBurnsExfoliativedermatitisAcuteincapacitatingillnessSevereinfectionsDKAPsychoticdisordersOtherconditionscausingimpairedtherm

oregulatoryfunctionResuscitationwithroomtemperaturefluidPathophysiologyMildHypothermia34-36̊C(93.2-96.8̊F)ExcitationPhysiologica

djustmentstoretainheatModerateHypothermia32-34̊C(89.6-93.2̊F)AdynamicMetabolismslowsDecreasedO2demandDecreasedCO2productionSevereH

ypothermia<32̊9(89.6̊F)ShiveringceasesPathophysiology(cont.)ExcitationSympatheticresponse(HR,BP,andC

ardiacOutputallrise).AdynamicHR,CO,BPdecreaseduetonegativeino/chronotropiceffectsofhypothermiaPathophysio

logy(cont.)HypothermicEKGchangesOsborneorJwavesT-waveinversionProlongedPR,QRS,QTintervalsArrhythmiasmayincludebrad

ycardia,slowAF,VF,orasystoleExample26°C28°C28.5°C29.5°CabcdPathophysiology(cont.)Pathophysiology(cont.)Systemi

cEffectsofProgressingHypothermiaPulmonary:TachypneaRR&TVBronchorrhea,gag/coughreflexCNSDiscoordinationconfusionlethargycomaFurther

deteriorationmaybecerebro-protectiveRenal“ColdDiuresis”duetorenalhypoperfusion3rdspacinghemoconcentrationemboliccomplicationsrh

abdomyolysis,etc.CoagulopathyTreatmentStopfurtherheatlossBeginwarmingprocessPassiveexternalwarmingActiveext

ernalwarmingActiveinternalrewarmingWarmedoxygenandIVfluidsTreatment(cont.)MaintainhorizontalpositionVerticalpositionmaycompromisecerebralandsyst

emicperfusionAvoidroughmovementsandactivitiesHandlevictimgentlyduringCPR,intubation,BVMventilation,vasculara

ccessTreatment(cont.)CardiacArrestIfVFpresent:Defibrillatex3prnETTw/warmed,humidifiedO2WarmedIVfluids(avoidoverhydration)Iftemp<30̊

C(86̊F)CPR,limitshocksx3WithholdIVmedsContinuerewarmingTreatment(cont.)CardiacArrest(cont.)Ifte

mp>30̊CCPRDefibprnascoretemprisesIVmedsasindicated(longerthannormalintervals)ContinuerewarmingduringtransportOtherTreatmentCo

nsiderationsAMSNarcan2mgIVThiamine100mgIVD50/W25gmIVifBGLTreatment(cont.)PassiveRewarmingRemovalfromenvironmentI

nsulationActiveCoreRewarmingInhalationrewarmingHeatedIVfluidsGItractlavageBladderlavagePeritoneallavagePleurallavageExtracorporealrewar

mingMediastinallavageActiveExternalRewarmingWarmH2OImmersionHeatingblanketsHeatedobjectsRadiantHeatForcedairRewarmingCautionAfter-dropPh

enomenonTemperaturedropandacidosisprovokeseriousarrhythmiasColdacidoticbloodcausesdropincoretempColdbloodfromdilatedperipheralvesselsca

rrieshighlacticacidlevelstocorevesselsPeripheralvasodilation(BPdrops)InitialactiveexternalrewarmingleadstoHypothermia–TraumaPt.Threemechanismst

hatcontributetohypothermia-inducedcoagulopathyintraumainclude:1.PlateletDysfunction2.EnhancedFibrinolyticActivity3.Alt

erationInEnzymeFunctionsHypothermia–TraumaPt.PlateletDysfunctionInhibitionofThromboxaneB2productioncausesthenormalresponseo

fplateletaggregationtodecrease.Theplateletsarethereforestoredinthespleenandliver,andleftunavailableforuse.Hypothermia–TraumaPt.Enha

ncedFibrinolyticActivityTrauma-inducedhypothermiacausesaheparin-likesubstancetobereleased,thuscausingadisseminatedint

ravascularclotting(DIC)-likesyndrome.Thisismarkedbyanincreaseinprothrombin(PT)andpartialthromboplastintimes(PTT),andanincreaseinfibrinsplitpr

oducts.Hypothermia–TraumaPt.AlterationInEnzymeFunctionsHagemanfactorandThromboplastinareneededtoformclotsatthesiteofi

njuredendothelium.Hypothermiaaltersthefunctionoftheseenzymesandothers,thereforeincreasingbleedingandclottingtimes.Hypothermia–

TraumaPt.Coagulopathy–PerpetuatedBloodtransfusions/fluidresuscitationmayleadtoorexacerbatehypothermia.

Silbergleitetalreportthatroom(orambient)temperatureIVfluids,usedinresuscitation,increasehypothermiaormayactuallycausesecondaryhypothermiaintraumapa

tients.CrystalloidsdilutetheavailabilityofcoagulationfactorsBankedbloodislowinplateletsandclottingfactors,especiallyF

actorsVandVIIIHypothermia–NearDrowningCerebralProtectionProtectiveHypothermia(H2O<5̊C)corebodytemp<28̊CWatermustbei

cy.Heatlossmustoccurrapidlytometabolicratebeforesignificanthypoxemiabegins.VeryunlikelyforthistohappenMorecommo

nly,hypothermicneardrowninghavehighermortalityrate.AcuteEthanolIntoxicationEthanolMostfrequentlyusedandabused

intoxicant¾ofadultAmericanswillconsumeatleastonedrinkperyear36%willsmokeafagBeerisnumber4onthemostconsumed

beveragelist(pop,milk,coffee)AverageAmericanpounded2gallonsofpureethanol1997Downfrom2.77in1981EthanolDistilledspir

its40-50%(80-100proof)Someashighas75%Wine10-20%Beer2-6%OtherStuffMouthwash(upto75%)Cologne(40-60%)Medicinalpreparations(as

highas65%)Pathophysiology-EthanolCNSdepressantStimulanteffectmayoccur@concentrationAbsorbedmainlyinsmallbowelAlsooccursinmouth,esopha

gus,stomach,andlargebowelMajoritymetabolizedbyliverSmall%excretedbylungs,inurine,orsweatPathophysiology-EthanolAlcoholandWomenMore

pronetoalcoholrelatedhealthproblemsSmallervolumeofdistributionNofirstpassmetabolismcapabilityAlcoholdehydrogenaseAlc

oholandPregnancyLowbirthweightinfantsFetalalcoholsyndromeFacialdysmorphologyMental/growthretardationEthanolIntoxic

ationSignsandSymptomsDisinhibitedbehaviorCNSdepressionNystagmusSlurredspeechmotorcoordination/controlEthanolIntoxicationSignsandSymptoms(co

nt.)BPhypotensionDuetoPVRand/orvolumelossTachycardiaRespiratorydepressionUsuallyinunhabituated

usersMorbidity/MortalityUsuallyduetoimpairedjudgmentsequelaeTreatmentSupportiveABC‟sPreparetosupportrespirationsAlter

edMentalStatus25gmD50/WprnNarcan2mgThiamine100mgEffectsofAlcoholAbuseTraumaandAlcohol4thhighestcauseofdeath,aftercoronarydisease,cereb

ro-vascularaccidentsandcancer.Maincauseofdeathbeforetheageof40years.40-50%oftrafficdeaths25-35%ofnonfata

lcaraccidents64%offiresandburns48%ofcasesofhypothermiaandfreezing~20%ofsuicidesImplicatedin40%offallsand50%ofmurders(victimsorcriminals)

.EffectsofAlcoholAbuseCNSAcuteIntoxicationAlcoholwithdrawalSeizuresHallucinationsWernicke‟sencephalopathyKorsakoff‟spsychosi

sDementiaDepression/antisocial/suicidalEffectsofAlcoholAbuseGastrointestinalEsophagealvaricesErosivegastritisHepatitis/liv

erfailurePepticulcerdiseasePancreatitisOropharyngeal,esophageal,gastric,hepaticandpancreaticmalignanciesEffectsofAlcoholAbuseCardiov

ascularHypertensionCardiomyopathyStrokeDysrhythmicevents(intoxicationorwithdrawal)Endocrine/MetabolicTesticularatrophyAlco

holicketoacidosisFolicacidandthiaminedeficienciesEffectsofAlcoholAbuseChallengesofEvaluationandTreatmentObtainingreliablehistory

ObtainingcooperativecareandevaluationDifficulttoreasonwith„theintoxicated‟EvaluatingunderlyingdisorderOftenoverlookedduetointo

xicatedstateComorbidcomplicationsofunderlyingorgansystemdysfunctioninchronicalcoholicAffectspt.presentationandresponsetotrea

tmentEffectsofAlcoholAbuseHypothermiaMostcasesrelatedtoETOHuseContributestocoolingvia:DepressingcentralthermoregulationVasodilitationDepres

sedshiveringSedativeeffectsabilitytoremoveoneselffromacoldenvironment.PoliceinPolandsaythatabouthalfofthe270peoplewh

ohavefrozentodeathsofarthiswinterweredrunk.BritishBroadcastingCorporation©2001-2002EffectsofAlcoholAbuseWithdraw

alPeaksxusually~48hrsafterlastdrinkAutonomichyperactivityCardiacdysrhythmiasTremor/anxietyAgitationVisualdisturban

cesSeizuresEffectsofAlcoholAbuseWithdrawalTreatmentSupportive(ABC‟sprn)AMSThiamine,D50/W,NarcanIfseizing/tremorsV

ersed2.5-10mgMagnesium2gm