Niehaus, Matthew, DO

Pechulis, Rita, MD, FCCP

Wu, James K., MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Emergency MedicineA Case of Three Patients with Severe HypothermiaRewarmed with ECMOMatthew Niehaus DOLehigh Valley, Matthew.Niehaus@lvhn.orgRita Pechulis MD, FCCPLehigh Valley Health Network, Rita_M.Pechulis@lvhn.orgJames K. Wu MDLehigh Valley Health Network, james.wu@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/emergency-medicinePart of the Emergency Medicine Commons, and the Surgery CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtNiehaus, M., Pechulis, R., Wu, J. (2015, September 18). A Case of Series of Three Patients with Severe Hypothermia Rewarmed withECMO. Poster presented at Extracorporeal Life Support Organization Conference, Atlanta, GA.Lehigh Valley Health Network, Allentown, PennsylvaniaA Case Series of Three Patients with Severe Hypothermia Rewarmed with ECMOMatthew Niehaus, DO; Rita Pechulis, MD; James Wu, MDIntroduction Severe accidental hypothermia, defined as a core body temperature <28oC, is associated with multiple neurologic, cardiac, and metabolic complications.1 Here we report outcomes of three patients with severe hypothermia and cardiovascular collapse rewarmed and supported on ECMO. © 2015 Lehigh Valley Health NetworkReferences:1.  Sawamoto K, Bird SB, Katayama Y, et al. Outcome from severe accidental hypothermia with cardiac arrest resuscitated with extracorporeal cardiopulmonary resuscitation. Am J Emerg Med 2014;32(4):320-2.  American College of Surgeons. Advanced Trauma Life Support: Student Course Manual (9th ed.) 2012. Chicago, IL: Author. 3.  Freude T, Gillen S, Ehnert S, et al. Therapeutic peritoneal lavage with warm saline solution as an option for a critical hypothermic trauma patient. Wein Klin Wochenschr 2014;126(1-2):56-61.4.  Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2015; 86:88-94.Title  PATIENT 1 PATIENT 2 PATIENT 3Etiology of Hypothermia Intoxicated, found in woods Intoxicated, found in snow bank Heroin overdose, found outside his houseGender F M MAge 25 yo 26 yo 21 yoInitial Temperature 260C 21.70C 27.20CInitial Presentation Cardiac arrest Cardiac arrest Refractory shockRhythm in ED Ventricular fibrillation Asystole Atrial fibrillationTotal Time of CPR 37 min 265 min. NAType of ECMO VA VA VVCannula Site Single Lumen Fem-Fem Single Lumen Fem-Fem Dual Lumen R UTime to Target Temperature Attained 360C in 30 min Attained 28.60C in 46 min Attained 370C in 360 minTotal Time on ECMO 10 hours 36 hours 120 hoursComplications• Rhabdomyolysis• Bilateral transmetatarsal amputations• Acute renal failures• Transmetatarsal/finger amputations• Tracheostomy• PEG tube placement• Aspiration pneumonia• ARDS• Tracheostomy• PEG tube placementLength of Stay 37 days 57 days 45 daysOutcome Neurologically intact Neurologically intact Neurologically intact  DiscussionRewarming therapies are classified as either passive (warm blankets, overhead heaters) or active (infusion of warm fluids, lavage of the peritoneal and thoracic cavities),2 with active methods recommended for severe hypothermia.  In hypothermic cardiac arrest, the time to regain normal body temperature is the most influential parameter for a good recovery.1 The most common cause of death from severe hypothermia is cardiac arrest, resulting from slowing of conduction velocity in the myocardium and subsequent ventricular fibrillation (VF).2 The myocardium will quickly recover normal, organized electrical activity when rewarmed; consequently, aggressive warming techniques should accompany standard CPR in hypothermic cardiac arrest. While body temperature can be raised 2-40 C using warm saline infusion, increases as high as 120 C per hour have been noted with the use of extracorporeal membrane oxygenation (ECMO).1,3 In hypothermic cardiac arrest, the time to regain normal body temperature is the most influential parameter for a good recovery.1  A recent study found an association between ECMO in CPR and higher survival rates with good neurologic outcomes.4 In two of our cases, the use veno-arterial of ECMO rapidly rewarmed our patient’s core body temperature and provided hemodynamic support in the peri-arrest period. In our third case, veno-venous ECMO was used to rewarm our patient and prevent continued cardiac deterioration. ECMO should be considered early on as a primary means for rewarming in patients who present with severe accidental hypothermia.

A Case of Three Patients with Severe Hypothermia Rewarmed with ECMO

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A Case of Three Patients with Severe Hypothermia Rewarmed with ECMO

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