Akzidentelle Hypothermie: ein Update

In der Notfallmedizin muss mit dem Auftreten einer akzidentellen Hypothermie ganzjährig und auch in geschlossenen Räumen gerechnet werden. Eine Zunahme von sekundären Hypothermiefällen insbesondere bei älteren vorerkrankten Patienten ist im urbanen Umfeld zu beobachten. Die Körpertemperatur sollte als Vitalparameter bei jedem Notfallpatienten mit einem geeigneten Thermometer routinemäßig gemessen werden und wird bei einem Abfall auf < 35 °C als Hypothermie gewertet.

Kernaussagen

• Die akzidentelle Hypothermie ist definiert als ein unwillkürlicher Abfall der Körperkerntemperatur auf < 35 °C und kann anhand von Klinik und Körpertemperatur in 4 Schweregrade eingeteilt werden.

• Die Hypothermie geht mit einer Vielzahl an pathophysiologischen Veränderungen einher. Ab einer Körperkerntemperatur von < 30 °C sistiert das Kältezittern, die Patienten sind meist bewusstlos und haben ein hohes Risiko für das Auftreten von malignen Arrhythmien und Herz-Kreislauf-Stillstand.

• Die Hypothermie kann ganzjährig und auch in geschlossenen Räumen auftreten. Die Temperatur sollte bei jedem Notfallpatienten als Vitalparameter erhoben werden.

• Ein mild hypothermer Patient kann durch aktive Bewegung, trockene Kleidung und warme Getränke wiedererwärmt werden.

• Eine prähospitale Wiedererwärmung ist beim schwer hypothermen Patienten nicht möglich. Hier stehen die Sicherung der Vitalfunktionen, ein möglichst bewegungsarmes Handling sowie eine Ganzkörperisolation zur Vermeidung weiterer Wärmeverluste im Vordergrund.

• Patienten mit einem hypothermiebedingten Herz-Kreislauf-Stillstand sollten unter kontinuierlicher kardiopulmonaler Reanimation in ein Zentrum mit der Möglichkeit der extrakorporalen Wiedererwärmung gebracht werden und haben häufig eine auch neurologisch günstige Prognose: „no one is dead until warm and dead“.

Schlüsselwörter

akzidentelle Hypothermie - Pathophysiologie - hypothermer Herz-Kreislauf-Stillstand

• Literatur

• 1 Brown DJ, Brugger H, Boyd J. et al. Accidental hypothermia. N Engl J Med 2012; 367: 1930-1938
• 2 Sakurada S, Shido O, Sugimoto N. et al. Autonomic and behavioural thermoregulation in starved rats. J Physiol 2000; 526 Pt 2: 417-424
• 3 Tattersall GJ, Milsom WK. Transient peripheral warming accompanies the hypoxic metabolic response in the golden-mantled ground squirrel. J Exp Biol 2003; 206: 33-42
• 4 Romanovsky AA, Shido O, Sakurada S. et al. Endotoxin shock: thermoregulatory mechanisms. Am J Physiol 1996; 270: R693-R703
• 5 Fonseca MT, Rodrigues AC, Cezar LC. et al. Spontaneous hypothermia in human sepsis is a transient, self-limiting, and nonterminal response. J Appl Physiol 2016; 120: 1394-1401
• 6 Matsuyama T, Morita S, Ehara N. et al. Characteristics and outcomes of accidental hypothermia in Japan: the J-Point registry. Emerg Med J 2018; 35: 659-666
• 7 Miller JW, Danzl DF, Thomas DM. Urban accidental hypothermia: 135 cases. Ann Emerg Med 1980; 9: 456-461
• 8 Buchanan TA, Cane P, Eng CC. et al. Hypothermia is critical for survival during prolonged insulin-induced hypoglycemia in rats. Metabolism 1991; 40: 330-334
• 9 Madden CJ. Glucoprivation in the ventrolateral medulla decreases brown adipose tissue sympathetic nerve activity by decreasing the activity of neurons in raphe pallidus. Am J Physiol Regul Integr Comp Physiol 2012; 302: R224-R232
• 10 Mégarbane B, Axler O, Chary I. et al. Hypothermia with indoor occurrence is associated with a worse outcome. Intens Care Med 2000; 26: 1843-1849
• 11 Herity B, Daly L, Bourke GJ. et al. Hypothermia and mortality and morbidity. An epidemiological analysis. J Epidemiol Community Health 1991; 45: 19-23
• 12 Vassal T, Benoit-Gonin B, Carrat F. et al. Severe accidental hypothermia treated in an ICU: prognosis and outcome. Chest 2001; 120: 1998-2003
• 13 Brandstrom H, Johansson G, Giesbrecht GG. et al. Accidental cold-related injury leading to hospitalization in northern Sweden: an eight-year retrospective analysis. Scand J Trauma Resusc Emerg Med 2014; 22: 6
• 14 Hislop LJ, Wyatt JP, McNaughton GW. et al. Urban hypothermia in the west of Scotland. West of Scotland Accident and Emergency Trainees Research Group. BMJ 1995; 311: 725
• 15 Woodhouse P, Keatinge WR, Coleshaw SR. Factors associated with hypothermia in patients admitted to a group of inner city hospitals. Lancet 1989; 2: 1201-1205
• 16 MacDonell JE, Wrenn K. Hypothermia in the summer. South Med J 1991; 84: 804-805
• 17 Gallaher MM, Fleming DW, Berger LR. et al. Pedestrian and hypothermia deaths among Native Americans in New Mexico. Between bar and home. JAMA 1992; 267: 1345-1348
• 18 Marsigny B, Lecoq-Jammes F, Cauchy E. Medical mountain rescue in the Mont-Blanc massif. Wilderness Environ Med 1999; 10: 152-156
• 19 Schober A, Sterz F, Handler C. et al. Cardiac arrest due to accidental hypothermia-a 20 year review of a rare condition in an urban area. Resuscitation 2014; 85: 749-756
• 20 Paal P, Rauch S. Indoor accidental hypothermia in the elderly: an emerging lethal entity in the 21st century. Emerg Med J 2018; 35: 667-668
• 21 Young AJ, Castellani JW. Exertion-induced fatigue and thermoregulation in the cold. Comp Biochem Physiol A Mol Integr Physiol 2001; 128: 769-776
• 22 Paal P, Gordon L, Strapazzon G. et al. Accidental hypothermia-an update : The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med 2016; 24: 111
• 23 Prec O, Rosenman R. et al. The cardiovascular effects of acutely induced hypothermia. J Clin Invest 1949; 28: 293-300
• 24 Covino BG, DʼAmato HE. Mechanism of ventricular fibrillation in hypothermia. Circ Res 1962; 10: 148-155
• 25 Bjornstad H, Tande PM, Refsum H. Cardiac electrophysiology during hypothermia. Implications for medical treatment. Arctic Med Res 1991; 50 (Suppl. 06) 71-75
• 26 Vassallo SU, Delaney KA, Hoffman RS. et al. A prospective evaluation of the electrocardiographic manifestations of hypothermia. Acad Emerg Med 1999; 6: 1121-1126
• 27 Darocha T, Sobczyk D, Kosinski S. et al. Electrocardiographic Changes Caused by Severe Accidental Hypothermia. J Cardiothorac Vasc Anesth 2015; 29: e83-e86
• 28 Kanna B, Wani S. Giant J wave on 12-lead electrocardiogram in hypothermia. Ann Noninvasive Electrocardiol 2003; 8: 262-265
• 29 Maaravi Y, Weiss AT. The effect of prolonged hypothermia on cardiac function in a young patient with accidental hypothermia. Chest 1990; 98: 1019-1020
• 30 Pasquier M, Zurron N, Weith B. et al. Deep accidental hypothermia with core temperature below 24° presenting with vital signs. High Alt Med Biol 2014; 15: 58-63
• 31 Danzl DF, Pozos RS. Accidental hypothermia. N Engl J Med 1994; 331: 1756-1760
• 32 Severinghaus JW. Respiration and hypothermia. Ann NY Acad Sci 1959; 80: 384-394
• 33 Strapazzon G, Nardin M, Zanon P. et al. Respiratory failure and spontaneous hypoglycemia during noninvasive rewarming from 24.7°C (76.5°F) core body temperature after prolonged avalanche burial. Ann Emerg Med 2012; 60: 193-196
• 34 DʼAmato HE, Hegnauer AH. Blood volume in the hypothermic dog. Am J Physiol 1953; 173: 100-102
• 35 Buse S, Blancher M, Viglino D. et al. The impact of hypothermia on serum potassium concentration: A systematic review. Resuscitation 2017; 118: 35-42
• 36 Guyton AC. Transport of Oxygen and Carbon Dioxide in the Blood and Body Fluids. In: Textbook of medical Physiology, 8th edn. Philadelphia: Saunders; 1991: 433-443
• 37 Rohrer MJ, Natale AM. Effect of hypothermia on the coagulation cascade. Crit Care Med 1992; 20: 1402-1405
• 38 Wang HE, Callaway CW, Peitzman AB. et al. Admission hypothermia and outcome after major trauma. Crit Care Med 2005; 33: 1296-1301
• 39 Durrer B, Brugger H, Syme D. et al. The medical on-site treatment of hypothermia: ICAR-MEDCOM recommendation. High Altitude Med Biol 2003; 4: 99-103
• 40 Bristow GK, Giesbrecht GG. Contribution of exercise and shivering to recovery from induced hypothermia (31.2 degrees C) in one subject. Aviat Space Environ Med 1988; 59: 549-552
• 41 Hildebrand F, Giannoudis PV, van Griensven M. et al. Pathophysiologic changes and effects of hypothermia on outcome in elective surgery and trauma patients. Am J Surg 2004; 187: 363-371
• 42 Strapazzon G, Procter E, Paal P. et al. Pre-hospital core temperature measurement in accidental and therapeutic hypothermia. High Altitude Med Biol 2014; 15: 104-111
• 43 Darocha T, Kosinski S, Jarosz A. et al. Severe accidental hypothermia center. Eur J Emerg Med 2015; 22: 288-291
• 44 Kosinski S, Darocha T, Galazkowski R. et al. Accidental hypothermia in Poland – estimation of prevalence, diagnostic methods and treatment. Scand J Trauma Resusc Emerg Med 2015; 23: 13
• 45 Brugger H, Oberhammer R, Adler-Kastner L. et al. The rate of cooling during avalanche burial; a “Core” issue. Resuscitation 2009; 80: 956-958
• 46 Walpoth BH, Galdikas J, Leupi F. et al. Assessment of hypothermia with a new “tympanic” thermometer. J Clin Monit 1994; 10: 91-96
• 47 Strapazzon G, Procter E, Putzer G. et al. Influence of low ambient temperature on epitympanic temperature measurement: a prospective randomized clinical study. Scand J Trauma Resusc Emerg Med 2015; 23: 90
• 48 Durrer B, Brugger H, Syme D. Advanced challenges in resuscitation: special challenges in EEC-hypothermia. Resuscitation 2001; 50: 243-244
• 49 Grissom CK, McAlpine JC, Harmston CH. et al. Hypercapnia effect on core cooling and shivering threshold during snow burial. Aviat Space Environ Med 2008; 79: 735-742
• 50 Durrer B, Brugger H, Syme D. et al. The medical on-site treatment of hypothermia: ICAR-MEDCOM recommendation. High Alt Med Biol 2003; 4: 99-103
• 51 Danzl D. Accidental Hypothermia. In: Auerbach P, Cushing T, Harris S. eds. Wilderness Medicine. New York: Elsevier; 2016
• 52 Striebel HW, Steinhoff U, Krause H. et al. Die Zuverlässigkeit der pulsoximetrischen Überwachung der arteriellen Sauerstoffsättigung bei zentralisierten und hypothermen Patienten. Anasth Intensivther Notfallmed 1988; 23: 200-204
• 53 Clayton DG, Webb RK, Ralston AC. et al. A comparison of the performance of 20 pulse oximeters under conditions of poor perfusion. Anaesthesia 1991; 46: 3-10
• 54 Zafren K, Giesbrecht GG, Danzl DF. et al. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med 2014; 25: S66-S85
• 55 Caldwell JE, Heier T, Wright PM. et al. Temperature-dependent pharmacokinetics and pharmacodynamics of vecuronium. Anesthesiology 2000; 92: 84-93
• 56 Heier T, Caldwell JE. Impact of hypothermia on the response to neuromuscular blocking drugs. Anesthesiology 2006; 104: 1070-1080
• 57 Leslie K, Sessler DI, Bjorksten AR. et al. Mild hypothermia alters Propofol pharmacokinetics and increases the duration of action of Atracurium. Anesth Analg 1995; 80: 1007-1014
• 58 Marland S, Ellerton J, Andolfatto G. et al. Ketamine: use in anesthesia. CNS Neurosci Ther 2013; 19: 381-389
• 59 Matsukawa T, Kurz A, Sessler DI. et al. Propofol linearly reduces the vasoconstriction and shivering thresholds. Anesthesiology 1995; 82: 1169-1180
• 60 Sessler DI. Thermoregulatory defense mechanisms. Crit Care Med 2009; 37: S203-S210
• 61 Darocha T, Kosinski S, Jarosz A. et al. Should capnography be used as a guide for choosing a ventilation strategy in circulatory shock caused by severe hypothermia? Observational case-series study. Scand J Trauma Resusc Emerg Med 2017; 25: 15
• 62 Lloyd EL, Croxton D. Equipment for the provision of airway warming (insulation) in the treatment of accidental hypothermia in patients. Resuscitation 1981; 9: 61-65
• 63 Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest-report of a case and review of the literature. Resuscitation 2005; 66: 99-104
• 64 Weinberg AD. Hypothermia. Ann Emerg Med 1993; 22: 370-377
• 65 Truhlar A, Deakin CD, Soar J. et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95: 148-201
• 66 Paal P, Milani M, Brown D. et al. Termination of cardiopulmonary resuscitation in mountain rescue. High Alt Med Biol 2012; 13: 200-208
• 67 Gilbert M, Busund R, Skagseth A. et al. Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest. Lancet 2000; 355: 375-376
• 68 Niazi SA, Lewis FJ. Profound hypothermia in man; report of a case. Ann Surg 1958; 147: 264-266
• 69 Odegaard S, Olasveengen T, Steen PA. et al. The effect of transport on quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest. Resuscitation 2009; 80: 843-848
• 70 Putzer G, Braun P, Zimmermann A. et al. LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescue-a prospective, randomized, cross-over manikin study. Am J Emerg Med 2012; 31: 384-389
• 71 Gordon L, Paal P, Ellerton JA. et al. Delayed and intermittent CPR for severe accidental hypothermia. Resuscitation 2015; 90: 46-49
• 72 Krismer AC, Lindner KH, Kornberger R. et al. Cardiopulmonary resuscitation during severe hypothermia in pigs: does epinephrine or vasopressin increase coronary perfusion pressure?. Anesth Analg 2000; 90: 69-73
• 73 Kornberger E, Lindner KH, Mayr VD. et al. Effects of epinephrine in a pig model of hypothermic cardiac arrest and closed-chest cardiopulmonary resuscitation combined with active rewarming. Resuscitation 2001; 50: 301-308
• 74 Stoner J, Martin G, OʼMara K. et al. Amiodarone and bretylium in the treatment of hypothermic ventricular fibrillation in a canine model. Acad Emerg Med 2003; 10: 187-191
• 75 Walpoth BH, Walpoth-Aslan BN, Mattle HP. et al. Outcome of survivors of accidental deep hypothermia and circulatory arrest treated with extracorporeal blood warming. N Engl J Med 1997; 337: 1500-1505
• 76 Ruttmann E, Weissenbacher A, Ulmer H. et al. Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest. J Thorac Cardiovasc Surg 2007; 134: 594-600
• 77 Forti A, Brugnaro P, Rauch S. et al. Hypothermic cardiac arrest with full neurologic recovery after approximately nine hours of cardiopulmonary resuscitation: management and possible complications. Ann Emerg Med 2018; pii:S0196-0644(18)31278-2
• 78 Lexow K. Severe accidental hypothermia: survival after 6 hours 30 minutes of cardiopulmonary resuscitation. Arctic Med Res 1991; 50 (Suppl. 06) 112-114
• 79 Pasquier M, Hugli O, Paal P. et al. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: The HOPE score. Resuscitation 2018; 126: 58-64
• 80 Brugger H, Durrer B, Adler-Kastner L. et al. Field management of avalanche victims. Resuscitation 2001; 51: 7-15