POSSIBLE DEAD BODY

     At the scene, a police officer directs the crew through the snow to the back porch of a home. A young woman, maybe in her mid 20s, is lying on the back porch, partially in the accumulated ice and snow. She is clad only in a tank top and a pair of shorts. The back glass door of the house has been broken out, and a small trail of blood dried on the porch suggests the young lady went through the door to arrive at her current position about 15 feet away. The blood is dried and frozen, so it has been there for a while. A family member is nearby and is appropriately upset as she tells someone on the cell phone, "My sister is dead!"

     A crew member reaches down to the victim and notes dilated pupils and no breathing—through the cold of his fingers, he can't feel a pulse. The woman's jaw is tightly closed, and she does not respond to vigorous shaking. The responders look at each other. Everyone is ready to report a dead person to the dispatch center. But one of the crew members, still watching the victim's position, asks for another chance. "I thought I saw her breathe!" he insists.

     The provider takes his gloves off. His hands are so cold he can barely feel his own fingers. He feels no pulse. He places a pulse oximeter on the woman's finger, but no reading can be obtained.

     Then she gasps—signs of life! But it's too cold to initiate care on the icy porch. The Attack One crew leader feels the best chance for the patient is rapid movement into the medic unit, being handled very carefully, and immediate initiation of warming procedures. The medic unit will also be a better site to initiate cardiac monitoring. Her movement and breathing indicate she's still able to generate some blood flow, but rough handling and a cycle of warming and then cooling again can irritate the heart, resulting in ventricular fibrillation and death. Immediate aid can be delivered by wrapping her in a warmed blanket, removing her wet clothing and administering warmed oxygen and fluids.

     It will be a 15-minute transport to the closest appropriate hospital, so the Attack One crew feels warming can be initiated en route with warm IV fluids and warmed humidified oxygen. The crew does not have a warmer available in the ambulance (commercial warmers are available, and ambulances in cold locations often have them), but they notice a microwave oven in the house near the doorway the victim came through.

     As the victim is being bundled up, one crew member asks the family if they can quickly warm some fluid for her. The family also volunteers that they have a microwave heating pad that might be useful. The crew takes two liters of fluid and warms them to around 104°F in the microwave, and also warms the heating pad.

     The patient is gently moved and carefully wrapped in a warm blanket. Her cold, wet clothing is removed and her skin dried, and she's placed on the stretcher in the ambulance.

     As a crew member applies a three-lead cardiac monitor, the patient takes two or three slow breaths. When the monitor is turned on, a rhythm wave is noted, but at a very slow rate. It's time for aggressive resuscitation.

Prehospital Impressions
     The patient's arms feel ice cold, and only an external jugular vein is present. The IV line is started there. The interior cabin of the ambulance is warmed as much as possible. The oxygen cylinder is relatively warm, but the oxygen line can be warmed and humidified more aggressively if an inline nebulizer cup is filled with warm fluid. The IV fluid from the microwave will provide that heat, so the nebulizer cup is filled with it and kept warm. Assisted ventilation by the medic crew will supplement the patient's very slow breaths.

     The IV line is started, and a blood sample tested for glucose, since the patient is unconscious. The blood sugar is 23. The line is started, and a 300cc bolus of fluids is administered. Why is the blood sugar so low? Is that related to her cold temperature?

     The family members need to provide some additional history. The patient had been ill recently, with a lot of vomiting and diarrhea. She lives alone, and her sister had come that morning to check on her. She knew the patient had diabetes and was taking medication, "but not shots." When the sister arrived, she found the victim outside and called 9-1-1.

     The victim's care will be best provided at a hospital that has cardiovascular bypass capability, as that is the most effective method to warm a victim of severe hypothermia. Medical control will be needed to guide fluid and glucose therapy. Hospital communication will also serve as a "medical alert" for this critically unstable patient, and allow the team there to prepare for a rewarming intervention.

     Medical therapy would be to give modest amounts of both fluids and sugar. Medical direction asks that dextrose be limited to 25 grams, and volume to one liter of warmed fluid. The remaining warmed water will be used in the respiratory circuit to warm and humidify.

     The victim has clenched teeth, so it is necessary to intubate her nasally. This is performed smoothly.

Hospital Course
     The emergency team is prepared on arrival to do rewarming with warmed cushions, fluids, lights and a breathing circuit. But the designated cold-temperature thermometer measures the patient's rectal temperature at a number that is almost too low to be believed: 72°F. The cardiovascular team is immediately notified, and the patient is rapidly prepared to go to the operating room and be placed on cardiac bypass. This is the most aggressive form of rewarming that can be accomplished. She is again moved carefully, to avoid a lethal dysrhythmia. Her heart rate has increased to about 35 bpm, and no chest compressions are needed. Her bladder is catheterized and empties a significant amount of urine. Her repeat blood sugar is 73, and at that level no further sugar is needed.

     She is moved to the operating suite, has catheters placed in her femoral artery and vein, and is placed on cardiac bypass with blood warming in the circuit. This is done in a very controlled manner, to raise body temperature only a few degrees every 30 minutes. After 12 hours, she begins to awaken and after a week in the ICU, she recovers completely.

Case Discussion
     Cold patients present difficult decision-making scenarios for EMS providers. When should the victim be pronounced dead? How can the rewarming process take place without causing the patient to go into ventricular fibrillation? What other factors might have caused the patient to become hypothermic to begin with?

     This patient had a classic presentation of hypothermia, and careful handling prevented a fatal outcome. After awakening, the victim remembered being ill, but had no recollection of being outside. Police found no evidence of foul play; it was concluded that the victim's illness likely caused a drop in blood sugar, and she fell through the outside door and could not get back inside. Fortunately, she was found by her sister in time, and the crew provided the initial resuscitation and quick removal. Notification and removal to an appropriate hospital allowed timely and invasive rewarming treatment, and the patient recovered.

     Hypothermia rarely occurs in isolation from another medical problem. Typically there is another issue that puts the victim in the cold environment and does not allow them to return to one that's warm and safer.

Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.