Thursday, February 25, 2010

Don't Know Jack Forst: How to Handle Hypothermia

You know I have been debating whether or not to write more about hypothermia. It has no guts, no glory, no raving zombies you have to fight off. It is just Jack Frost taking a chunk out of your hiney then calling it a day. What kind of criminal locks a person in a refrigerator and just leaves whistling like Frosty the Snowman? The boring kind, that's who.

See that's why I like writing about wilderness wound care. Because no bear smacks you upside the head then leaves; they finish you off. Then gnaw on you for a few more days. Now, that's civil.

But mean old Jack, he just sits there on his cold-hearted balloon-knot and blows frosty mist in your face. But we, weak, mortal non-mutated humans tremble under his ice cold breath. (We shiver.) Then being the rough and tough rumbler John Wayne-wannabees, we still get in Jack's face and say, "You want a peice of me, you icy beast-ard!" (We get irritable.)

And of course, we dance around like Mohammid Ali with butterflies in our pants. By this time we're looking like insane bunnies on crack. (We start to get an altered mental status.) Jack just sits there and yawns. He's got all winter. But sooner or later Jack tires of us and gives us the cold shoulder, so we freeze into a human-sicles, and he leaves. (That's when spring comes and some park ranger finds a defrosting human-sicle in the wilderness.) That's it. Where's the excitement in that?

So, I thought long and hard about this, contemplating the universe without zombies but instead with frost bite. Yes, the debate was heartfelt. It lasted all of but three seconds. So here I am writing more on hypothermia.

The Three Stages of Defeat:

When God created Adam and Eve, and they were naked in the Garden of Eden... God make heck of sure that the temperature was an ambient 72-74 degrees fahrenheit, otherwise we would have had two frostbitten first parents. The human body is designed to handle moderate temperatures being bare-buck-naked, and Heavenly Father knew that. Life was paradise before that nappy serpent introduced the forbidden fruit. Stupid snake.

Now, being in the lone and dreary world, we have to bundle up or our core body temperature drops fast... because not every day is going to be paradise. (If you're in medical school, than no day is paradise... because you're living in a literal hell. ;).)

Mild Hypothermia

This starts when the body's core temperature drops below 95 degrees fahrenheit (35 degrees Celsius), but is still above 90 degrees.

This is where we start shivering, our extremities become numb, and we experience a reduction in manual dexterity. Remember the last post: 'drop of 1 degree Celsius' and we turn into 'mean drunks'? Well, here we are. Mean shivering drunks. Complex skills become difficult. We become tired, can't throw a snowball to save our lives, and forget about cooperating with anything or anyone.

Here's a mnemonic device developed by Giesbrecht and Wilkerson in their book, "Hypothermia, Frostbite, and Other Cold Injuries":


Moderate Hypothermia

This is the stage that happens when either we are kidnapped by the abominable snowman to be his snowbride and can't get away, or we are too irritable and argumentative to listen to our friends about going inside somewhere warm.

The core body temperature drops below 90 degrees Fahrenheit (32 degrees Celsius), yet is still above 82 degrees.

The signs and symptoms are as follows:

Violent shivering to No Shivering (the shivering is progressively inhibited until it stops)
Loss of muscle control
Loss of ability to make rational decisions

(I know what you're thinking: there are some people out there that are so irrational that they must be hypothermic in 120 degree weather. Those people don't count. They would already have been eaten by abominable snowman for irritating him.)

Staggering Gait
Profoundly altered mental status
(Think a fifth of vodka and a billy club to the head)
Apathetic attitude
Urinate in Clothing
Paradoxical Undressing (You might get a strip show)
Finally, consciousness will be lost

The line between moderate and severe hypothermia gets blurred.

You know what, all this talk about cold and hypothermia made me want to make myself some hot chocolate... well, actually, hot vanilla, because I am allergic to the cocoa plant. Since I like my drinks robust, I got this hazelnut flavoring product just to add more calories.

After putting two tablespoons of it in my drink, I noticed on the side of the hazelnut powder a warning label that says: 'Warning: Don't store near open flame. May combust.' And I thought to myself: It may combust, but we can still eat it. How is that supposed to be healthy?

Then I suddenly remembered as I almost burnt my tongue on the hot vanilla that hot beverages can give you esophageal cancer. Yes, while studying for the board exams, I discovered that fact. So I added whip cream to it. Mmmmm, extra calories. But they're cold calories so they combat the esophageal cancer.

So here's to spontaneous combustion and esophageal cancer. Bottoms up. Mmm... hazelnut-chemical-induced-hot vanilla-water-that-has-been-nuked-in-a-microwave. Yummy!

Severe Hypothermia: Human Popsicle

Core temperature below 82 degrees fahrenheit. At this point, the heart is at risk of going into ventricular fibrillation.

Loss of Consciousness
Pupils fixed and dilated
Rigid and unresponsive
Can't feel their pulses
No respirations
Not yet dead

Here's a deal in prehospital medicine: The person is not dead until they are warm and dead. So here you have two EMTs debating whether or not the caveman trapped in a block of ice was still alive or not.

Treatment of Hypothermia: Handle with care

Let me put it this: manhandling a hypothermic patient is a very bad thing. You rustle them too much, you can cause them to have a heart attack.

1. Remove the patient from the cold and keep them laying down.

2. Remove wet and/or constrictive clothing. Constrictive clothing, especially boots, should be removed to reduce the risk of frostbite.

3. Wrap them in warm/insulating layers. Preferably two layers or more. (Protect the insulation from getting wet as well.) No water for you! [Note: Fabrics such as fleece, wool, or polyesters, actually retain their insulating capabilities, even when wet.]

Insulate from snow, ground, wind, etc. If it's cold, keep it out.

4. Add a vapor barrier to eliminate evaporation. Saran wrap. Just kidding, but a water barrier such as a space blanket would work.

5. A fire should be built with a reflective surface behind it to direct the heat at the victim. I'm thinking a mirror or a log with aluminum foil over it.

Keep in mind that a fire itself does not effectively rewarm a hypothermic patient. And whatever you do, don't put them to close to the fire. You're trying to rewarm them, not flambe them.

If Mild Hyperthermia:

6. Give the patient warm high-energy drinks like my hazelnut-combustible-hot-vanilla-nuked-water. No alcohol. Chicken noodle soup works as well.

(Warning: before you start shoving liquids and food down the patient, make sure they can swallow without choking.)

7. Use external heat sources. Preferably in their armpits and on their chest.

Don't rub their extremities! Rubbing them sends cold blood back to their heart and actually lowers their core body temperature.

Heat sources can include: hot water bottles, warming blankets, blow by heaters, and/or chemical or charcoal heat packs. Don't apply the heat sources directly to their skin, but over thin layer of cloth.

If Moderate-Severe Hypothermia: Think slow cooking.

Field warming can be a very slow process. Just check your turkey thermometer every hour... 24 hours or more may be needed in order to rewarm them.

8. All of the above. Except don't give an unconscious patient drinks.

Don't use hot water or a heating pad on them. Instead apply warm compresses to their neck, chest wall, armpits, and groin.

And cut off their wet/constrictive clothing to avoid moving them too much.

9. Add warm and humidified oxygen.

I know what you are thinking: You're out in the wild, where would you get an oxygen tank. So if one is not present, don't think that you have to sit there and blow in their face.

This is not a major means of warming the patient.

10. DO NOT immediately initiate chest compressions in a moderately-severely hypothermic patient with no pulse. First, do rescue breathing for three minutes, then take another sixty seconds to assess their pulse.

CPR should only be preformed if there are no signs of life present in the victim.

If you have anymore questions concerning hypothermia and its treatment, please feel free to email me.