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A potato doesn’t heat up just because it’s wrapped in kitchen foil…

This may be a strange blog title, but please keep reading and hopefully you will understand what I mean.

In a very late follow-up to my blog, “Why Warming Patients is Important…” September 2018, it is time for me to offer more information regarding the critical need to warm both pre-hospital and hospital patients who are in our care. So we could call this blog “Why Warming Patients Is Important # 201”.

I’m starting off by following my September 2018 blog statement, “to help the hypothermic patient, metabolic heat loss must be matched with metabolic heat production”. This sounds simple but perhaps not always that easy to follow.

Step 1:
Recognize that just because you are warm does not mean your patient is warm. The patient is experiencing human pathophysiological conditions that you are hopefully not experiencing. Additionally, prolonged exposure to the cold, wet and the perfusion of cold fluids / blood will continue to decrease your patient’s core body temperature. .

Step 2
Understand how trauma, with or without the loss of blood, influences your patient’s level of hypothermia and the ability for them to generate their own body heat. Critical for survival is regulation of body temperature and trauma has a negative influence on the body’s thermoregulation system. Bleeding complicates this by decreasing tissue perfusion.
Your patient could easily be heading toward the “lethal triad” of hypothermia, acidosis and coagulopathy, which requires immediate treatment. So remember, cold affects not only the body’s temperature but also, if this “cold pathway” progresses to a more severe stage of hypothermia, your patient will deteriorate due to acidosis and coagulopathy.

Step 3:
Know the different levels of hypothermia, based on those accepted by your medical organization.

Here are the most commonly accepted levels:
1.Level One – MILD – body temperature 32 – 35°C:
a. if associated with trauma the temperature range shifts to 34 – 36°C
b. most easily recognized by body shivering – this is the body’s attempt to warm itself
c. teeth chattering – which may sound funny, but as a result you will hear slurred speech and muttering
d. other clinical signs and symptoms may include increase in blood pressure / respirations / heart rate and impaired judgement
e. you need to prevent your patient from progressing to Level Two
f. AT LEVEL ONE, THE BODY NORMALLY HAS ENOUGH ENERGY TO GENERATE IT’S OWN HEAT IF ADEQUATE PROTECTION FROM OUTSIDE ELEMENTS IS SOON PROVIDED AND BLOOD LOSS IS CONTROLLED
– the use of high quality passive warming products should be sufficient
– thermal retention is important so a passive warming product must be capable of trapping the heat that the body is still capable of generating
– BUT remember, without adequate body coverage there will continue to be the flow of cold blood going through the body; a single layer “space blanket” does provides minimum reflection of body heat back toward the body but should always be covered with another blanket to retain body heat, unless used in a warm environment
– for passive warming protection it is much better to use a product that has 2 – 3 layers of protection; this will trap the patient’s intrinsically produced heat in toward the body
g. avoid infusing cold IV fluids or blood because this could take your patient over to Level Two

2.Level Two – MODERATE – body temperature 28 – 32°C
a. if associated with trauma the temperature range shifts to 32 – 34°C
b. body shivering may stop at this stage
c. symptoms include irregular heartbeat, decreased blood pressure / heart rate / respirations / level of consciousness / body reflexes and dilatation of pupils
d. you need to prevent your patient from progressing to Level Three
e. AT LEVEL TWO, THE BODY IS LOOSING THE ABILITY TO GENERATE IT’S OWN HEAT AND PASSIVE WARMING PRODUCTS ARE NOT EFFECTIVE IN INCREASING BODY TEMPERATURE
– initiate the use of active warming products – i.e. products that self-generate heat
– never place an active warming product directly on the patient’s skin – always have a thin layer of clothing or cover between the warming product and the patient
– always cover the outside of the active warming product with a passive warming product or clothing to keep the heat inside and toward your patient; warm air rises and you need to warm your patient and not the area around your patient
– do not lay your patient on top of an active warming product because the pressure and close skin contact may harm the skin
f. DO NOT administer cold intravenous fluids or blood
– warm fluids or blood prior to their infusion by whatever means you have available
– protect fluids / blood from exposure to the cold environment during infusion
– it is highly recommended you use a IV fluid / blood warming system

3.Level Three – SEVERE – body temperature < 28°C:
a. if associated with trauma the temperature range shifts to < 32°C
b. symptoms include labored breathing, nonreactive pupils, signs of heart failure / pulmonary edema and will lead to cardiac arrest
c. your job is now to act fast and save your patient’s life by providing them with the right treatment
d. AT LEVEL THREE, THE BODY HAS RETAINED HIGH LEVELS OF ACIDOTIC BLOOD, ESPECIALLY IN THE EXTREMETIES
– sudden movement of your patient will rush this acidotic blood to the heart and can result in cardiac arrest – so be very gentle during treatment and transfer
– keep the patient in a horizontal position if possible
e. immediately initiate actions from Level Two, Point e, that are listed up above
f. DO NOT administer cold intravenous fluids or blood
– warm fluids or blood prior to their infusion by whatever means you have available
– protect fluids / blood from exposure to the cold environment during infusion
– it is highly recommended you use a IV fluid / blood warming system

Recommended Products – based on the 3 levels of hypothermia:
1. Level One
– if your only “hypothermia protection blanket” available is a single-layer space blanket then use it; cover as much of the body as possible and place over the space blanket a normal blanket or whatever you can find to keep the heat in
– best blankets – use a 2 – 3 layer “hypothermia blanket”, such as MediWrap® https://www.cantelmedical.co.uk/product/mediwrap-passive-warming-products/ or Blizzard Reflexcell™ https://www.blizzardsurvival.com/
– if IV fluids or blood are necessary, keep the fluid / blood as warm as possible for short rescue / transport times; consider the use of a fluid / blood warming system, such as the QinFlow Warrior or QinFlow Warrior Lite www.qinflow.com
– for longer rescue / transport times consider the use of a fluid / blood warming system, such as the QinFlow Warrior or QinFlow Warrior Lite www.qinflow.com

2. Level Two
– without active warming products you are in a race against time to get this patient to a facility that can provide this treatment
– use an active warming blanket, one that preferably does not require a battery (self-generating)
– best blanket – Ready-Heat™ active warming blanket https://www.ready-heat.com/
– best IV fluid / blood warmer – QinFlow Warrior or QinFlow Warrior Lite http://www.qinflow.comwww.qinflow.com

3. Level Three
– without active warming products you have little chance to save this patient’s life
– use an active warming blanket, one that preferably does not require a battery (self-generating)
– best blanket – Ready-Heat™ active warming blanket https://www.ready-heat.com/https://www.ready-heat.com/
– cover the active warming blanket with a passive warming product, such as the MediWrap® (https://www.cantelmedical.com) or Blizzard Reflexcell™ https://www.blizzardsurvival.com/
– best IV fluid / blood warmer – QinFlow Warrior or QinFlow Warrior Lite http://www.qinflow.com\

Recommended Published Literature:
– Pozos, R., Chapter 11, Human physiological responses to cold stress and hypothermia: Medical Aspects of Harsh Environments, Volume 1
– Mills, W. Jr., Chapter 14, Clinical aspects of freezing cold injury: Medical Aspects of Harsh Environments, Volume 1
– McCullough, L., Diagnosis and treatment of hypothermia. American Family Physician, Dec. 15, 2004, Volume 70, Number 12
– Lehavi, A., et al., Comparison of the performance of battery-operated fluid warmers. Emerg Med J 2018; 0:1-7.
– Beilman, G.J., Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality. Annals of Surgery. 249(5): 845-850, May 2009

Please contact me directly if any additional clarification is needed. dmcgirt@medicalsci.com