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This is actually a good topic for discussion; I think the "you're not
dead until you're warm and dead" mantra has created quite a bit of
confusion
For EM and other providers. Usually when there is confusion it is
because the medical literature is not adequate to allow defensible
recommendations and to an extent that is true as one attempts to answer
Steve's original question...how warm do you have to be to stop
resuscitation attempts (assuming as Maureen points out that hypothermia
preceded death....obviously the first question to be asked and often
just as confusing!). Another way to ask the question might be: at what
temperature does hypothermia mimic death? Much of the literature on this
comes from intentional cooling in operating rooms, animal studies, and
anecdotal case reports/reviews. That having been said, the consensus
numbers used in most articles I have read state that the myocardium
becomes irritable with possible atrial and ventricular fib below 28-30
C. True asystole (cardiac standstill) doesn't occur until 20 degrees,
but profound bradycardia can fool clinicians into thinking there is
asystole. Fixed and dilated pupils and unconsciousness also don't occur
until the 28 degree or lower range. If these numbers are accurate and
apply to children then it seems to me we have a reasonable answer on
when to stop...when asystolic and temp is above 28-30 C. The AHA
acknowledges this clinical dilemma and infers the 30 degree cut off but
does not explicitly state as much: "Once the patient is in the hospital,
physicians should use their clinical judgment to decide when
resuscitative efforts should cease in a victim of hypothermic
arrest."(Circulation, 2005, 112 IV-136-138)

Steve, you may also be interested in other methods of core rewarming
other than bypass. See case report on "endovascular warming for profound
hypothermia" (Annals of EM Feb 2008 Vol 51 160-163)

Pete



-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Maureen McCollough
Sent: Tuesday, January 11, 2011 9:36 AM
To: [log in to unmask]
Subject: Re: Hypothermia

yes, there is a difference between being COLD...then DEAD.     and
DEAD...then
COLD.     all dead bodies eventually reach room temperature.     what
has
anecdotal success is COLD...then DEAD.

I remember those trauma cases in L.A.   The water was cold enough too
cool them
because they were in there long enough.   They did not become instant
popsicles.   And as I understand this really involves drownings (breaks
through
the ice), not patients also suffering massive blunt trauma.

maureen mccollough
lac+usc







________________________________
From: Michael Falk <[log in to unmask]>
To: [log in to unmask]
Sent: Mon, January 10, 2011 6:47:10 PM
Subject: Re: Hypothermia

Brought this up last year on the list serv with minimal response.  From
what I
have been taught the hypothermia effect works best with extreme cold,
there is
ice on the water etc!!  Learned this from an PICU attending on the West
Coast
when we had car full of kids (4 in total) came in in traumatic arrest,
after the

car went off the highway into part of the LA river.  All were
hypothermic and
all were stopped before reaching normothermia because of persistent
asytole.
Have heard this from others since then but you still don't see it in the
textbooks.
Mike Falk,
King's County Hospital Center
Brooklyn, NY



________________________________
From: Steve Socransky <[log in to unmask]>
To: [log in to unmask]
Sent: Mon, January 10, 2011 10:16:39 AM
Subject: Hypothermia

Hello,



Just wondering to what core temp you continue your resuscitation efforts
for
asystolic hypothermia cases before discontinuing efforts.  35 C? 32 C?
30
C? Do you vary your practice based on age?  Does absence of cardiac
activity
on bedside ultrasound influence your decision?  Any other factors?



Bypass is not an option in my setting and transport is too prolonged to
be
practical.



Thanks very much,



Steve Socransky






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