EKG case 1

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Coming In From The Cold Date: January 11, 2003 by: Colleen Hayes, Village Manager (Bio & Email The Author)

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You are called to the private residence to eval‎uate a 66-year-old male who is “unconscious”. His wife meets you in her bathrobe and slippers and states she can’t wake her husband up.

You locate the patient who is lying in the left lateral recumbent position on the front porch in the cold winter air (temp 27 degrees F). He is dressed in a long wool winter coat and has his shoes on. You approach the patient and begin your initial assessment. He does not open his eyes or stir to verbal or noxious stimuli.

Airway: no audible noises, clear of foreign debris.

Breathing: RR = 8/min.

Circulation: there is no palpable carotid pulse.

You and your partner go to work and expose the man’s chest. His clothing is stiff and needs to be cut off. You smell an odor of a mixture of cigarettes and alcohol. His body appears extremely cold and the joints are somewhat stiff, but movable. The Fire Department has also responded to the scene and offers two EMTs to help. CPR is begun.

You wonder what happened to the patient. His wife harshly says, “I’ve told him if he’s gonna stay married to me he’ll get his butt inside before 1 AM or I’m locking the doors. Well, he didn’t make it home before 1 AM so I locked him out.”

“This morning I found his drunken self outside…maybe he’ll believe me now that he’s gonna land himself in a hospital bed.”

You’re stunned as you hear the wife’s story, but of course, you don’t show your feelings. You reassure the wife that you will do everything possible for him, but explain that he is in very serious condition. As CPR is continued and you prepare to attach a cardiac monitor you briefly explain to the wife that he is in cardiac arrest. Your partner reports that the patient’s temperature is 84 degrees F (29 degrees Centigrade).

The cardiac monitor shows the following rhythm:

 

EKG Challenge: Answer and Discussion to: 'Coming in From the Cold' Date: January 18, 2003 by: Colleen Hayes, MBA, RN, EMT-P (Bio & Email The Author)

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Excellent discussion in the EKG message forum on this interesting EKG case! This case is clinically quitre interesting and, unfortunately a gruesome demonstration of good love gone very, very bad!

Clinically, this patient appears to be very close to being dead. However, there is a old saying in emergency medicine that will help you remember not to write off a patient who has been exposed to the cold: "You aren't dead until you're warm and dead." This patient had a rectal core temperature of 85.1° Farenheit (29.5° Centigrade). The diagnosis: severe hypothermia.

Editor's Note: As you read this discussion keep in mind that the patient in this case falls into the "Severe Hypothermia" category and the discussion about treatment will be specifically about this category of hypothermia. Realize that treatment of hypothermia may vary depending on differences in core temperature, distance from a hospital, transport time and other specific situations.

According to the American Heart Association's Advanced Cardiac Life Support (ACLS), Guidelines 2000, patients with hypothermia are further categorized according to their core body temperature:

• Mild Hypothermia: Core temperature of 34° - 36° Centigrade
• Moderate Hypothermia: Core temperature of 30° - 34° Centigrade
• Severe Hypothermia: Core temperature of <30° Centigrade

This patient was exposed to frigid temperatures and was acutely intoxicated from drinking alcohol. The intoxication caused him to have an altered mental status leading him to fall asleep on the porch. Acute alcohol intoxication is a significant risk factor for cold exposure since the intoxicated patient may not realize the danger and fail to promptly remove himself from the cold. Physiologically, alcohol dilates blood vessels hastening cooling of the blood, impairs shivering and impairs the ability of the hypothalamus in the brain from regulating temperature.

The EMS crew assessed the patient to be pulseless with bradypneic (slow) respirations. However, if we had a Doppler, it is possible that a weak pulse, that is not palpable could be heard. Remember that in the severely hypothermic patient all body systems slow down including the heart rate and force of contraction. It is for this reason that "You aren't dead until you're warm and dead."

Interestingly, the EKG shows a Sinus Bradycardia with a heart rate of about 40 per minute. Since there is no palpable pulse and the patient is not breathing adequately he is in cardiac arrest secondary to hypothermia. We would further classify his cardiac arrest as pulseless electrical activity (PEA). This patient falls into the "severe hypothermia" category, defined in Advanced Cardiac Life Support as a core body temperature <30° Centigrade. Let's discuss the unique aspects of the EKG and then prehospital management of the severely hypothermic patient.

The unique feature of this EKG demonstrates the Osborne wave, also called a J wave. The abnormal wave is associated with hypothermia. To clearly see the wave in this patient's EKG look in leads II, AVF, V3-V5. You are looking for a small notch on the descending R-wave.

The J, or Osborne wave is usually positive in the left precordial leads, and has an amplitude that is inversely proportional to body temperature. Other EKG changes caused by hypothermia can include prolongation of the PR, QRS, and QT intervals; T wave inversion; and bradyarrhythmias consisting of sinus bradycardia, junctional rhythm, or atrial fibrillation with a slow ventricular response.

Treatment of the severely hypothermic patient
Prehospital personnel must realize that the patient is hypothermic and needs to be treated according to a cardiac arrest guideline for hypothermia. It is absolutely critical that EMTs and Paramedics realize that rewarming a seriously hypothermic patient is a complex procedure that must be done within the controlled conditions of a hospital. In fact, many hypothermic patients die during the rewarming phase because once the rewarmed peripheral blood vessels dilate a rapid influx of cold, acidotic and hyperkalemic blood into the central circulation occurs. The central circulation perfuses the core of the body. Once the toxic and acidotic blood reaches the heart irreversible cardiac collapse is possible. It is because of this life threatening sequelae that most prehospital guidelines recommend that EMS not undertake rewarming procedures in the field. Rewarming of the severely hypothermic patient should be done "from the inside out", slowly and in an intensive care setting.

In the field the pulseless hypothermic patient with a core temperature <30 degrees Centrigrade should receive the following treatment:

• Cardiopulmonary resuscitation, BLS and ALS
  
• Prevent further heat loss, remove wet clothing and cover with blankets.
  
• Handle the patient very gently and maintain the patient in the horizontal position to avoid precipitating ventricular fibrillation (VF). Remember that cold hearts are more susceptible to VF.
  
• Monitor the EKG. Prehospital personnel should know about some problems that may be encountered in very cold environments or in severely hypothermic patients. First, adhesive pads for monitor leads might not stick to cold skin. Prep the skin well and try tincture of benzoin to help them to adhere. In some situations, monitoring is impossible with inserting special needle electrodes into the skin. In some cases the EKG complexes may appear very small or you may not see them at all. You can most often overcome this by increasing the gain on the monitor. Turn the gain all the way up to ensure that the QRS amplitude is maximally amplified before deciding the rhythm is asystole.
  
• Defibrillation of ventricular fibrillation or pulseless ventricular tachycardia can be performed at 200j, 300j, 360j, up to a total of 3 shocks.
  
• Intubate gently and ventilate. If warmed, humidified oxygen is available it can be used. Hyperventialtion of the hypothermic patient may be detrimental. A slow ventilatory rate is recommended. Intubation may induce VF and some guidelines may recommend avoiding intubation altogether, opting for BLS airway management techniques.
  
• Establish a large bore IV. Withhold IV fluid unless you specifically have access to warmed normal saline, or if ordered by emergency physician. Note that in the severely hypothermic patient it may be recommended to avoid obtaining IV access.
  
• Withhold IV medications unless ordered by the emergency physician. Routine medications used in cardiac arrest may build up to toxic levels in the bloodstream. Once rewarming is underway, the toxic drugs may all at once be released into the central circulation precipitating arrhythmias, hyper or hypotension, seizures and/or irreversible cardiac arrest. The emergency physician may instruct you administer thiamine, 50% dextrose and narcan.
  
• Transport promptly.

  Note: The above prehospital hypothermia treatment strategies are based on the American Heart Association, ACLS Guidelines 2000.

Summary
Severe hypothermia is associated with marked depression of cerebral blood flow and oxygen requirement, reduced cardiac output, and decreased arterial pressure. Victims may appear clinically dead because of marked depression of brain and cardiovascular function: full resuscitation with intact neurological recovery is possible, although unusual. If resuscitation is successful, the patient can still suffer from several complications due to end-organ damage. Complications include aspiration pneumonia, adult respiratory distress syndrome, pulmonary edema, rhabdomyolysis, acute tubular necrosis (type of renal failure), GI bleed, gangrene, thrombosis, and disseminated intravascular coagulation (DIC).