Pediatric emergency medicine trisk 1955 1955

saline or lactated Ringer solution, warmed to about 43°C (109.4°F) in a bloodwarming coil, is appropriate initially. Electrolyte determinations should guide
further replacement. If clotting abnormalities occur, fresh-frozen plasma (10
mL/kg) is a useful choice for volume expansion (see Chapter 93 Hematologic
Emergencies ). As temperature rises and peripheral vasoconstriction diminishes,
hypovolemia is expected. Fluid volume should be sufficient to maintain an
adequate arterial BP.
Hypoglycemia, if present, is treated with glucose (0.5 to 1 g/kg by IV).
Hyperglycemia, which may result from impaired insulin release in the
hypothermic pancreas, should be tolerated to avoid severe hypoglycemia with
rewarming.

FIGURE 90.8 Algorithm for rewarming. (Adapted from Danzl DF, Pozos RS. Accidental
hypothermia. N Engl J Med 1994;331(26):1756–1760.)

A number of rewarming strategies exist ( Fig. 90.8 ). Passive rewarming
implies removal of the patient from a cold environment and use of blankets to
maximize the effect of basal heat production. For patients with mild hypothermia
(temperature higher than 32°C [89.6°F]), this may be adequate. As shown in the
algorithm, the adequacy of perfusion and the degree of hypothermia are the major
factors in the selection of rewarming strategies. For patients with an adequate
pulse, passive rewarming is used as the initial strategy if the temperature is
greater than 32°C and active core rewarming if the temperature is less than 32°C.
Those with poor perfusion require active rewarming with a temperature greater
than 32°C and ECMO, if available, with temperature less than 32°C.
Active rewarming is divided into external and core rewarming techniques.
Electric blankets, hot-water bottles, overhead warmers, and thermal mattresses
are simple, easily available sources of external heat. Immersion in warm-water