A 41-year-old woman is brought to the emergency department after being rescued during an open-water swim. She became weak and disoriented after swimming 2 miles but did not lose consciousness. The patient's past medical history is unremarkable, although she is taking amoxicillin for streptococcal pharyngitis that was diagnosed 4 days ago. Temperature is 33.3 C (92 F), blood pressure is 86/45 mm Hg, and pulse is 106/min. The heart has regular rate and rhythm. The patient is shivering and vomiting. She responds to questions sluggishly, but neurologic examination is otherwise normal. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 41-year-old woman is brought to the emergency department after being rescued during an open-water swim.  She became weak and disoriented after swimming 2 miles but did not lose consciousness.  The patient's past medical history is unremarkable, although she is taking amoxicillin for streptococcal pharyngitis that was diagnosed 4 days ago.  Temperature is 33.3 C (92 F), blood pressure is 86/45 mm Hg, and pulse is 106/min.  The heart has regular rate and rhythm.  The patient is shivering and vomiting.  She responds to questions sluggishly, but neurologic examination is otherwise normal.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d1c4_dfff_bc81_05278dc507b0_MD0003_00 This patient is suffering from mild hypothermia and likely mild hypovolemia. Endurance athletes may be at risk for hypothermia due to cool ambient temperatures, lightweight clothing, and excessive sweating. Characteristic features of mild hypothermia (core body temperature 32-35 C [90-95 F]) include increased shivering, confusion, ataxia, slurred speech, tachycardia, and tachypnea. Patients with moderate hypothermia (core temperature 28-32 C [82-90 F]) may have significant central nervous system depression along with decreased shivering, hypoventilation, hypotension, bradycardia, and cardiac conduction abnormalities. Severe hypothermia (core temperature <28 C [82 F]) can cause marked hypotension, areflexia, coma, malignant ventricular arrhythmias (ventricular fibrillation), and significant acidosis. acidosis Most patients with mild hypothermia will respond to conservative measures, including fluid resuscitation and passive warming (ie, removing wet clothes and covering with blankets). Treatment should target a warming rate of approximately 1-2 C/hr. Core temperature may initially fall slightly due to increased return of blood from cold extremities. Once patients are euthermic and hemodynamically stable, they may be transitioned to oral fluids and nutrition (Choice E). (Choice A) Inotropic support with dopamine may be necessary for hypothermic patients if intravenous fluids and rewarming measures are ineffective in restoring normal blood pressure. (Choice B) Empiric antibiotics are not needed for patients with mild hypothermia unless there is concern for infection as the cause. This patient is receiving effective therapy for her pharyngitis and has no other history or signs of infection. (Choice D) Intravenous glucocorticoids are occasionally used in the management of acutely ill athletes, usually in the context of severe asthma or anaphylaxis (eg, Vespidae allergy). However, glucocorticoids are not indicated for hypothermia. (Choice F) Active internal rewarming with pleural or peritoneal irrigation may occasionally be needed for patients with severe hypothermia (core temperature <28 C [82 F]). External warming is more appropriate for patients with mild to moderate hypothermia. Educational objective: Endurance athletes are at risk for thermal illness, both hyper- and hypothermia. Mild hypothermia is generally managed with passive rewarming. More severe hypothermia requires aggressive treatment, including active external (heated blankets) and internal (heated peritoneal irrigation) rewarming. References: Pathophysiology, management and complications of hypothermia. (http://www.ncbi.nlm.nih.gov/pubmed/22241407) Hypothermia in open-water swimming events: a medical risk that deserves more attention. (http://www.ncbi.nlm.nih.gov/pubmed/20030455)

A 41-Year-Old Woman Is Brought to the Emergency Department After