Hypothermia

doi:10.1016/S0196-0644(05)80467-6

Annals of Emergency Medicine

Volume 22, Issue 2, Part 2, February 1993, Pages 370-377

https://doi.org/10.1016/S0196-0644(05)80467-6 Get rights and content

Significant hypothermia is an increasing clinical problem that requires a rapid response with properly trained personnel and techniques. Although the clinical presentation may be such that the victim appears dead, aggressive management may allow successful resuscitation in many instances. Initial management should include CPR if the victim is not breathing or is pulseless. Further core heat loss should be prevented by removing wet garments, insulating the victim, and ventilating with warm humidified air/oxygen to help stabilize core temperature. Core temperature and cardiac rhythm should be monitored in the prehospital setting, if possible, and CPR should be continued during transport. In-hospital management should consist of rapid core rewarming in the severely hypothermic victim with heated humidified oxygen, centrally administered warm IV fluids (43 C), and peritoneal dialysis until extracorporeal rewarming can be accomplished. Postresuscitation complications should be monitored; they include pneumonia, pulmonary edema, cardiac arrhythmias, myoglobinuria, disseminated intravascular thrombosis, and seizures. The decision to terminate resuscitative efforts must be individualized by the physician in charge.

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Extreme temperatures are becoming increasingly common due to global warming. Extreme cold and heat events lead to an increase in mortality rates. More deaths occur in cold weather as a result of hypothermia. However, the change progress of body core temperature and the survival time during cold exposure has yet to be extensively studied.
To establish a mathematical thermoregulatory model for prolonged cold air exposure and to propose a method for predicting survival time under sedentary conditions.
We extended the classical multi-segment multi-node human thermoregulatory model by considering the effects of thermoregulatory fatigue on shivering and vasoconstriction based on the variable setpoint theory. The core threshold temperatures and the sensitivity of the responses decreased with the degree of fatigue (fa). The model was then used to systematically examine the effects of environmental parameters on the time course of body core temperature in the development of fatal hypothermia. A new wind chill index was constructed based on the simulated data of our thermoregulatory model to estimate the survival time.
Our extended thermoregulatory model predicted that during prolonged cold air exposures, body core temperature would decrease in three distinct stages: an initial decrease due to uncompensated cooling load, an equilibrium plateau due to shivering, and a final rapid drop due to thermoregulatory fatigue. Fatal hypothermia occurred at the third stage due to impaired shivering and vasoconstriction caused by fatigue. Lower air temperature and higher air speed can accelerate the occurrence of hypothermia. We proposed a predictive equation for survival time, i.e., the maximum endurance time before fatal hypothermia occurs, which is an exponential function of the wind chill index, and the newly defined wind chill index considers the contribution from both air temperature and air speed.
We suggest a new thermoregulatory model to predict the fatal hypothermia due to thermoregulatory fatigue during cold air exposure. We proposed a survival time chart based on a new wind chill index, which can be used to alert the early risk of fatal hypothermia during extreme cold events.
Iatrogenic third-degree burn caused by off-label use of an infrared radiant heat lamp in a patient with accidental hypothermia
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We report a case of third-degree burn involving 5% of the total body surface area caused by off-label use of Hanautherm®, an infrared radiant heat lamp for bed-warming, in a patient with severe accidental hypothermia. This iatrogenic burn required repeated surgical interventions and long-term hospitalization and caused subsequent cosmetic disfigurement and functional disability. To our knowledge, this is the first reported adult case of iatrogenic burn occurring during treatment for hypothermia. Radiant heat lamps should never be used for rewarming of patients with hypothermia without careful observation.
Successful Defibrillation at a Core Temperature of 18.2 Degrees Celsius
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Both the temperature at which defibrillation can be effectively used and how often it should be repeated in severe accidental hypothermia have not been definitely established. Current recommendations are based mainly on expert opinion and suggest withholding defibrillation after 3 shocks when the core temperature is below 30°C (86°F). However, growing evidence supports the effectiveness of defibrillation in patients with a core temperature below 30°C (86°F). We present a case of successful defibrillation of a 54-y-old, severely hypothermic patient with a core temperature of 18.2°C (64.8°F). The shock was delivered automatically by an implanted cardioverter-defibrillator shortly after the implementation of extracorporeal rewarming. The patient survived and was discharged from the hospital neurologically intact. It might be reasonable to consider defibrillation attempts in severely hypothermic patients despite current guidelines to the contrary. Increasing coronary perfusion using extracorporeal circulation may result in a better response to defibrillation.
A Large Discrepancy between Oral versus Rectal Temperatures as an Early Warning Sign in a Patient with Acute Infrarenal Aortic Occlusion
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Citation Excerpt :
In other case reports of patients with AAO, authors have reported similar diagnostic challenges due to comorbidities, such as a prior spinal cord injury (6). In our case, another possibility is that a prothrombotic state during rewarming measures propagated what was a partial occlusion within atherosclerotic aortoiliac vessels (7). Regardless, an early clinical warning sign for AAO in patients with otherwise limited evaluation would be useful to prompt further evaluation with imaging studies and treatment with surgical intervention.
Acute aortic occlusion is a rare condition that requires early diagnosis to help prevent considerable morbidity and mortality. Typical clinical findings, such as acute lower extremity pain, acute paralysis, and absent pedal pulses, may be masked by a variety of underlying medical conditions.
We present a patient with altered mental status, hypothermia, and a large discrepancy between oral and rectal temperature measurements, who was ultimately diagnosed with aortic occlusion. This case report describes a marked difference between oral and rectal temperatures in a case of acute aortic occlusion.
Acute aortic occlusion is a true vascular emergency that, without early intervention, can lead to limb ischemia, bowel necrosis, paralysis, or death. Emergency physicians should consider acute aortic occlusion in a patient with a marked difference between oral and rectal temperature measurements who otherwise has a limited clinical evaluation.
Peritoneal dialysis beyond kidney failure?
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Citation Excerpt :
Hypothermia consists of abnormally low core temperatures (≤ 36 °C) [70] and is caused by prolonged exposure to low temperatures and/or drug poisoning. Patients suffering from hypothermia are typically managed by passive techniques, such as removal of wet clothes and covering with warm blankets [70]. Active, internal core-warming is only indicated in severe cases [70].
Compared to extracorporeal modalities, peritoneal dialysis (PD) is less invasive and more cost-effective, wherein blood is dialyzed intra-corporeally against a solution instilled in the peritoneal cavity. Although PD is mainly indicated for patients with end-stage renal failure, it has also been used for several non-renal indications. The aim of this review is to provide an overview of the role of PD beyond kidney failure. The alternative indications of PD include hypothermia, congestive heart failure, hyperammonemia and poisoning with xenobiotics. The use of PD as a treatment for acute pancreatitis and psoriasis was initially proposed but could not be established; these indications are therefore classified as historically relevant. Recent developments have led to a potential application of PD during the management of stroke and as an oxygenation therapy with the use of oxygen carriers. Novel colloid-based dialysates with improved functionality with respect to detoxification and oxygenation are currently underway, though their efficacy has so far only been demonstrated in pre-clinical settings. Finally, insight into potential future developments of PD is given. Characterization studies are proposed to better understand the fate of non-recovered carriers following dialysate removal, their efficacy following multiple administrations and potential immune response to optimize their formulation, enabling their clinical translation.
Accidental hypothermia
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Accidental hypothermia causes profound changes to the body's physiology. After an initial burst of agitation (e.g., 36–37°C), vital functions will slow down with further cooling, until they vanish (e.g. < 20–25°C). Thus, a deeply hypothermic person may appear dead, but may still be able to be resuscitated if treated correctly.
The hospital use of minimally invasive rewarming for nonarrested, otherwise healthy patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionized the management of hypothermic cardiac arrest, with survival rates approaching 100%. Hypothermic patients with risk factors for imminent cardiac arrest (i.e., temperature < 28°C, ventricular arrhythmia, systolic blood pressure < 90 mmHg), and those who have already arrested, should be transferred directly to an ECLS center. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanic CPR can be helpful. Intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern postresuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimize prehospital triage, transport, and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and postresuscitation care.

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View full text

State of the art reportHypothermia

Am J Med

Anesthesiology

J Appl Physiol

Ann Emerg Med

J Trauma

Ann Emerg Med

Surg Gynecol Obstet

Anesth Analg

Ann Emerg Med

Body temperature in the elderly: A national study of physiological, social and environmental conditions

Br Med J

A pilot study of low body temperatures in old people admitted to hospital

J R Coll Physicians Lond

Cold injuries and disorders

Current Concepts Trauma Care

Hypothermia: Pathophysiology, clinical settings and management

Ann Intern Med

Hypothermia: From recognition to rewarming

Emergency Medicine Reports

Hypothermia: The Bellvue experience

Ann Emerg Med

A review of the literature concerning resuscitation from hypothermia: I and II

Aviat Space Eviron Med

A review of the literature concerning resuscitation from hypothermia: I and II

Aviat Space Eviron Med

The use of extracorporeal rewarming in a child submerged for 66 minutes

JAMA

Accidental deep hypothermia with cardiopulmonary arrest: Extracorporeal blood rewarming in eleven patients

Eur J Cardiothoracic Surgery

The J wave in accidental hypothermia

J Electrocardiol

State of the art report
Hypothermia