You are at elmhurst in the cardiac room. It is FREEZING outside. The triage nurse tells you there is a frequent flier in triage, EMS found him sleeping on the street with +AOB. He is confused and moaning to sternal rub. They cannot get an oral temp and they cannot find the rectal probe, but the nurse thinks he is “freezing” and she shows you this EKG.
First off, what do you think might be going on. Hypothermia.
What is the definition of hypothermia?
Core body temp < 35C or 95F.
Mild is 32-35C. Excitation stage. characterized by shivering, increased metabolic rate, peripheral vasoconstriction, increased metabolic rate.
Moderate 30-32C. Adynamic stage. Shivering decreases and pts enter a stage of slowing metabolic rate.
Severe <30C. Patient is unresponsive. V fib risk is very high.
EKG
What do you see on the EKG? An Osborn wave! What does it indicate? Hypothermia.
The Osborn wave or J wave is a positive deflection between the QRS complex and ST segment of an ECG and has a camel hump appearance. It is most often associated with hypothermia. The magnitude of the wave often correlates with level of hypothermia and should improve as rewarming occurs.
TREATMENT
Passive rewarming – remove cold or wet clothes. add blankets, dry clothes. Keep room temperature warm.
Active external rewarming – use heating lamps, bair huggers, warm blankets, warm humidified O2. This is useful for patients with severe hypothermia without cv instability.
Active internal rewarming – use for patients with severe hypothermia and cv instability.
This involves:
Warm IV fluids
Gastric, peritoneal, pleural and bladder lavage. For the pleural lavage, you will need unilateral/bilateral chest tubes for with warm solution (one placed anterior and high and the other posterior and low on same side).
Final option is ECMO, but it can be difficult to attain if not in house.
Summary: check rectal temp, expose, rewarm externally, rewarm internally, ECMO as last resort.
