Hypothermia

 

 Buy Article Permissions and Reprints

ABSTRACT

Accidental hypothermia is defined as an unintentional decline in the core temperature below 35°C. The population of patients at risk is very heterogeneous. Common thermal stressors include both primary exposures and secondary contributory diseases or injuries. As the core temperature progressively declines, the compensatory metabolic, adrenergic, and cardiovascular responses that attempt to maintain thermal homeostasis fail.

At this juncture, therapeutic intervention must occur. An understanding of the pathophysiological variables impacting rewarming is critical. For example, the effects of cold on the coagulation system impact both the approach to cardiovascular resuscitation and the choice of rewarming technique. There are no randomized controlled trials that definitively establish the ideal rewarming strategy for each unique presentation. The resuscitative goal is to match the clinical presentation with the threshold temperatures at which various rewarming modalities and pharmacological interventions should occur.

Identification of the indications for both noninvasive and invasive active rewarming techniques in patients requiring critical care is key. Poikilothermia, failure to rewarm, endocrinologic insufficiency, cardiovascular instability, traumatic or toxicological induced peripheral vasodilation, or the presence of major predisposing factors mandates active rewarming. The simultaneous or sequential use of the various rewarming techniques permits a versatile approach to therapy.

Outcome remains problematic to predict because there may never be a validated prognostic neurological scale. The history, physical examination, and, ironically, the vital signs are routinely misleading. A tachycardia that is not proportionate to the degree of hypothermia suggests hypovolemia, hypoglycemia, or the presence of toxins. Given the decreased carbon dioxide production, persistent hyperventilation implies an underlying organic acidosis or central nervous system abnormality. Finally, toxic or traumatic or infectious impairment of the central nervous system may be obscured by hypothermia.

REFERENCES

• 1 Kammersgaard L P, Rasmussen B H, Jorgensen H S, Reith J, Weber U, Olsen T S. Feasibility and safety of inducing modest hypothermia in awake patients with acute stroke through surface cooling: a case-control study: the Copenhagen Stroke Study.  Stroke . 2000;  31 2251-2256
  CrossrefPubMedGoogle Scholar
• 2 Jiang J, Yu M, Zhu C. Effect of long-term mild hypothermia therapy in patients with severe traumatic brain injury: 1-year follow-up review of 87 cases [see comments].  J Neurosurg . 2000;  93 546-549
  CrossrefPubMedGoogle Scholar
• 3 Marion D W, Penrod L E, Kelsey S F. Treatment of traumatic brain injury with moderate hypothermia.  N Engl J Med . 1997;  336 540-546
  CrossrefPubMedGoogle Scholar
• 4 Gallaher M M, Fleming D W, Berger L R, Sewell C M. Pedestrian and hypothermia deaths among Native Americans in New Mexico: between bar and home [published erratum appears in JAMA 1992;268(17):2378] [see comments].  JAMA . 1992;  267 1345-1348
  CrossrefPubMedGoogle Scholar
• 5 Danzl D F, Pozos R S. Accidental hypothermia.  N Engl J Med . 1994;  331 1756-1760
  CrossrefPubMedGoogle Scholar
• 6 Miller J W, Danzl D F, Thomas D M. Urban accidental hypothermia: 135 cases.  Ann Emerg Med . 1980;  9 456-461
  PubMedGoogle Scholar
• 7 Mills Jr J W. Field care of the hypothermic patient.  Int J Sports Med . 1992;  Suppl 1 S199-S202
  PubMedGoogle Scholar
• 8 Hypothermia-related deatHypothermia-related deaths: Alaska, October 1998-April 1999 Hypothermia-related deaths: Alaska October 1998-April 1999, trendsn in the United States 1979-1996. MMWR Morb Mortal Wkly Rep .  2000;  49(1) 11-14
  PubMedGoogle Scholar
• 9 Marsigny B. Medical mountain rescue in the Mont-Blanc massif.  Wilderness Environ Med . 1999;  10 152-156
  CrossrefPubMedGoogle Scholar
• 10 Danzl D F, Pozos R S, Auerbach P S. Multicenter hypothermia survey.  Ann Emerg Med . 1987;  16 1042-1055
  CrossrefPubMedGoogle Scholar
• 11 Pozos R S, Israel D, McCutcheon R, Wittmers Jr E L, Sessler D. Human studies concerning thermal-induced shivering postoperative ``shivering,'' cold-induced vasodilation.  Ann Emerg Med . 1987;  16 1037-1041
  PubMedGoogle Scholar
• 12 Giesbrecht G G. Cold stress near drowning accidental hypothermia: a review.  Aviat Space Environ Med . 2000;  71 733-752
  PubMedGoogle Scholar
• 13 Sessler D I. Perioperative heat balance.  Anesthesiology . 2000;  92 578-596
  CrossrefPubMedGoogle Scholar
• 14 Vassallo S U, Delaney K A, Hoffman R S, Slater W, Goldfrank L R. A prospective evaluation of the electrocardiographic manifestations of hypothermia.  Acad Emerg Med . 1999;  6 1121-1126
  PubMedGoogle Scholar
• 15 Danzl D F, O'Brien D J. The ECG computer program: mort de froid.  J Wilderness Med . 1992;  3 328-329
  PubMedGoogle Scholar
• 16 Hayward J S, Eckerson J D, Kemna D. Thermal cardiovascular changes during three methods of resuscitation from mild hypothermia.  Resuscitation . 1984;  11 21-33
  CrossrefPubMedGoogle Scholar
• 17 Giesbrecht G G, Johnston C E, Bristow G K. The convective afterdrop component during hypothermic exercise decreased with delayed exercise onset.  Aviat Space Environ Med . 1998;  69 17-22
  PubMedGoogle Scholar
• 18 Fishbeck K H, Simon R P. Neurological manifestations of accidental hypothermia.  Ann Neurol . 1981;  10 384-387
  CrossrefPubMedGoogle Scholar
• 19 Lloyd E L. Accidental hypothermia.  Resuscitation . 1996;  32 111-124
  CrossrefPubMedGoogle Scholar
• 20 Nicholson R W, Iserson K V. Core temperature measurement in hypovolemic resuscitation.  Ann Emerg Med . 1991;  20 62-65
  PubMedGoogle Scholar
• 21 Clayton D G, Webb R K, Ralston A C, Duthie D, Runciman W B. A comparison of the performance of 20 pulse oximeters under conditions of poor perfusion [see comments].  Anaesthesia . 1991;  46 3-10
  PubMedGoogle Scholar
• 22 Silbergleit R, Satz W, Lee D C, McNamara R M. Hypothermia from realistic fluid resuscitation in a model of hemorrhagic shock.  Ann Emerg Med . 1998;  31 339-343
  PubMedGoogle Scholar
• 23 Cohen J A, Blackshear R H, Gravenstein N, Woeste J. Increased pulmonary artery perforating potential of pulmonary artery catheters during hypothermia.  J Cardiothorac Vasc Anesth . 1991;  5 234-236
  CrossrefPubMedGoogle Scholar
• 24 Handrigan M T, Wright R O, Becker B M, Linakis J G, Jay G D. Factors methodology in achieving ideal delivery temperatures for intravenous lavage fluid in hypothermia.  Am J Emerg Med . 1997;  15 350-353
  CrossrefPubMedGoogle Scholar
• 25 Baraka A S, Baroody M A, Haroun S T. Effect of alpha-stat versus pH-stat strategy on oxyhemoglobin dissociation whole-body oxygen consumption during hypothermic cardiopulmonary bypass.  Anesth Analg . 1992;  74 32-37
  PubMedGoogle Scholar
• 26 Delaney K A, Howland M A, Vassallo S, Goldfrank L R. Assessment of acid-base disturbances in hypothermia their physiologic consequences [review] [106 refs].  Ann Emerg Med . 1989;  18 72-82
  PubMedGoogle Scholar
• 27 Kroncke G M, Nichols R D, Mendenhall J T, Myerowitz P D, Starling J R. Ectothermic philosophy of acid-base balance to prevent fibrillation during hypothermia.  Archives of Surgery . 1986;  121 303-304
  PubMedGoogle Scholar
• 28 Cosgriff N, Moore E E, Sauaia A, Kenny-Moynihan M, Burch J M, Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia acidoses revisited.  J Trauma . 1997;  42 857-861
  CrossrefPubMedGoogle Scholar
• 29 Eddy V A, Morris Jr A J, Cullinane D C. Hypothermia coagulopathy and acidosis.  Surg Clin North Am . 2000;  80 845-854
  CrossrefPubMedGoogle Scholar
• 30 Rohrer M J, Natale A M. Effect of hypothermia on the coagulation cascade.  Crit Care Med . 1992;  20 1402-1405
  CrossrefPubMedGoogle Scholar
• 31 Reed R L, Bracey Jr W A, Hudson J D, Miller T A, Fischer R P. Hypothermia blood coagulation: dissociation between enzyme activity clotting factor levels.  Circulatory Shock . 1990;  32 141-152
  PubMedGoogle Scholar
• 32 Watts D D, Trask A, Soeken K, Perdue P, Dols S, Kaufmann C. Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed platelet function fibrinolytic activity .  J Trauma . 1998;  44 846-854
  CrossrefPubMedGoogle Scholar
• 33 Poulos N D, Mollitt D L. The nature reversibility of hypothermia-induced alterations of blood viscosity.  J Trauma . 1991;  31 996-998
  PubMedGoogle Scholar
• 34 Lewin S, Brettman L R, Holzman R S. Infections in hypothermic patients.  Arch Intern Med . 1981;  141 920-925
  CrossrefPubMedGoogle Scholar
• 35 Chernow B, Lake C R, Zaritsky A, Finton C K, Casey L, Rainey T G, Fletcher J R. Sympathetic nervous system ``switch off'' with severe hypothermia.  Crit Care Med . 1983;  11 677-680
  CrossrefPubMedGoogle Scholar
• 36 Weiss S J, Muniz A, Ernst A A, Lippton H L. The physiological response to norepinephrine during hypothermia rewarming.  Resuscitation. 1998;  39 189-195
  CrossrefPubMedGoogle Scholar
• 37 Rankin A C, Rae A P. Cardiac arrhythmias during rewarming of patients with accidental hypothermia.  Br Med J . 1984;  289 874-877
  PubMedGoogle Scholar
• 38 Murphy K, Nowak R M, Tomlanovich M C. Use of bretylium tosylate as prophylaxis treatment in hypothermic ventricular fibrillation in the canine model.  Ann Emerg Med . 1986;  15 1160-1166
  PubMedGoogle Scholar
• 39 Danzl D F, Sowers M B, Vicario S J. Chemical ventricular defibrillation in severe accidental hypothermia.  Ann Emerg Med . 1982;  11 698-699
  PubMedGoogle Scholar
• 40 Kochar G, Kahn S E, Kotler M N. Bretylium tosylate ventricular fibrillation in hypothermia [letter].  Annals of Internal Medicine . 1986;  105 624
  PubMedGoogle Scholar
• 41 Orts A, Alcaraz C, Delaney K A, Goldfrank L R, Turndorf H, Puig M M. Bretylium tosylate electrically induced cardiac arrhythmias during hypothermia in dogs.  Am J Emerg Med . 1992;  10 311-316
  CrossrefPubMedGoogle Scholar
• 42 Dixon R G, Dougherty J M, White L J, Lombino D, Rusnak R R. Transcutaneous pacing in a hypothermic-dog model.  Ann Emerg Med . 1997;  29 602-606
  PubMedGoogle Scholar
• 43 Maningas P A, DeGuzman L R, Hollenbach S J, Volk K A, Bellamy R F. Regional blood flow during hypothermic arrest.  Ann Emerg Med . 1986;  15 390-396
  PubMedGoogle Scholar
• 44 Althaus U, Aeberhard P, Schupbach P. Management of profound accidental hypothermia with cardiorespiratory arrest.  Ann Surg . 1982;  195 492-495
  CrossrefPubMedGoogle Scholar
• 45 Rogers I. Which rewarming therapy in hypothermia?.  <~>A review of the randomized trials. Emerg Med . 1997;  9 213-220
  PubMedGoogle Scholar
• 46 Lazar H L. The treatment of hypothermia.  New Engl J Med . 1997;  337 1545-1547
  CrossrefPubMedGoogle Scholar
• 47 Kornberger E. Forced air surface rewarming in patients with severe accidental hypothermia.  Resuscitation . 1999;  41 105-111
  CrossrefPubMedGoogle Scholar
• 48 Giesbrecht G G, Bristow G K. Recent advances in hypothermia research.  Ann New York Acad Sci . 1997;  813 676-681
  PubMedGoogle Scholar
• 49 Goheen M S, Ducharme M B, Kenny G P. Efficacy of forced-air inhalation rewarming by using a human model for severe hypothermia.  J Appl Physiol . 1997;  83 1635-1640
  PubMedGoogle Scholar
• 50 Steele M T, Nelson M J, Sessler D I. Forced air speeds rewarming in accidental hypothermia.  Ann Emerg Med . 1996;  27 479-484
  CrossrefPubMedGoogle Scholar
• 51 Vangaard L, Eyolfson D, Xu X, Giesbrecht G G. Arteriovenous anastomoses (AVA) rewarming in 45°C water is effective in moderately hypothermic subjects.  FASEB J . 1998;  12 A90
  PubMedGoogle Scholar
• 52 Ducharme M B, Giesbrecht G G, Frim J. Forced-air rewarming in -20°C simulated field conditions.  Ann NY Acad Sci . 1997;  813 676-681
  PubMedGoogle Scholar
• 53 Soreide E, Grahn D A, Brock-Utne J G, Rosen L. A non-invasive means to effectively restore normothermia in cold stressed individuals: a preliminary report.  J Emerg Med . 1999;  17 725-730
  CrossrefPubMedGoogle Scholar
• 54 Grahn D, Brock-Utne J G, Watenpaugh D E, Heller H C. Recovery from mild hypothermia can be accelerated by mechanically distending blood vessels in the hand [see comments].  J Appl Physiol . 1998;  85 1643-1648
  PubMedGoogle Scholar
• 55 Taguchi A. Negative pressure rewarming versus forced air warming in hypothermic postanesthetic volunteers.  Anesth Analg . 2001;  92 261-266
  PubMedGoogle Scholar
• 56 Zhong H, Qinyi S, Mingjlang S. Rewarming with microwave irradiation in severe cold injury syndrome.  Chin Med J . 1980;  93 19-20
  PubMedGoogle Scholar
• 57 Weinberg A D. The role of inhalation rewarming in the early management of hypothermia.  Resuscitation . 1998;  36 101-104
  CrossrefPubMedGoogle Scholar
• 58 Canivet J L, Larbuisson R, Lamy M. Interest of face mask-CPAP in one case of severe accidental hypothermia.  Acta Anaesthesiol Belg . 1989;  40 281-283
  PubMedGoogle Scholar
• 59 Fisher A, Foex P, Emerson P M, Darley J H, Rauscher L A. Oxygen availability during hypothermic cardiopulmonary bypass.  Crit Care Med . 1977;  5 154-158
  PubMedGoogle Scholar
• 60 Wallace W. Does it make sense to heat gases higher than body temperature for the treatment of cold water near-drowning or hypothermia?.  <~>A point of view paper. Alaska Med . 1997;  39 75-77
  PubMedGoogle Scholar
• 61 Levitt M A, Kane V, Henderson J, Dryjski M. A comparative rewarming trial of gastric versus peritoneal lavage in a hypothermic model.  Am J Emerg Med . 1990;  8 285-288
  CrossrefPubMedGoogle Scholar
• 62 Winegard C. Successful treatment of severe hypothermia prolonged cardiac arrest with closed thoracic cavity lavage.  J Emerg Med . 1997;  15 629-632
  CrossrefPubMedGoogle Scholar
• 63 Hall K N, Syverud S A. Closed thoracic cavity lavage in the treatment of severe hypothermia in human beings.  Ann Emerg Med . 1990;  19 204-206
  PubMedGoogle Scholar
• 64 Brunette D D, Biros M, Mlinek E J, Erlandson C, Ruiz E. Internal cardiac massage mediastinal irrigation in hypothermic cardiac arrest.  Am J Emerg Med . 1992;  10 32-34
  CrossrefPubMedGoogle Scholar
• 65 Iversen R J, Atkin S H, Jaker M A, Quadrel M A, Tortella B J, Odom J W. Successful CPR in a severely hypothermic patient using continuous thoracostomy lavage.  Ann Emerg Med . 1990;  19 1335-1337
  PubMedGoogle Scholar
• 66 Walpoth B H, Locher T, Leupi F, Schupbach P, Muhlemann W, Althaus U. Accidental deep hypothermia with cardiopulmonary arrest: extracorporeal blood rewarming in 11 patients.  Eur J Cardiothorac Surg . 1990;  4 390-393
  CrossrefPubMedGoogle Scholar
• 67 Splittgerber F H, Talbert J G, Sweezer W P, Wilson R F. Partial cardiopulmonary bypass for core rewarming in profound accidental hypothermia.  Am Surg . 1986;  52 407-412
  PubMedGoogle Scholar
• 68 Bolgiano E, Sykes L, Barish R A. Accidental hypothermia with cardiac arrest: recovery following rewarming by cardiopulmonary bypass.  J Emerg Med . 1992;  10 427-433
  CrossrefPubMedGoogle Scholar
• 69 Brunette D D, McVaney, K. Hypothermic cardiac arrest: an 11-year review of ED management outcome.  Am J Emerg Med . 2000;  18 418-422
  CrossrefPubMedGoogle Scholar
• 70 Gentilello L M, Jurkovich G J, Stark M S, Hassantash S A, O'Keefe G E. Is hypothermia in the victim of major trauma protective or harmful? A randomized prospective study.  Ann Surg . 1997;  226 439-447
  CrossrefPubMedGoogle Scholar
• 71 Gregory J S, Flancbaum L, Townsend M C, Cloutier C T, Jonasson O. Incidence timing of hypothermia in trauma patients undergoing operations.  J Trauma . 1991;  31 795-798
  CrossrefPubMedGoogle Scholar
• 72 Heise D, Rathgeber J, Burchardi H. Severe accidential hypothermia: active rewarming with a simple extracorporeal veno-venous warming-circuit.  Anaesthesist . 1996;  45 1093-1096
  CrossrefPubMedGoogle Scholar
• 73 Niazi S A, Lewis F J. Profound hypothermia in man: report of a case.  Ann Surg . 1958;  147 264-266
  PubMedGoogle Scholar
• 74 Dobson J AR, Burgess J J. Resuscitation of severe hypothermia by extracorporeal rewarming in a child.  J Trauma . 1996;  40 483-485
  PubMedGoogle Scholar
• 75 Gilbert M, Busund R, Skagseth A, Nilsen P A, Solbo J P. Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest [letter].  Lancet . 2000;  355 375-376
  CrossrefPubMedGoogle Scholar
• 76 Danzl D F, Hedges J R, Pozos R S. Hypothermia outcome score: development implications.  Crit Care Med . 1989;  17 227-231
  PubMedGoogle Scholar
• 77 Walpoth B H, Walpoth-Aslan B N, Mattle H P. Outcome of survivors of accidental deep hypothermia circulatory arrest treated with extracorporeal blood warming [see comments].  N Engl J Med . 1997;  337 1500-1505
  CrossrefPubMedGoogle Scholar
• 78 Pillgram-Larsen J, Svennevig J L, Abdelnoor M, Fjeld N B, Semb G, Osterud A, Skulberg A. [Accidental hypothermia. Risk factors in 29 patients with body temperature of 30 degrees Cbelow].[Norwegian].   Tidsskrift for Den Norske Laegeforening . 1991;  111 180-183
  PubMedGoogle Scholar
• 79 Schaller M D, Fischer A P, Perret C H. Hyperkalemia: a prognostic factor during acute severe hypothermia.  JAMA . 1990;  264 1842-1845
  CrossrefPubMedGoogle Scholar
• 80 Hauty M G, Esrig B C, Hill J G, Long W B. Prognostic factors in severe accidental hypothermia: experience from the Mt. Hood tragedy.  J Trauma . 1987;  27 1107-1112
  PubMedGoogle Scholar