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Hypothermia and drowning

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A PEM adventure

It’s time for another PEM adventure. Join us on another journey (with an inbuilt time travel machine) as we manage Elsa, a 2-year-old girl who is a huge fan of the Disney movie Frozen.

Elsa was found face down in the family pool 20 minutes after the last visual contact and was picked up without resuscitation. Emergency Medical Services found her apneic and pulseless.

She was intubated at the scene and transported to your ED, with cardiopulmonary resuscitation (CPR) performed en route.

Upon arrival in resus, she had a core temperature of 27.3⁰C and remained pulseless.

She received three rounds of adrenaline, and her pulse returned approximately 30 minutes after retrieval from the pool.

She’s intubated and ventilated on 100% FiO2.

The PICU team is with you in resus, stabilising Elsa for transfer to the unit. Her GCS is 3, and her pupils are sluggish but reactive.

You look at her monitor and an arterial blood gas performed moments ago. 

ABG in the drowning case

 

Your eye catches an unusual rhythm on the monitor.

You request a 12 lead ECG and repeat a blood gas, asking for it to be run on the PICU analyser.



Your trusted nurse hands you the ECG:

Paediatric ECG interpretation has never been your strong suit. You convince yourself that you can see widespread ST depression and T-wave inversion.

But the PICU is a few corridors and a flight of stairs away, and you don’t have those electrolytes yet. You try to think from the first principles – what electrolyte shifts happen in severe acidosis? Does the temperature play a role? “Oh,” you say out loud, “I wish I paid more attention in physiology class.” 

What is the likely cause of Elsa’s ECG changes?

a) Hyperkalaemia?

b) Hypokalaemia?

c) Hypocalcaemia

d) Hypothermia

e) Metabolic acidosis

Knowing Elsa’s blood gas, what are you going to do next? 

a) Give IV K+?

As the infusion is put up, Elsa goes into a VF rhythm due to a rapid shift in potassium and arrests soon after.

Despite good quality CPR, there is no ROSC. Maybe we shouldn’t have given that potassium after all.

If only I had a time machine, you think to yourself…

Oh, we do! Let’s hop in.

Close the tab and choose another option.

Zydlewski, A. W., & Hasbargen, J. A. (1998). Hypothermia-induced hypokalemiaMilitary medicine163(10), 719-721.

b) Rewarm

Correct.

Treat the cause, not the numbers.

Elsa is cardiovascularly stable, so there is no urgent reason to replace the potassium.

Rewarming in itself can cause rebound hyperkalaemia. Adding more potassium at this stage would only add to the risk. Avoid additional potassium unless the arrhythmia causes CVS instability, and check the potassium frequently. 

Kattih, Z., J. Le, E. L. Altschul, and B. A. Mina. “Hypothermia, Rewarming, and Potassium Shifting: A Case of Accidental Hypothermia and Hyperkalemia.” In C44. CRITICAL CARE CASE REPORTS: METABOLIC, RENAL, AND ENDOCRINE, pp. A5175-A5175. American Thoracic Society, 2020

c) Rewarm and give IV K+

As the infusion is put up, Elsa goes into a VF rhythm due to a rapid shift in potassium and arrests soon after.

Despite good quality CPR, there is no ROSC. Maybe we shouldn’t have given that potassium after all.

If only I had a time machine, you think to yourself…

Oh, we do! Let’s hop in.

Close the tab and choose another option.

Zydlewski, A. W., & Hasbargen, J. A. (1998). Hypothermia-induced hypokalemiaMilitary medicine163(10), 719-721.

d) Just add 20mmol/L of K+ to the bag of IV fluids

A few hours later Elsa goes into a VF rhythm due to a rapid in potassium and arrests soon after.

Despite good quality CPR, there is no ROSC. Maybe we shouldn’t have given that potassium after all.

If only I had a time machine, you think to yourself…

Oh, we do! Let’s hop in.

Close the tab and choose another option.

Zydlewski, A. W., & Hasbargen, J. A. (1998). Hypothermia-induced hypokalemiaMilitary medicine163(10), 719-721.

A rectal thermometer is inserted to have a more accurate temperature reading.

It reads 30.1⁰C.

Hmmm, it feels like there’s a decision to make here. 

How fast and to what target should you rewarm Elsa?

a) 5⁰C/hr to 36⁰C

b) 3⁰C/ hr to 34⁰C

c) 3⁰C/ hr to 36⁰C

d) 1⁰C/ hr to 36⁰C

As the PICU reg finishes their teaching and prescribes some warm IV fluids, Elsa’s sats drop to 54%.

She is already on 100% FIO2, a PEEP of 10 and a Ti of 1.2.

The PICU reg has checked DOPE,
and all is in order. The CXR shows evolving ARDs with pulmonary oedema but no pneumothoraces. Aggressive bagging and physio fail to have the desired outcome and only serve in further derecruitment with lots of bloody, frothy secretions.

25 minutes in, Elsa’s sats are 40%. 

What is your plan? How are you going to improve Elsa’s ventilation?

a) Place her prone

b) Inhaled nitrous oxide 

c) Call ECMO

d) Surfactant 

Elsa’s gases are better three hours later, her PEEP is down to 8, and she’s oxygenating well on 80% oxygen. The ECMO team finally arrived and decided that you’d done such a good job that she may not need ECMO after all. You get a congratulatory nod from the PICU consultant when you’re called to resus by the matron for the next patient… 

This post is part of the PEM Adventure at NEPTUNE 2023, hosted by Dani, Kat, Costas and Sarah. NEPTUNE 2023 was the inaugural UK PEM trauma conference, hosted by Nottingham University Hospitals Trust, one of the largest major trauma centres in the UK.

Selected references

Zydlewski, A. W., & Hasbargen, J. A. (1998). Hypothermia-induced hypokalemiaMilitary medicine163(10), 719-721

Kattih, Z., J. Le, E. L. Altschul, and B. A. Mina. “Hypothermia, Rewarming, and Potassium Shifting: A Case of Accidental Hypothermia and Hyperkalemia.” In C44. CRITICAL CARE CASE REPORTS: METABOLIC, RENAL, AND ENDOCRINE, pp. A5175-A5175. American Thoracic Society, 2020

Mazur P, Kosinski S, Podsiadlo P, et al.: Extracorporeal membrane oxygenation for accidental deep hypothermia-current challenges and future perspectives. Ann Cardiothorac Surg 2019; 8:137–142

Saczkowski, R., Kuzak, N., Grunau, B. and Schulze, C., 2021. Extracorporeal life support rewarming rate is associated with survival with good neurological outcome in accidental hypothermiaEuropean Journal of Cardio-Thoracic Surgery59(3), pp.593-600

Moler, Frank W., Faye S. Silverstein, Richard Holubkov, Beth S. Slomine, James R. Christensen, Vinay M. Nadkarni, Kathleen L. Meert et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in childrenNew England Journal of Medicine 372, no. 20 (2015): 1898-1908

Authors

  • Costas Kanaris is a Paediatric Intensive Care Consultant in Cambridge and an Associate Editor of the Journal of Child Health Care. He has a PhD in Medical Ethics and Law and is an Honorary Senior Lecturer at Queen Mary University of London.

  • In 2018, 3 PEM clinicians (Dani, Rachael and Sarah) were invited to give some paediatric case-based teaching in the last session of a European EM conference. Having been warned that by the end of the day audience enthusiasm waned, they set out to make the session interactive, educational and funny. And thus begun PEM Adventures. Two years on, the team has grown in size and strength, with Costas and Kat joining the ranks to bring their intensivist and trauma magic to the mix. But the team is far bigger than these 5 PEM adventurers, who are indebted to their clever (and sometimes devious) friends and colleagues, helping craft each story into the very ethos of PEM adventures: meaningful education.

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