Hypothermia

Hypothermia (from Greek ὑποθερμία) is a condition in which the body's core temperature drops below that required for normal metabolism and body functions. This is generally considered to be 35.0 C. Body temperature is usually maintained near a constant level of 36.5 – through biologic homeostasis or thermoregulation. If a person is exposed to cold, and their internal mechanisms cannot replenish the heat that is being lost, the body's core temperature falls, and characteristic symptoms occur such as shivering and mental confusion.

One of the lowest documented body temperatures from which anyone has recovered was 13.0 C in a near-drowning incident involving a 7-year-old girl in Sweden in December 2010. Hypothermia is the opposite of hyperthermia which is present in heat exhaustion and heat stroke.

Classification
Normal human body temperature in adults is 34.4 –. Sometimes a narrower range is stated, such as 36.5 –. Hypothermia is defined as any body temperature below 35.0 C. Hypothermia is classified in four different degrees: mild, 32 - 35 C; moderate, 28 - 32 C; severe, 20 - 28 C; and profound at less than 20 C. This is in contrast to hyperthermia and fever which are defined as a temperature of greater than 37.5-38.3 C.

Other cold-related injuries that can be present either alone or in combination with hypothermia include:


 * Chilblains are superficial ulcers of the skin that occur when a predisposed individual is repeatedly exposed to cold.
 * Frostbite involves the freezing and destruction of tissue.
 * Frostnip is a superficial cooling of tissues without cellular destruction.
 * Trench foot or immersion foot is due to repetitive exposure to water, at non-freezing temperatures.

Signs and symptoms
The signs and symptoms vary depending on the degree of hypothermia, and may be divided by the three stages of severity. Infants with hypothermia may feel cold when touched, with bright red skin and unusual lack of energy.

Mild
Symptoms of mild hypothermia may be vague, with sympathetic nervous system excitation (shivering, hypertension, tachycardia, tachypnea, and vasoconstriction). These are all physiological responses to preserve heat. Cold diuresis, mental confusion, and hepatic dysfunction may also be present. Hyperglycemia may be present, as glucose consumption by cells and insulin secretion both decrease, and tissue sensitivity to insulin may be blunted. Sympathetic activation also releases glucose from the liver. In many cases, however, especially in alcoholic patients, hypoglycemia appears to be a more common presentation. Hypoglycemia is also found in many hypothermic patients, because hypothermia may be a result of hypoglycemia.

Moderate
Low body temperature results in shivering becoming more violent. Muscle mis-coordination becomes apparent. Movements are slow and labored, accompanied by a stumbling pace and mild confusion, although the person may appear alert. Surface blood vessels contract further as the body focuses its remaining resources on keeping the vital organs warm. The subject becomes pale. Lips, ears, fingers and toes may become blue.

Severe
As the temperature decreases, further physiological systems falter and heart rate, respiratory rate, and blood pressure all decrease. This results in an expected heart rate in the 30s at a temperature of 28 C.

Difficulty in speaking, sluggish thinking, and amnesia start to appear; inability to use hands and stumbling is also usually present. Cellular metabolic processes shut down. Below 30 C, the exposed skin becomes blue and puffy, muscle coordination becomes very poor, walking becomes almost impossible, and the person exhibits incoherent/irrational behavior including terminal burrowing (see below) or even a stupor. Pulse and respiration rates decrease significantly, but fast heart rates (ventricular tachycardia, atrial fibrillation) can occur. Major organs fail. Clinical death occurs.

Paradoxical undressing
Twenty to fifty percent of hypothermia deaths are associated with paradoxical undressing. This typically occurs during moderate to severe hypothermia, as the person becomes disoriented, confused, and combative. They may begin discarding their clothing, which, in turn, increases the rate of heat loss.

Rescuers who are trained in mountain survival techniques are taught to expect this; however, some may assume incorrectly that urban victims of hypothermia have been subjected to a sexual assault.

One explanation for the effect is a cold-induced malfunction of the hypothalamus, the part of the brain that regulates body temperature. Another explanation is that the muscles contracting peripheral blood vessels become exhausted (known as a loss of vasomotor tone) and relax, leading to a sudden surge of blood (and heat) to the extremities, fooling the person into feeling overheated.

Terminal burrowing
An apparent self-protective behaviour known as terminal burrowing, or hide-and-die syndrome, occurs in the final stages of hypothermia. The afflicted will enter small, enclosed spaces, such as underneath beds or behind wardrobes. It is often associated with paradoxical undressing. Researchers in Germany claim this is "obviously an autonomous process of the brain stem, which is triggered in the final state of hypothermia and produces a primitive and burrowing-like behavior of protection, as seen in hibernating animals." This happens mostly in cases where temperature drops slowly.

Causes
Hypothermia usually occurs from exposure to low temperatures, and is frequently complicated by alcohol. Any condition that decreases heat production, increases heat loss, or impairs thermoregulation, however, may contribute. Thus, hypothermia risk factors include: substance abuse (including alcohol abuse) homelessness, any condition that affects judgment (hypoglycemia), the extremes of age, poor clothing, chronic medical conditions (such as hypothyroidism and sepsis), and living in a cold environment. Hypothermia also occurs frequently in major trauma. Hypothermia is also observed in severe cases of anorexia nervosa.

Alcohol
Alcohol consumption increases the risk of hypothermia by its action as a vasodilator. It increases blood flow to the body's skin and extremities, making a person feel warm, while increasing heat loss. Between 33% and 73% of hypothermia cases are complicated by alcohol.

Poverty
In the UK 28,354 cases of hypothermia were treated in 2012/13 – an increase of 25% from the previous year. Some cases of hypothermia including deaths as well as other preventable deaths happen because poor people cannot easily afford to keep warm. Rising fuel bills have increased the numbers who have difficulty paying for adequate heating in the UK. Some pensioners and disabled people are at risk because they do not work and cannot easily get out of their homes. Better heat insulation can help.

Water immersion
Hypothermia continues to be a major limitation to swimming or diving in cold water. The reduction in finger dexterity due to pain or numbness decreases general safety and work capacity, which consequently increases the risk of other injuries. Due to the use of gas mixtures containing helium at extreme depths, the use of argon inflation for dry suits, or hot water suits become a necessity for diving deep in colder waters.

Other factors predisposing to immersion hypothermia include dehydration, inadequate rewarming between repetitive dives, starting a dive while wearing cold, wet dry suit undergarments, sweating with work, inadequate thermal insulation (for example, thin dry suit undergarment), and poor physical conditioning.

Heat is lost much more quickly in water than in air. Thus water temperatures that would be quite reasonable as outdoor air temperatures can lead to hypothermia in survivors, although this is not usually the clinical cause of death for those who are not rescued. A water temperature of 10 C can lead to death in as little as one hour, and water temperatures near freezing can lead to death in as little as 15 minutes. A notable example of this occurred during the sinking of the Titanic, when most people who entered the -2 C water died within 15–30 minutes.

The actual cause of death in cold water is usually the bodily reactions to heat loss and to freezing water, rather than hypothermia (loss of core temperature). For example, plunged into freezing seas, around 20% of victims die within 2 minutes from cold shock (uncontrolled rapid breathing and gasping causing water inhalation, massive increase in blood pressure and cardiac strain leading to cardiac arrest, and panic); another 50% die within 15–30 minutes from cold incapacitation (inability to use or control limbs and hands for swimming or gripping, as the body "protectively" shuts down the peripheral muscles of the limbs to protect its core), and exhaustion and unconsciousness cause drowning, claiming the rest within a similar time.

Pathophysiology
Heat is primarily generated in muscle tissue, including the heart, and in the liver, while it is lost through the skin (90%) and lungs (10%). Heat production may be increased 2 to 4 fold through muscle contractions (i.e. exercise and shivering). The rate of heat loss is determined, as with any object, by convection, conduction, and radiation. The rates of these can be affected by body mass index, body surface area to volume ratios, clothing and other environmental conditions.

Many changes to physiology occur as body temperature decreases. These occur in the cardiovascular system leading to the Osborn J wave and other dysrhythmias, decreased CNS electrical activity, cold diuresis, and non-cardiogenic pulmonary edema.

Research has shown that glomerular filtration rate (GFR) decreases as a result of hypothermia. In essence, Hypothermia increases preglomerular vasoconstriction, thus decreasing both renal blood flow (RBF) and GFR.

Diagnosis
Accurate determination of core temperature often requires a special low temperature thermometer, as most clinical thermometers do not measure accurately below 34.4 C. A low temperature thermometer can be placed rectally, esophageally, or in the bladder. The classical ECG finding of hypothermia is the Osborn J wave. Also, ventricular fibrillation frequently occurs below 28 C and asystole below 20 C. The Osborn J may look very similar to those of an acute ST elevation myocardial infarction. Thrombolysis as a reaction to the presence of Osborn J waves is not indicated, as it would only worsen the underlying coagulopathy caused by hypothermia.

As a hypothermic person's heart rate may be very slow, prolonged palpation could be required before detecting a pulse. In 2005, the American Heart Association recommended at least 30–45 seconds to verify the absence of a pulse before initiating CPR.

Most physicians are recommended not to declare a patient dead until their body is warmed to a normal body temperature, since extreme hypothermia can suppress heart and brain function.

Prevention
Appropriate clothing helps to prevent hypothermia. Synthetic and wool fabrics are superior to cotton as they provide better insulation when wet and dry. Some synthetic fabrics, such as polypropylene and polyester, are used in clothing designed to wick perspiration away from the body, such as liner socks and moisture-wicking undergarments. Clothing should be loose fitting. In planning outdoor activity, prepare appropriately for possible cold weather. Those who drink alcohol before or during outdoor activity should ensure at least one sober person is present responsible for safety.

Covering the head is effective, but no more effective than covering any other part of the body. While common folklore says that people lose most of their heat through their heads, heat loss from the head is no more significant than that from other uncovered parts of the body. However, heat loss from the head is significant in infants, whose head is larger relative to the rest of the body than in adults. Several studies have shown that for uncovered infants, lined hats significantly reduce heat loss and thermal stress. Children have a larger surface area per unit mass, and other things being equal should have one more layer of clothing than adults in similar conditions, and the time they spend in cold environments should be limited. However children are often more active than adults, and may generate more heat. In both adults and children, overexertion causes sweating and thus increases heat loss.

Building a shelter can aid survival where there is danger of death from exposure. Shelters can be of many different types, metal can conduct heat away from the occupants and is sometimes best avoided. The shelter should not be too big so body warmth stays near the occupants. Good ventiation is essential especially if a fire will be lit in the shelter. Fires should be put out before the occupants sleep to prevent carbon monoxide poisoning. People caught in very cold, snowy conditions can build an igloo or snow cave to shelter.

The United States Coast Guard promotes using life vests to protect against hypothermia through the 50/50/50 rule: If someone is in 50 F water for 50 minutes, he/she has a 50 percent better chance of survival if wearing a life jacket. A heat escape lessening position can be used to increase survival in cold water.

Babies should sleep at 16-20°C (61-68°F) and housebound people should be checked regularly to make sure the temperature of the home is sufficient.

Management
Aggressiveness of treatment is matched to the degree of hypothermia. Treatment ranges from noninvasive, passive external warming to active external rewarming, to active core rewarming. In severe cases resuscitation begins with simultaneous removal from the cold environment and concurrent management of the airway, breathing, and circulation. Rapid rewarming is then commenced. Moving the person as little and as gently as possible is recommended as aggressive handling may increase risks of a dysrhythmia.

Hypoglycemia is a frequent complication of hypothermia, and needs to be tested for and treated. Intravenous thiamine and glucose is often recommended, as many causes of hypothermia are complicated by Wernicke's encephalopathy.

Detecting vital signs in those who are severely hypothermic may be difficult, so it should not be assumed that the person is dead but resuscitation should be continued until the body is warm.

Rewarming
Rewarming can use a number of different methods including passive external rewarming, active external rewarming, and active internal rewarming. In the case of first aid by people who are not medically qualified gradual rewarming is recommended. Passive external rewarming involves the use of a person's own ability to generate heat by providing properly insulated dry clothing and moving to a warm environment. It is recommended for those with mild hypothermia. Wet clothing should be replaced with dry clothes including head covering. Person to person warming is also helpful. Emergency services should be called if the person does not improve within a few minutes or worsens.

Active external rewarming involves applying warming devices externally, such as warmed forced air (a Bair Hugger is a commonly used device). In austere environments, hypothermia can according to some sources be treated by placing a hot water bottle in both armpits and groin. It is recommended for moderate hypothermia. Other sources warn this can burn the skin. Active core rewarming involves the use of intravenous warmed fluids, irrigation of body cavities with warmed fluids (the thorax, peritoneal, stomach, or bladder), use of warm humidified inhaled air, or use of extracorporeal rewarming such as via a heart lung machine. Extracorporeal rewarming is the fastest method for those with severe hypothermia. The UK NHS advises against unqualified people attempting some of the above. They also recommend against putting a person in a hot bath, massaging their arms and legs or using heating pad.

Fluids
Warm sweetened liquids can be given provided the person is alert and can swallow. Many recommend that alcohol and drinks with lots of caffeine be avoided. As most people are moderately dehydrated due to hypothermia induced cold diuresis, intravenous fluids are often helpful (250–500 cc 5% dextrose and normal saline warmed to a temperature of 40 – is often recommended).

Rewarming collapse
Rewarming collapse (or rewarming shock) is a sudden drop in blood pressure in combination with a low cardiac output which may occur during active treatment of a severely hypothermic person. There is theoretical concern that external rewarming rather than internal rewarming may increase the risk. However, recent studies have not supported these concerns.

Dysrhythmias
For ventricular fibrillation or ventricular tachycardia, a single defibrillation should be attempted. People with severe hypothermia however may not respond to pacing or defibrillation. If a single defibrillation is not effective, CPR should be continued during active rewarming. It is not known if medication and further defibrillation should be withheld until the core temperature reaches 30 C. Once a temperature of 30 C is reached, normal ACLS protocols should be followed.

Prognosis
There is considerable evidence that children who suffer near-drowning accidents in water near 0 C can be revived over an hour after losing consciousness. The cold water lowers metabolism, allowing the brain to withstand a much longer period of hypoxia. While survival is possible, mortality from severe or profound hypothermia remains high despite optimal treatment. Studies estimate mortality at between 38% and 75%. If there are obvious fatal injuries or the chest is too frozen, compression resuscitation is futile.

Epidemiology
In the past, hypothermia occurred most frequently in homeless people, but recreational exposure to cold environments is now the main cause of hypothermia. Between 1995 and 2004 in the United States, an average of 1560 cold-related emergency department visits occurred per year and in the years 1999 to 2004, an average of 647 people died per year due to hypothermia.

History
Hypothermia has played a major role in the success or failure of many military campaigns from Hannibal's loss of nearly half his men in the Second Punic War (218 B.C.) to the near destruction of Napoleon's armies in Russia in 1812. Men wandered round confused through hypothermia, some lost consciousness and died, others shivered, later developed torpor and tended to sleep. Others to weak to walk fell on their knees, some stayed that way some time resisting death. The pulse was of some was weak and hard to detect, others groaned, yet others had eyes open and wild with quiet delirium. Loss of life to hypothermia in Russian regions continued through the first and second world wars, especially in the Battle of Stalingrad.

Civilian examples of deaths caused by hypothermia are found during the sinkings of the RMS Titanic and RMS Lusitania, and more recently of the MS Estonia.

Antarctic explorers developed hypothermia, Ernest Shackleton and his team measured body temperatures "below 94.2° which spells death at home" though this probably referred to oral temperatures rather than core temperature and corresponded to mild hypothermia. One of Scott's team, Atkinson became confused through hypothermia.

Nazi human experimentation during World War II amounting to medical torture included hypothermia experiments and many victims died. There were 360 to 400 experiments and 280 to 300 victims indicating some victims suffered more than one experiment. Different methods of rewarming were attempted, "One assistant later testified that some victims were thrown into boiling water for rewarming"

Other animals
Many animals other than humans often induce hypothermia during hibernation or torpor.

Water bears (Tardigrade), microscopic multicellular organisms, can survive freezing at low temperatures by replacing most of their internal water with the sugar trehalose, preventing the crystallization that otherwise damages cell membranes.