DON'T MESS WITH TEXAS? DON'T MESS WITH THE COLD! ACCIDENTAL HYPOTHERMIA WITH CARDIAC ARREST TREATED SUCCESSFULLY WITH PROLONGED RESUSCITATION AND REWARMING

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Accidental hypothermia is an uncommon but potentially life-threatening presentation, more frequently occurring in colder climates. We present a case of severe hypothermia with cardiac arrest in the characteristically warm state of Texas, in a patient who had arrived to the emergency department (ED) several times during the prior week. CASE PRESENTATION: A 55 year old man with a history of alcohol (ETOH) abuse and schizophrenia is brought into the ED after being found down. Records indicate that he had arrived here 10 different times in the prior 2 weeks due to ETOH intoxication and mild hypothermia, with oral and rectal temperatures between 90-95°F. Each time, after being rewarmed, he would act inappropriately, verbally abusing staff despite warnings from security. Social workers provided warm clothing, shelter information, food pantry and other basic needs, but he would decline assistance and was escorted out by security. On this presentation, he was hypothermic to 79°F rectally, unresponsive and pulseless, in ventricular fibrillation (VF) cardiac arrest. CPR was initiated along with intubation, and a cardioversion once returned pulses. Active rewarming began with forced air blankets, warm IV fluids, bladder and esophageal irrigation. The patient again lost pulses, CPR was resumed and a second shock delivered with return of pulses. He then went into pulseless electrical activity (PEA), received multiple rounds of CPR and epinephrine, and had a return of pulses after 3 hours of resuscitation. Bilateral chest tubes were inserted and warm thoracic lavage began. His rectal temperatures improved to 85°F then to the 90s°F, in sinus rhythm with good distal pulses, and the medical Intensive care unit staff was notified for further management. Within days, he showed complete recovery neurologically and was successfully extubated. He did not meet criteria for involuntary commitment, engaged in motivational interviewing and was discharged in good spirits. He was provided transportation to another city where he stated his family resides. DISCUSSION: This patient arrived to the ED several times in the days prior with Stage I and II hypothermia, but his care was complicated by intoxication, combativeness, and he repeatedly refused resources. His last arrival to the ED required full cardiac resuscitation and active rewarming with thoracic lavage. This case illustrates the importance of identifying patients at risk for accidental hypothermia, particularly the homeless, and those with a history of alcohol abuse, even in central Texas. His case may highlight a paucity of guidelines and framework for homeless individuals at risk for hypothermia, in areas that typically remain warm year-round. CONCLUSIONS: Accidental hypothermia can be a life threatening presentation, and identification of those at risk, particularly the homeless, those with a history of alcohol abuse, and poor mental health, is vital. Reference #1: J L Tan, M Saks, J M DelCollo, M Paryavi, S Visvanathan, C Geller; Accidental hypothermia cardiac arrest treated successfully with invasive body cavity lavage, QJM: An International Journal of Medicine, Volume 111, Issue 8, 1 August 2018, Pages 563–564, https://doi.org/10.1093/qjmed/hcy075 Reference #2: Husby, P., Andersen, K.S., Owen-Falkenberg, A. et al. Intensive Care Med (1990) 16: 69. https://doi.org/10.1007/BF01706328 DISCLOSURES: No relevant relationships by Liwayway Andrade, source=Web Response No relevant relationships by Zachary Pinchover, source=Web Response No relevant relationships by Mohi Syed, source=Web Response