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HYPOTHERMIAAlcoholRelatedIllnessHypothermia-AlcoholHypothermiaEpidemiologyPhysiologyofTemperatureControlEtiologyofHypothermiaPathophys

iology/TreatmentHypothermiaandTraumaAlcoholEthanolIntoxicationPathophysiology/TreatmentAlcoholAbuseHypothermiaEpidemi

ologyDefinedastemp<35OC(<95OF)>700dieeachyearinUSfromhypothermia½ofthoseare65+yearsoldIndividualsatageextremesandthosewithAMSarea

tgreatestriskPhysiologyofTemperatureControlConductionTransferofheatbydirectcontactdowntemperaturegradient.ConvectionTransferofheatbymovementofhe

atedmaterial.(i.e.wind)RadiationLossofheatfromnon-insulatedareasH2OEvaporationLossofheatthroughexha

lationTemperatureHomeostasisOppositionofHeatLossHypothalamusStimulationofsympatheticnervoussystemiftempbelow„setpoint

‟BehavioralresponsesWearingclotheswhenit‟scoldLeavingcoldenvironmentHeatGainShivering“Non-shiveringthermogenesis”

EtiologyofHypothermiaAccidentalImmersionandnon-immersioncoldexposureMetabolicHypoendocrinestates(hypothyr

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

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

aldiseaseBurnsExfoliativedermatitisAcuteincapacitatingillnessSevereinfectionsDKAPsychoticdisordersOthercon

ditionscausingimpairedthermoregulatoryfunctionResuscitationwithroomtemperaturefluidPathophysiologyMildHypothermia34-36̊C(93.2-96.8̊F)ExcitationP

hysiologicadjustmentstoretainheatModerateHypothermia32-34̊C(89.6-93.2̊F)AdynamicMetabolismslowsDecreasedO2demandDecreas

edCO2productionSevereHypothermia<32̊9(89.6̊F)ShiveringceasesPathophysiology(cont.)ExcitationSymp

atheticresponse(HR,BP,andCardiacOutputallrise).AdynamicHR,CO,BPdecreaseduetonegativeino/chronotropiceffectsofhypothermiaPathophysiology(c

ont.)HypothermicEKGchangesOsborneorJwavesT-waveinversionProlongedPR,QRS,QTintervalsArrhythmiasmayincludebra

dycardia,slowAF,VF,orasystoleExample26°C28°C28.5°C29.5°CabcdPathophysiology(cont.)Pathophysiology(co

nt.)SystemicEffectsofProgressingHypothermiaPulmonary:TachypneaRR&TVBronchorrhea,gag/coughreflexCNSDisc

oordinationconfusionlethargycomaFurtherdeteriorationmaybecerebro-protectiveRenal“ColdDiuresis”duetorenalhypoperfusion3rdspacinghem

oconcentrationemboliccomplicationsrhabdomyolysis,etc.CoagulopathyTreatmentStopfurtherheatlossBeginwarmingprocessPassiveexternalwarmingActive

externalwarmingActiveinternalrewarmingWarmedoxygenandIVfluidsTreatment(cont.)MaintainhorizontalpositionVerticalpos

itionmaycompromisecerebralandsystemicperfusionAvoidroughmovementsandactivitiesHandlevictimgentlyduringCPR,intub

ation,BVMventilation,vascularaccessTreatment(cont.)CardiacArrestIfVFpresent:Defibrillatex3prnETTw/wa

rmed,humidifiedO2WarmedIVfluids(avoidoverhydration)Iftemp<30̊C(86̊F)CPR,limitshocksx3WithholdIVmedsContinuere

warmingTreatment(cont.)CardiacArrest(cont.)Iftemp>30̊CCPRDefibprnascoretemprisesIVmedsasindicated(longerthannormalintervals)Continuerewarmin

gduringtransportOtherTreatmentConsiderationsAMSNarcan2mgIVThiamine100mgIVD50/W25gmIVifBGLTreatment(cont.)P

assiveRewarmingRemovalfromenvironmentInsulationActiveCoreRewarmingInhalationrewarmingHeatedIVfluidsGItractlavageBladderlavagePeritoneallava

gePleurallavageExtracorporealrewarmingMediastinallavageActiveExternalRewarmingWarmH2OImmersionHeatingblanketsHeatedobjects

RadiantHeatForcedairRewarmingCautionAfter-dropPhenomenonTemperaturedropandacidosisprovokeseriousarrhythmiasColdacidoticbloodcausesdropincoretem

pColdbloodfromdilatedperipheralvesselscarrieshighlacticacidlevelstocorevesselsPeripheralvasodilation(BPdrops)Initialactiveexternalrewarmi

ngleadstoHypothermia–TraumaPt.Threemechanismsthatcontributetohypothermia-inducedcoagulopathyintraumainclude:1.PlateletDysfunction2.EnhancedFibrinoly

ticActivity3.AlterationInEnzymeFunctionsHypothermia–TraumaPt.PlateletDysfunctionInhibitionofThromboxaneB2productionc

ausesthenormalresponseofplateletaggregationtodecrease.Theplateletsarethereforestoredinthespleenandliver,andleftunavailableforuse.Hypothe

rmia–TraumaPt.EnhancedFibrinolyticActivityTrauma-inducedhypothermiacausesaheparin-likesubstancetobereleased,thuscausingadisseminatedintravascularc

lotting(DIC)-likesyndrome.Thisismarkedbyanincreaseinprothrombin(PT)andpartialthromboplastintimes(PTT),andanincreaseinfibrin

splitproducts.Hypothermia–TraumaPt.AlterationInEnzymeFunctionsHagemanfactorandThromboplastinareneededtoformclotsatthesiteofinjureden

dothelium.Hypothermiaaltersthefunctionoftheseenzymesandothers,thereforeincreasingbleedingandclottingti

mes.Hypothermia–TraumaPt.Coagulopathy–PerpetuatedBloodtransfusions/fluidresuscitationmayleadtoorexacerbatehypothermia.

Silbergleitetalreportthatroom(orambient)temperatureIVfluids,usedinresuscitation,increasehypothermiaormayactuallycausesecondaryhypothermiaint

raumapatients.CrystalloidsdilutetheavailabilityofcoagulationfactorsBankedbloodislowinplateletsandclottingfactors,especiallyFactorsVandVIIIHypo

thermia–NearDrowningCerebralProtectionProtectiveHypothermia(H2O<5̊C)corebodytemp<28̊CWatermustbeicy.Heatlossmus

toccurrapidlytometabolicratebeforesignificanthypoxemiabegins.VeryunlikelyforthistohappenMorecommonly,hypothermicn

eardrowninghavehighermortalityrate.AcuteEthanolIntoxicationEthanolMostfrequentlyusedandabusedintoxicant¾ofadultAmericanswillconsumeatl

eastonedrinkperyear36%willsmokeafagBeerisnumber4onthemostconsumedbeveragelist(pop,milk,coffee)AverageAmericanpounded2g

allonsofpureethanol1997Downfrom2.77in1981EthanolDistilledspirits40-50%(80-100proof)Someashighas75%Wine10-20%Beer

2-6%OtherStuffMouthwash(upto75%)Cologne(40-60%)Medicinalpreparations(ashighas65%)Pathophysiology-EthanolCNSdepressantStimulanteffectmayo

ccur@concentrationAbsorbedmainlyinsmallbowelAlsooccursinmouth,esophagus,stomach,andlargebowelMajoritymetabol

izedbyliverSmall%excretedbylungs,inurine,orsweatPathophysiology-EthanolAlcoholandWomenMoreproneto

alcoholrelatedhealthproblemsSmallervolumeofdistributionNofirstpassmetabolismcapabilityAlcoholdehydrogenaseAlcoholandPregnancyLowbi

rthweightinfantsFetalalcoholsyndromeFacialdysmorphologyMental/growthretardationEthanolIntoxicationSignsandSymptomsDi

sinhibitedbehaviorCNSdepressionNystagmusSlurredspeechmotorcoordination/controlEthanolIntoxicationSignsandSymptoms(cont.)BPhypotensionDueto

PVRand/orvolumelossTachycardiaRespiratorydepressionUsuallyinunhabituatedusersMorbidity/MortalityUsuallyduetoimpairedjudgme

ntsequelaeTreatmentSupportiveABC‟sPreparetosupportrespirationsAlteredMentalStatus25gmD50/WprnNarcan2mgThi

amine100mgEffectsofAlcoholAbuseTraumaandAlcohol4thhighestcauseofdeath,aftercoronarydisease,cerebro-vascularaccide

ntsandcancer.Maincauseofdeathbeforetheageof40years.40-50%oftrafficdeaths25-35%ofnonfatalcaraccidents64%offiresandburns48%ofcase

sofhypothermiaandfreezing~20%ofsuicidesImplicatedin40%offallsand50%ofmurders(victimsorcriminals).Effect

sofAlcoholAbuseCNSAcuteIntoxicationAlcoholwithdrawalSeizuresHallucinationsWernicke‟sencephalopathyKorsakoff‟spsycho

sisDementiaDepression/antisocial/suicidalEffectsofAlcoholAbuseGastrointestinalEsophagealvaricesErosivegastritisHepatitis/liverfailure

PepticulcerdiseasePancreatitisOropharyngeal,esophageal,gastric,hepaticandpancreaticmalignanciesEffec

tsofAlcoholAbuseCardiovascularHypertensionCardiomyopathyStrokeDysrhythmicevents(intoxicationorwithd

rawal)Endocrine/MetabolicTesticularatrophyAlcoholicketoacidosisFolicacidandthiaminedeficienciesEffect

sofAlcoholAbuseChallengesofEvaluationandTreatmentObtainingreliablehistoryObtainingcooperativecareandevaluationDifficulttoreaso

nwith„theintoxicated‟EvaluatingunderlyingdisorderOftenoverlookedduetointoxicatedstateComorbidcomplicationsofunderlyingorgansystemdys

functioninchronicalcoholicAffectspt.presentationandresponsetotreatmentEffectsofAlcoholAbuseHypothermiaMostcases

relatedtoETOHuseContributestocoolingvia:DepressingcentralthermoregulationVasodilitationDepressedshiveringSedativeeffe

ctsabilitytoremoveoneselffromacoldenvironment.PoliceinPolandsaythatabouthalfofthe270peoplewhohavefrozentodeathsofarthiswinter

weredrunk.BritishBroadcastingCorporation©2001-2002EffectsofAlcoholAbuseWithdrawalPeaksxusually~48hrsafterlastdrinkAutonomichyperact

ivityCardiacdysrhythmiasTremor/anxietyAgitationVisualdisturbancesSeizuresEffectsofAlcoholAbuseWithdrawalTr

eatmentSupportive(ABC‟sprn)AMSThiamine,D50/W,NarcanIfseizing/tremorsVersed2.5-10mgMagnesium2gm