To: All EMS Leaders & Educators
Re: Call for Protocol Update
The numerous medical journal quotes enclosed indicate a near epidemic level of hypothermia in serious trauma victims. One study from 1987 documents the "high prevalence" of hypothermia among seriously injured patients, 43% were 1-3° C hypothermic. Another study, in the same year, states "hypothermia is common among severely traumatized patients." Ten years later in 1997, another journal states "secondary hypothermia continues to exact a large toll in terms of morbidity and mortality in trauma victims."
Combinations of new technologies now offer reasonable, feasible, and a cost effective means to help minimize the rampant occurrence and devastating effects of concurrent hypothermia and serious trauma. One journal in 1992 states that "early management should focus on aggressive rewarming and careful monitoring..." while another written back in 1987 states that "Aggressive efforts to limit heat loss and provide conducted heat to the body do affect the degree and duration of hypothermia and should be used in the treatment of critically injured patients."
Careful review of the excerpt compendium will reveal a whole host of very expensive and potentially life threatening secondary consequences associated with hypothermia and serious trauma victims. A complete review of costs associated with these secondary injuries should prove the enormous savings potential associated with keeping or quickly returning serious trauma victims to a normothermic state.
The urgency of the matter cannot be overstated. It will not be adequately addressed until leadership and all those involved take the time to study this material carefully. Readily available, highly cost effective technologies capable of significantly reducing the devastating effects hypothermia exacts have been available in this country since early 1995. The medical journal quotes indicate clearly hypothermia in serious trauma victims is wasting huge amounts of dollars and medical resources and wreaking devastating consequences in terms of human morbidity, mortality and suffering.
Time is of the essence. Delays in understanding, consensus, protocol revision, and effective implementation will all increase the waste and suffering. This is a call to action for those with leadership responsibilities. How quickly can effective procedures be implemented to minimize and negate the immanent dangers posed by the horrific, still unsolved problem of hypothermia in serious trauma victims. Knowing how many serious trauma injuries occur per day (ISS 40+) should provide additional meaning to the urgency. Identifying and pricing all the secondary injury inflicted by the hypothermia will clearly show that every wise dollar spent on prevention will save many thousands of dollars in cure.
Reduction in insurance costs and worker productivity issues should be addressed. The insurance industry would benefit from knowing this information. They could provide reliable data for cost savings potential.
The LifeSuit is a highly technical state-of-the-art-device with many hidden technical advantages for both the patient and first responder alike. The materials enclosed are provided to help you become fully aware of all the hidden technical aspects the LifeSuit has to offer for the safety and well-being of everyone involved.
Additional crucial informational materials are immediately available upon request. They will unveil other hidden details and equally advantageous aspects of the LifeSuit. The next segment in the series deals with protecting the first responders from various physical injuries while packaging, lifting and transporting the patient. A similar segment shows numerous other protections and use advantages for the first responders. In other segments, containment of bloodborne pathogens in the work place will be considered as well as some federal regulations that relate to that circumstance.
HYPOTHERMIA
The Chilling Truth
The following information is directly quoted excerpts from current periodic medical journals on the topic of hypothermia in the seriously traumatized patient. This page provides information on the cause, devastating consequences and the huge unnecessary associated medical expenses. The second page provides information indicating that the only acceptable protocol for treating hypothermia in the seriously traumatized patient is high quality rapid rewarming. This information is a must read for any medical professional involved in the treatment of these types of patients.
Body Temperature After Accidental Injury R.A. Little and H.B. Stoner (The British Journal of Surgery, Vol. 68, #4 Ap.1981
Core and mean skin temperature have been measured in 82 patients shortly after accidental injuries of different severity in order to study the effects of injury on thermoregulation. Skin temperature fell after injury and core temperature also when the injury was severe. After severe injuries both core and mean body temperatures were negatively related to the severity of the injury, measured by the Injury Severity Score. The fall in skin temperature was attributed to vasoconstriction and that in core temperature to decreased heat production due to the reduced oxygen transport to the tissues. These changes in temperature should have stimulated shivering which was not observed in the severely injured. This suggests that thermoregulation is affected after injury, and possible mechanisms are discussed. ···
The findings were consistent with the views that the body temperature is lowered by serious injury. The observations on these patients go further by showing, for the first time, that the fall in body temperature is related to the severity of the injury. The injuries to these patients were varied and the fall could not be linked to any particular type of injury. Furthermore, at this early stage the temperature changes were not related to any treatment which had been given.
Advances in the Management of Hypothermia
Larry M. Gentillello, MD. (Surgical Clinics of North America Vol. 75, No 2, April,95)
In a multi center study of 401 cases of hypothermia due to exposure, the mortality rate was 21% when the core temperature decreased to 28º to 32ºC. In contrast, in a trauma victim, a core temperature of 32ºC or less is associated with a mortality rate near 100%, and any hypothermia is considered a poor prognostic sign. The prognosis associated with hypothermia in a trauma victim is so poor that some have proposed patients were treated with slow rewarming methods, and the mean duration of hypothermia was 3.2 hours. · · · However, hypothermia itself has a deleterious effect on physiology, and the use of physiologic data as a means of determining injury severity in cold patients can potentially result in overestimation of the severity of injury. In this same study, when patients were stratified using the Injury Severity Score (ISS), a strictly anatomical index of injury severity, hypothermic patients had significantly higher mortality rates than patients with the same ISS who remained warm
Mild Hypothermia Increases Blood Loss and Transfusion Requirements during Total Hip Arthroplasty
Harold Schmied, Andrea Kurz, Daniel I. Sessler, Sybille Kozek, Albert Reiter (Lancet 1996; 347: 289-92)
Findings Intra and postoperative blood loss was significantly greater in the hypothermic patient: 2·2 (0·5) L vs. 1·7 (0·3) L, p<0-001). Eight units of allegoric packed red cells were required in seven of the hypothermic patients, whereas only one normothermic patient required a unit of blood (p<0·05 for administered volume). A typical decrease in core temperature in patients undergoing hip Arthroplasty will thus augment blood loss by approximately 500 ml.
Interpretations The maintenance of intra operative normothermia reduces blood loss and allogenic blood requirements in patients undergoing total hip Arthroplasty.
Discussion Consistent with in-vitro data our results indicate that mild hypothermia significantly increased bleeding. Less than 2º C preoperative core hypothermia increased blood loss about 500 ml. (1 unit).· · · Nonetheless, Many more hypothermic patients required allogenic transfusions and the overall volume transfused was significantly greater in the unwarmed patients.
In addition to its direct cost ( excess costs in our hypothermic patients was about $US1050), the administration of allogenic blood carries risks of infection, transfusion reaction, immune suppression and may violate religious dictates of some patients.
Preoperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization
Andrea Kurtz, MD., Daniel I Sessler, MD and Rainer Lenhardt, MD. (For the Study of Wound Infection and Temperature Group)
(The New England Journal of Medicine Vol. 334, No 19, 5/9/96)
Wound infections are common and serious complications of anesthesia and surgery. A wound infection can prolong hospitalization by 5 to 20 days and substantially increase medical costs. Conclusion: Hypothermia itself may delay healing and predispose patients to wound infections. Maintaining normothermia intra operatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations
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Hypothermia in Trauma Victims: An Ominous Predictor of Survival
Gregory J Jurkovich, MD, William B. Greaser, MD., Arnold Luterman, MD., FRCS, FACS, and P. William Currier, MD., FACS ( The Journal of Trauma, Vol. 27, No 9, Sept,87)
Hypothermia is common in severely traumatized patients. Current management protocols often are unsuccessful in preventing its occurrence. ··· The present study demonstrates an additional finding previously unreported. It is known that with progressive elevation of the ISS, mortality increases. However, at each level of increased mortality there are two groups created: those who became hypothermic and those who did not. The mortality in the hypothermia group was higher then the mortality in the group that stayed warm. ··· It is generally accepted that shock in trauma patients increases mortality. This was confirmed in the present study ··· Hypothermia was more prevalent in the patients that sustained shock. ··· The data from this review suggests that the critical temperature in trauma patients is 32-33° C. Severely traumatized patients whose core temperature fell below 32° C are non-salvageable. ···
" · · · would it be better to more quickly scoop and run in the field or to add a little bit of excess exogenous heat in the field on the way to the hospital by the paramedics, and then in the emergency room ? ". Dr. John F. Hansborough (University Hospital, San Diego, CA 92103)
Incidence and Effect of Hypothermia in Seriously Injured Patients
Gregory K. Luna, M.D., Ronald V. Maier, M.D., Edward G. Pavlin, M.D., Doreen Anardi, R. N., Michael K. Copass, MD.. D., and Michael R. Oreskovich, M.D. ( The Journal of Trauma September 1987; Vol. 27, No.9: 1014-1018)
This study documents a high prevalence of hypothermia among seriously injured patients. Forty-three percent of our patients had initial temperature reductions of 1º to 3º C. · · · The physiologic impact of any heat loss, however, is likely to be accentuated in seriously injured patients. Additionally, since standard resuscitation and treatment measures often augment heat loss and prevent normal compensation, mild hypothermia can be rapidly compounded following institution of therapy. · · · Environmental exposure is a major factor responsible for excessive heat loss · · · The elderly are particularly prone to hypothermia. · · · The association found between initial severe hypothermia and injury severity suggests that critically injured patients are unable to maintain body temperature in the immediate post injury period. · · · Since the duration of environmental exposure is a primary factor in all types of accidental hypothermia the rapidity and quality of pre hospital treatment will influence the initial temperature. · · · Patients with the most severe injuries generally had to lowest recorded temperatures and the longest time to rewarm. These patients also received the greatest blood replacement and longest operating room times · · · Finding that rewarming time was directly related to the aggressiveness of the rewarming efforts, however, suggests that early attention to minimizing heat loss and providing conducted heat to the body can reduce the degree of hypothermia resulting from initial treatment. · · · The physiologic alterations induced by hypothermia are detrimental and add to the metabolic insult from severe injury. Aggressive efforts to limit heat loss and provide conducted heat to the body do effect the degree and duration of hypothermia and should be used in the treatment of critically injured patients. · · ·
Hypothermia: Impact on the Trauma Victim
Daniel C Cullinane, MD., John G Bass, Graig R Nunn, MD. ( Tennessee Medicine, August,97)
· · · Secondary hypothermia can be defined as a cold stress that is compounded by illness, injury, or drug induced alterations in heat productions and thermoregulation. The hypothermia seen most commonly in trauma patients is secondary hypothermia. These patients have lost their normal thermoregulation, and in fact, exposure to cold environmental conditions is not required to produce the profound impact of secondary hypothermia in the trauma victim. · · ·
Homeostasis. Despite the many deleterious effects of reduced core temperature, impact on enzyme function may be the most damaging and far reaching in the surgical patient. Hypothermia causes a reduction in the rate of nearly all chemical reactions and the enzymatic clotting cascade is no exception. · · · Bleeding time is also prolonged in hypothermia, presumably due to platelet dysfunction.
Summary Secondary hypothermia may present the clinician with an extraordinary set of challenging problems. Rapid rewarming using both passive and active techniques is essential to correct the many reversible changes associated with hypothermia. Despite aggressive management, secondary hypothermia continues to exact a large toll in terms of the mortality of trauma victims.
Accidental Hypothermia
B Tilman Jolly, MD. And Keith T. Ghezzi, MD. FACEP (Emergency Medicine Clinics of North America Vol. 10. No, 2, May,92)
Accidental hypothermia is a major public health problem. From 1970 to 1979 the Public Health Service recorded 4826 deaths attributed to hypothermia in the United States. Data from the District of Columbia shows that 68 deaths resulted from hypothermia from 1972 to 1982. Although hypothermia is classically a condition seen only in colder climes, cases have been reported as far south as Texas and Florida even under relatively mild climatic conditions. The rise in poverty levels and the growing elderly population in addition to other factors make it imperative for all physicians to have some understanding of the management of hypothermic patients. · · · Passive methods are useful in mild hypothermia with patients who are capable of heat generation. Active methods should be considered in most other patients. · · · Treatment of the hypothermic patient is directed toward prevention of further heat loss; prevention of complications, especially cardiac dysrhythmias; and rewarming. Pre hospital care providers have limited access to rewarming methods but can do a great deal toward preventing further deterioration. Removal of the patient from the cold environment should take place as quickly as possible. It should be remembered, however, that unnecessary manipulation can precipitate lethal dysrhythmias. · · · Severely hypothermic patients require a tremendous use of resources for resuscitation. Early management should focus on aggressive rewarming and careful monitoring for potential complications, particularly malignant cardiac dysrhythmias.