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Don't overlook onset of hypothermia in trauma
A 40-year-old man landed in a small stream after a motor vehicle accident and arrives fully dressed and bleeding from the head. Emergency medical services (EMS) tells you the patient was lying on the ground when they found him. Would you ask the question, "How can this patient lose heat?"
"The better question is, 'How has he already lost heat?'" says Shelley L. Sides, RN, MSN, EMT-I, trauma coordinator at Eastern Maine Medical Center in Bangor. "The patient has already been exposed to heat loss through conduction, convection, and evaporation."
Sides says that "it is very easy for ED nurses to become so involved in the critical care of a patient that they do not pay as close attention to the patient's body temperature." Your goal is to minimize further heat loss and promote re-warming, says Sides.
Crissy Kuhlmann, RN, BSN, CPN, CPEN, trauma services at St. Louis Children's Hospital, warns, "Hypothermia is often recognized late in the resuscitation of an injured child, especially if the patient is critically ill with distracting injuries. Your priorities simply become lifesaving."
When caring for an injured child, your assumption should be that they are hypothermic until proven otherwise, says Kuhlmann.
Preventing trauma patients from becoming hypothermic is extremely important to the overall survivability of the patient, says Sides. "Hypothermia in trauma can begin at the time of injury, as the patient begins to lose body heat through different mechanisms," says Sides.
To prevent hypothermia in trauma patients:
Obtain a thorough EMS report.
You might learn, for example, that the patient was a prolonged extrication from a vehicle in cold weather.
Remember that children lose heat more rapidly than adults.
'Shivering causes them to increase metabolism and exert extra energy," says Kuhlmann. "It can assist in the development of acidosis, cardiac arrhythmias, and coagulopathies."
Obtain and document a temperature as soon as possible.
"Remember that the body's core temperature has an effect on cerebral blood flow," says Sides. "Monitor your patients for changes in levels of consciousness and neurologic deficits."
Continuously monitor temperature by inserting a rectal probe to monitor the patient's core temperature, says Sides. "This might be the easiest way to monitor the patients' temperature in the ED, especially if this is a sick patient. More internal means of monitoring temperature include temperature-sensing indwelling urinary catheters as well as pulmonary artery catheters."
Often, reassessment of temperature is not performed, says Sides. "One reading is not enough. Patients are continually being moved, transported, assessed, and exposed to heat loss behaviors."
Pre-warm your ED treatment room.
"Increasing the ambient temperature can reduce heat loss," says Sides. "Apply warm blankets to the patient, or use equipment designed to assist with raising body temperature passively."
Administer warm IV fluids.
IV fluids can be warmed in using a warmer that is thermo-regulated and monitored regularly or by using fluid administration devices that allow warming of fluids, says Sides. "It is also important to note that administration of room temperature fluids can have an effect on overall core body temperature."
Look for signs of perfusion
You might not immediately obtain a rectal or oral temperature when a trauma patient comes through the door, but a good initial assessment should include signs of perfusion, such as skin color, warmth, and moisture, says Shelley L. Sides, RN, MSN, EMT-I, trauma coordinator at Eastern Maine Medical Center in Bangor.
"Though peripheral perfusion is not a true reflection of core temperature due to vasoconstriction, it may help to clue you in to a patient who is already hypothermic or who is at increased risk of hypothermia," Sides says.
Don't let this bad outcome happen
A hypothermic trauma patient can rapidly decline, warns Shelley L. Sides, RN, MSN, EMT-I, trauma coordinator at Eastern Maine Medical Center in Bangor.
"Research shows that patients who present with severe hypothermia are more likely to die," she says. "Hypothermia is considered one of the components of the 'lethal triad' and can be a causative factor of the other two: coagulopathy and acidosis."
Sides says that "prevention should begin as they come through the door," with these interventions:
Cover points of bleeding when at all possible.
If patients are wet by any type of fluids, they need to be dried off and covered.
Because any patient with wet hair can lose heat rapidly, keep heads covered with warm blankets.
Cover patients with warmed blankets. While a severely injured trauma patient should be completely exposed in an attempt to identify any and all life-threatening injuries, leaving them exposed is unnecessary most of the time, says Sides.
"Patients who are left in saturated clothing or undressed and left with one blanket or no blanket at all are at increased risk," says Sides. "It is essential to maintain a normothermic patient."