Adaira Landry

Ice water submersion for rapid cooling in severe drug-induced hyperthermia

Abstract Context. The optimal method of cooling hyperthermic patients is controversial. Although controlled data support ice water submersion, many authorities recommend a mist and fan technique. We report two patients with drug-induced hyperthermia, to demonstrate the rapid cooling rates of ice water submersion. Case details. Case 1. A 27-year-old man presented with a sympathomimetic toxic syndrome and a core temperature of 41.4°C after ingesting 4-fluoroamphetamine. He was submerged in ice water and his core temperature fell to 38°C within 18 minutes (a mean cooling rate of 0.18°C/min). His vital signs stabilized, his mental status improved and he left on hospital day 2. Case 2. A 32-year-old man with a sympathomimetic toxic syndrome after cocaine use was transported in a body bag and arrived with a core temperature of 44.4°C. He was intubated, sedated with IV benzodiazepines, and submerged in ice water. After 20 mins his temperature fell to 38.8°C (a cooling rate of 0.28°C/min). He was extubated the following day, and discharged on day 10. Discussion. In these two cases, cooling rates exceeded those reported for mist and fan technique. Since the priority in hyperthermia is rapid cooling, clinical data need to be collected to reaffirm the optimal approach.

Does Calcium Administration During Cardiopulmonary Resuscitation Improve Survival for Patients in Cardiac Arrest

TUDY SELECTION his review was conducted to pdate the Guidelines on ardiopulmonary Resuscitation nd Emergency Cardiac Care, using he 2010 International Liaison ommittee on Resuscitation ILCOR) evidence evaluation rocess. Forty-eight articles were etrieved but only 10 included. ach included article matched one f the 5 levels of evidence reported y ILCOR (Table). Editorial articles, bstracts, reviews, commentaries, nd guidelines were excluded.

In Patients With Acute Ischemic Stroke, Do Different Thrombolytic Doses, Agents, or Routes of Administration Lead to Different Outcomes?

IAS AND DATA ANALYSIS o assess study quality and risk of ias, randomization, allocation oncealment, blinding, and ntention-to-treat analysis data ere collected. Primary outcome as functional outcome at the end f follow-up. An intention-to-treat nalysis was performed for econdary outcomes: early and otal deaths at the end of follow-up, ymptomatic and fatal intracranial leeding events, and major xtracranial bleeding events.

Letter in response to: "Stimulant-induced hyperthermia and ice-water submersion: practical considerations".

We appreciate Drs. Richards’ and Colby’s comments and will address each of their concerns to clarify our advocacy of a technique that has been a standard approach to hyperthermia for over 30 years at our institution. Concerns of safety and feasibility of ice-water submersion are realistic when planning to replicate this effort in a novel setting. Healthcare provider and staff safety should always be prioritized. At our institution, a number of factors make this approach both safe and readily accessible: availability of a water-impermeable bed (manufactured by Arjo Huntleigh Sweden; shower trolley model), large volume icemaker, and staff experienced in mobilizing this technique. Without these, implementation becomes more challenging, but not impossible. Without access to a water-impermeable bed or, for example, in the hypothetical case of the hyperthermic, morbidly obese patient (when patient mobilization poses an unacceptable risk to staff), we recommend using bed sheets taken up from under the patient and then tied to the bed railing, to provide a semipermeable layer for the containment of ice, with the placement of towels below to absorb excess water. Consideration of institution-specific limitations and individualized risk-benefit analyses, however, remain essential. Agitation is another factor that poses challenges to this technique. The approach to controlling psychomotor agitation in these patients is similar to any agitated patient. Parenteral (either IM or IV) benzodiazepines should be given either initially or in parallel with exposure, transfer and submersion in ice. In doing so, psychomotor effects on body temperature are mitigated, while life-sustaining efforts at cooling are facilitated. In both of our cases, efforts at chemical sedation were initiated prior to and throughout ice-water submersion; in neither case did agitation prevent effective cooling. Additional safety concerns raised by the authors include risks of drowning and electrocution. Because application of this technique requires close monitoring and multi-staff participation, patients are unlikely to suffer from complete submersion, neglect and subsequent drowning. In addition, the bed’s sidewalls are only nine inches tall, making complete submersion nearly impossible. We advise placing a roll or pillow under the patient’s head and advocate ice submersion only from the neck down. Because most monitoring leads and equipment are designed to be impermeable to body fluids, the risk for electric shock is improbable. An exception to this is if the patient develops an unstable or pulseless dysrhythmia requiring cardioversion or defibrillation. We have used remote defibrillation pads with success, but many would advocate CPR and cooling prior to defibrillation. While ice-water submersion seems ‘‘messier’’ than ice packs or mist and fan, the literature suggests it is more effective.[1,2] Benefits are that it can be performed in any ED with access to ice, does not necessitate (although benefits from) specialized equipment, is rapid and effective. We acknowledge that it requires a coordinated team, vigilant monitoring, and is resource-intensive for the duration (20–30 min) that a patient is being actively cooled. This coordination is no different than a trauma resuscitation or a cardiac arrest and becomes second nature when rehearsed or applied repeatedly in clinical practice. Although submersion may seem excessive to some, compared to the ease of applying axillary/groin ice packs and specialized cooling devices, with or without mist and fan, our risk-benefit analysis supports this approach to prevent the morbidity and mortality associated with severe hyperthermia.

Should Triple Rule-Out CT Angiography Be Used in Patients With Suspected Acute Coronary Artery Disease, Aortic Dissection, or Pulmonary Embolus?

One randomized control trial, 7 casecontrol studies, and 3 cohort studies were included; 791 patients received triple rule-out CT and 2,748 patients had other diagnostic modalities (eg, nuclear stress testing, pulmonary angiographic CT). There was variation in the diagnostic modalities compared, use of adjunct laboratory values such as D-dimer, and use of b-blockers to improve image quality. Using prespecified scoring criteria, the individual studies ranged from low to high risk for bias; however, sensitivity analysis based on the higher-quality studies yielded similar results.