Hypothermia itself causes bradycardia. All the reports were from women and two were made by people over 70. Two people under the age of 65 developed coronavirus symptoms but did not require hospitalization. Clin Ther. Once you become moderately hypothermic, the situation must be addressed, or you will continue to worsen and will develop severe hypothermia. That raises the chances that the person will recover. Thats why many people dont recover after cardiac arrest. See, resuscitating the hypothermic pulseless patient, treating underlying issues: sepsis, adrenal insufficiency, myxedema, Underlying problems: sepsis, hypothyroidism, adrenal insufficiency, http://traffic.libsyn.com/ibccpodcast/IBCC_EP_65_-_Hypothermia.mp3. We are vaccinating all eligible patients. Therapeutic Hypothermia after Cardiac Arrest. http://www.seagrant.umn.edu/coastal_communities/hypothermia. You may be on a ventilator to help with breathing. Dosing and antipyretic efficacy of oral acetaminophen in children. Confusion. privacy practices. Hypothermia is a dangerous condition involving low body temperature. However, even young, seemingly strong people, are affected by hypothermia when exposed to the cold for long periods of time. Hypothermia occurs when your body loses heat faster than it can produce heat and your body temperature falls below 95 F (35 C). Authors . "Initially [with] the milder forms, you can get some pain and some numbness of the tips, but the skin can change its color," Dr. Kakar says. If we combine this information with your protected Findings In this cohort study using a US national registry, survival outcomes were compared for 26 183 patients who were treated vs not treated with therapeutic hypothermia after surviving an in-hospital cardiac arrest. (b) ECMO circuit can be used to warm the patient (via in-line warmer) at 7-10C per hour. https://www.nia.nih.gov/health/cold-weather-safety-older-adults. Further management depends on the cortisol level: If cortisol levels are low (<20 ug/dL), then an ACTH stimulation test should be performed immediately to clarify whether the patient truly has adrenal insufficiency. If this signal is disrupted or abnormal, the heart may not be able to pump the right way. Pancreatitis (can get confusing: hypothermia may cause mild pancreatitis). https://www.nsc.org/home-safety/tools-resources/seasonal-safety/winter/frostbite. In addition, the use of alcohol or recreational drugs can affect your judgment about the need to get inside or wear warm clothes in cold-weather conditions. Some of these risks include: This procedure is used only for people who are unconscious after cardiac arrest. While you wait for emergency help to arrive, gently move the person inside if possible. Accessed March 31, 2020. Therapeutic hypothermia is a type of treatment. Hypothermia is often caused by exposure to cold weather or immersion in a cold body of water. During this period, 2,315 adverse reactions to the drug have been reported to the State Agency of Medicines, which is 1.2 percent of the total doses. Get the victim into a warm room or shelter. Alternatively, two chest tubes may be placed in the lateral chest, with one directed more anteriorly and one directed more posteriorly. Advertising revenue supports our not-for-profit mission. And it can be a very serious injury.". CPR should continue until the person responds or medical aid becomes available. Insulate the individual from the cold ground. Visnjevac O, Kocz R, Visnjevac T, Annam SK, Toufexis G. J Arthroplasty. For active hemorrhage in the hypothermic patient, desmopressin might improve platelet function. health information, we will treat all of that information as protected health Disclaimer. Application of therapeutic hypothermia (32-34 degrees C for 12-24 h) applied after cardiac arrest could help to improve this dreadful situation. (ii) External adaptive temperature control device using a circulating water bath (e.g. Common Side Effects Side effects after a COVID-19 vaccination tend to be mild, temporary, and like those experienced after routine vaccinations. other information we have about you. Supplies may include several blankets, matches, candles, a clean can where you can melt snow into drinking water, a first-aid kit, dry or canned food, a can opener, tow rope, booster cables, compass, and a bag of sand or kitty litter to spread for traction if you're stuck in the snow. They help us to know which pages are the most and least popular and see how visitors move around the site. The brain may also not get enough blood. Blood tests also can help confirm hypothermia and its severity. You may opt-out of email communications at any time by clicking on A single copy of these materials may be reprinted for noncommercial personal use only. Left untreated, it can be life-threatening. Make a donation. Accessed March 31, 2020. information highlighted below and resubmit the form. You may need medicine, procedures, and physical therapy. Do not try to give beverages to an unconscious person. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. If this isn't available, there are reports of using warm tap water. There isn't any high-quality evidence on this, so it's a clinical decision based on the individual patient. This lowered body temperature affects the brain, and a person's ability to think clearly or move well. A single copy of these materials may be reprinted for noncommercial personal use only. You will not remember anything about the procedure afterward. 1.2 percent of people report side effects The Health Board said 191,207 doses of coronavirus vaccines have been administered since December 27. Elsevier; 2017. https://www.clinicalkey.com. Loss of consciousness. If the windchill drops below negative 15 degrees Fahrenheit, not unheard of in the northern half of the U.S., frostbite can set in within half an hour. Lowering the body temperature right away after cardiac arrest can reduce damage to the brain. For example, mild hypothermia cannot explain a coma. The symptoms were recorded one month and 1.5 months after the second vaccinations. People who remain outdoors for long periodsthe homeless, hikers, hunters, etc. It leads to a loss of feeling and color in the areas it affects, usually extremities such as the nose, ears, cheeks, chin, fingers, and toes. A body temperature under 95F(35C)is a medical emergency and canbe fatalif not promptly treated. Left untreated, it can be life-threatening. They will need therapy. We report the case of a 4-month-old baby boy who presented hypothermia (rectal temperature 36C) after acetaminophen intake for post-vaccination fever. Do not use a heating pad, heat lamp, or the heat of a stove, fireplace, or radiator for warming. There were 11 serious side effects related to vaccinations reported last week, Estonia's Agency of Medicines (Ravimiamet) has said. Centers for Disease Control and Prevention. A heart attack happens when part of the heart doesnt get enough blood. Walls RM, et al., eds. Before you agree to the test or the procedure make sure you know: At Another Johns Hopkins Member Hospital: Assessing Cardiovascular Risk with C Reactive Protein, Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov, Another abnormal heart rhythm, especially slow heart rates. People who develop hypothermia because of exposure to cold weather or cold water are also vulnerable to other cold-related injuries, including: Before you or your children step out into cold air, remember the advice that follows with the simple acronym COLD cover, overexertion, layers, dry: To help prevent hypothermia when children are outside in the winter: Whenever you're traveling during bad weather, be sure someone knows where you're headed and at what time you're expected to arrive. This should be stopped within 48 hours unless there is further evidence to support infection (e.g. Accidental hypothermia in adults. An official website of the United States government. Cold weather safety for older adults. Hypothermia is defined as <35C (95F). Accessed April 20, 2018. Glucose may initially be elevated, due to catecholamine release and insulin resistance (both resulting from hypothermia). Litin SA (expert opinion). http://www.seagrant.umn.edu/coastal_communities/hypothermia. ii) Instill 300 ml of warmed fluid, clamp the Foley for 15 minutes, then drain the bladder and repeat. National Institute on Aging. https://www.cdc.gov/disasters/winter/duringstorm/indoorsafety.html. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 8600 Rockville Pike Be cautious with vasopressors, given the risk of inducing arrhythmias. information is beneficial, we may combine your email and website usage information with Make sure a window is slightly open and the exhaust pipe isn't covered with snow while the engine is running. Your family should know that the healthcare providers are working hard to give you the best possible chance of recovery. clinical consequences of hypothermia The table above summarizes the clinical effects of different levels of hypothermia. Warm drinks can help increase body temperature, but do not give alcoholic drinks. Usually, the measured levels of clotting factors will be normal (the lab measures these after warming blood to 37C). Once these patients are successfully resuscitated, they may be maintained at 36C using a targeted temperature management approach. If (1) a person shows signs of frostbite, but no signs of hypothermia and (2) immediate medical care is not available, do the following: Dont substitute these steps for proper medical care. Get the person proper medical attention as soon as possible. You won't remember anything about the procedure afterward. A 55-year-old woman developed an allergic reaction 10 minutes after the vaccine dose and required treatment. Accessed March 31, 2020. Source: National Center for Chronic Disease Prevention and Health Promotion. Carefully remove his or her wet clothing, replacing it with warm, dry coats or blankets. 1.2 percent of people report side effects. Alcohol may make your body feel warm inside, but it causes your blood vessels to expand, resulting in more rapid heat loss from the surface of your skin. If further warming is needed, do so gradually. Hypothermia often stimulates diuresis (cold diuresis), so patients are often volume depleted. Primary treatments for hypothermia are methods to warm the body back to a normal temperature. Some people might need surgery for heart disease. National Safety Council. Specific conditions leading to hypothermia include: The mechanisms of heat loss from your body include the following: Alcohol and drug use. A human's normal body temperature is about 98.6 degrees Fahrenheit. This is expensive (a set of pads may cost >$1,000). The worst cases, the tissue can die, and you may need surgery to remove it. Auerbach PS. Kasutamist jtkates nustute kikide ERR-i veebilehtede kpsiste seadetega, Teoste avaldamine sel lehel on koosklastatud EA/NCB-ga. Hea lugeja, neme et kasutate vanemat brauseri versiooni vi vhelevinud brauserit. "Literally think of it as freezing of the tissues," Dr. Sanj Kakar Mayo Clinic Orthopedic hand and wrist surgeon says frostbite is more common than many people think. This video answers important questions about Hypothermia. We are vaccinating all eligible patients. How does Estonia's Riigikogu electoral system work? Know how the COVID-19 pandemic can affect disaster preparedness and recovery, and what you can do to keep yourself and others safe. A femoral line might be the preferred site. In total, more than 33,000 vaccinations were administered last week. This can cause more damage. Put the areas affected by frostbite in warmnot hotwater (the temperature should be comfortable to the touch for unaffected parts of the body). Fluid bags should feel comfortably, mildly warm. 9th ed. We are the EMCrit Project, a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM. A person with severe hypothermia may appear unconscious, with no apparent signs of a pulse or breathing. The alveoli have the combined surface area of a tennis court. Absence of shivering. The practice was abandoned in the 1980s after a retrospective study of near-drowning victims reported that children treated with hypothermia were at an increased risk for death, neutropenia, and sepsis compared with children treated without hypothermia. It is known that mRNA vaccines, such as the Pfizer/BioNTech, cause slightly more complaints after the second dose and can be more severe. the internal mammary artery). Offer the person warm, sweet, nonalcoholic drinks. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. information submitted for this request. Sometimes, cardiac arrest may harm other organs, like the kidneys. Older adults with inadequate food, clothing, or heating. The confused thinking can also lead to risk-taking behavior. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. To be considered dead, the patient's core temperature must be at least ~32 C (warm and dead). If the windchill drops below negative 15 degrees Fahrenheit, not unheard of in the northern half of the U.S., frostbite can set in within half an hour. The agency said that because thrombocytopenia and bleeding have been reported in relation to some vaccines, a family doctor should be contacted if you experience bruising or recurrent/prolonged bleeding after receiving the vaccine. High Resolution [209 MB]
A 68-year-old woman, had a cerebral haemorrhage the day after receiving a dose of the vaccine. The table above summarizes the clinical effects of different levels of hypothermia. Also, the confused thinking associated with hypothermia prevents self-awareness. Hypothermia is often caused by exposure to cold weather or immersion in a cold body of water. HHS Vulnerability Disclosure, Help piperacillin-tazobactam). Transcript [80 KB, 2 page]
If infection is suspected, consider starting empiric antibiotics. "[Those most at risk are] certain patients with diabetes, patients who have previous history of frostbite are prone to it, the elderly or your very young children, and also, for example, if you're dehydrated," he says. There were three serious side effects. You will be in the intensive care unit. Esophageal probe might be ideal for intubated patients: Tracks most closely with real-time core temperature. Hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. Paroxysmal hypothermia and hyperhidrosis with exacerbation after COVID-19 Infection. Thus, adequate urine output doesn't necessarily indicate adequate renal perfusion. You may place one anterior chest tube and one lateral chest tube, if you're comfortable with anterior chest tubes (making sure to avoid vascular structures, e.g. Knowing what to do is an important part of protecting your health and the health of others. Our results show that patients who have hypothermia at the time of admission spend a longer time intubated (p < 0. . <28C). Accessed March 31, 2020. National Library of Medicine Get the person into a warm room or shelter. There were eight serious side effects. This is the cadillac of the hypothermic pulseless resuscitation, if available. Jarring movements can trigger dangerous irregular heartbeats. Mayo Clinic, Rochester, Minn. Feb. 25, 2015. Epub 2014 Jul 2. Alcohol hinders the rewarming process, and tobacco products interfere with circulation that is needed for rewarming. This site needs JavaScript to work properly. Taking a first aid or emergency resuscitation (CPR) course is a good way to prepare for health problems related to cold weather. If central access is needed, make sure not to stimulate the ventricle with the guidewire (cold hearts are very susceptible to VT/VF). Before Severe hypothermia can also cause an irregular heartbeat leading to heart failure and death. If you use hot water bottles or a chemical hot pack, first wrap it in a towel before applying. Mayo Clinic does not endorse companies or products. health information, we will treat all of that information as protected health MeSH In: Rosen's Emergency Medicine: Concepts and Clinical Practice. Accidental hypothermia. Case reports describe excellent outcomes for patients with accidental hypothermia. Don't apply a warm compress to the arms or legs. Hypothyroidism and adrenal insufficiency can both cause hypothermia and must always be considered. Warm any fluids administered (but give fluid only if indicated, based on volume status). The patient received emergency treatment and has fully recovered. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). When in doubt about whether a potassium level is real, repeat it immediately (e.g. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Zafren K, et al. You may also get another medicine to keep you from moving. Being prepared is your best defense against having to deal with extremely cold weather. You may have a greater chance of developing frostbite if you. For example, they might do heart catheterization after a cardiac arrest caused by a heart attack. This site complies with the HONcode standard for trustworthy health information: verify here. It makes you sleep and keeps you from shivering. Dexamethasone is used because it doesn't interfere with the cortisol test. Others might have some problems with thinking. Affected areas are numb and can easily burn. Hacer Hbitos Saludables Ms Fcil en Guarderas Infantiles, Faites-vous vacciner et prvenez la rougeole, U.S. Department of Health & Human Services. Don't give the person alcohol or cigarettes. Instill 300-500 ml of warmed fluid, clamp the chest tube for 15 minutes, then drain fluid and repeat. This content does not have an English version. Do not rewarm the person too quickly, such as with a heating lamp or hot bath. All rights reserved. If thoracic lavage is pursued, right-sided lavage might be superior (to avoid stimulating the heart and thereby inducing an arrhythmia). Moderate hypothermia after perinatal asphyxia resulted in improved neurocognitive outcomes in middle childhood. And you can get these blisters on your hands. Corneli HM, et al. The antipyretic effect of paracetamol occurs independent of transient receptor potential ankyrin 1-mediated hypothermia and is associated with prostaglandin inhibition in the brain. The medical team may start the hypothermia within 4 to 6 hours after the cardiac arrest. They are usually a source of, Providing heated, humidified gas reverses this: instead of. A single copy of these materials may be reprinted for noncommercial personal use only. are not properly dressed for extremely cold temperatures. Follow ERR News on Facebook and Twitter and never miss an update! Elsevier; 2018. https://www.clinicalkey.com. The volume of fluid administered may rapidly fill a standard chest tube drainage system (Pleurovac). The 63-year-old woman died after suffering head trauma from fainting while experiencing a high fever. Hypothermia prevention: Survival in cold water. You will need follow-up care. If warm water is not available, warm the affected area using body heat. If you are a Mayo Clinic patient, this could Accessed March 31, 2020. The lowered temperature may also lessen inflammation in the brain. The .gov means its official. 7th ed. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. The goal is to cool as quickly as possible. information is beneficial, we may combine your email and website usage information with Use a first-aid warm compress (a plastic fluid-filled bag that warms up when squeezed) or a makeshift compress of warm water in a plastic bottle or a dryer-warmed towel. Hyperthermia occurs when your body absorbs or generates more heat than it can release. Less commonly, hypothermia may also cause disseminated intravascular coagulation (DIC). information submitted for this request. If the patient. Auerbach PS, et al., eds. Using the left pleura may be superior for directly warming the myocardium. Common. The following measures may be considered for patients with moderate or severe hypothermia (or mild hypothermia with failure to rewarm with less aggressive measures). Some people do eventually wake up after therapeutic hypothermia. Severe hypothermia can also cause an irregular heartbeat leading to heart failure and death. You could be at increased risk if you're also exhausted or dehydrated. It can raise the chance that you will wake up. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. The medical team will slowly rewarm you over several hours. Bladder probe may be used for any patient. "Initially [with] the milder forms, you can get some pain and some numbness of the tips, but the skin can change its color," Dr. Kakar says. information and will only use or disclose that information as set forth in our notice of Mayo Clinic is a not-for-profit organization. Stay safe during and after a winter storm. Infuse warmed crystalloid (temperature of 42C or 107F) into the more anterior chest tube. Within 6 hours after the return of circulation, comatose children older than 48 hours and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0 . Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. 2002 Oct;153(6):411-3. "Literally think of it as freezing of the tissues," Dr. Sanj Kakar Mayo Clinic Orthopedic hand and wrist surgeon says frostbite is more common than many people think. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 2018 Oct;32(10):5751-5759. doi: 10.1096/fj.201800272R. The practice was abandoned in the 1980s after a retrospective study of near-drowning victims reported that children treated with hypothermia were at an increased risk for death, neutropenia, and sepsis compared with children treated without hypothermia. include protected health information. Replace wet things with warm, dry coats or blankets. That way, if you get into trouble on your way, emergency responders will know where to look for your car. There were no serious reactions reported. Additional toxicology workup as is appropriate. Other health problems you have will also determine the care you need. In some cases, they may use rewarming devices as well. Therapeutic hypothermia can help only some people who have had cardiac arrest. Main results Of the 57 patients enrolled in the study, 21 developed hypothermia during their stay and 36 did not. In this case, handle the person gently, and get emergency assistance immediately. People who drink alcohol or use illicit drugs. Normal body temperature is around 98.6 F (37 C). Therefore, avoid repeated doses of medications. Thus, serial shocks for VT/VF arrest are unlikely to add benefit. Perform CPR, even if the person appears dead. Corneli HM, et al. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. Mirrasekhian E, Nilsson JL, Shionoya K, Blomgren A, Zygmunt PM, Engblom D, Hgesttt ED, Blomqvist A. FASEB J. This may be preferred for patients with altered mental status and risk of emesis. Epub 2021 Feb 2. The medical team will carefully watch you. Shake before administration to equilibrate the temperature. The following are the most common symptoms of hypothermia: Slow, slurred speech, or shallow breathing, Achange in behavior or appearance during cold weather, Poor control over body movements or slow reactions, In infants, bright red, cold skin and/or very low energy. A healthcare provider will give you medicine to help you relax (sedative). Subcutaneous heparin for DVT prophylaxis is contraindicated in severe hypothermia, due to poor skin absorption. ERR News is the English-language service of Estonian Public Broadcasting, run by a fully independent editorial team.To read up on ERR News' comments rules and to contact ERR's other services, please follow the link below.Staff, contacts & comments, ERR kasutab oma veebilehtedel http kpsiseid. It can be white. Videos are prepared for different audiences including, children, parents, and public health professionals. All information these cookies collect is aggregated and therefore anonymous. Hypothermia is a medical emergency. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Copyright 2009-. While hypothermia happens most often in very cold temperatures, even cool temperatures (above 40F or 4C) can be dangerous to a person who has become chilled from rain, sweat, or being in cold water for an extended period of time. Acetaminophen; Hypothermia; Pediatrics. Signs of Moderate to Severe Hypothermia. Body temperature that is too low affects the brain, making the victim unable to think clearly or move well. Sometimes cardiac arrest happens after a heart attack. It makes you sleep and keeps you from shivering. Accessed April 20, 2018. Respiratory warming (HFNC if not intubated, or heated humidification via ventilator). Avoid giving lots of insulin while the patient is still hypothermic (insulin may accumulate and cause. External warming (warming blankets vs. circulated-water temperature management system). On Dec. 18, one ANDA for furosemide injection, indicated for the treatment of edema (fluid retention) associated with congestive heart failure, cirrhosis of the liver, and renal disease. Walls RM, et al., eds. 28,29 Important limitations of this study were the limited sample size, use of historical . The person may be unable to regain consciousness. for video Mayo Clinic Minute: Why the risk of frostbite is greater than you think, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition, Extracorporeal membrane oxygenation (ECMO). It's also a good idea to keep emergency supplies in your car in case you get stranded. The medical team may start the hypothermia within 4 to 6 hours after the cardiac arrest. But it can also happen without one. We reviewed 14 other pediatric cases of hypothermia secondary to therapeutic doses of acetaminophen. While your body temperature is lower, you may look, act, and feel lifeless. Acabe con los microbios. The following people are most at risk for hypothermia: Elderly people, who often have other illnesses, such as hypothyroidism, heart disease, or circulation problems, or take medicines that interfere with the body's ability to regulate its temperature, Elderlypeople with inadequate food, clothing, or heat; often thesepeople sit alone for hours or days at a time in a cold apartment or home; improper nutrition also makes them more susceptible to the cold, Infantsand toddlers sleeping in cold bedrooms, People who stay outdoors for long periods of time, such as the homeless, hikers, and hunters. In some cases, hypothermia victims who appear to be dead can be successfully resuscitated. https://www.cdc.gov/disasters/winter/duringstorm/indoorsafety.html. 7th ed. Accidental hypothermia. Medical care will depend on the reason for the cardiac arrest and the degree of damage. Healthcare providers often wait at least 3 days after the procedure to see how the cardiac arrest affected the brain. In this case, measured levels of coagulation labs will be. As winter drags on and temperatures drop way down, your risk of cold-related injury like frostbite can go way up. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. Lvese las manos! These studies demonstrated that hypothermia after cardiac arrest could improve neurological outcome as well as overall . Accessibility Published by Elsevier Masson SAS. Babies on the Move: Protecting Babies with, Centers for Disease Control and Prevention. What do you think of our videos? Hypothermia causes a clinical tendency to bleed despite normal levels of clotting factors. 57 percent of reports were related to the second dose of the vaccine, 30 percent to the first and 13 percent to both doses. National Institute on Aging. The reason you are having the test or procedure, What results to expect and what they mean, The risks and benefits of the test or procedure, What the possible side effects or complications are, When and where you are to have the test or procedure, Who will do the test or procedure and what that persons qualifications are, What would happen if you did not have the test or procedure, Any alternative tests or procedures to think about, Who to call after the test or procedure if you have questions or problems, How much will you have to pay for the test or procedure.