Hypothermia

No previously healthy person should die of hypothermia after

they have been rescued and treatment has been started."
Cameron C. Bangs, M.D. The Mountaineers 1986
Objectives

• Describe the regulation of temperature by the hypothalamus

• Discuss effects of cold exposure.

• Discuss hypothermia causes, signs and symptoms and prevention

• Discuss management and specific re-warming methods in the field

Hypothermia - definition

– A state of low body temperature,

specifically a low CORE
temperature (< 35º C) and
confirmed with a low reading
thermometer.

– Temperatures below 30º C

indicate severe hypothermia

– MEDICAL EMERGENCY; life

threatening condition.
Hypothermia – review of anatomy and physiology

• Humans are warm-

blooded mammals who
maintain a constant
body temperature
Hypothermia – review of anatomy and physiology

• Temperature regulation is
controlled by the
hypothalamus in the base
of the brain
Hypothermia – review of anatomy and physiology
Hypothermia – heat loss
Hypothermia – effects of cold exposure
• Muscular

– Muscle and tendon tears

– Shivering

• Cardiovascular

– Angina on decreased exertion

– in BP - risk of stroke, MI or
heart failure
– Osborn or J wave on ECG

• Respiratory

– Asthma
– Rhinorrhoea on return to warm
room
Hypothermia – effects of cold exposure cont’
• Peripheral nervous system

– Loss of manual dexterity

– Loss of sensitivity

• Central nervous system

– Co-ordination impaired
– Visual acuity reduced
– Alertness reduced
– Reflexes slowed
– Increased mistakes
– Visual and auditory input
misinterpreted

• Other

– Increased risk of diving ills

Hypothermia - prevention
• Eat properly and often

• Warm liquids and water

• Wear clothing properly (layers worn

loosely)

• Keep active

• Stay dry

• Warm living quarters and limit exposure

• Get plenty of rest

• Buddy watch/observation

• If in water
Hypothermia – prevention
Floor’s too cold

I think I’ll sleep here!

Hypothermia - predisposing factors
• Previous cold weather injury • Sick or injured

• • Ethnic/geographic origin
Inadequate nutrition
• Age
• Alcohol, nicotine use
• Poor physical condition
• Dehydration
• Little experience/training in cold
weather
• Overactivity (sweating)
• Poor clothing and equipment
• Underactivity

• Long exposure to the cold

Hypothermia – presentation and diagnosis
• Consider hypothermia based on history and a temperature taken with
a low reading thermometer

• The body’s normal physiological response to a cold challenge

– Blood is shunted from the periphery to the core

– Mild shivering: if exercise is not adequate for heat production

– A normal level of consciousness

– Fine motor function may be impaired

– Increased urination causing a loss of fluid

Hypothermia – signs and symptoms
Core Temp ‘C Signs and Symptoms
37.6 ‘Normal’ rectal temperature.
37 ‘Normal’ oral temperature.
36 Increased metabolic rate to attempt to balance heat loss. Respiratory and pulse rate increase.
35 Shivering maximum at this temperature. Hyper-reflexia, dysarthria, delayed cerebration.
34 Patients usually responsive and with normal blood pressure, lower limit compatible with continued exercise.
33 – 31 Retrograde amnesia, consciousness clouded, blood pressure difficult to obtain, pupils dilated, most shivering ceases.
30 – 28 Progressive loss of consciousness, increased muscular rigidity, slow pulse and respiration, cardiac arrhythmia develops,
ventricular fibrillation may develop if heart irritated.
27 Voluntary motion lost along with papillary light reflex deep tendon and skin reflexes. Appears dead.
26 Victims seldom conscious.
25 Ventricular fibrillation may appear spontaneously.
24 – 21 Pulmonary oedema develops: 100% mortality in shipwreck victims in World War II.
20 Heart standstill.
18 Lowest adult accidental hypothermic patient with recovery.
17 Iso-electric EEG.
15.2 Lowest infant accidental hypothermic patient with recovery.
9 Lowest artificially cooled hypothermic patient with recovery.
4 Monkeys revived successfully.
1–7 Rats and hamsters revived successfully.
Hypothermia – signs and symptoms cont’
• Initial Symptoms • Severe Stages

– Shivering - Stops shivering

– Dizzy, drowsy - Desire to lie down and sleep

– Withdrawn behavior - Heartbeat and breathing is

faint or undetectable
– Irritability
- paradoxical undressing – 20-
– Confusion 50% suffer this

– Slowed, slurred speech - Unconsciousness followed

by DEATH
– Altered vision

– Stumbling
Hypothermia – signs and symptoms cont’

Mountaineer found on Everest showing signs of paradoxical undressing

Hypothermia - aspects of rescue
• Rarely availability are tympanic thermometers and rectal temperature
difficult therefore diagnosis will usually be clinical.

• Casualties in water must be rescued horizontally or head down if

possible

• Shelter is of paramount importance

• Wet clothes NOT removed until sheltered in warm, safe environment

• Initially insulate with blankets and additional clothes. Keep covered

and insulated even when in the warmth to prevent further heat loss

• Physical exercise is contraindicated where the core temperature is <

35’C

• Handle casualties gently when managing airway to avoid V - Fib

Hypothermia – complications
• Death can occur as a consequence of

– Concomitant illness/injury

– Continued heat loss

– The “after – drop” in temperature (controversial)

– Relative hypovolaemia due to vasodilation

– Circulatory overload by too rapid re-warming – excessive fluid

shifts into intravascular space

– Ventricular fibrillation - most patients who die during active re-

warming die from ventricular fibrillation
Hypothermia - management
Safety – self, scene, casualty

Assess and treat

C - Catastrophic haemorrhage

A - Airway with C – spine control

B - Breathing

C - Circulation

D - Disability (CNS)

E - Environment and extremities

Hypothermia – management cont’
• Re-warming should be methodical and at
rate of 0.5’C per hour

• Recommended re-warming methods:

– Prevent further cold exposure

– Airway warming devices – Res-Q-

Air/Little Dragon

– Generalised surface re-warming with

Bair Hugger

– remove wet clothing

– Re-warm in dry clothing, blankets or

sleeping bag

– Heat packs placed in groin and axilla

Hypothermia – management cont’
• Recommended re-warming
methods:

– warm, sweet liquids if

conscious or warm IV fluids

– minimize handling of the

unconscious victim with a low
heartbeat so as to not induce
cardiac arrest

– Blood glucose checked

– Urgent contact with Topside

Support

– Do not rub skin, use alcohol or

use radiant heaters
Hypothermia – red flags

– Minimize handling of the unconscious victim with a low heartbeat so as to

not induce cardiac arrest

– Avoid adrenaline and other drugs in cardiac arrest until core temperature >
30’C. Between 30’ and 35’C double the interval time between administration
of drugs

– If VT/VF occur – defibrillate – if VT/VF persists after three shocks delay

further shocks until core temeprature is >30’C

– Do not overheat the patient. In comatose casualties a period of therapeutic

hypothermia (32 – 34’C) may be beneficial

– The patient is not dead until he is warm and dead

Hypothermia and cardiac arrest
• Cardiac arrest difficult to diagnose
in hypothermia

– Profound reduction in level of

consciousness

– Bradypnoea

– Bradycardia

– Hard to palpate pulses

• Giving impression of ‘dead’

patient when they are not
Hypothermia and cardiac arrest
• Indications for initiating CPR:

• No carotid pulse after feeling in correct place for at least one minute

• Cardiac arrest is witnessed; pulse present then disappears

• Reasonable chance arrest occurred within last two hours

• CPR can be started in the knowledge that it will be effective before

movement of the patient takes place

• Core temperature must be 30’C or above or it is likely to be unsuccessful

• Maintain CPR during re-warming

Hypothermia – long term effects

• Pancreatitis

• Haemolysis

• Renal failure

• Coagulopathy
Questions
Summary

• Effects of cold exposure can show signs and symptoms that affect
many systems including the heart

• Signs and symptoms range from difficulty with fine motor in the early
stages to deeply unconscious and dead

• Management includes gentle re-warming using both external and

internal methods

• “A hypothermic patient is not dead until he is warm and dead”