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Accidental Hypothermia

Gordon G. Giesbrecht, Ph.D., Professor


Health Leisure and Human Performance Research Institute
University of Manitoba, Winnipeg, Manitoba, Canada, R3T 2N2

the rate of change of skin and core


Learning Objectives:
temperature.
1) Understand the different effects of cold
The effectiveness of shivering depends on
exposure;
the balance between many factors (Figure 1).
2) Diagnosis and treatment of hypothermia Generally, local heat production in
in the field or hospital. peripheral muscles is transferred to the core
via venous return. On the other hand
Introduction
shivering may increase heat loss through
The primary effect of body cooling is a increased blood flow to the periphery.
decrease in tissue metabolism and inhibition However, in almost all circumstances this
of neural control and transmission. However, balance favors heat gain and ultimate
in the intact conscious condition, the protection against cooling.
secondary responses to skin cooling
Figure 2 indicates that shivering heat
predominate. Therefore, sudden cooling
production (indicated by VO 2) can maintain
initiates shivering thermogenesis, and
increased metabolism (V O2 ), ventilation core temperature (Tes) in cold air (A) and
(VE ), heart rate (HR), cardiac output (CO),
and mean arterial pressure (MAP). The
primary effects of cooling can be seen during
anesthesia or at lower core temperatures
(i.e., <30C) when shivering ceases and,
VO2, HR, MAP, and CO decrease with core
temperature while hematocrit and total
peripheral resistance increase.
Decrease in core temperature
The factors that affect the rate of body
cooling include: the medium of exposure (i.e.,
water or air); ambient temperature;
redistribution of blood flow between the
body core and periphery; insulation of
superficial layers (i.e., fat and clothing); and
endogenous heat production (i.e., exercise
and shivering).
One important protective factor is
shivering; an involuntary function where
increased heat production is generated in an
effort to prevent body core cooling.
Shivering intensity depends on: ambient
temperature; body composition (shivering
intensity at a given ambient temperature is
lower with greater skinfold thickness); and
Hypothermia Giesbrecht

can arrest the fall in core temperature in factors occur at the local level (i.e., within
warm and cool water (B and C). However, each body cylinder; upper leg, lower leg etc.).
if the cold stress is great enough (D) cooling First, conductive cooling occurs based on
may be retarded but will continue. The temperature gradients that depend on the
power of shivering is especially important in extent of the cold exposure. These gradients
the consideration of classification of mainly promote radial surface-to-center
hypothermia and eventual treatment because cooling (1) although some longitudinal distal-
this valuable heat source is efficient at to-proximal gradients may also exist (3).
rewarming the core post-cooling. Second, local tissue heat production will, to
some extent, offset the physical effect of
Post-cooling
conductive cooling. Finally, local tissue
Following cooling the body core continues blood flow will be affected by the
to drop. This afterdrop is a function of a temperature and flow rate of incoming
dynamic combination of mechanisms. Two blood. Although conductive cooling is
Hypothermia Giesbrecht

indisputable, the only way that cooling in collapse with symptoms ranging from
any body cylinder (other than the trunk) can syncope to ventricular fibrillation and
affect core temperature is by convective cardiac arrest. There are 3 probable factors
transfer via blood flow from these distal that generally lead to rewarming shock: 1)
areas to the heart. If peripheral blood flow hypovolemia, hypotension and decreased
is similar before and after cooling, the brain blood flow; 2 humoral factors such as
conductive component of afterdrop an increase in metabolic byproducts and
predominates. If however, peripheral catecholamines); and 3) a significant
vasodilation occurs, the increased blood afterdrop in core temperature. It is likely
flow will cause a redistribution of heat from that the afterdrop in core temperature is an
the core to the periphery much like occurs important factor because decreased
immediately following induction of myocardial temperature precipitates
anesthesia (4). The contribution of the ventricular fibrillation or asystole. Also, a
convective mechanism will be proportional secondary effect of cooling the myocardium
to the relative increase in peripheral blood may be hypersensitization of the heart to
flow. This also has important implications humoral factors (i.e., catecholamines and
in the handling and treatment of victims metabolic byproducts) and mechanical
post-cooling. Several clinical case reports stimulation (i.e., intubation). The
indicate afterdrop values ranging between importance of the phenomenon is shown in a
1.3 to 6.4 C (2). review of 21 patients with initial core
temperatures between 14 and 28 C, initial
There are many clinical examples of
functional cardiac rhythms and who were
victims being removed from a cold exposure
eventually treated with cardiopulmonary.
in an apparently stable and conscious
Five of the 21 patients developed ventricular
condition only to degenerate from one level
fibrillation or asystole after rescue and
of hypothermia to another. This can result in
commencement of treatment (2).
rewarming shock or post-rescue
Hypothermia Giesbrecht

or secondary to impaired thermoregulation


Diagnosis
from metabolic disease, old age or alcohol
There are several classification and drug abuse. It may also depend on
systems for hypothermia based on core whether the onset of hypothermia was acute
temperature. We use a simple classification (minutes to a few hours) or chronic (several
system (Figure 3) which is based on general hours to days). The main priorities for
functional characteristics: Mild hypothermia treatment are to arrest the fall in core
[core temperature (Tco): 35-32C, conscious, temperature, and maximize a safe rewarming
vigorous shivering as thermoregulatory rate while maintaining the stability of the
mechanisms are fully functional, and cardiovascular system and correcting
locomotion]; Moderate hypothermia (Tco: metabolic imbalances. Rewarming methods
32-28C, altered consciousness, shivering can be classified according to: a) the source
diminishing as thermoregulatory mechanisms of heat (i.e., exogenous or endogenous); b)
are becoming less effective, cardiac where the heat is applied (i.e., core or shell,
dysrhythmias); and Severe hypothermia (Tco internal or external, central or peripheral); c)
whether it is invasive or noninvasive; d) the
< 28C, unconscious, shivering has ceased,
amount of heat (moderate or high); or e)
ventricular fibrillation, asystole, ultimately
whether heat is even applied (active or
death). Core temperature measurements are,
passive).
at best, difficult in the field. Both diagnosis
and treatment can be effectively based on For our purposes the following
the functional characteristics listed above. rewarming classifications will be used (see
Table 1). Endogenous Rewarming includes
Rewarming
shivering and exercise, and clarifies that
Treatment may depend on whether the there is active heat production occurring.
hypothermia is simply a primary result of Exogenous External Rewarming
excessive heat loss in individuals with differentiates between moderate and high
otherwise normal thermoregulatory function, sources of heat that are applied to the body
Hypothermia Giesbrecht

surface and Exogenous Internal Rewarming * Regardless of the level of hypothermia or


includes noninvasive and invasive methods the rewarming method to be used, patients
for application of heat to the core. should first be removed from the cold
exposure as gently as possible, dried and
In conclusion, the following general
provided with as much insulation as
principles apply to treatment selection (see
practical.
Figure 4). If vigorous shivering is present,
Endogenous Rewarming should be
If the patient is severely hypothermic,
maximized by drying the patient and
rapid (but gentle) evacuated is required. In
providing insulation and a vapor barrier.
pre-hospital conditions, where possible,
Exogenous External Rewarming provides
Exogenous External Rewarming should be
little afterdrop protection or rewarming
provided for each level of hypothermia with
advantage unless either a large amount of
a target rewarming rate between 1 and 2
heat is provided, or core temperature is in
C/hr. Warming can cease once core
the range of moderate hypothermia and
temperature reaches 35C (if measurements
shivering is waning.
are possible). Finally, treatment selection
depends on location. For example treatment
Table 1. Rewarming Classifications*
in nursing stations is limited to Exogenous
External Rewarming techniques, in addition
Endogenous Rewarming
to warm IV fluid infusion and heated
Basal metabolism
humidified air/oxygen. In 1 and 2
Shivering
hospitals, more invasive Exogenous Internal
Exercise
Rewarming techniques like peritoneal lavage
and continuous arteriovenous rewarming can
Exogenous External Rewarming
be performed. Cardiopulmonary bypass is
a) Moderate sources of heat:
the most effective rewarming method for
Forced air warming
severe hypothermia but is only available in
Heating pads
3 hospitals.
Charcoal heaters
Human body
References
Hot water bottles (other objects)
Warmed blankets (electric, water perfused) 1. Bristow, G. K., D. I. Sessler, and G.
Piped suits G. Giesbrecht. Leg temperature and heat
Radiant heat content in humans during immersion
Hibler technique (hot water soaked sheets) hypothermia and rewarming. Aviat. Space
b) High sources of heat Environ. Med. 65: 220-226, 1994.
Forced air warming
2. Giesbrecht, G. G. Cold stress, near
Warm water immersion
drowning and accidental hypotherima: A
review. Aviat. Space and Environ. Med.
Exogenous Internal Rewarming
71:733-52,2000.
a) Noninvasive
Hot food and drink 3. Saltin, B., A. P. Gagge, and J. A. J.
Inhalation of heated saturated air/oxygen Stolwijk. Muscle temperature during
b) Invasive submaximal exercise in man. J. Appl.
Warm IV fluids Physiol. 25: 679-688, 1968.
Arteriovenous fistula
4. Sessler, D. I., J. McGuire, A.
Lavage (peritoneal, gastric, thoracic,
Moayeri, and J. Hynson. Isoflurane-induced
bladder)
vasodilation minimally increases cutaneous
Cardiopulmonary bypass
heat loss. ANESTHESIOLOGY. 74: 226-
232, 1991.