Sudden Cardiac Arrest in a Patient With COVID-19 as a Result of Severe Hyperkalemia After Administration of Succinylcholine Chloride for Reintubation. A Case Report.

Background: We present a case study of a man with coronavirus disease 2019 (COVID-19) who developed cardiac arrest as a result of hyperkalemia following administration of chlororsuccinylcholine during endotracheal intubation. Case Summary: A patient with a severe course of COVID-19, hospitalized in the Intensive Care Unit, underwent reintubation on day 16. The applied scheme was rapid sequence induction and intubation with administration of chlororsuccinylcholine. Immediately after intubation, there was a sudden cardiac arrest due to hyperkalemia (cK + 10.2 meq/L). Treatment was initiated as per guidelines, which resulted in a return to spontaneous circulation after 6 min. Conclusion: Chlorsucynylcholine may cause life-threatening hyperkalemia. We recommend using rocuronium as a neuromuscular blocking agent in critically ill COVID-19 patients due to its more optimal safety profile.

Prehospital Use of Ultrathin Reflective Foils.

Ultrathin reflective foils (URFs) are widely used to protect patients from heat loss, but there is no clear evidence that they are effective. We review the physics of thermal insulation by URFs and discuss their clinical applications. A conventional view is that the high reflectivity of the metallic side of the URF is responsible for thermal protection. In most circumstances, the heat radiated from a well-clothed body is minimal and the reflecting properties of a URF are relatively insignificant. The reflection of radiant heat can be impaired by condensation and freezing of the moisture on the inner surface and by a tight fit of the URF against the outermost layer of insulation. The protection by thermal insulating materials depends mostly on the ability to trap air and increases with the number of covering layers. A URF as a single layer may be useful in low wind conditions and moderate ambient temperature, but in cold and windy conditions a URF probably best serves as a waterproof outer covering. When a URF is used to protect against hypothermia in a wilderness emergency, it does not matter whether the gold or silver side is facing outward.

Artifacts in fluoroscopy and changes in radiation dose caused by heating blankets and insulating covers during simulated endovascular treatment.

PURPOSE: We aimed to assess whether insulating covers and warming systems cause artifacts in fluoroscopy, and whether they alter the radiation dose. METHODS: Eight insulating and warming systems were wrapped around the phantom in order to obtain images in fluoroscopy, and to measure the absorbed and scattered radiation dose. A dosimeter, endovascular catheters, and stents were placed into a phantom. The other dosimeter was placed outside of a C-arm table, at the operator's and anesthesiologist's locations. RESULTS: Most of the insulating covers did not cause artifacts in the fluoroscopy and led to a significant decrease in both the absorbed and scattered radiation dose. The highest decrease in the absorbed dose was observed with metalized foil (- 2.09%; p = 0.001) and in the scattered dose with Helios cover (- 55%; p < 0.001). Only one heating system (Ready Heat combined with Hypothermia Prevention and Management Kit cover) caused significant artifacts and increased radiation up to 99% (p < 0.001). CONCLUSION: Thermal insulation may be maintained during X-ray-guided emergency endovascular procedures in trauma victims. Self-heating blankets should be replaced with another warming system.

Effect of Thermal Insulation on Image Quality and Radiation Dose in Polytrauma Computed Tomography.

PURPOSE: Unintentional drop in body temperature in trauma victims is an independent risk factor for mortality. We aimed to assess the impact of thermal insulation on image quality and radiation dose in polytrauma computed tomography (CT). METHODS: Thirteen different insulating covers were used to wrap CT phantoms. Images were assessed subjectively at a radiological workstation and analyzed digitally with dedicated software evaluating the noise intensity, spatial resolution, and image homogeneity. The radiation dose was measured using a dosimeter. RESULTS: Most materials did not cause significant artifacts apart from 2 heating pads. Although the radiation dose was increased by the majority of insulating covers (up to 64.66%), certain covers decreased the absorbed radiation (up to -7.35%). CONCLUSIONS: The majority of insulating systems do not cause artifacts in CT scans. When using covers with self-heating warmers, removing the heating pad is suggested due to the risk of considerable artifacts appearing. Certain insulating covers may increase or decrease the radiation dose.

Prognostic Factors for Nonasphyxia-Related Cardiac Arrest Patients Undergoing Extracorporeal Rewarming - HELP Registry Study.

OBJECTIVE: Extracorporeal rewarming is the treatment of choice for patients who had hypothermic cardiac arrest, allowing for best neurologic outcome. The authors' goal was to identify factors associated with survival in nonasphyxia-related hypothermic cardiac arrest patients undergoing extracorporeal rewarming. DESIGN: All 38 cardiac surgery departments in Poland were encouraged to report consecutive hypothermic cardiac arrest patients treated with extracorporeal life support. All variables collected were analyzed in order to compare survivor and nonsurvivor groups. The parameters available at the initiation of extracorporeal rewarming were considered as potential predictors of survival in a logistic regression model. The primary outcome was survival to discharge from the intensive care unit. The secondary outcome was neurologic status. SETTING: Multicenter retrospective study. PARTICIPANTS: Ninety-eight cases in the final analysis. INTERVENTIONS: All patients in nonasphyxia-related hypothermic cardiac arrest rewarmed with extracorporeal life support. MEASUREMENTS AND MAIN RESULTS: The survival rate was 53.1%, and 94.2% of survivors had favorable neurologic outcome. The lowest reported core temperature with cerebral performance category scale 1 was 11.8°C. A univariate analysis identified 3 variables associated with survival, namely: age, initial arterial pH, and lactate concentration. In a multivariate analysis, 2 independent predictors of survival were age (0.957; 95% confidence interval [CI] 0.924-0.991) and lactates (0.871; 95% CI 0.789-0.961). The area under the receiver operating characteristics curve for this fitted model was 0.71; 95% CI 0.602-0.817. CONCLUSIONS: Favorable survival with good neurologic outcome in nonasphyxiated hypothermic patients treated with extracorporeal life support was reported. Age and initial lactate level are independently associated with survival.

Body temperature measurement in ambulance: a challenge of 21-st century?

BACKGROUND: Some crucial decisions in treatment of hypothermic patients are closely linked to core body temperature. They concern modification of resuscitation algorithms and choosing the target hospital. Under- as well as over-estimation of a patient's temperature may limit his chances for survival. Only thermometers designed for core temperature measurement can serve as a guide in such decision making. The aim of the study was to assess whether ambulance teams are equipped properly to measure core temperature. METHODS: A survey study was conducted in collaboration with the Health Ministry in April 2018. Questionnaires regarding the model, number, and year of production of thermometers were sent to each pre-hospital unit of the National Emergency Medical System in Poland. RESULTS: A total of 1523 ground ambulances are equipped with 1582 thermometers. 53.57% are infrared-based ear thermometers, 23.02% are infrared-based surface thermometers, and 20.13% are conventional medical thermometers. Only 3.28% of devices are able to measure core body temperature. Most of analyzed thermometers (91.4%) are not allowed to operate in ambient temperature below 10 °C. CONCLUSIONS: There are only 3.28% of ground ambulances that are able to follow precisely international guidelines regarding a patient's core body temperature. A light, reliable thermometer designed to measure core temperature in pre-hospital conditions is needed.

Prehospital emergency thoracotomy performed by helicopter emergency medical service team: A case report.

Emergency thoracotomy can be a life-saving procedure in critically injured patients who present with chest injuries. Currently, the indications for an on-the-scene thoracotomy are penetrating trauma of the chest or upper abdomen with cardiac arrest that has occurred in the presence of an emergency team or within 10 minutes prior to their arrival. The indications for an emergency thoracotomy in blunt chest trauma are less clearly defined. In the present case, a helicopter emergency medical service (HEMS) team performed an emergency thoracotomy at the scene. To the best of our knowledge, it is the first description of such a procedure in Poland. A 41-year-old male was crushed in a tractor accident. Though all available measures were taken, a sudden cardiac arrest occurred. The HEMS team performed an emergency thoracotomy at the scene as an integral part of prehospital cardiopulmonary arrest management. The patient survived, and was later discharged from the hospital in good physical condition. No neurological deficit was identified (cerebral performance category 1). The patient returned to his previous activities with no complications or deficits. The presence of a fully trained crew allows for the performance of a potentially critical on-the-scene emergency thoracotomy. In a well-selected group of patients with blunt thoracic injury, a prehospital emergency thoracotomy may be a significant and life-saving procedure.

Is an emergency department a safer place for hypothermic victims than an ambulance? A comparison of the knowledge of medical personnel concerning hypothermia.

OBJECTIVE: Introduction: Improper initial management of a victim in severe hypothermia is associated with a risk of cardiac arrest. At the same time, an uncontrolled drop in core body temperature in trauma victims is an independent risk factor for mortality. Medical personnel require a thorough understanding of the pathophysiology and treatment of hypothermia. Gaps in this understanding can lead to serious complications for patients. The aim: To compare knowledge concerning hypothermia between medical personnel working in emergency departments (ED) and emergency medical services (EMS). PATIENTS AND METHODS: Materials and methods: A total of 5,362 participants were included in the study. In this study, EMS and ED personnel were encouraged to participate in an e-learning course on hypothermia. Subsequently, the scores of a pre-test, lesson tests and post-test completed by participants of this course were compared. RESULTS: Results: Pre-test scores were significantly higher among personnel working in EMS compared with those working in EDs. Nurses employed in EDs had significantly more failures in completing the course than EMS nurses. The most difficult topics for all practitioners were post-traumatic hypothermia and hypothermia-related clotting disorders. CONCLUSION: Conclusions: EMS personnel have a higher level of knowledge of hypothermia than ED personnel. Moreover, an e-learning course is an effective tool for improving medical personnel's knowledge of hypothermia.

[Hypothermia - e-learning course dedicated to lifeguards, border guards and policemen].

OBJECTIVE: Introduction: The paper covers the problem of pre-hospital hypothermia recognition and management among lifeguards, board guards and policemen, who took part in e-learning course Academy of Hypothermia. PATIENTS AND METHODS: Materials and methods: The subject of analysis were the results of pre-test, post-test and lesson revision tests of Academy of Hypothermia e-learning course, taken by lifeguards (WOPR), board guards (SG) and policemen (POL). RESULTS: Results: 221 participants were enrolled in a study. Lifeguards were significantly younger than other groups (mean age respectively: 34,13 years SG; 32,95 years POL and 23,31 years WOPR; p< 0,001) and median work experience (respectively: 10 years SG, 8 years POL and 2 years WOPR; p< 0,001). Pre-test analysis showed significant difference in results of board guards and lifeguards (median and q1-q3 values respectively: 61%; 43%-92% for SG and 53%; 46%-69% for WOPR, p = 0,02). Post-test analysis proved significantly better results of board guards (median and q1-q3 values: 92%; 77%-100%) in comparison to policemen (median and q1-q3 values: 85%; 69%-92%) and lifeguards (median and q1-q3 values: 85%; 69%-92%). Extra analysis was performed for lesson revision tests. The least correct answers were noted in lessons covering the topic of post trauma hypothermia and the algorithm of hypothermia casualty management. CONCLUSION: Conclusions: Lifeguards have least knowledge on accidental hypothermia than board guards and policemen. E-learning course is an effective tool for improving knowledge of hypothermia recognition and treatment.

The Use of E-Learning in Medical Education for Mountain Rescuers Concerning Hypothermia.

Podsiadlo, Pawel, Sylweriusz Kosinski, Tomasz Darocha, Kinga Salapa, Tomasz Sanak, and Hermann Brugger. The use of e-learning in medical education for mountain rescuers concerning hypothermia. High Alt Med Biol 19:272-277, 2018. OBJECTIVE: Victims of mountain accidents are often exposed to wet and cold environments which may increase the risk of hypothermia. Mountain rescuers should be able to recognize and manage hypothermia. We aimed to assess relevant knowledge in professional and volunteer mountain rescuers, as well as to evaluate the efficacy of an e-learning platform for continuing medical education. METHODS: An e-learning platform was developed to provide access to updated information about hypothermia. Volunteer and professional mountain rescuers participated in an e-learning course. Pretest, post-test, and specific lesson test scores were compared. After 1 year, a follow-up course was performed. RESULTS: In total, 187 rescuers, comprising 136 (72.7%) volunteers and 51 (27.3%) professionals, were enrolled. Ahead of the course, no difference in knowledge was found between professionals and volunteers. After the course, one's knowledge of hypothermia increased significantly (p < 0.001). The scores achieved in the field management of hypothermia were better among professional rescuers than among volunteer rescuers (p = 0.003), whereas in post-traumatic hypothermia half of the results were insufficient in both groups. Moreover, 57 rescuers repeated the course after 12 months. While professionals partially retained the achieved level of knowledge, the volunteers had dropped back to their initial level. CONCLUSIONS: The e-learning course increased the knowledge of hypothermia among mountain rescuers. The poor retention after 1 year indicates that the interval between lectures should be reduced. An e-learning platform is an effective tool for the medical education of mountain rescuers.

Evaluation of tourniquet application in a simulated tactical environment.

BACKGROUND: Application of a tourniquet in a tactical environment is implemented in two ways: the so-called self-aid, which is the application of a tourniquet by the injured, and the so-called buddy aid, which is the application of a tourniquet by the person provide aid. This study aimed to test the quality of tourniquet use in a simulated situation, close quarter battle. METHODS: The study involved 24 injured operators and 72 operators in the whole simulation, implying 12 sections of six individuals. To validate the application of tourniquets, the recommendations of the Committee of Tactical Combat Care of the Injured were used, and ultrasound with Doppler function was employed to assess the hemodynamic effect of applying tourniquets. RESULTS: Native flow was observed in 15 operators; in three people, a trace flow was noticed, whereas in six people, a full flow was observed. No significant difference was found between the qualities of tourniquet application by the operators themselves compared with those of tourniquet application by another person. The median distance of tourniquet application from the armpit was 9.5 cm for self-aid and buddy aid. In 16 participants the outer arrangement of tourniquets was observed, and in only eight participants tourniquets were correctly located on the internal part of the arm. In 18 participants, tourniquets were not correctly prepared for use in the tactical environment, whereas in only six participants, they were correctly prepared. Most operators with a negative ultrasound flow revealed negative distal observed pulse (DOP). Positive DOP occurred in the majority of operators with full ultrasound flow. CONCLUSION: The application of tourniquets poses a challenge even in case of specialized units; therefore, there is a need to provide regular training for implementing that procedure.

[Assessment of knowledge about hypothermia among the medical personnel of polish medical air rescue].

Polish Medical Air Rescue is tasked to deal with the most serious incidents associated with life threatening situations, in multiple circumstances. As a consequence, medical personnel have to meet high standards of education and show a continuous theoretical and practical development of the skills which are necessary during medical treatment. Thanks to the introduction of ECMO treatment for accidental hypothermia patients, new clinical and operational possibilities have arisen, so more patients can be saved with a very good neurological outcome. AIM: To analyze the data on hypothermia collected by the personnel of Polish Medical Air Rescue and to assess the e-learning platform as an educational tool. MATERIALS AND METHODS: 123 persons were involved. The subject of analysis were the e-learning platform results of the Polish Medical Air Rescue medical personnel. The e-learning consisted of a pre-test, 8 lessons followed by MCQ's (multi choice questions) and a post-test. RESULTS AND CONCLUSIONS: We could not prove a statistically significant difference in the knowledge about hypothermia between doctors and other medical professionals. Post-traumatic hypothermia and associated coagulation disturbances are two important topics requiring particular focus during the design of further educational and training projects. As a consequence of the training, both groups significantly improved their knowledge: i.e. a statistically significant improvement of knowledge about hypothermia between pre-test and post-test results in both groups was shown. The hypothermia e-learning platform for medical personnel is an effective educational tool.

Severe Hypothermia Management in Mountain Rescue: A Survey Study.

Podsiadlo, Pawel, Tomasz Darocha, Sylweriusz Kosinski, Kinga Salapa, Miroslaw Zietkiewicz, Tomasz Sanak, Rachel Turner, and Hermann Brugger. Severe hypothermia management in mountain rescue: A survey study. High Alt Med Biol 18:411-416, 2017. INTRODUCTION: Severe hypothermia is a rare but demanding medical emergency. Although mortality is high, if well managed, the neurological outcome of survivors can be excellent. The aim of the study was to assess whether mountain rescue teams (MRTs) are able to meet the guidelines in the management of severe hypothermia, regarding their equipment and procedures. METHODS: Between August and December 2016, an online questionnaire, with 24 questions to be completed using Google Forms, was sent to 123 MRTs in 27 countries. RESULTS: Twenty-eight MRTs from 10 countries returned the completed questionnaire. Seventy-five percent of MRTs reportedly provide advanced life support (ALS) on-site and 89% are regularly trained in hypothermia management. Thirty-two percent of MRTs transport hypothermic patients in cardiac arrest to the nearest hospital instead of an Extracorporeal Life Support facility; 39% are equipped with mechanical chest compression devices; 36% measure core body temperature on-site and no MRT is equipped with a device to measure serum potassium concentration on-site in avalanche victims. CONCLUSIONS: Most MRTs are regularly trained in the treatment of severe hypothermia and provide ALS. The majority are not equipped to follow standard procedural guidelines for the treatment of severely hypothermic patients, especially with cardiac arrest. However, the low response rate-23% (28/123)-could have induced a bias.

[Early complications of extracorporeal rewarming].

BACKGROUND: Application of appropriate method of rewarming is the key issue in the management of hypothermia. Severely hypothermic, life-threatened patients require advanced extracorporeal rewarming. Such procedure is not free of possible complications, yet, if the qualification for extracorporeal rewarming is correct, it guarantees restoration of hemodynamic stability, and what is the most important, leads to full neurologic recovery, even with long resuscitation times. THE AIM: The summary of complications observed during extracorporeal rewarming with ECMO in severely hypothermic patients and analysis of their prevalence in managed group. Presentation of possible etiology and means of prevention of anticipated complications and suggested strategies of their treatment. MATERIALS AND METHODS: Retrospective analysis of medical records of all 33 patients with severe accidental hypothermia, accepted for extracorporeal rewarming with venoarterial ECMO. CONCLUSIONS: Based on reviewed medical records of severely hypothermic patients subjected to extracorporeal rewarming it was possible to identify these complications of management, that are hypothermia related, and which are not to be seen in patients treated with ECMO for other reasons.

Difficulties in funding of VA-ECMO therapy for patients with severe accidental hypothermia.

BACKGROUND: Severe accidental hypothermia is defined as a core temperature below 28 Celsius degrees. Within the last years, the issue of accidental hypothermia and accompanying cardiac arrest has been broadly discussed and European Resuscitation Council (ERC) Guidelines underline the importance of Extracorporeal Rewarming (ECR) in treatment of severely hypothermic victims. The study aimed to evaluate the actual costs of ECR with VA-ECMO and of further management in the Intensive Care Unit of patients admitted to the Severe Accidental Hypothermia Centre in Cracow, Poland. METHODS: We carried out the economic analysis of 31 hypothermic adults in stage III-IV (Swiss Staging) treated with VA ECMO. Twenty-nine individuals were further managed in the Intensive Care Unit. The actual treatment costs were evaluated based on current medication, equipment, and dressing pricing. The costs incurred by the John Paul II Hospital were then collated with the National Health Service (NHS) funding, assessed based on current financial contract. RESULTS: In most of the cases, the actual treatment cost was greater than the funding received by around 10000 PLN per patient. The positive financial balance was achieved in only 4 (14%) individuals; other 25 cases (86%) showed a financial loss. CONCLUSION: Performed analysis clearly shows that hospitals undertaking ECR may experience financial loss due to implementation of effective treatment recommended by international guidelines. Thanks to new NHS funding policy since January 2017 such loss can be avoided, what shall encourage hospitals to perform this expensive, yet effective method of treatment.

Clinical course and prognostic factors of patients in severe accidental hypothermia with circulatory instability rewarmed with veno-arterial ECMO - an observational case series study.

BACKGROUND: Recently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatment METHODS: From July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients' condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters. RESULTS: Nine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO3) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment. DISCUSSION AND CONCLUSIONS: In our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.