Title: How to warm your frozen patient
题目：如何对你的冰冻患者进行加温
Author作者: Feras Khan

A 50yo man found down in the snow was brought into our ER last week in cardiac arrest with a bladder temperature of 21° C. Let’s warm him up!
一星期前一个50岁的男性被发现躺在雪里，送到我们的急诊科时心脏已停跳，膀胱温度为21°C。下面就让我们给他复温吧！

• Passive external warming (good for mild hypothermia > 34°C): remove all wet clothing, use warm blankets.
• 被动外部加温（适合轻度低温> 34 ℃） ：脱掉所有的湿衣服，用温暖的毛毯。

• Active external rewarming (Used for temp between 30-34° C): Radiant heat, electric blankets, Bair-Hugger. Disadvantages: “core temperature after drop” theory: drop in core temp because of peripheral vasodilatation. Therefore, focus on warming the chest and torso area. May not occur with certain warming techniques.
• 主动外部加温（用于30-34之间°C的温度） ：辐射热，电热毯，Bair－Hugger加热器。缺点： “中心温度下降”理论：即由于外周血管扩张而导致中心温度下降。因此，主要对胸部和躯干区域加温。可能有些加温方法不会出现这种现象。

• Active core rewarming (<30 °C, above techniques and several other options):
• 主动中心加温（ < 30℃ ，上述技术和其他几项） ：
1. Heated humidified oxygen via mechanical ventilation at 42-46°
用加热（42-46°C）和湿化的氧气进行机械通气
2. IV normal saline warmed to 41-43° C
静脉输加热到41-43 °C的生理盐水
3. Cardio-pulmonary bypass: 1-2° C increase every 5 minutes
心肺体外循环：每5分钟增加1-2 °C
4. ECMO (best option in cardiac arrest): Up to 4-6° C/hr. VV or VA ECMO. Provides Cardio-pulmonary support. Can continue CPR while placing a cannula.
ECMO （是心脏骤停时的最佳选择）：速度可达4-6 ℃/小时。 可用VV或VA ECMO治疗。提供心肺支持。放置导管时可以继续心肺复苏。
5. CVVHless costly, more available, 1-4°C/hr. Case reports only.
CVVH ：成本更低，更容易获得， 升温1-4 ℃/小时。但只有个案报告。
6. Artic Sun; external rewarming pads: used in hypothermia protocols. Easy to use. Case reports only.
北极太阳;外部复温垫，用于低温方案。易于使用。只有个案报告。

• Other methods (use if other methods are unavailable):
• 其他方法（如果其他方法都无法使用时） ：
1. Pleural irrigation: one chest tube in the mid-clavicular line w saline at 42° and another chest tube in the post-axillary line and connected to a pleurovac.
胸腔灌洗：从锁骨中线的胸导管灌入42°生理盐水，将另一个在腋后线的胸腔引流管连接到一个闭式引流器。
2. Peritoneal lavage: 8 Frcatheter into the peritoneum using a standard paracentesis method. Use 40-45° C dialysate.
腹腔灌洗： 使用标准腹腔穿刺术方将8F导管插入腹腔。用40-45℃的透析液冲洗。
3. Gastric, bladder, colonic irrigations
胃，膀胱，结肠灌洗

We were able to get ROSC with CPR and ACLS and then used Artic Sun to re-warm successfully.
我们通过CPR和按ACLS方按取得了ROSC，然后用北极太阳来成功地复温。

• Other tips/tricks: 其他提示/技巧：
• Continue CPR while rewarming (This is debatable: monitor ECG for new rhythms)
• 在复温的同时继续心肺复苏，（这是值得商榷的：心电图监测心律改变）
• How warm is “warm and dead”? Probably around 32°C
• 什么样的温度可以说“温暖死亡” ？大概在32 °C
• How fast to rewarm? Would warm quickly in cardiac arrest and then 1-2° C/hr thereafter; (No good evidence here)
• 复温速度？心脏骤停时要快速复温，然后1-2 ℃/小时（这里没有很好的循证证据）
• Arrhythmias corrected by rewarming (bradycardiaetc); no need for pacing
• 复温可纠正心律失常 （心动过缓等）;无需起搏
• Up to three defibrillations for V. fib/V. tach; hold if no benefit
• 对室颤／室速最多除颤三次，如无效，不要再除颤
• Can give epinephrine per ACLS protocol but would be cautious with further dosing
• 可以按ACLS方案给肾上腺素，但再给药要谨慎
• Pressors: can use epinephrine drip cautiously for hypotension
• 升压药：如血压低可小心滴注肾上腺素
• Cisatracurium for paralysis w/ sedation to prevent shivering
• 防止发抖可用顺式阿曲库铵进行麻痹和镇静药
• Rule out hypoglycemia, adrenal insufficiency, hypothyroidism, sepsis if patient does not rewarm as expected!
• 如果病人不能预期复温，要排除低血糖，肾上腺皮质功能不全，甲状腺功能减退症，脓毒症！
• Avoid IJ lines or irritating the myocardium with a guidewire.
• 避免放置颈内静脉导管或用导丝刺激心肌
• K>12 mmol /L: consider termination of CPR
• K> 12 mmol / L时：考虑终止心肺复苏

Reference参考文献：
nejm_hypothermia2012.pdf (581 Kb)
http://umem.org/files/uploads/1402111256_nejm_hypothermia2012.pdf