Hypothermia

Hypothermia is defined as a body core temperature below 35.0 °C (95.0 °F). Symptoms depend on the temperature. In mild hypothermia there is shivering and mental confusion. In moderate hypothermia shivering stops and confusion increases. In severe hypothermia there may be paradoxical undressing, in which a person removes his or her clothing, as well as an increased risk of the heart stopping.

Hypothermia has two main types of causes. It classically occurs from exposure to extreme cold. It may also occur from any condition that decreases heat production or increases heat loss. Commonly this includes alcohol intoxication but may also include low blood sugar, anorexia, and advanced age, among others. Body temperature is usually maintained near a constant level of 36.5–37.5 °C (97.7–99.5 °F) through thermoregulation. Efforts to increase body temperature involve shivering, increased voluntary activity, and putting on warmer clothing. Hypothermia may be diagnosed based on either a person's symptoms in the presence of risk factors or by measuring a person's core temperature.

The treatment of mild hypothermia involves warm drinks, warm clothing and physical activity. In those with moderate hypothermia heating blankets and warmed intravenous fluids are recommended. People with moderate or severe hypothermia should be moved gently. In severe hypothermia extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass may be useful. In those without a pulse cardiopulmonary resuscitation (CPR) is indicated along with the above measures. Rewarming is typically continued until a person's temperature is greater than 32 °C (90 °F). If there is no improvement at this point or the blood potassium level is greater than 12 mmol/liter at any time resuscitation may be discontinued.

Hypothermia is the cause of at least 1500 deaths a year in the United States. It is more common in older people and males. One of the lowest documented body temperatures from which someone with accidental hypothermia has survived is 13.0 °C (55.4 °F) in a near-drowning of a 7-year-old girl in Sweden. Survival after more than six hours of CPR has been described. In those in whom ECMO or bypass is used survival is around 50%. Deaths due to hypothermia have played an important role in many wars. Hyperthermia is the opposite of hypothermia, being an increased body temperature due to failed thermoregulation. The term is from Greek ὑπο meaning under and θερμία meaning heat.

Signs and symptoms

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, high blood pressure, fast heart rate, fast respiratory rate, and contraction of blood vessels). These are all physiological responses to preserve heat. Increased urine production due to cold, 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 (82 °F).

Difficulty speaking, sluggish thinking, and amnesia start to appear; inability to use hands and stumbling are also usually present. Cellular metabolic processes shut down. Below 30 °C (86 °F), the exposed skin becomes blue and puffy, muscle coordination very poor, and walking almost impossible, and the person exhibits incoherent/irrational behavior, including terminal burrowing (see below) or even stupor. Pulse and respiration rates decrease significantly, but fast heart rates (ventricular tachycardia, atrial fibrillation) can also occur. Atrial fibrillation is not typically a concern in and of itself. 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 consumption. 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 (such as hypoglycemia), the extremes of age, poor clothing, chronic medical conditions (such as hypothyroidism and sepsis), and living in a cold environment. Hypothermia occurs frequently in major trauma, and 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 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 death, 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.

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 direct clinical cause of death for those who are not rescued. A water temperature of 10 °C (50 °F) can lead to death in as little as one hour, and water temperatures near freezing can cause 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 (28 °F) water died in 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) itself. 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). 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.