A man went into cardiac arrest after spending a night without adequate clothing at temperatures below −9°C
A 33-year-old male was brought to the trauma centre in an unresponsive state by the EMS. The patient was found wearing no coat in the morning hours despite a cold night with temperatures below −9°C (15°F).
Primary Survey
A primary survey was performed in the emergency department, which revealed a patent airway, palpable distal pulses, bilateral normal breath sounds, and trismus. The patient had a Glasgow Coma Scale score of 3.
Secondary Survey
When a secondary survey was performed, the patient was cold on touch, but the rectal temperature could not be recorded. There was a laceration of 2 cm above his left eyebrow. The rest of the physical examination was normal.
Management:
The patient was given 14 mg etomidate and 80 mg succinylcholine, and rapid sequence intubation (RSI) was performed to protect the airway. Two large-bore IV lines were maintained and warm fluids (40°C) were started. Foleys catheter and nasogastric tubes were also placed through wich additional warm fluids were instilled. An external warming blanket was applied.
After rewarming, the rectal temperature was recorded; the first reading showed a temperature of 26.6°C (80°F).
Serological results revealed elevated potassium of 8.5 mmol/l, a pH of 7.14 with a base deficit of 10.5, and lactic acid of 6.2 mmol/l. The blood alcohol level was 250 mg/dl.
After the patient’s vitals were stabilized, the patient was transported for a computed tomography scan to screen for traumatic injuries.
During the CT scan, the patient became unstable, pulseless, and progressed to ventricular fibrillation. ACLS protocol was initiated, and the patient was given:
- 23 rounds of epinephrine
- 300 mg of Amiodarone
- 2 g of calcium gluconate
- 1 g magnesium
- 40 units of vasopressin
- 250 mEq of bicarbonate
- 22 shocks
Two liters of warm fluids at 40°C were instilled through a peritoneal catheter into his abdominal cavity. Ultimately the patient regained vital after approximately 90 mins of CPR performed in the CT scan room.
The patient was then shifted to the medical intensive care unit where the warm fluids were continued at an intended rate of 2–4°C/h. The patient was extubated on Day 3 on hospital admission when his GCS was 15.
The patient renal profile was deranged with the following results:
- Peak creatinine of 2.2 mg/dl
- Elevated creatine kinase
- Elevated myoglobin
The deranged renal profile was most likely secondary to trauma during the resuscitation.
The creatinine returned to a baseline of 0.8 mg/dL.
The patient was started on anticoagulant but still, he developed compartment syndrome on 6th day of admission for which a decompressive fasciotomy followed by a split-thickness skin graft closure later on
Thereafter, the patient remained neurologically stable, therefore, he was discharged on the 26th day of admission with 15/15 GCS.
