Hyperthermia

Hyperthermia

An analog medical thermometer showing a temperature

of 38.7 °C (101.7 °F)

Specialty Critical care medicine

ICD-9 780.6

DiseasesDB 18924

MeSH D005334

Hyperthermia is elevated body temperature due to failed thermoregulation that occurs when a
body produces or absorbs more heat than it dissipates. Extreme temperature elevation then
becomes a medical emergency requiring immediate treatment to prevent disability or death.

The most common causes include heat stroke and adverse reactions to drugs. The former is an
acute temperature elevation caused by exposure to excessive heat, or combination of heat and
humidity, that overwhelms the heat-regulating mechanisms. The latter is a relatively rare side
effect of many drugs, particularly those that affect the central nervous system. Malignant
hyperthermia is a rare complication of some types of general anesthesia.

Hyperthermia differs from fever in that the body's temperature set point remains unchanged. The
opposite is hypothermia, which occurs when the temperature drops below that required to
maintain normal metabolism.

Contents

 1 Classification
 2 Signs and symptoms
 3 Causes
o 3.1 Heat stroke
 o 3.2 Drugs
o 3.3 Personal protective equipment
o 3.4 Other
 4 Pathophysiology
 5 Diagnosis
 6 Prevention
 7 Treatment
 8 Epidemiology
 9 Research
 10 See also
 11 References
 12 External links

Classification
Temperature classification
Core (rectal, esophageal, etc.)
Hypothermia <35.0 °C (95.0 °F)[1]
Normal 36.5–37.5 °C (97.7–99.5 °F)[2]
Fever >37.5 or 38.3 °C (99.5 or 100.9 °F)[3][4]
Hyperthermia >37.5 or 38.3 °C (99.5 or 100.9 °F)[3][4]
Hyperpyrexia >40.0 or 41.5 °C (104.0 or 106.7 °F)[5][6]
Note: The difference between fever and hyperthermia is the underlying mechanism.
Different sources have different cuts offs for fever, hyperthermia and hyperpyrexia.

 v
 t
 e

In humans, hyperthermia is defined as a temperature greater than 37.5–38.3 °C (99.5–100.9 °F),

depending on the reference used, that occurs without a change in the body's temperature set
point.[3][4]

The normal human body temperature can be as high as 37.7 °C (99.9 °F) in the late afternoon.[7]
Hyperthermia requires an elevation from the temperature that would otherwise be expected. Such
elevations range from mild to extreme; body temperatures above 40 °C (104 °F) can be life-
threatening.

Signs and symptoms

An early stage of hyperthermia can be "heat exhaustion" (or "heat prostration" or "heat stress"),
whose symptoms include heavy sweating, rapid breathing and a fast, weak pulse. If the condition
progresses to heat stroke, then hot, dry, skin is typical[7] as blood vessels dilate in an attempt to
increase heat loss. An inability to cool the body through perspiration may cause the skin to feel
dry.

Other signs and symptoms vary. Accompanying dehydration can produce nausea, vomiting,
headaches, and low blood pressure and the latter can lead to fainting or dizziness, especially if
the standing position is assumed quickly.

In severe heat stroke, there may be confused, hostile, or seemingly intoxicated behavior. Heart
rate and respiration rate will increase (tachycardia and tachypnea) as blood pressure drops and
the heart attempts to maintain adequate circulation. The decrease in blood pressure can then
cause blood vessels to contract reflexly, resulting in a pale or bluish skin color in advanced cases.
Young children, in particular, may have seizures. Eventually, organ failure, unconsciousness and
death will result.

Causes

Heat stroke

Heat stroke occurs when thermoregulation is overwhelmed by a combination of excessive

metabolic production of heat (exertion), excessive environmental heat, and insufficient or
impaired heat loss, resulting in an abnormally high body temperature.[7] In severe cases,
temperatures can exceed 40 °C (104 °F).[8] Heat stroke may be non-exertional (classic) or
exertional.

Significant physical exertion in hot conditions can generate heat beyond the ability to cool,
because, in addition to the heat, humidity of the environment may reduce the efficiency of the
body's normal cooling mechanisms.[7] Human heat-loss mechanisms are limited primarily to
sweating (which dissipates heat by evaporation, assuming sufficiently low humidity) and
vasodilation of skin vessels (which dissipates heat by convection proportional to the temperature
difference between the body and its surroundings, according to Newton's law of cooling). Other
factors, such as insufficient water intake, consuming alcohol, or lack of air conditioning, can
worsen the problem.

The increase in body temperature that results from a breakdown in thermoregulation affects the
body biochemically. Enzymes involved in metabolic pathways within the body such as cellular
respiration fail to work effectively at higher temperatures, and further increases can lead them to
denature, reducing their ability to catalyse essential chemical reactions. This loss of enzymatic
control affects the functioning of major organs with high energy demands such as the heart and
brain.

Non-exertional heat stroke mostly affects the young and elderly. In the elderly in particular, it
can be precipitated by medications that reduce vasodilation and sweating, such as anticholinergic
drugs, antihistamines, and diuretics.[7] In this situation, the body's tolerance for high
environmental temperature may be insufficient, even at rest.
Heat waves are often followed by a rise in the death rate, and these 'classical hyperthermia'
deaths typically involve the elderly and infirm. This is partly because thermoregulation involves
cardiovascular, respiratory and renal systems which may be inadequate for the additional stress
because of the existing burden of aging and disease, further compromised by medications.
During the July 1995 heat wave in Chicago, there were at least 700 heat-related deaths. The
strongest risk factors were being confined to bed, and living alone, while the risk was reduced for
those with working air conditioners and those with access to transportation. Even then, reported
deaths may be underestimates as diagnosis can be misclassified as stroke or heart attack.[9]

Drugs

Some drugs cause excessive internal heat production.[7] The rate of drug-induced hyperthermia is
higher where use of these drugs is higher.[7]

 Many psychotropic medications, such as selective serotonin reuptake inhibitors (SSRIs),

monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants, can cause hyperthermia.[7]
Serotonin syndrome is a rare adverse reaction to overdose of these medications or the use of
several simultaneously. Similarly, neuroleptic malignant syndrome is an uncommon reaction to
neuroleptic agents.[10] These syndromes are differentiated by other associated symptoms, such
as tremor in serotonin syndrome and "lead-pipe" muscle rigidity in neuroleptic malignant
syndrome.[7]
 Various stimulant drugs, including amphetamines,[11] cocaine,[12] PCP, LSD, and MDMA can
produce hyperthermia as an adverse effect.[7]
 Malignant hyperthermia is a rare reaction to common anesthetic agents (such as halothane) or
the paralytic agent succinylcholine. Those who suffer this reaction, which is potentially fatal,
have a genetic predisposition.[7]
 The use of anticholinergics, more specifically muscarinic antagonists are thought to cause mild
hyperthermic episodes due to its parasympatholytic effects. The sympathetic nervous system
a.k.a. the "Fight or Flight Response" dominates by raising catecholamine levels by the blocked
action of the Rest and Digest System.[13]

Personal protective equipment

Those working in industry, in the military, or as first responders may be required to wear
personal protective equipment (PPE) against hazards such as chemical agents, gases, fire, small
arms and even Improvised Explosive Devices (IEDs). PPE includes a range of hazmat suits,
firefighting turnout gear, body armor and bomb suits, amongst others. Depending on design, the
wearer may be encapsulated in a microclimate,[14] due to an increase in thermal resistance and
decrease in vapor permeability. As physical work is performed, the body’s natural
thermoregulation (i.e., sweating) becomes ineffective. This is compounded by increased work
rates, high ambient temperature and humidity levels, and direct exposure to the sun. The net
effect is that desired protection from some environmental threats inadvertently increases the
threat of heat stress.

The effect of PPE on hyperthermia has been noted in fighting the 2014 Ebola virus epidemic in
Western Africa. Doctors and healthcare workers were only able to work 40 minutes at a stretch
in their protective suits, fearing heat strokes.[15]

Other

Other rare causes of hyperthermia include thyrotoxicosis and an adrenal gland tumor, called
pheochromocytoma, both of which can cause increased heat production.[7] Damage to the central
nervous system, from brain hemorrhage, status epilepticus, and other kinds of injury to the
hypothalamus can also cause hyperthermia.[7]

Pathophysiology

A summary of the differences between hyperthermia, hypothermia, and fever.

Hyperthermia: Characterized on the left. Normal body temperature (thermoregulatory set-point) is
shown in green, while the hyperthermic temperature is shown in red. As can be seen, hyperthermia can
be conceptualized as an increase above the thermoregulatory set-point.
Hypothermia: Characterized in the center: Normal body temperature is shown in green, while the
hypothermic temperature is shown in blue. As can be seen, hypothermia can be conceptualized as a
decrease below the thermoregulatory set-point.
Fever: Characterized on the right: Normal body temperature is shown in green. It reads "New Normal"
because the thermoregulatory set-point has risen. This has caused what was the normal body
temperature (in blue) to be considered hypothermic.

A fever occurs when the core temperature is set higher, through the action of the pre-optic region
of the anterior hypothalamus. For example, in response to a bacterial or viral infection, certain
white blood cells within the blood will release pyrogens which have a direct effect on the
anterior hypothalamus, causing body temperature to rise, much like raising the temperature
setting on a thermostat.
In contrast, hyperthermia occurs when the body temperature rises without a change in the heat
control centers.

Some of the gastrointestinal symptoms of acute exertional heat stroke, such as vomiting,
diarrhea, and gastrointestinal bleeding, may be caused by barrier dysfunction and subsequent
endotoxemia. Ultraendurance athletes have been found to have significantly increased plasma
endotoxin levels. Endotoxin stimulates many inflammatory cytokines, which in turn may cause
multiorgan dysfunction. Experimentally, monkeys treated with oral antibiotics prior to induction
of heat stroke do not become endotoxemic.[16]

There is scientific support for the concept of a temperature set point - that is, maintenance of an
optimal temperature for the metabolic processes that life depends on. Nervous activity in the
preoptic-anterior hypothalamus of the brain triggers heat losing (sweating, etc.) or heat
generating (shivering and muscle contraction, etc.) activities through stimulation of the
autonomic nervous system. The pre-optic anterior hypothalamus has been shown to contain
warm sensitive, cool sensitive, and temperature insensitive neurons, to determine the body's
temperature setpoint. As the temperature that these neurons are exposed to rises above 37 °C, the
rate of electrical discharge of the warm-sensitive neurons increases progressively. Cold-sensitive
neurons increase their rate of electrical discharge progressively below 37 °C.[17]

Diagnosis

Hyperthermia is generally diagnosed by the combination of unexpectedly high body temperature

and a history that supports hyperthermia instead of a fever.[7] Most commonly this means that the
elevated temperature has occurred in a hot, humid environment (heat stroke) or in someone
taking a drug for which hyperthermia is a known side effect (drug-induced hyperthermia). The
presence of signs and symptoms related to hyperthermia syndromes, such as extrapyramidal
symptoms characteristic of neuroleptic malignant syndrome, and the absence of signs and
symptoms more commonly related to infection-related fevers, are also considered in making the
diagnosis.

If fever-reducing drugs lower the body temperature, even if the temperature does not return
entirely to normal, then hyperthermia is excluded.[7]

Prevention

When ambient temperature is excessive, humans and many animals cool themselves below
ambient by evaporative cooling of sweat (or other aqueous liquid; saliva in dogs, for example);
this helps prevent potentially fatal hyperthermia. The effectiveness of evaporative cooling
depends upon humidity. Wet-bulb temperature, which takes humidity into account, or more
complex calculated quantities such as wet-bulb globe temperature (WBGT), which also takes
solar radiation into account, give useful indications of the degree of heat stress and are used by
several agencies as the basis for heat-stress prevention guidelines. (Wet-bulb temperature is
essentially the lowest skin temperature attainable by evaporative cooling at a given ambient
temperature and humidity.)
A sustained wet-bulb temperature exceeding 35 °C is likely to be fatal even to fit and healthy
people unclothed in the shade next to a fan; at this temperature, environmental heat gain instead
of loss occurs. As of 2012, wet-bulb temperatures only very rarely exceeded 30 °C anywhere,
although significant global warming may change this.[18]

In cases of heat stress caused by physical exertion, hot environments, or protective equipment,
prevention or mitigation by frequent rest breaks, careful hydration, and monitoring body
temperature should be attempted.[19] However, in situations demanding one is exposed to a hot
environment for a prolonged period or must wear protective equipment, a personal cooling
system is required as a matter of health and safety. There is a variety of active or passive
personal cooling systems;[14] these can be categorized by their power sources and whether they
are person- or vehicle-mounted.

Because of the broad variety of operating conditions, these devices must meet specific
requirements concerning their rate and duration of cooling, their power source, and their
adherence to health and safety regulations. Among other criteria are the user's need for physical
mobility and autonomy. For example, active-liquid systems operate by chilling water and
circulating it through a garment; the skin surface area is thereby cooled through conduction. This
type of system has proven successful in certain military, law enforcement, and industrial
applications. Bomb-disposal technicians wearing special suits to protect against improvised
explosive devices (IEDs) use a small, ice-based chiller unit that is strapped to one leg; a liquid-
circulating garment, usually a vest, is worn over the torso to maintain a safe core body
temperature. By contrast, soldiers traveling in combat vehicles can face microclimate
temperatures in excess of 65 °C and require a multiple-user, vehicle-powered cooling system
with rapid connection capabilities. Requirements for hazmat teams, the medical community, and
workers in heavy industry vary further.

Cost per
Hyperthermia Prevention
day

Keep water on head (such as by using a commercial, wetted sweat band) 0

Keep cool water on head +

Provide shade, or move to a shaded area +

Dress as if for running a marathon +

Stay sweaty or keep the patient wet with water 0

Increase air movement (e.g., use fans or move the person / patient into an area with better
+
air current)

Use a water mister, as used by some restaurants on their patios, or by sporting venues +

Lower the air temperature (e.g., open windows, operate mechanical refrigeration, and / or
+
let the air flow over or through ice)
Place the person / patient in a tub of water, pool, or other body of water +

Treatment

The underlying cause must be removed. Mild hyperthemia caused by exertion on a hot day may
be adequately treated through self-care measures, such as increased water consumption and
resting in a cool place. Hyperthermia that results from drug exposure requires prompt cessation
of that drug, and occasionally the use of other drugs as counter measures. Antipyretics (e.g.,
acetaminophen, aspirin, other nonsteroidal anti-inflammatory drugs) have no role in the
treatment of heatstroke because antipyretics interrupt the change in the hypothalamic set point
caused by pyrogens; they are not expected to work on a healthy hypothalamus that has been
overloaded, as in the case of heatstroke. In this situation, antipyretics actually may be harmful in
patients who develop hepatic, hematologic, and renal complications because they may aggravate
bleeding tendencies.[20]

When body temperature is significantly elevated, mechanical cooling methods are used to
remove heat and to restore the body's ability to regulate its own temperatures.[7] Passive cooling
techniques, such as resting in a cool, shady area and removing clothing can be applied
immediately. Active cooling methods, such as sponging the head, neck, and trunk with cool
water, remove heat from the body and thereby speed the body's return to normal temperatures.
Drinking water and turning a fan or dehumidifying air conditioning unit on the affected person
may improve the effectiveness of the body's evaporative cooling mechanisms (sweating).[citation
needed]

Sitting in a bathtub of tepid or cool water (immersion method) can remove a significant amount
of heat in a relatively short period of time. It was once thought that immersion in very cold water
is counterproductive, as it causes vasoconstriction in the skin and thereby prevents heat from
escaping the body core. However, a British analysis of various studies stated: "this has never
been proven experimentally. Indeed, a recent study using normal volunteers has shown that
cooling rates were fastest when the coldest water was used."[21] The analysis concluded that cool
water immersion is the most-effective cooling technique for exertional heat stroke.[21] No
superior cooling method has been found for non-exertional heat stroke.[22] Thus, aggressive ice-
water immersion remains the gold standard for life-threatening heat stroke.[23][24]

When the body temperature reaches about 40 °C, or if the affected person is unconscious or
showing signs of confusion, hyperthermia is considered a medical emergency that requires
treatment in a proper medical facility. In a hospital, more aggressive cooling measures are
available, including intravenous hydration, gastric lavage with iced saline, and even
hemodialysis to cool the blood.[7]

Epidemiology

The frequency of environmental hyperthermia can vary significantly from year to year depending
on factors such as heat waves. Statistically, outdoor workers, including agricultural workers, are
at increased risk of experiencing heat stress and the resulting negative health effects. Between
1992 and 2006 in the United States, 68 crop workers died from heat stroke, representing a rate 20
times that of US civilian workers overall.[25]

In India, hundreds die every year from summer heat waves,[26] including more than 2,500 in the
year 2015.[27] Later that same summer, the 2015 Pakistani heat wave killed about 2,000 people.[28]
An extreme 2003 European heat wave caused tens of thousands of deaths.[29]

Research

Hyperthermia can also be deliberately induced using drugs or medical devices and is being
studied as a treatment of some kinds of cancer.[30]

See also

 Important information

There are many brands and forms of paracetamol available and not all brands are listed on this
leaflet.

Do not use more of this medication than is recommended. An overdose of paracetamol can cause
serious harm. The maximum amount of paracetamol for adults is 1 gram (1000 mg) per dose and
4 grams (4000 mg) per day. Taking more paracetamol could cause damage to your liver. If you
drink more than three alcoholic beverages per day, talk to your doctor before taking
paracetamol and never use more than 2 grams (2000 mg) per day.

Do not use this medication without first talking to your doctor if you drink more than three
alcoholic beverages per day or if you have had alcoholic liver disease (cirrhosis). You may not
be able to use paracetamol .

Before using paracetamol , tell your doctor if you have liver disease or a history of alcoholism.

Do not use any other over-the-counter cough, cold, allergy, or pain medication without first
asking your doctor or pharmacist. Paracetamol is contained in many combination medicines. If
you use certain products together you may accidentally use too much paracetamol . Read the
label of any other medicine you are using to see if it contains paracetamol, acetaminophen or
APAP. Avoid drinking alcohol while taking this medication. Alcohol may increase your risk of
liver damage while taking paracetamol .

Before taking this medicine

Do not use this medication if you are allergic to acetaminophen or paracetamol.

Ask a doctor or pharmacist if it is safe for you to take paracetamol if you have:

 liver disease; or
  a history of alcoholism;

It is not known whether paracetamol will harm an unborn baby. Before using paracetamol , tell
your doctor if you are pregnant. This medication can pass into breast milk and may harm a
nursing baby. Do not use paracetamol without telling your doctor if you are breast-feeding a
baby.

How should I use paracetamol ?

Use paracetamol exactly as directed on the label, or as prescribed by your doctor.

Do not use more of this medication than is recommended. An overdose of paracetamol can cause
serious harm. The maximum amount for adults is 1 gram (1000 mg) per dose and 4 grams (4000
mg) per day. Using more paracetamol could cause damage to your liver. If you drink more than
three alcoholic beverages per day, talk to your doctor before taking paracetamol and never use
more than 2 grams (2000 mg) per day. If you are treating a child, use a pediatric form of
paracetamol . Carefully follow the dosing directions on the medicine label. Do not give the
medication to a child younger than 2 years old without the advice of a doctor.

Measure the liquid form of paracetamol with a special dose-measuring spoon or cup, not a
regular table spoon. If you do not have a dose-measuring device, ask your pharmacist for one.
You may need to shake the liquid before each use. Follow the directions on the medicine label.

The paracetamol chewable tablet must be chewed thoroughly before you swallow it.

Make sure your hands are dry when handling the paracetamol disintegrating tablet. Place the
tablet on your tongue. It will begin to dissolve right away. Do not swallow the tablet whole.
Allow it to dissolve in your mouth without chewing.

To use the paracetamol effervescent granules, dissolve one packet of the granules in at least 4
ounces of water. Stir this mixture and drink all of it right away. To make sure you get the entire
dose, add a little more water to the same glass, swirl gently and drink right away.

Do not take a paracetamol rectal suppository by mouth. It is for use only in your rectum. Wash
your hands before and after inserting the suppository.

Try to empty your bowel and bladder just before using the paracetamol suppository. Remove the
outer wrapper from the suppository before inserting it. Avoid handling the suppository too long
or it will melt in your hands.

For best results from the suppository, lie down and insert the suppository pointed tip first into the
rectum. Hold in the suppository for a few minutes. It will melt quickly once inserted and you
should feel little or no discomfort while holding it in. Avoid using the bathroom just after
inserting the suppository.

Stop using paracetamol and call your doctor if:

  you still have a fever after 3 days of use;

 you still have pain after 7 days of use (or 5 days if treating a child);

 you have a skin rash, ongoing headache, or any redness or swelling; or

 if your symptoms get worse, or if you have any new symptoms.

Urine glucose tests may produce false results while you are taking paracetamol . Talk to your
doctor if you are diabetic and you notice changes in your glucose levels during treatment.

Store paracetamol at room temperature away from heat and moisture. The rectal suppositories
can be stored at room temperature or in the refrigerator.

What happens if I miss a dose?

Since paracetamol is often used only when needed, you may not be on a dosing schedule. If you
are using the medication regularly, use the missed dose as soon as you remember. If it is almost
time for your next regularly scheduled dose, skip the missed dose and use your next dose as
directed. Do not use extra medicine to make up for a missed dose.

What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine.

The first signs of an paracetamol overdose include loss of appetite, nausea, vomiting, stomach
pain, sweating, and confusion or weakness. Later symptoms may include pain in your upper
stomach, dark urine, and yellowing of your skin or the whites of your eyes.

What should I avoid?

Do not use any other over-the-counter cough, cold, allergy, or pain medication without first
asking your doctor or pharmacist. Paracetamol is contained in many combination medicines. If
you use certain products together you may accidentally use too much paracetamol . Read the
label of any other medicine you are using to see if it contains paracetamol, acetaminophen or
APAP. Avoid drinking alcohol while taking this medication. Alcohol may increase your risk of
liver damage while taking paracetamol .

Paracetamol side effects

Get emergency medical help if you have any of these signs of an allergic reaction to
paracetamol: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using
this medication and call your doctor at once if you have a serious side effect such as:

 low fever with nausea, stomach pain, and loss of appetite;

  dark urine, clay-colored stools; or

 jaundice (yellowing of the skin or eyes).

This is not a complete list of paracetamol side effects and others may occur. Call your doctor for
medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

See also: Side effects (in more detail)

Paracetamol dosing information

Usual Adult Paracetamol Dose for Fever:

General Dosing Guidelines: 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours
orally or rectally.

Paracetamol 500mg tablets: Two 500 mg tablets orally every 4 to 6 hours

Usual Adult Paracetamol Dose for Pain:

General Dosing Guidelines: 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours
orally or rectally.

Paracetamol 500mg tablets: Two 500 mg tablets orally every 4 to 6 hours

Usual Pediatric Dose for Fever:

Oral or Rectal:

<=1 month: 10 to 15 mg/kg/dose every 6 to 8 hours as needed.

>1 month to 12 years: 10 to 15 mg/kg/dose every 4 to 6 hours as needed (Maximum: 5 doses in

24 hours)

Fever: 4 months to 9 years: Initial Dose: 30 mg/kg (Reported by one study (n=121) to be more
effective in reducing fever than a 15 mg/kg maintenance dose with no difference regarding
clinical tolerance.)

>=12 years: 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours.

Usual Pediatric Dose for Pain:

Oral or Rectal:

<=1 month: 10 to 15 mg/kg/dose every 6 to 8 hours as needed.

>1 month to 12 years: 10 to 15 mg/kg/dose every 4 to 6 hours as needed (Maximum: 5 doses in
24 hours)

Fever: 4 months to 9 years: Initial Dose: 30 mg/kg (Reported by one study (n=121) to be more
effective in reducing fever than a 15 mg/kg maintenance dose with no difference regarding
clinical tolerance.)

>=12 years: 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours.

What other drugs will affect paracetamol ?

There may be other drugs that can interact with paracetamol . Tell your doctor about all your
prescription and over-the-counter medications, vitamins, minerals, herbal products, and drugs
prescribed by other doctors. Do not start a new medication without telling your doctor.

Hyperthermia treatment and prevention

Treatment of hyperthermia consisting of measures which will rapidly

lower core body temperature. However, care must be taken to avoid
causing vasoconstriction or shivering. Vasoconstriction will impede
heat loss and shivering will create heat.

Once heat stroke has developed, the prognosis is poor, particularly

with advanced age. The treatment goal is to reduce tissue damage
by lowering the temperature of vital structures such as the brain,
heart and liver. Tissue damage ensues when core temperature
reaches 109F (43C). Cooling treatments can be internal or external.

Internal cooling techniques such as ice water gastric or rectal

lavage, extracorporeal blood cooling, and peritoneal or thoracic
lavage are effective but they are also difficult to manage and
associated with complications.

External cooling techniques are usually easier to implement, well

tolerated and effective.

 Conductive cooling techniques include direct application of

sources such as hypothermic blanket, ice bath, or ice packs to
neck, axillae and groin
  Convective techniques include removal of clothing and use of
fans and air conditioning.
 Evaporative cooling can be accelerated by removing clothing
and using a fan in conjunction with misting the skin with tepid
water or applying a single layer wet sheet to bare skin.

Hyperthermia is a condition that is much better prevented than

treated in an elderly person. Elderly patients should be cautioned
about the dangers of hot weather. For those elders at very high
risk, such as those living alone without air conditioning or
ventilation, temporary relocation to a more protected environment
such as a shelter or community center should be implemented.
Nurses can suggest several specific strategies that can help elderly
people avoid hyperthermia during heat waves.

These strategies include:

 Drink 2 to 3 quarts of water daily.

 Avoid exertion or exercise, especially during the hottest part of
the day.
 If traveling, allow 2 to 3 weeks in an unusually hot climate
before attempting any type of exertion.
 When outside, wear a hat and loose clothing; when indoors,
remove as much clothing as needed to be comfortable.
 Take a tepid bath or shower.
 Use cold wet towels or dampen clothing with tepid water when
the heat is extreme.
 Avoid hot, heavy meals.
 Avoid alcohol.
 Determine if the person is taking any medications that
increase hyperthermia risk; if so, consult with the patient's
physician.

ment

In this section

 About Clinical Guidelines (Nursing)

 Development process
 Guideline index
 Contact us
Temperature Management

 Introduction

Aim

Definition of Terms

Assessment

Management

Companion Documents

Links

References

Evidence Table

Introduction

Temperature management is a significant area of clinical practice particularly within

paediatric nursing. Maintaining a constant body temperature is important and especially
so in the neonatal population. Hypothermia and hyperthermia should be avoided as they
can have severe adverse outcomes, increasing morbidity and mortality. Maintaining
correct body temperature maximizes metabolic efficiency, decreases oxygen use, protects
enzyme function and to decrease caloric expenditure.

Aim

To provide health care staff with information that enables them to manage temperature
management in patients at the Royal Children’s Hospital.

Definition of Terms

Thermoregulation: The ability to balance heat production and heat loss in order to
maintain body temperature within a certain “normal” range.
Neutral thermal environment (NTE): narrow range of environmental temperature in
which a person is able to maintain a neutral thermal temperature. A neutral thermal
temperature is the body temperature at which an individual’s oxygen and energy
consumption is minimised.

Fever:

o pertaining to or marked by a fever

o is caused by a change in the body’s temperature set point, usually caused by infection

Temperature 37.2 – 38.0°C -

Temperature > 38.0° C-
Hypothermia: Body’s core temperature drops below that required for normal metabolism
and body functions Neonate- a temperature <36.5 ºC
Infant/child- a temperature <36 ºC
Link to Onc – febrile neutropaenia CPG

Hyperthermia: Is an elevated body temperature due to failed thermoregulation that

occurs when the body produces or absorbs more heat than it can dissipate. Hyperthermia
differs from fever in the mechanism that causes the elevated body temperature.
Mild hyperthermia -a temperature>37.5 ºC
Extreme hyperthermia – a temperature > 38.8 ºC
Link to fever in the Peadiatric patient CPG

 
Heat Stroke: thermoregulation is overwhelmed by a combination of excessive metabolic
production of heat (exertion), excessive environmental heat and insufficient or impaired
heat loss. This results in an abnormally high body temperature

 
Neonate: an infant that is up to 28 days corrected post term (e.g. an infant born at 34
weeks gestation and is 8 weeks old is 14 days corrected post term).

 
Non shivering thermogenesis: The primary source of heat production in the neonate. It
is the production of heat by metabolism of brown fat Brown fat (deposited after 28 weeks
gestation principally around the scapulae, kidneys, adrenals, neck and axilla) is a
thermogenic organ unique neonates

Methods of heat loss:

o Conduction: Transfer of heat from one solid object to another solid object in direct
contact with it
o Convection:Transfer of heat from the body surface to the surrounding air via air current
o Radiation:Transfer of heat to cooler solid objects not in direct contact with the body
o Evaporation: Heat loss occurring during conversion of liquid to vapour
 

Radiant warmer:

Radiant warming cots are designed to provide thermal stability to infants while allowing
direct observation. These cots can be operated in servo control mode (the heating
elements turn on and off according to measured changes in the infant’s skin temperature)
or manual control (the heater is set to a constant power level).

Isolette: The trademark name for an autonomous incubator unit that provides a controlled
heat, humidity and oxygen microenvironment for the isolation and care of premature and
low birth weight neonates, and infants. The device is made of a clear plastic material and
has a large door and smaller portholes for easy access to the infant with a minimum of
heat and oxygen loss. A servo control mechanism can be used to constantly monitor the
infant’s temperature and control the heat within the unit.

Assessment
At risk groups:

o Neonates, especially if premature or small for gestational age

o Burns patients
o Trauma patients
o Theatre patients

Physical Assessment:

Temperature should be measured on admission and as per care plan (3-4 hourly for
neonates) unless the temperature falls outside the normal limits- then it should be
measured hourly till back within normal limits (link to Febrile Child CPG)

Method of taking temperature:

o Neonate -to 3 months age- rectal or axilla temperature using digital thermometer
o > 3 months age- tympanic temperature

 (Refer to manufacturer’s instructions for correct use of thermometers)

Temperature may also be monitored in specialty areas e.g theatre, PICU, by the following
methods

o Oesphageal
o Skin
o nasopharyngeal
Management

For peri-operative management refer to peri-operative services

If hypothermic

Neonate:

o Notify doctor
o Assess environment and what clothing baby wearing
o Correct any environmental factors e.g. remove from draughts
o Add layer of clothing and extra blanket if needed (within SIDS guidelines)
o Maximum layers for neonate- singlet, grow suit, hat (if on continuous monitoring),
socks/booties, one wrap and one blanket
o Re-measure neonate’s temperature half to one hour after each intervention
o If temperature is still <36.5ºC with the above layers, into Isolette (refer to use of Isolette
on Ward procedure/policy)
o For prolonged procedures place neonate on radiant warmer (on low manual heat
setting), consider using other warming devices as indicated by condition. Observe for
signs of complications (see below)

Infant/child:

o Notify doctor
o Assess environment and what clothing is being worn
o Add extra layer of clothing or blanket as required
o Use warming devices as necessary during procedures and post-operatively
o Observe for signs of complications

If Hyperthermic

o Notify Doctor
o Assess environmental factors and what clothing is being worn. Check and alter NTE if
required
o Correct environmental factors if relevant
o Ensure patient appropriately dressed for environment, remove layer of clothing or
blankets as necessary
o If temperature remains high despite appropriate environmental temperature, consider
other causes i.e. sepsis Link to Sepsis CPG
If Febrile

o If temperature 37.5 – 38.0° C- observe patient for signs of infection, notify doctor, take
temperature hourly till back within normal range (link to Sepsis CPG)
o Neonate: If temperature >38ºC - notify doctor, take temperature hourly till back within
normal range, prepare for septic workup if ordered by Doctor
o Infant/Child: report temperatures > 38.5°C in patients > 3 months of age, consider
medical review (link to Febrile Child CPG, Oncology- febrile neutropaenia CPG)
o Refer to each department for management of febrile infants/children specific to that
department

Potential Complications

Cold stress

The neonate’s initial response to a cold environment is to constrict superficial blood

vessels to minimize transfer of heat from the core to the surface of the body. Superficial
vasoconstriction causes the mottled appearance of the skin. If the neonate is not warmed
then cold stress can occur.
Cold stress may result in:

o Increased metabolic rate, leading to increased oxygen consumption

o Increased caloric consumption and decreased glycogen stores which can lead to
hypoglycaemia
o Development of acidosis due to pulmonary vasoconstriction
o Thermal shock and disseminated intravascular coagulation, progressing to death

Hypothermia

May result in:

Mild (32-36ºC)

o Constant shivering
o Tiredness
o Low energy
o Cold or pale skin
o Tachypnoea
o Feed intolerance

Moderate (28-32ºC)

o Confusion, unable to think or pay attention

 o Loss of judgement/reasoning
o Loss of coordination
o Drowsiness
o Slurred speech
o Slow, shallow breathing

Severe (>28ºC)

o Unconsciousness
o Shallow breathing/apnoea
o Weak, irregular pulse
o Dilated pupils

Hyperthermia

May result in:

o Vasodilatation
o Increased metabolic rate
o Increased fluid loss/dehydration
o Poor feeding
o Nausea and Vomiting
o Headaches
o Decreased Blood Pressure
o Fainting/dizziness

Heat Stroke

May result in:

o Confusion
o Hostile behaviour
o Appearance of being intoxicated
o Tachycardia
o Tachypnoea
o Decreased blood pressure
o Seizures