HYPOTHERMIA

Mohd Hafis Zul Arif Bin Awang 01201005 0476

Contents
Introduction & Definition Pathophysiology History Physical Examination Causes Differential Diagnoses

Introduction
Hypothermia describes a state in which the body's mechanism for temperature regulation is overwhelmed in the face of a cold stressor. Hypothermia is classified as o accidental or intentional, o primary or secondary, and o degree of hypothermia (mild, moderate & severe).

 ACCIDENTAL HYPOTHERMIA generally results from unanticipated exposure in an inadequately prepared person;
o

examples include inadequate shelter for a homeless person, someone caught in a winter storm or motor vehicle accident, or an outdoor sport enthusiast caught off guard by the elements.

INTENTIONAL HYPOTHERMIA is an induced state generally directed at neuroprotection after an at-risk situation (therapeutic hypothermia after cardiac arrest,).

 PRIMARY HYPOTHERMIA is due to environmental exposure, with no underlying medical condition causing disruption of temperature regulation. SECONDARY HYPOTHERMIA is low body temperature resulting from a medical illness lowering the temperature set-point. Many patients have recovered from severe hypothermia, so early recognition and prompt initiation of optimal treatment is paramount. Systemic hypothermia may also be accompanied by localized cold injury (frostbite).

Pathophysiology
The body's core temperature is tightly regulated in the thermo neutral zone between 36.5C and 37.5C, outside of which thermoregulatory responses are usually activated. The body maintains a stable core temperature through balancing heat production and heat loss. At rest, humans produce 40-60 kilocalories (kcal) of heat per square meter of body surface area through generation by cellular metabolism, most prominently in the liver and the heart. Heat production increases with striated muscle contraction; shivering increases the rate of heat production 2-5 times.

 Mechanisms of Heat Loss o Radiation 55 65% - under dry conditions

the most significant.

are the most common causes of accidental hypothermia conduction is a particularly significant mechanism of heat loss in drowning/immersion accidents as thermal conductivity of water is up to 30 times that of air.

Convection & Conduction 15%

Respiration & Evaporation 20%

 The hypothalamus controls thermoregulation via increased heat conservation (peripheral vasoconstriction and behavior responses) and heat production (shivering and increasing levels of thyroxine and epinephrine).
o

Alterations of the CNS may impair these mechanisms.

The threshold for shivering is 1 degree lower than that of vasoconstriction and is considered a last resort mechanism by the body to maintain temperature. The mechanisms for heat preservation may be overwhelmed in the face of cold stress and core temperature can drop secondary to fatigue or glycogen depletion.

Effect of Hypothermia
Hypothermia affects virtually all organ systems. Perhaps the most significant effects are seen in the cardiovascular system and the CNS. o Hypothermia results in decreased depolarization of cardiac pacemaker cells, causing bradycardia. o Mean arterial pressure and cardiac output decrease o Electrocardiogram (ECG) may show characteristic J or Osborne wave.

While generally associated with hypothermia, the J wave may be a normal variant and is seen occasionally in sepsis and myocardial ischemia.

Osborne (J) waves (V3) in a patient with a rectal core temperature of 26.7C (80.1F).

Atrial and ventricular arrhythmias can result from hypothermia; asystole and ventricular fibrillation have been noted to begin spontaneously at core temperatures below 2528C. Hypothermia progressively depresses the CNS, decreasing CNS metabolism in a linear fashion as the core temperature drops. At core temperatures less than 33C, brain electrical activity becomes abnormal; Between 19C and 20C, an electroencephalogram (EEG) may appear consistent with brain death. Tissues have decreased oxygen consumption

History
Hypothermia is usually readily apparent in the setting of severe environmental exposure. In elderly patients or indoor patients, or for a patientparticularly a wet patient, with exposure to less extreme cold, the history may be subtle and less obvious. These patients may have a higher mortality rate secondary to a longer time to diagnosis and increased age and fragility. Mild or moderate hypothermia can present with misleading symptoms, such as confusion, dizziness, chills, or dyspnea.

 A patient's companions often note initial symptoms in the field. Symptoms can include mood change, irritability, poor judgment, and lassitude. Companions may note the patient to demonstrate paradoxical undressing (a severely hypothermic person removes clothing in response to prolonged cold stress) or rhythmic or repeated motions such as rocking. Slurred speech and ataxia may mimic a stroke, alcohol intoxication, or high-altitude cerebral edema. Similarly, profound hypothermia may present as coma or cardiac arrest.

 In an urban environment, the use of alcohol or illicit drugs, overdose, psychiatric emergency, and major trauma all are associated with an increased risk of hypothermia.

Physical Examination
The key to establishing a diagnosis of hypothermia is rapid determination of true core temperature. In the emergency department, core temperature is best measured using a low-reading temperature probe in the bladder or rectum or an esophageal probe. Obtaining a core temperature may help prevent erroneous diagnosis for patients with an altered mental status due to stroke, drug overdose, alcohol intoxication, or mental illness.

 Standard temperature measuring devices commonly used for triage may lack the capability to report unusually low temperature; obtain a core temperature reading for any patient suspected of being significantly hypothermic. At a given temperature, specific physical examination findings vary among patients. However, an examination does provide a frame of reference for dividing presenting symptoms into mild, moderate, and severe hypothermic signs.

Mild Hypothermia (32-35C)

Between 34C and 35C, most people shiver vigorously, usually in all extremities. As the temperature drops below 34C, a patient may develop altered judgment, amnesia, and dysarthria. Respiratory rate may increase. At approximately 33C, ataxia and apathy may be seen. Patients generally are stable hemodynamically and able to compensate for the symptoms. In this temperature range, the following may also be observed: hyperventilation, tachypnea, tachycardia, and cold diuresis as renal concentrating ability is compromised.

 Oxygen consumption decreases, and the CNS depresses further; hypoventilation, hyporeflexia, decreased renal flow, and paradoxical undressing may be noted. Most patients with temperatures of 32C or lower present in stupor. As the core reaches temperatures of 31C or below, the body loses its ability to generate heat by shivering.

Moderate Hypothermia (2832C)

 At 30C, patients develop a higher risk for arrhythmias.

o

Atrial fibrillation and other atrial and ventricular rhythms become more likely. The pulse continues to slow progressively, and cardiac output is reduced. J wave may be seen on ECG in moderate hypothermia.

Between 28C and 30C, pupils may become markedly dilated and minimally responsive to light, a condition that can mimic brain death.

Severe Hypothermia (< 28C)

At 28C, the body becomes markedly susceptible to ventricular fibrillation and further depression of myocardial contractility. Below 27C, 83% of patients are comatose. Pulmonary edema, oliguria, coma, hypotension, rigidity, apnea, pulselessness, areflexia, unresponsiveness, fixed pupils, and

Causes
A. Decreased Heat Production
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Endocrine derangements - hypopituitarism, hypoadrenalism, and hypothyroidism. Consider all these conditions in patients presenting with unexplained hypothermia who fail to rewarm with standard therapy. Other causes include severe malnutrition or hypoglycemia and neuromuscular inefficiencies seen in the extremes of age.

B. Increased Heat Loss

o

Accidental hypothermia due to both immersion etiologies and non-immersion etiologies and is the most common form of hypothermia encountered in the emergency department. Patients may present with induced vasodilatation from pharmacologic or toxicologic agents. Erythrodermas, such as burns or psoriasis, that decrease the body's ability to preserve heat, or Iatrogenic etiologies, such as cold infusions, overenthusiastic treatment of heatstroke, or emergency deliveries, may cause hypothermia

C. Impaired Thermoregulation
o

A variety of causes may be associated with impaired thermoregulation, but, generally, it is associated with failure of the hypothalamus to regulate core body temperature. This may occur with CNS trauma, strokes, toxicologic and metabolic derangements, intracranial bleeding, Parkinson disease, CNS tumors, Wernicke disease, and multiple sclerosis.

D. Other Causes o Miscellaneous causes include sepsis, multiple trauma, pancreatitis, prolonged cardiac arrest, and uremia. o Hypothermia may be related to drug administration; such medications include beta-blockers, clonidine, meperidine, neuroleptics, and general anesthetic agents. o Ethanol, phenothiazines, and sedativehypnotics also reduce the bodys ability to respond to low ambient temperatures.

Differentials
Hemorrhagic Stroke Ischemic Stroke Therapeutic Hypothermia Alcohols Toxicity Barbiturate Toxicity Benzodiazepine Toxicity Carbon Monoxide Toxicity Narcotics Toxicity Ventricular Fibrillation Ventricular Tachycardia

To Be Continued

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