HYPOTHERMIA

Alcohol Related Illness

Lynn K. Wittwer, MD, MPD

Clark County EMS
 Hypothermia - Alcohol
 Hypothermia
 Epidemiology
 Physiology of Temperature Control
 Etiology of Hypothermia
 Pathophysiology/Treatment
 Hypothermia and Trauma
 Alcohol
 Ethanol Intoxication
 Pathophysiology/Treatment
 Alcohol Abuse
 Hypothermia
 Epidemiology
 Defined as temp <35O C (<95O F)
 >700 die each year in US from hypothermia
 ½ of those are 65+ years old
 Individuals at age extremes and those with
AMS are at greatest risk
Physiology of Temperature Control
 Conduction
 Transfer of heat by direct contact down temperature
gradient.
 Convection
 Transfer of heat by movement of heated material. (i.e.
wind)
 Radiation
 Loss of heat from non-insulated areas
 H2O Evaporation
 Loss of heat through exhalation
 Temperature Homeostasis
 Opposition of Heat Loss
 Hypothalamus
 Stimulation of sympathetic nervous system if temp below
‘set point’
 Behavioral responses
 Wearing clothes when it’s cold
 Leaving cold environment
 Heat Gain
 Shivering
 “Non-shivering thermogenesis”
 Etiology of Hypothermia
 Accidental
 Immersion and non-immersion cold exposure
 Metabolic
 Hypoendocrine states (hypothyroid,
hypoadrenalism, hypopituitarism)
 Hypoglycemia
 Head trauma
 Tumor
 Etiology of Hypothermia (cont.)
 Wernicke’s disease.
 Drug induced
 Alcohol (majority of hypothermic pt’s in US
are intoxicated)
 Sedatives
 Phenothiazines
 Insulin
 Sepsis
 Etiology of Hypothermia (cont.)
 Severe dermal disease
 Burns
 Exfoliative dermatitis
 Acute incapacitating illness
 Severe infections
 DKA
 Psychotic disorders
 Other conditions causing impaired thermoregulatory
function
 Resuscitation with room temperature fluid
 Pathophysiology
 Mild Hypothermia 34-36̊ C (93.2-96.8̊ F)
 Excitation
 Physiologic adjustments to retain heat
 Moderate Hypothermia 32-34̊ C (89.6-93.2̊ F)
 Adynamic
 Metabolism slows
 Decreased O2 demand
 Decreased CO2 production
 Severe Hypothermia <32̊ 9 (89.6̊ F)
 Shivering ceases
 Pathophysiology (cont.)
 Excitation
 Sympathetic response (HR, BP, and Cardiac
Output all rise).
 Adynamic
 HR, CO, BP decrease due to negative
ino/chrono tropic effects of hypothermia
 Pathophysiology (cont.)
 Hypothermic EKG changes
 Osborne or J waves
 T-wave inversion
 Prolonged PR, QRS, QT intervals
 Arrhythmias may include bradycardia, slow
AF, VF, or asystole

Example
 Pathophysiology (cont.)
26°C

a
28°C

b
28.5°C

c
29.5°C

d
 Pathophysiology (cont.)
 Systemic Effects of Progressing Hypothermia
 Pulmonary:
 Tachypnea   RR & TV
 Bronchorrhea,  gag/cough reflex

 CNS
 Discoordination  confusion  lethargy  coma
 Further deterioration may be cerebro-protective
 Renal
 “Cold Diuresis” due to renal hypoperfusion
 3rd spacing  hemoconcentration  embolic
complications  rhabdomyolysis, etc.
 Coagulopathy
 Treatment
 Stop further heat loss
 Begin warming process
 Passive external
warming
 Active external warming
 Active internal
rewarming
 Warmed oxygen and IV
fluids
 Treatment (cont.)
 Maintain horizontal position
 Vertical position may compromise cerebral
and systemic perfusion
 Avoid rough movements and activities
 Handle victim gently during CPR,
intubation, BVM ventilation, vascular
access
 Treatment (cont.)
 Cardiac Arrest
 If VF present:
 Defibrillate x 3 prn
 ETT w/ warmed, humidified O2

 Warmed IV fluids (avoid overhydration)

 If temp <30 ̊ C (86 ̊ F)

 CPR, limit shocks x 3
 Withhold IV meds

 Continue rewarming
 Treatment (cont.)
 Cardiac Arrest (cont.)
 If temp >30 ̊ C
 CPR
 Defib prn as core temp rises

 IV meds as indicated (longer than normal intervals)

 Continue rewarming during transport

 Other Treatment Considerations

 AMS
 Narcan 2mg IV
 Thiamine 100mg IV

 D50/W 25gm IV if BGL

 Treatment (cont.)
Passive Rewarming Active Core Rewarming
 Removal from environment  Inhalation rewarming
 Insulation  Heated IV fluids
Active External Rewarming
 GI tract lavage
 Bladder lavage
 Warm H2O Immersion
 Peritoneal lavage
 Heating blankets
 Pleural lavage
 Heated objects
 Extracorporeal rewarming
 Radiant Heat
 Mediastinal lavage
 Forced air

Rewarming Caution
After-drop Phenomenon
Initial active external rewarming leads to

Peripheral vasodilation (BP drops)

Cold blood from dilated peripheral vessels

carries high lactic acid levels to core vessels

Cold acidotic blood causes drop in core temp

Temperature drop and acidosis provoke

serious arrhythmias
Hypothermia – Trauma Pt.
Three mechanisms that contribute to
hypothermia-induced coagulopathy in
trauma include:
1. Platelet Dysfunction
2. Enhanced Fibrinolytic Activity
3. Alteration In Enzyme Functions
 Hypothermia – Trauma Pt.
 Platelet Dysfunction
 Inhibition of Thromboxane B2 production
causes the normal response of platelet
aggregation to decrease. The platelets
are therefore stored in the spleen and liver,
and left unavailable for use.
 Hypothermia – Trauma Pt.
 Enhanced Fibrinolytic Activity
 Trauma-induced hypothermia causes a
heparin-like substance to be released, thus
causing a disseminated intravascular clotting
(DIC)-like syndrome.
 This is marked by an increase in prothrombin
(PT) and partial thromboplastin times (PTT),
and an increase in fibrin split products.
 Hypothermia – Trauma Pt.
 Alteration In Enzyme Functions
 Hageman factor and Thromboplastin are
needed to form clots at the site of injured
endothelium.
 Hypothermia alters the function of these
enzymes and others, therefore increasing
bleeding and clotting times.
 Hypothermia – Trauma Pt.
 Coagulopathy – Perpetuated
 Blood transfusions/fluid resuscitation may lead
to or exacerbate hypothermia.
 Silbergleit et al report that room (or ambient)
temperature IV fluids, used in resuscitation,
increase hypothermia or may actually cause
secondary hypothermia in trauma patients.
 Crystalloids dilute the availability of coagulation

factors
 Banked blood is low in platelets and clotting

factors, especially Factors V and VIII

 Hypothermia – Near Drowning
 Cerebral Protection
 Protective Hypothermia (H2O <5 ̊
C) core body temp <28 ̊ C
 Water must be icy.
 Heat loss must occur rapidly to 
metabolic rate before significant
hypoxemia begins.
 Very unlikely for this to happen
 More commonly, hypothermic
near drowning have higher
mortality rate.
 Acute Ethanol Intoxication
 Ethanol
 Most frequently used and abused intoxicant
 ¾ of adult Americans will consume at least
one drink per year
 36% will smoke a fag
 Beer is number 4 on the most consumed
beverage list (pop, milk, coffee)
 Average American pounded 2 gallons of pure
ethanol 1997
 Down from 2.77 in 1981
 Ethanol
 Distilled spirits  Other Stuff
 40-50% (80-100  Mouthwash (up to
proof) 75%)
 Some as high as 75%  Cologne (40-60%)
 Wine  Medicinal preparations
 10-20% (as high as 65%)
 Beer
 2-6%
 Pathophysiology - Ethanol
 CNS depressant
 Stimulant effect may occur @  concentration
 Absorbed mainly in small bowel
 Also occurs in mouth, esophagus, stomach,
and large bowel
 Majority metabolized by liver
 Small % excreted by lungs, in urine, or sweat
 Pathophysiology - Ethanol
 Alcohol and Women
 More prone to alcohol related health problems
 Smaller volume of distribution
 No first pass metabolism capability
 Alcohol dehydrogenase
 Alcohol and Pregnancy
 Low birth weight infants
 Fetal alcohol syndrome
 Facial dysmorphology
 Mental/growth retardation
 Ethanol Intoxication
 Signs and Symptoms
 Disinhibited behavior
 CNS depression
 Nystagmus
 Slurred speech
  motor coordination/control
 Ethanol Intoxication
 Signs and Symptoms (cont.)
  BP  hypotension
 Due to  PVR and/or volume loss
 Tachycardia

 Respiratory depression
 Usually in unhabituated users
 Morbidity/Mortality
 Usually due to impaired judgment sequelae
 Treatment
 Supportive
 ABC’s
 Prepare to support respirations
 Altered Mental Status
 25 gm D50/W prn
 Narcan 2 mg
 Thiamine 100 mg
 Effects of Alcohol Abuse
 Trauma and Alcohol
 4th highest cause of death, after coronary disease,
cerebro-vascular accidents and cancer.
 Main cause of death before the age of 40 years.
 40-50% of traffic deaths
 25-35% of non fatal car accidents
 64% of fires and burns
 48% of cases of hypothermia and freezing
 ~20% of suicides
 Implicated in 40% of falls and 50 % of murders
(victims or criminals).
 Effects of Alcohol Abuse
 CNS
 Acute Intoxication
 Alcohol withdrawal
 Seizures
 Hallucinations

 Wernicke’s encephalopathy
 Korsakoff’s psychosis
 Dementia
 Depression/antisocial/suicidal
 Effects of Alcohol Abuse
 Gastrointestinal
 Esophageal varices
 Erosive gastritis
 Hepatitis/liver failure
 Peptic ulcer disease
 Pancreatitis
 Oropharyngeal, esophageal, gastric, hepatic
and pancreatic malignancies
 Effects of Alcohol Abuse
 Cardiovascular
 Hypertension
 Cardiomyopathy
 Stroke
 Dysrhythmic events (intoxication or withdrawal)
 Endocrine/Metabolic
 Testicular atrophy
 Alcoholic ketoacidosis
 Folic acid and thiamine deficiencies
 Effects of Alcohol Abuse
 Challenges of Evaluation and Treatment
 Obtaining reliable history
 Obtaining cooperative care and evaluation
 Difficult to reason with ‘the intoxicated’
 Evaluating underlying disorder
 Often overlooked due to intoxicated state
 Comorbid complications of underlying organ
system dysfunction in chronic alcoholic
 Affects pt. presentation and response to treatment
 Effects of Alcohol Abuse
 Hypothermia
 Most cases related to
ETOH use
 Contributes to cooling
via:
 Depressing central
thermoregulation
 Vasodilitation
 Depressed shivering
 Sedative effects ability
to remove oneself from
a cold environment. Police in Poland say that about half
of the 270 people who have frozen
to death so far this winter were
drunk. British Broadcasting Corporation © 2001-2002
 Effects of Alcohol Abuse
 Withdrawal
 Peak sx usually ~48hrs after last drink
 Autonomic hyperactivity
 Cardiac dysrhythmias
 Tremor/anxiety
 Agitation

 Visual disturbances

 Seizures
 Effects of Alcohol Abuse

 Withdrawal Treatment
 Supportive (ABC’s prn)
 AMS
 Thiamine, D50/W, Narcan
 If seizing/tremors
 Versed 2.5-10 mg
 Magnesium 2 gm