Ear Temperatures Temperatures During During Ear Rewarming From Hypothermia Hypothermia Rewarming W John Zehner, Zehner, MD WJohn
Thomas MD, FACEP FACEP Thomas E Terndrup, Tern&up, MD, Efficacy Efficacyof Adenosine Adenosine in WideComplex Complex Tachycardia Tachycardia
Peter C Wyer, MD, FACEP FACEP Peter Wyer, MD,
Reply Reply MD, FACEP FACEP Donald M Yealy, Yealy, MD, Kaveh Ilkhanipour, Ilkhanipour, MD, MD, FACEP FACEP Kaveh "Rock"-A "Rock"--A Deadly Deadly Aphrodisiac Aphrodisiac
Michael Weinblatt, MD, FACC FACC Michael Weinblatt, MD, Altered Altered Mental Mental Status Status and
Nonconvulsive Status Epilepticus Epilepticus Nonconvulsive Status Jagoda, MD, MD, FACEP FACEP Andy Jagoda, Reply Reply
Steven K Kulick, Kulick, MD Kramer, MD, MD, FACEP FACEP David A Kramer,
Ear Ear Temperatures Temperatures During During Rewarming Rewarming From Hypothermia Hypothermia From To Editor: To the Editor." Monitoring of body body temperature during rewarming from from hypothermia hypothermia is important to assess assess the severity of hypothermia hypothermia and and the effectiveness therapy. 1 Accurate temperature of therapy.' determination has traditionally required required placement of contact thermistors into such such body body cavities as the rectum, rectum, bladder, bladder, or esophaesophagus.2,3 Recently, Recently, data from nonconnoncongus2.3 tact infrared emission emission detection (IRED) (IRED)thermometers indicate that core core body body temperature may be accuaccurately determined with selected IRED IREDdevices operated operated in the audito-6 However, ry canal canal.44-6 However, no no information is available from any patient with environmentally induced induced hypothermia in which IRED IREDthermometer readings readings could could be compared compared with traditional measurements. measurements. A 67-year-old A 67-year-old man was found unconscious unconscious having having spent the night in an automobile with ambient temperatures peratures ranging ranging from 5°C 5°C to rc. 7°C. He He was transported by emergency emergency medical medical services services with hypotension, hypotension,
bradypnea, bradypnea, and bradycardia. bradycardia. The The initial, digital electronic rectal temperature (28.9°C) failed to detect the (28.9°0)failed severity of hypothermia hypothermia (27.5"C) (27.5°0) as measured measured with an an indwelling indwelling Foley Foley catheter thermistor. The The physical physical examination revealed revealed an unresponunresponsive, sive, flaccid, aphonic aphonic man man with absent rectal rectal tone and and reflexes. reflexes. Laboratory Laboratory and and radiologic radiologic assessment assessment demonstrated demonstrated a metabolic metabolic acidosis acidosis (pH (pH 7.13), 7.13), ethanolism ethanolism (0.19 (0.19 g/dL), g/dL), sinus sinus bradycardia bradycardiawith Osborne Osborne waves, waves, and and a 1-cm 1-cm anterior cervical cervical subluxation subluxation of C4. 04. After endotracheal endotracheal intubation and cervical immobilization, active (heated oxygen oxygen and and heated IV and and nasogastric fluids) and and passive passive (ambient and and blanket) rewarming techniques resulted in a gradual gradual increase increase in body body temperature (Figure). (Figure).The The rectal temperature subsequently obtained with a thermistor (30.1 °Cl was simi(30.1°C) lar to simultaneous IRED IREDear (left, 304°C; 30.4°C; right, 30.4°C) 30.4°C)and and bladder (30.2°CI (30.2°C)temperatures temperatures at 1430 1430 hours. hours. The sudden decrease in ambient temperature occurred at the time of the patient's transfer to the ICU. ICU. An excellent correlation coefficient coefficient between be~een all body body cavities cavities was present present
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throughout rewarming (all more more than 0.99), 0.99), from 27.5"C 27.5°C to 36.5"C 36.5°C. Over the course of 13 hours, the mean difference between right and left IRED IRED ear temperatures (0.064°0 ± -I- 0.177°C) 0.177oC) was signifi(0.064°C cantly smaller than the difference between right IRED IRED ear and rectal (0.358°C °C) or rectal and (0.358°0 ± -I- 0.161 0.161o0) bladder (0.21 n ± (0.212°0 __. 0.139°C) temperatures (P (P<< .05; repeat measures analysis of variancel. variance). The mean difference between IRED IRED ear and 144°C ± and bladder bladder (0. (0.144°C __.0.189°C) 0.189°0) was smaller than that between bladder and rectal, after eliminating the initial erroneous erroneous rectal temperature. This case case demonstrates that IRED IRED ear temperatures were accurate during a case case of acute, environmenenvironmentally induced induced hypothermia. hypothermia. These These temperatures followed very closely simultaneously obtained values from thermistors thermistors placed placed in the bladder bladder and and rectum. rectum. The The failure of the standard standard digital electronic thermometer to provide provide an an accurate accurate initial temperature because because the patient's patient's body body temperature temperature was out of range rangewas not the case casefor the IRED IREDear thermometer. thermometer. Previously, Previously,data data on on IRED IREDear temperatemperatures tures in post-cardiac post-cardiacsurgery surgerypatients patients during during rewarming rewarmingdemonstrated demonstratedan an excellent excellentcorrelation correlationbetween betweenthe IRED, IRED, pulmonary pulmonaryartery, artery, and and rectal rectal temperatemperatures A tures over overarange a rangeof 34°C 34°C to 39°C.6 39°0.6 A 20-minute 20-minuteexposure exposureto cold cold ambient ambient temperature temperature(-5°C) (-5°C)caused causedadepresa depression sion of IRED IREDear readings readingsfor about about eight minutes minutes in in men. men.55This This effect was eight not observed observedin in women women in the same same study or at more more moderate decreases in ambient temperature temperature (ie, 18.3°C) in a related investiga18.3°0)in
tion.77 In our patient, the rectal tion temperature lagged behind other body cavities during rewarming by about 20 minutes. Our patient may have had time for equilibration of body cavity temperatures during his 7.5-hour exposure to cold ambient temperatures, whereas the acute exposure in healthy volunteers did not allow for such equilibration. In tympanic thermistor studies, accurate core temperature is obtained by placement placement of a a bead in direct contact contact with the tympanic membrane membrane.B8 In these studies, investigators have demonstrated demonstrated that a a countercurrent countercurrent temperature exchange may exist in the head to protect protect the brain, especially from heat stress. 99 The arterial blood in proximity to environmentally cooled venous blood facilitates temperature exchange, which in turn affects the tympanic temperature. temperature. 10 1° The relative lack of vasoconstriction vasoconstriction of scalp vessels may explain why cold exposure results in less effect on tympanic temperature temperature than does warm exposure. 11 11 This may explain the exposure differences between IRED IRED ear small differences
and other body temperatures temperatures in our hypothermic hypothermic patient. WJohn W John Zehner, Zehner, MD Thomas ThomasETerndrup, E Temdrup,MD, MD, FACE? FACEP Department Departmentof Emergency EmergencyMedicine Medicine State State University Universityof New York YorkHealth Health Science ScienceCenter Centerat Syracuse Syracuse
7. Doyle F, 7. Doyle F, Zehner WJ, WJ, Terndrup TE: TE: The The effect efject of oj ambient temperature extremes on tympanic tympanic and oral oral temperatures. Am Am J Emerg Med Med 1992; 10:285-289. 1992;I0:285-289. 8. Brinnel Brinnel H, H, Cabanac Cabanac M: M: Tympanic Tympanic
temperature isis a core core temperature in humans. J Therm Therm BioI1989;14:47-53. Biol 1989;14:47-53.
9. Brinnel Brinnel H, Nagasaka Nagasaha T, T, Cabanac Cabanac M: M: Enhanced brain protection during Enhanced brain protection during passive hyperthermia in humans. humans. Eur J J Appl Appl PhysioI1987;56:540-545. Physiol 1987;56:540-545.
1. Jolly BT, BT, Ghezzi KT: KT: Accidental 1. Jolly hypothermia. Emerg Med Med Clin North Am Am 1992;10:311-327. I992;10:311-327. 2. 2. Cranston Cranston WI, WI, Gerbrandy GerbrandyJ, Snell Snell ES: ES: Oral, Oral, rectal rectal and oesophageal oesophageal temperatures temperatures and some some factors factors affecting affecting them them in man. man. Jj PhysioI1954;126347-358. Physiol 1954;126:347-358.
10. Cabanac Cabanac M, M, Germain Germain M, Brinnel Brinnel H: H: Tympanic Tympanic temperatures temperatures during during hemiface hemiface cooling cooling. Eur EurJJ Appl Physiol Physiol 1987;56:534-539.
3. Livingstone Livingstone SO, SD, Grayson], GraysonJ, Frim], Frim J, et al: Effect of cold al: EfJect cold exposure exposure on various various sites of sites oj core core temperature temperature measurements. J Appl PhysioI1983;54:1025-1031. Physiol I983;54:1025-1031.
11. Nielsen B. 11. Nielsen B. Natural cooling cooling of the brain during bicycling? Pflugers during outdoor outdoor bicycling? Pflugers Arch 1988;411:456-461.
4. Kenney 4. Kenney RD, Fortenberry Fortenberry JD, JD, Surratt 55, Evaluation of an SS, et al: al: Evaluation infrared tympanic membrane thermometer in pediatric pediatric patients. Pediatrics 1990;85:854-858.
Efficacy of Adenosine in Wide-Complex Wide-Complex Tachycardia
5. Zehner WJ, WJ, Terndrup Terndrap TE: TE: The The impact of moderate moderate ambient temperature variance on the the relationship relationship between between oral, oral, rectal, rectal, and tympanic membrane temperature. Clin Pediatr 1991;suppl:61-64. 1991 ;suppI:61-64
To To the the Editor: Editor. In their article, "Therapeutic "Therapeutic and diagnostic diagnostic efficacy of adenosine in wide-complex tachycardia [August 1993;22:1361-1364J,llkhanipour 1993;22:1361-1364], Ilkhanipour et al describe the successful use of
6. Deane R, Perkins FM: 6. 5hinozaki Shinozaki T, T, Deane R, Perkins FM: 1nfrared Infrared tympanic thermometer: thermometer: Evaluation of a new new clinical thermometer. thermometer. Crit Care Med Med 1988;16:148-149.
adenosine in conversion of stable supraventricular supraventricular tachycardia into sinus rhythm in two patients with previously diagnosed WolffParkinson-White Parkinson-White syndrome. Beyond Beyond adenosine's adenosine's previously documented efficacy in this context,l context, 1 the authors also present the cases as evidence of this drug's utility as a a "diagnostic" modality in relationship to emergency department department management of broad-complex tachycardia. Presumably, their suggestion is that conversion to sinus rhythm of a a broad-complex regular tachycardia after adenosine administration constitutes diagnostic diagnostic evidence that the supraventricular in dysrhythmia is supraventricular origin. It is this latter inference of the problematical. The report that I find problematical. authors' authors' strongly implied proposal that adenosine be administered administered "blindly" in stable broad-complex tachycardia without concern for the diagnostic diagnostic value of the 12-lead ECG ECG is in no way supported by the case evidence presented. Several authors have previously suggested adiagnostic a diagnostic utility of adenosine in relationship relationship to the
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