Considering that May was dedicated to “Stop the Bleed,” I felt it only fair that we discuss an essential facet of trauma and the ever-lurking lethal triad of death, hypothermia. June is a summer month that has shown to be correlated with a substantial increase in trauma-related injuries(Wilson et al., 2018 (Pape-Kohler, Simanski, Nienaber, & Lefering, 2014). So, following in the footsteps of the Stop the Bleed campaign, this article will focus on hypothermia-related with hemorrhage, trauma, and definitions associated with the lethal triad and hypothermia. Additionally, how we as pre-hospital providers might do a better job with the management of these patients.
Following a brief review of the literature surrounding the lethal triad of death, it dawned on me that there may be some innovative techniques that providers could use during trauma situations to keep this subset of patients from becoming hypothermic. Our goal is not only to get patients to the hospital, but it is also to improve mortality rates. The evidence is clear that ensuring a patient who has suffered a mechanism of injury (MOI) that is causing him or her to bleed, internally or externally, warm is just one key to improving mortality rates (Balvers et al., 2016). Putting it bluntly, Balvers et al., (2016), state that patients who are hypothermic with temperatures lower than 32 degrees Celsius or 89.6 degrees Fahrenheit have a 100% mortality rate. Later in the article, I will explore what the definition of warm is and some potential techniques that can be used as adjuncts to keep your patients at this temperature.
However, first, let us discuss, briefly what the lethal triad of death is and how being hypothermic affects the overall cascading impacts from this deadly sequela. The deadly triad of death is comprised of three different components; coagulopathy, acidosis, and of course hypothermia (Shields & Crowley, 2014). A quick refresher, the triad occurs when a patient suffers a traumatic event and has a substantial hemorrhage which causes him or her to become hypothermic, acidotic, and have issues with blood clotting (coagulopathy) (Gerecht, 2014). What does this mean, well, in essence, it is synergistically making your trauma patient sicker and causing him or her to bleed more ultimately leading to their untimely death, which is partially preventable, if we do our jobs well.
The average body temperature for a human being is 35.6-37 degrees Celsius, and for my fellow paramedics and EMTs, that equates to 96-98.6 degrees Fahrenheit, while hypothermic is considered anything less than 35 degrees Celsius or 95 degrees Fahrenheit (Moffat, 2012 (Peiris, Jaroudi, & Gavin, 2018). However, as mentioned by Gerecht (2014), a trauma patient classification for hypothermia is different from the standard definition. According to Gerecht (2014), a trauma patient is considered hypothermic between the 32-36 degrees Celsius or 89.6- 96.8 degrees Fahrenheit, so maybe normothermic is not the best term to use. Let us say we need to be keeping our patients warm.
According to a book published in the United Kingdom, a patient is comfortably warm when he or she is 36.5-37.5 degrees Celsius or 97.7-99.5 degrees Fahrenheit and keep this in mind when transporting a trauma patient (National Collaborating Center for Nursing and Supportive Care (UK), 2008). Also to think about is that season has no effect on hypothermia, just because it is June does not mean the trauma patient will be less likely to become hypothermic, the season has no bearing on whether a patient becomes hypothermic (Helm, Lampl, Hauke, & Bock, 1995). This is something to always take into consideration, just because you are hot does not mean your patient is.
Herein lies the problem; hypothetically, you are dispatched to a motor vehicle accident and arrive to find a 35-year-old male patient still being extricated from the vehicle. According to the crew extricating the patient you find out that he is suffering from at least one compound fracture to the left femur and possible a tibia/fibula fracture on the same leg. There is “a lot” of blood on the floorboard, and the patient feels cold to the touch. He is extricated after 25 minutes and is placed on a long backboard and carried to your apparatus.
You receive the patient, only to partially remove his clothing, that includes his shirt, pants, shoes, and socks. Now that he is exposed you perform a rapid trauma assessment and note the only noticeable external bleeding is from his fractures, and a laceration to his forehead, however, he has a distended belly and is complaining a bilateral hip pain. Since the femur fracture is midline, you use a traction splint to stabilize and ultimately place a commercial grade pelvic binder on your patient. You assess your ABC’s and vitals to find a blood pressure (BP) of 86/62 and an SPO2 of 93 percent on room air, with a GCS of 14 so you decide to start intravenous fluids wide open due to your patient’s vast amount of blood loss and BP. Finally, you leave the scene and depart to the closest level one trauma center.
On the way to the hospital your patient remains partially exposed, the normal saline you started is flowing to gravity at a rate uncountable, and he is still on the long backboard. So what is the problem? You have controlled the bleeding, and your patient is being transported to the closest trauma center, all is well or is it? The problem is that we are not managing the patient’s body temperature and have likely contributed to the worsening of the lethal triad by not removing his bloody clothing, he is still on a backboard that conducts heat away from the body, and finally by administering ambient temperature normal saline. These are all things that can be prevented.
Let us discuss how to mitigate the cascading effects of the lethal triad and potentially improve these patients chances of survival. First, but do not delay managing life threats, check an oral temperature, this is the most accurate, and if done correctly and trended transport it is information you can provide to receiving staff in the emergency department (Perlman, Callum, & Alam, 2017). When removing clothing, remove anything wet or bloody, but also only remove what is necessary to assess and once your assessment is complete place a blanket or two or even three or a mylar blanket if available on your patient. Or use this innovative technique referred to as the Hibler Method (basically a blanket and a plastic barrier on top of the blanket) that has shown to be one of the most effective methods of preventing heat loss (Thomassen et al., 2011). Even in June turn on the heater to ensure the compartment is warm.
If the patient must be on a backboard place a blanket between your patient and the backboard or remove the backboard altogether if it is not indicated, (remember that backboards are no longer standard practice and contraindicated for most of our blunt trauma as well as penetrating trauma patients) remove the backboard (White, Domeier, & Millin, 2014). If it is not then place a sheet or blanket in between the mattress and your patient. These are basic techniques that require nothing more than the tools we carry on almost every ambulance and helicopter.
When administering fluids, it is best to administer blood, we know that crystalloids such as normal saline contribute to acidosis (from a scientific standpoint crystalloid products such as normal saline add to the lethal triad of death if administered, so please avoid the use of these products at all costs), but if you must administer normal saline or any non colloid for that matter do so through a commercial warmer (Chatrath, Khetarpal, & Ahuja, 2015), Reddi, 2013). My suggestion for warmed normal saline is to place around your patient in an attempt to him or her warm, but avoid all inclinations to start that large bore intravenous catheter and open that room temperature normal saline wide open.
Warmed blood product will eliminate the potential for heat loss through transfusion (Spinella, Perkins, Grathwohl, Beekly, & Holcomb, 2009 (Smith & Wagner, 2008). However, for those of us who do not have access to a warmer, this may not be feasible. So, be mindful of the temperature of the fluid you are administering. The goal temperature for the fluids being administered should ideally be around 40-42 degrees Celsius or 104-107.6 degrees Fahrenheit (Gerecht, 2014 (Smith & Wagner, 2008). Even in situations where time is of the essence be mindful and utilize the resources available to you.
Time to wrap up, pun intended, but seriously, keep your trauma patients comfortably warm. Remember that the lethal triad is a “bloody vicious cycle” if not managed appropriately (Kashuk, Moore, Milikan, & Moore, 1982). Take the effort to follow these steps, and hopefully, you will not just be providing them a ride to the hospital but also increase their chances for survival.
- During prolonged extrication provide blankets to keep the patient warm, if possible.
- If placed on a backboard, place a blanket and sheet between your patient and the backboard to reduce the conduction of heat away from your patient. However, remember the practice of using backboards is contraindicated in many situations, and even as early as 1998 has shown no benefit to neurologic outcomes (Hauswald, Ong, Tandberg, & Omar, 1998).
- Only remove what is necessary and wet, remember that shivering utilizes glycogen stores which could lead to further heat loss.
- Replace and conserve body temperatures with several blankets, sheets, and warmers if available.
- Utilize the Hibler Method for barrier protection and insulation (images and links attached).
- Administer blood product with commercial warmers and use warmed crystalloids as passive warming.
- Check temperatures before, during, and after receiving the patient for the emergency department handoff(Perlman, Callum, & Alam, 2017).
Sadly, we have come to the end of this article, and I hope that you learned or reinforced some things you did or did not know about hypothermia and its effect on trauma patients. The techniques are really not innovative and I wish that I could have provided you some novel approach, like flipping your blanket roll from your cot upside down so that sheet faces out and the blanket is down against your patient’s body (something I learned from a preceptor years ago to conserve body heat in the winter). Remember the importance of keeping your patient warm during this chaotic situations, I know we can get tunnel vision, but outcomes matter, and at the end of the day it is about the patients quality of life and survival.
That said, I propose that we start a new campaign and call it the Keep Them Warm Campaign. The focus will be on providing education just after the Stop Bleed campaign to reinforce the importance of mitigating hypothermia in our trauma patients. Let me know what you think, and we can work on getting the ball rolling.
Balvers, K., Van der Horst, M., Graumans, M., Boer, C., Binnekade, J. M., Goslings, J. C., & Juffermans, N. P. (2016). Hypothermia as a predictor for mortality in trauma patients at admittance to the intensive care unit. Journal of Emergencies, Trauma, and Shock, 9(3), 97-102.
Chatrath, V., Khetarpal, R., & Ahuja, J. (2015). Fluid managment in patients with trauma: Restrictive versus liberal approach. Journal of Anaesthesiology Clinical Pharmacology, 31(3), 308-316.
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Spinella, P. C., Perkins, J. G., Grathwohl, K. W., Beekly, A. C., & Holcomb, J. B. (2009). Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. The Journal of Trauma, 66(4 Supplemental), S69-S76.
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Wilson, J., Staley, C. A., Boden, A. L., Boissonneault, A. R., Schwartz, A. M., & Schenker, M. L. (2018). The effect of season and weather on orthapaedic trauma: Consult volume is significantly correlated with daily weather. Advances in Orthopedics, 2018, 1-6.