Use of Extracorporeal Life Support for Active Rewarming in a Hypothermic, Nonarrested Patient with Multiple Trauma

PRACTICE | CASES CPD

Use of extracorporeal life support for active rewarming in a hypothermic, nonarrested patient with multiple trauma

Daniel K. Ting MD, Douglas J.A. Brown MD n Cite as: CMAJ 2018 June 11;190:E718-21. doi: 10.1503/cmaj.180117

53-year-old man was driving in the winter when he was involved in a single-vehicle collision in the early morning KEY POINTS hours (around 4:30). The vehicle travelled down a six- • Extracorporeal life support can be used both for metreA embankment and struck several large trees. The man was cardiopulmonary support and to rewarm patients who have had not wearing a seatbelt and was ejected through the windshield, multiple trauma, either during surgical or endovascular ending up pinned under a tree. The ambient temperature was procedures, or after major bleeding has been excluded. about –20°C. • Extracorporeal life support is resource intensive and invasive; in Loggers found the patient at 6:30 am with a decreased level of nonarrested patients with severe hypothermia, there are no consciousness. While extrication efforts were underway, the consensus criteria to guide its use, but current evidence suggests that patients who are unstable, comorbid or older are ambulance service was notified and arrived on scene at 9 am. likely to benefit. The initial assessment by the paramedics documented a • The decision to begin extracorporeal life support in these Glasgow Coma Scale score of 8, a heart rate of 42, and a blood patients must be weighed carefully against the risks of pressure of 61/43. They placed a tibial intraosseous line and intu- complications arising from the treatment. bated the patient under direct laryngoscopy. They measured an • More study is required to determine optimal protocols and who esophageal temperature of 23.5°C. The patient was transported may best benefit. via air ambulance under full spinal precautions to the regional trauma and extracorporeal life support centre. Paramedics began passive rewarming techniques and also infused a litre of team decided to proceed directly to the hybrid operating room warmed normal saline. Prehospital notification was sent to car- (which contains advanced imaging modalities within the surgical diac surgery, anesthesia and intensive care. theatre) to facilitate further imaging, resuscitation and primary At 11:15 am, the patient arrived at the emergency department rewarming using veno-arterial extracorporeal life support. and was assessed concurrently by the trauma team leader, car- In the hybrid operating room, an intraoperative chest radio- diac surgeon, anesthesiologist and intensivist. Vital signs included graph, pelvis radiograph and a computed tomography scan of a Glasgow Coma Scale score of 2T, a heart rate of 61, a blood the patient’s head were negative for acute injury. Systolic blood pressure of 60/39 and an esophageal temperature of 24.9°C. Pri- pressures remained below 80 mm Hg and core temperature at mary and secondary surveys did not show any life-threatening 25.9°C. The cardiac surgeon inserted a 25-Fr venous and 19-Fr injuries. Extended focused assessment with sonography for arterial cannula into the right femoral area and started extracor- trauma was negative for pneumothorax, hemothorax, abdominal poreal life support at 12:25 pm. The extracorporeal life support free fluid or pericardial effusion. Continuous cardiac monitoring circuit was programmed to have flow rates of 4.5 to 5 L/min, a showed intermittent premature ventricular complexes, but no temperature gradient of 1–2°C, and a fraction of inspired oxygen other cardiac arrhythmias. Initial laboratory investigations of 100%. The team decided to avoid using heparin, as the patient showed a hemoglobin of 130 g/L (normal range 135–169 g/L), a had sufficient physiologic fibrinolysis from hypothermia and lactate of 8.5 mmol/L (normal range 0.7–2.1 mmol/L) and a serum trauma. The patient was rewarmed to 36.5°C over two hours potassium of 3 mmol/L (normal range 3.4–4.5 mmol/L). Results of (5.3°C/h) and was then weaned and decannulated. Intravenous arterial blood gas were pH 7.06, partial pressure of carbon dioxide infusions of norepinephrine (0.02 to 0.12 µg/kg/min) and vaso- 53 and partial pressure of oxygen 428 on 100% oxygen. The pressin (0.06 units/min) were used during extracorporeal life sup- patient’s ethanol level was 50 mmol/L (he had a history of alco- port. No substantial arrhythmias occurred. Four units of crystal- holic liver cirrhosis). While in the emergency department, the loid and three units of packed red blood cells were transfused to patient received a second litre of warmed normal saline. The support intravascular volume.

E718 CMAJ | JUNE 11, 2018 | VOLUME 190 | ISSUE 23 © 2018 Joule Inc. or its licensors PRACTICE For 5 5 and and E719 10 Any hemorrhage 4 Furthermore, lactic acidosis Furthermore, lactic acidosis 3 In such patients, the presence or In such patients, the presence or 13 and survival may be particularly poor particularly poor and survival may be ), but other experts support differ- Box 1), but other experts support ( 12,13 5 11 In 2016, the International Commission for Moun- International Commission In 2016, the 10 ISSUE 23 ISSUE | Failure to improve with external active and minimally invasive rewarming methods Life-threatening arrhythmia Hypotension (systolic blood pressure < 90 mm Hg) Respiratory failure Refractory acidosis Before the development of heparin-free protocols, the use of use the protocols, heparin-free of development the Before • • • • • *As endorsed by the International Commission for Mountain Emergency Medicine. Box 1: Selected proposed criteria for extracorporeal life support rewarming in severe hypothermia* The clinician has limited existing evidence to guide manage- The clinician has limited Patients with severe hypothermia in addition to their addition to their Patients with severe hypothermia in these reasons, multiple trauma may be a comorbidity that pre- these reasons, multiple trauma may be a the multi-organ dys- vents patients from being able to tolerate safely. function associated with their hypothermia trauma was limited. extracorporeal life support in patients with have refractory hypox- More recently, patients with trauma who with extracorporeal life emia or hypotension are being managed or surgical through control damage undergoing while support endovascular treatments. - both hypothermia and trauma. Hypother ment of patients with associated with a threefold mia in trauma is independently increase in mortality, tain Emergency Medicine endorsed a review that proposed five proposed five that review a endorsed Medicine Emergency tain extracorporeal life support in nonarrested potential criteria for hypothermic patients absence of intracranial hemorrhage as well as the exclusion of as the exclusion of absence of intracranial hemorrhage as well the risk versus terminal illness may be pivotal to determining benefit of extracorporeal life support. unique decision- trauma, such as the case presented, pose have a substantial making challenges. Generally, such patients are immobile or unable to seek care for mechanism, traumatic level of consciousness a prolonged period, have a decreased of surviving long and are hypotensive. By the very nature enough to become severely hypothermic, many of these patients have declared that they do not have hemorrhagic injuries that require urgent intervention, despite their hypotension and mechanism. Accurate core temperature measure- ment showing mild hypothermia can help rule out hypothermia as the cause of a decreased level of consciousness, but comorbid illness that impairs tolerance for hypothermic multi- comorbid illness that organ dysfunction. is worsened by coagulopathy, which develops below 34°C and is which develops below 34°C and is worsened by coagulopathy, not measured by standard assays. with mechanisms involving water submersion. with mechanisms involving shock are all and hypoperfusion secondary to hypovolemic to patient harm. poorly tolerated in trauma and contribute rewarming is more rapid and provides cardiorespiratory support support cardiorespiratory provides rapid and is more rewarming associated with perfusion the poor organ that ameliorates an invasive, resource-intensive but it is severe hypothermia, or limb 1.2% risk of death with an approximate procedure amputation. ent criteria, including a core temperature below 28°C ent criteria, including VOLUME 190 VOLUME |

- 4,5 1,2 3 that identified that identified JUNE 11, 2018 reported a case case reported a | 8 carried out a ret- 7 that required neuro- that required CMAJ Extracorporeal life support Extracorporeal life support During this time, patients are patients are During this time, 5 7 4,5 as studies are mostly retrospective in in retrospective mostly are studies as

ggla and colleagues prospectively studied 16 adult patients prospectively studied 16 adult patients 9 conducted a historical before and after trial that trial that conducted a historical before and after 6 In severe hypothermia, minimally invasive rewarming tech rewarming invasive minimally hypothermia, severe In For nonarrested patients with severe hypothermia, it is hypothermia, it is For nonarrested patients with severe Expert opinion suggests using active external and minimally and minimally Expert opinion suggests using active external - on vasopres condition in stable transferred was The patient with temperatures lower than 32°C who were all safely with temperatures lower than 32°C who were all safely rewarmed noninvasively. unknown which patients may benefit from extracorporeal life extracorporeal life unknown which patients may benefit from with safely rewarm will patients which and rewarming support Morita and col- the use of minimally invasive techniques. leagues invasive rewarming methods for patients who are stable, and who are stable, and invasive rewarming methods for patients arrest. in cardiac patients for support life extracorporeal using surgical stabilization and severe frostbite to his right hand, which frostbite to his right and severe surgical stabilization The digits. all of amputation partial necessitated eventually for recovery. He declined referral patient had a full neurologic disorder. treatment of his alcohol sor support to the intensive care unit (ICU) for care and full and full care unit (ICU) for care to the intensive sor support and was dis- the ICU for 11 days, He remained in trauma workup. His trauma after admission. hospital 33 days charged from injury a C4–C5 ligamentous workup showed included 68 nonarrested patients with core temperatures less less temperatures core with patients nonarrested 68 included reduction in mortality than 28°C. They found a 30% absolute on extracorporeal after the implementation of protocols based with conventional life support for this population compared rewarming methods. RÖ at risk of hypothermic complications such as arrhythmia, coagulopathy and multi-organ failure. series in which three young nonarrested patients had core temperatures of less than or equal to 28°C and were rewarmed with conventional techniques without complications. Furthermore, Steele and colleagues

The choice of rewarming treatments for hypothermic patients treatments for hypothermic patients The choice of rewarming physician. to physician from and centre to centre from varies Discussion rospective cohort study in an urban setting less than 28°C 36 hypothermia patients with core temperatures who were rewarmed using conventional methods; patients had an in-hospital mortality of 42%, which increased to 65% for the 70 mm Hg. than less pressures blood systolic with subgroup They showed an 8% rate of in-hospital cardiac arrest during conventional rewarming and attributed death to comorbid illness for 13 of the 15 fatalities. In contrast, younger populations with fewer comorbidities may rewarm safely with minimally colleagues techniques. Wanschler and invasive There is not sufficient available literature to guide management available literature to guide management There is not sufficient patients, hypothermic of small patient numbers. Physiologic studies nature and limited by cooling below 35°C for in humans are generally restricted from models. ethical reasons, and there are no good animal are at risk of car- Nonarrested patients with severe hypothermia transport to a centre diac arrest and therefore may benefit from than the rather capable of providing extracorporeal life support, closest emergency department. niques take a median of 10 hours. 10 of a median take niques PRACTICE six hoursofcardiopulmonaryresuscitation. been reportedwithcoretemperaturesaslow13.7°Candover ure. Patientsurvivalwithfullyintactneurologicrecoveryhas consciousness, coagulopathyandprogressivemulti-organfail- E720 temperature below35°C. Accidental hypothermiaisdefinedasaninvoluntarydropincore Diagnosis illness. impairment andcanmasktraumaticbraininjuryorcomorbid below about29°C,hypothermiausuallycausesneurologic regardless ofcoretemperature. the closestappropriatetraumacentreisusuallyindicated, endovascular controlofhemorrhageasrequired.Transferto tized, includingtemperaturemanagementandsurgicalor lation, Disability,Exposure(ABCDE)approachshouldbepriori- Columbia ical practiceguidelinesuchastheonedevelopedinBritish infrequency with which providers manage hypothermia, a clin disciplinary natureofhypothermicpatientcareandtherelative temperature isnotneededtotriagetransport. main advantageofthisclassificationisthatanaccuratecore severe (HTIII,below28°C)andcardiacarrestIV)(Box2).The tem: mild(HTI,35°Cto32°C),moderateII,32°C28°C), classify andtreathypothermiausingthemodifiedstagingsys- remarkable casesofsurvival, oxygen consumption,andisneuroprotective,allowingfor regulation. Hypothermiaslowsmetabolism,markedlydecreases sure, orsecondaryhypothermia,causedbyimpairedthermo vided intoprimaryhypothermia,causedbyenvironmentalexpo- Mild (HTI) *Refer to Box 1for proposed ECLS criteria. Note: resuscitation, CPR=cardiopulmonary ECLS =extracorporeal life HT=hypothermia. support, (HT IV) Cardiac arrest Severe (HTIII) Moderate (HTII) Stage Box 2:Staging andtreatment of accidental hypothermia 5 Fortraumamanagement,theAirway,Breathing,Circu- 14 mayhelpimprovequalityofcare. Conscious, shivering signs absent Unconscious, vital signs present Unconscious, vital without shivering consciousness, withor Impaired 4 Accidentalhypothermiacanbesubdi- Clinical signs 5 butalsocausesalteredlevelof 4 CMAJ 5 Manycliniciansnow 4 Giventhemulti- Approximate core temperature (ºC) | JUNE11, 2018 < 28 (variable) 28 to <32 32 to 35 < 28 11 | VOLUME 190 selected astheoptimallocationforfurthertreatment. and treatlife-threateningpathologysimultaneously,was this case,theoperatingroom,whereitispossibletodiagnose department, asitisasuboptimallocationforresuscitation.In diac arrest were a contraindication to imaging in the radiology the patient’s need for ongoing resuscitation and the risk of car- patients withmultipletraumafully,thecliniciansjudgedthat intracranial injury. Whereas itwould beidealtoimage all futility shouldthepatienthavealreadysufferedacatastrophic ceeding directly to extracorporeallifesupport involved ariskof decompensation fromseverehypothermiaformanyhours.Pro- ischemic injury fromprolonged hypotension and circulatory minimally invasiverewarming,thepatientwouldbeatriskof support rewarmingwithorwithouttraumalaparotomy.With proceed directlytotheoperatingroomforextracorporeallife for traumaimagingbeforedeterminingpatientdisposition;or techniques orextracorporeallifesupport;transfertoradiology rewarm in the emergencydepartmentusingminimally invasive clinical decisiontodooneofthefollowing:resuscitateand potential traumaticinjuries.Theclinicianswerefacedwitha mechanism andlackofimagingcreateduncertaintyregarding raphy for trauma (EFAST) examination; however, the severe veys, includingtheextendedfocusedassessmentwithsonog since initialinjuryandthe negative primaryandsecondary sur- tributor totheprofoundhypotension(61/43)given4.5hours ethanol intoxication.Hypothermiawasprobablythemaincon- primary exposureandsecondaryhypothermiafromtrauma (core temperatureof23.5°C),likelyowingtoacombination In this case, the patient presented with severe hypothermia Management • • • • • • • • • • • (as perHTII) Active externalandminimallyinvasive rewarmingduringtransport apply heattohead) Prevent furtherheatloss(insulation, warmenvironment,donot Transport toECLScentre Airway management CPR andupto3dosesofepinephrinedefibrillation • • HT IImanagement,plus: Full bodyinsulation Minimize movements,horizontalposition,immobilization Cardiac andcoretemperaturemonitoring Active externalandminimallyinvasiverewarming movement ifpossible Warm environmentandclothing;warm,sweetdrinks;active Preference totreatinECLScentre* Airway managementasrequired | ISSUE 23 Treatment PRACTICE

. E721 . 8th ed. New . 8th ed. New Outcome of accidental hypothermia hypothermia Outcome of accidental Forced air speeds rewarming in acci- Forced air speeds The incidence and significance of acci- The incidence and significance Severe accidental hypothermia with or with accidental hypothermia Severe Extracorporeal-assisted rewarming in the in the Extracorporeal-assisted rewarming Extracorporeal membrane oxygenation in oxygenation in Extracorporeal membrane et al. et al. et al. , et al. J P, DI, A, et al. et al. , , O Ravn S , L Sessler Wagner Cameron Duff , M, R, E MJ, Voelkel , A Agersnap , Accidental hypothermia clinical practice guideline for British clinical practice guideline for British Accidental hypothermia Department of Emergency Medicine (Ting), University of Department of Emergency Medicine (Ting), University Nelson ISSUE 23 ISSUE Hypothermia. In: Tintinalli JE, Stapczynski JS, Ma OJ, et al., editors. Hypothermia. In: Tintinalli M Frossard | Christou Endacott , DJ. S, Philipp M, B DJ. MT, , M Röggla with or without circulatory arrest: experience from the Danish Praesto Fjord Fjord Praesto Danish the from experience arrest: circulatory without or with 1078-84. Resuscitation 2012;83: boating accident. Steele - extracorpo of use the without rewarming instability: hemodynamic without ;114:315-20. Wien Klin Wochenschr 2002 real circulation. Wanscher ;27:479-84. Ann Emerg Med 1996 dental hypothermia. Dunne management of accidental deep hypothermic cardiac arrest: a systematic systematic a arrest: cardiac hypothermic deep accidental of management 2014;23:1029-35. review of the literature. Heart Lung Circ Brown Tintinalli’s Emergency Medicine: A comprehensive study guide study comprehensive A Medicine: Emergency Tintinalli’s . York: McGraw-Hill; 2015:1357-65 Ireland dental hypothermia in major trauma — a prospective observational study. dental hypothermia in major . Resuscitation 2011;82:300-6 Arlt bleeding shock. Resuscitation 2010;81:804-9. severe trauma patients with Brown Accidental Hypothermia Working Group; 2016 Columbia. British Columbia Competing interests: None declared. This article has been peer reviewed. The authors have obtained patient consent. Affiliations: British Columbia, Kelowna, BC; Department of Emergency MedicineBritish Columbia, Kelowna, BC; Department of BC (Brown), University of British Columbia, Vancouver designContributors: Both authors contributed to the conception and important for critically it revised manuscript, the drafted work, the of to be publishedintellectual content, gave final approval of the version work.and agreed to be accountable for all aspects of the Acknowledgements: We are indebted to the interprofessional as well as the Britishhealth care team at Kelowna General Hospital care. In partic- Columbia Ambulance Service for their roles in patient Cleve. ular, we thank Drs. Nick Kuzak, Vance Beck and Paul Correspondence to: Daniel Ting, [email protected] 9. 8. 7.

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J JC, et al. et , C Boyd , H Yamagiwa Goslings , Strapazzon Handler S , , , L F

GJ, Brugger Sterz , Accidental hypothermia. In: Auerbach PS, Cushing TA, Harris NS, editors.Accidental hypothermia. In: Auerbach PS, Cushing TA, Harris Inokuchi A , Gordon DJ, The patient was later found to have an unstable cer have an unstable was later found to The patient S , , DF. 12 P

rewarming treatments, complications and outcomes from one university med- rewarming treatments, complications and outcomes ical centre. Resuscitation 2010;81:1550-5. Danzl van der Ploeg . Auerbach’s Wilderness Medicine. 7th ed. Milton (ON): Elsevier; 2016:135-62 Brown 2012;367:1930-8. Paal a 20 year review of a rare condition in an urban area. internal rewarmingdiopulmonary bypass rewarming versus that of conventional for patients with accidental deep hypothermia. Schober Med 2016;24:111. Morita the content of this review is endorsed by the International Commission for Commission for the content of this review is endorsed by the International Mountain Emergency Medicine (ICAR MEDCOM). It is impossible to know how the patient would have done done have would patient the how know to impossible is It . . . 5. 2. 4. 3 1

vical spine injury which, in the event of a malignant arrhythmia, arrhythmia, malignant a of event the in which, injury spine vical by cardiopulmonary resuscitation. might have been worsened without extracorporeal life support, but given his low core tem- core low his given but support, life extracorporeal without arrest and hypothermic cardiac was at high risk for perature, he traumatic of death from any increased chance had a threefold injuries.

References Conclusion - a nonarrested patient with severe acciden We report the case of neurologic full a had who trauma multiple and hypothermia tal extracorporeal life support for primaryrecovery after undergoing in to begin extracorporeal life support rewarming. The decision of be weighed carefully against the risks patients like this must further suggest We treatment. the from arising complications for contraindications and indications the to determine research in hypothermic patients with multipleextracorporeal life support trauma. 6