Hipotermi dan Hipertermi

Rahmad Aswin Juliansyah

Juliansyah,, SST., M.Kes
Temperature Regulation

 Hypothermia
 Hyperthermia
 Heat Cramps
 Heat Tetany
 Heat Exhaustion
 Heat Syncope
 Heat Stroke

 Fever
Temperature Regulation

 Humans are
warm--blooded
warm
mammals who
maintain a
constant body
temperature
(euthermia
euthermia).
).
Temperature Regulation

 Temperature
regulation is
controlled by
the
hypothalamus
in the base of
the brain.
Temperature Regulation

 The hypothalamus functions as a

thermostat for the body.
 Temperature receptors
(thermoreceptors) are located in
the skin, certain mucous
membranes, and in the deeper
tissues of the body.
Temperature Regulation

 Body Temperature = Thermogenesis–

Thermogenesis–Heat Loss
Temperature Regulation

 Basal Metabolic Rate:

 Themetabolism that occurs when the
body is completely at rest.
Temperature Regulation

 Metabolic Rate:
 Thebody continuously adjusts the
metabolic rate in order to maintain a
constant CORE temperature.
Temperature Regulation

 Normal body
temperature is
approximately 37º
37º
C (98.6º
(98.6º F).
 However, what is
normal for an
individual may
vary somewhat.
Hypothermia

 Definition of Hypothermia:
Hypothermia:
 CLASSIC DEFINITION: A state of low
body temperature, specifically a low CORE
temperature (< 35º
35º C or < 95º F).
F).
 ALTERNATIVE DEFINITION: It is best
defined as the unintentional decrease of
around 2º
2º C (3.6º F) from the “normal”
CORE temperature
Hypothermia

 What is the
CORE
temperature?
 The deep internal
temperature of
normothermic
humans.
Hypothermia

 How is the CORE

temperature
measured?
 There is little variance in
CORE temperature
because of perfusion.
 Esophageal and
tympanic temperatures
are essentially the same
as the temperature of the
pulmonary artery.
Hypothermia

 In steady-
steady-state
conditions, the
rectal temperature
is a good index of
CORE
temperature.
Hypothermia

 Oral temperature
is an excellent
index of CORE
temperature,
provided the
mouth is kept
closed.
Hypothermia

 The type of
temperature
measurement
utilized is less
important than using
the same device
and measurement
site to detect trends.
 Thermometer must
be able to read low
temperatures.
Hypothermia

 Heat loss results

from:
 Conduction
 Convection

 Radiation

 Evaporation

 Respiration
Hypothermia

 Conduction:
 Heat loss occurs due
to direct contact of
the body with a
cooler object.
 Heat flows from
higher temperature
matter to lower
temperature matter.
Hypothermia

 Convection:
 Heat loss occurs due to air currents passing
over the body.
 Heat must first be conducted to the air before
convection can occur.
Hypothermia

 Radiation:
 Heat loss results
from infrared
rays.
 All objects not at
absolute zero will
radiate heat to the
atmosphere.
Radiation
Radiation
Hypothermia

 Evaporation:
 Heat loss occurs as water evaporates from the
skin.
 Heat loss occurs as water evaporates from the
lungs during respiration.
Hypothermia

 Respiration:
 Respiration combines the heat loss
mechanisms of convection, radiation,
and evaporation.
 Expired air is normally 98.6 degrees
F. and 100% humidified.
Heat--conserving Mechanisms
Heat

 Vasoconstriction of
blood vessels in the
skin.
 Stimulated through
activation of the
sympathetic nervous
system.
 Causes pale, cool
skin.
Heat--conserving Mechanisms
Heat

 Caused by sympathetic
stimulation of arrector
pili muscles.
Heat--conserving Mechanisms
Heat

 Increased heat
production:
 Shivering
 Activation of futile
cycles (chemical
thermogenesis)
 Increased
thyroxine release
Hypothermia

 When the core

temperature of
the body drops
below
95ºº F, an
95
individual is
considered to be
hypothermic..
hypothermic
Hypothermia

 Clinically, hypothermia results from:

 Inadequate heat generation by the
body (thermogenesis).
 Excessive cold stress.

 A combination of both.
Hypothermia

 Normal Range:
 96
96--100
100ºº F
 Mild Hypothermia:
 90
90--95
95ºº F
 Severe Hypothermia
 < 90º
90º F
Hypothermia

 Predisposing Factors to
Hypothermia:
 Patient Age
 Patient Health

 Medications

 Prolonged or Intense Exposure

 Co
Co--existing Weather Conditions
Hypothermia

 Patient Age:
 Pediatric and geriatric patients cannot
tolerate cold environments and have
less capacity for heat generation.
 Older patients often become
hypothermic in environments that
seem only mildly cool to others.
Hypothermia

 Patient Health:
 Hypothyroidism (suppresses
metabolic rate)
 Malnutrition, hypoglycemia,
Parkinson’s disease, fatigue, and
other medical conditions can interfere
with the body’s ability to combat cold
exposure.
Hypothermia

 Medications:
 Some drugs interfere with the body’s
heat--generating mechanisms.
heat
 These include: narcotics, alcohol,
antihistamines, antipsychotics,
antidepressants, and many others.
Hypothermia

 Prolonged or Intense Exposure:

 The length and severity of cold
exposure have a direct effect on
morbidity and mortality.
 The Wind Chill Index (WCI) must be
taken into consideration.
Hypothermia

 Coexisting
Weather
Conditions:
 High humidity,
 brisk winds,
 accompanying rain can
all magnify the effect of
cold exposure on the
body by accelerating
heat loss from the skin.
Hypothermia

 Degrees of Hypothermia:
 Mild
Mild––Core temperature > 90 degrees
F (32 degrees C)
 Severe
Severe–– Core temperature < 90
degrees F (32 degrees C)
Signs and Symptoms

 MILD Hypothermia:
 Lethargy

 Shivering

 Lack of Coordination
 Pale, cold, dry skin

 Early rise in blood pressure, heart,

and respiratory rates.
Signs and Symptoms

 SEVERE Hypothermia:
 No shivering
 Heart rhythm problems

 Cardiac arrest

 Loss of voluntary muscle control

 Low blood pressure

 Undetectable pulse and respirations

Prevention

 Preventive Measures:
 Warm dress
 Plenty of rest

 Adequate diet

 Limit Exposure
Treatment

 Treatment for Hypothermia:

1. Remove wet garments
2. Protect against further heat loss
and wind chill.
3. Maintain patient in horizontal
position.
Treatment

 Treatment for Hypothermia:

4. Avoid rough handling.
5. Monitor the core temperature.
6. Monitor the cardiac rhythm.
Treatment

 ECG changes seen in hypothermia:

 Prolongation of first the PR interval, then
the QRS, then the QTc interval.
 J waves (also called Osborne waves) can
occur at any temperature < 32.3º
32.3º C (90º F).
 Most frequently seen in Leads II and V 6.

 The size of the J waves increase with

temperature depression.
“J” or Osborne Waves
“J” or Osborne Waves
“J” or Osborne Waves
Rewarming

 Methods of Rewarming:
 Active External Rewarming
 Active Internal Rewarming
Rewarming

 Active Rewarming of MILD

Hypothermia:
 Active external methods:
 Warm blankets

 Heat packs

 Warm water immersion (with caution)

 Active internal methods:

 Warmed IV fluids
Rewarming

 Active Rewarming of SEVERE

Hypothermia:
 Active external methods:
 Warm blankets
 Heat packs
 Warm water immersion (with caution)
 Active internal methods:
 Warmed IV fluids
 Warmed, humidified oxygen
Rewarming

 Rewarming of the SEVERE

hypothermia patient is best carried out
in the Emergency Department using a
pre--defined protocol, unless travel time
pre
exceeds 15 minutes.
 Most patients who die during active
rewarming die from ventricular
fibrillation.
Rewarming

 Application of external heat in the

prehospital setting is usually not
effective and not recommended
because:
 More heat transferrence is required than
generally possible in the prehospital
setting.
 Application of external heat may cause
“rewarming shock.”
Rewarming

 Rewarming Shock:
 Occurs due to peripheral reflex
vasodilation.
 Causes the return of cooled blood and
metabolic acids from the extremities.
 May cause a paradoxical afterdrop in the
core temperature further worsening
hypothermia.
Rewarming

 Rewarming Shock:
 Can be prevented in the prehospital
setting by using warmed IV fluids
during active rewarming.
Rewarming

 Portable IV fluid heaters

are available in the
United States and
Canada.
 Devices fit in-
in-line and
are powered by DC
power sources.
Rewarming

 The device is
single--use and
single
remains with the
patient in the
hospital (both the
ED and on the
floor).
Rewarming

 The HOT IV is
powered from a
Physio--Control
Physio
battery or from a
DC converter
plugged in to an
AC outlet.
Issues in Hypothermia

 Benefits of IV Fluid Warming:

 Maintains euthermia
 Increases patient comfort

 Prevents shivering
Issues in Hypothermia

 Benefits of IV Fluid Warming:

Warming:
 Prevents cold--induced dysrhythmias
cold
 Decreases hemorrhage in abdominal
trauma patients
 Decreases the incidence of infectious
complications in abdominal trauma
patients
Issues in Hypothermia

 Benefits of IV Fluid Warming:

Warming:
 Allows active internal rewarming to
begin in the prehospital setting.
 Less labor-
labor-intensive, freeing
emergency personnel to manage
other, more pressing care needs.
Cardiac Arrest

 Other Clinical Concerns:

 Resuscitation of cardiac arrest due to
hypothermia is only successful when
the patient is being re-
re-warmed.
 The hypothermic cardiac arrest
patient is not DEAD until he is WARM
and DEAD!
Survival from Hypothermia

 48.2º F (9º C)
48.2º - Lowest reported
survivor from therapeutic exposure.
 59.2
59.2ºº F (15.2º C) – Lowest reported
infant survival from accidental exposure.
 60.8
60.8ºº F (16º C) – Lowest reported adult
survival from accidental exposure.
Survival from Hypothermia

 64.4º F (18º C) – Asystole.

64.4º
 66.2
66.2ºº F (19º C) – Flat EEG.
 71.6
71.6ºº F (22º C) – Maximum risk for
ventricular fibrillation.
 77
77ºº F (25º C) – Cerebral blood flow
decreased by 66%.
 78.8
78.8ºº F (26º C) – No reflexes or
response to painful stimuli.
Issues in Hypothermia

 Other Clinical Concerns:

 Hypothermia is common, even in
persons with minor trauma.
 Hypothermia can worsen infectious
complications of abdominal trauma.
 Hypothermic trauma patients suffer
increased blood loss compared to
their normothermic cohorts.
Issues in Hypothermia

 Considerations in Emergency Care:

“Most traditional methods of
maintaining trauma patient
temperature during prehospital
transport appear to be
inadequate.”
From: Watts DD, Roche M, et al. The utility of traditional
prehospital interventions in maintaining thermostasis.
Prehosp Emerg Care 1999;3(2)115
1999;3(2)115--122
Issues in Hypothermia

 Considerations in Emergency Care:

“Based upon our findings, accidental
hypothermia poses a relevant problem in
the prehospital treatment of trauma
patients. It is not limited to a special
season of the year.”
From: Helm M, Lampl L, Hauke J, Bock KH. Accidental
hypothermia in trauma patients. Is it relevant to preclinical
emergency treatment? Anaesthesist 1995;44(2):101
1995;44(2):101--107
Issues in Hypothermia

 Considerations in Emergency Care:

“Thus, hypothermia is common in
patients undergoing a laparotomy for
trauma. Hypothermic patients with
similar injury severity have greater
blood loss.”
From: Bernabei AF, Levision MA, Bender JS. The effects of
hypothermia and injury severity on blood loss during trauma
laparotomy. J Trauma 1992;33(6):835
1992;33(6):835--839
Hyperthermia

 Heat cramps
 Heat tetany
 Heat exhaustion
 Heat syncope
 Heat stroke
Hyperthermia

 Abnormal
elevation in body
temperature.
 Not a normal
physiological
response (such
as fever).
Hyperthermia

 Caused by
environmental
temperature
increase.
 Increased
humidity.
 Still air.
Hyperthermia

 Heat waves not

uncommon.
 More devastating
where heat waves
are uncommon.
 600 heat-
heat-related
deaths in 1995
Chicago heat wave.
Heat Cramps

 Painful muscle
contractions.
 Frequent complication
of heat exhaustion.
 Salt depletion and other
electrolyte problems
commonly associated.
 Self--limited.
Self
 Symptomatic treatment.
Heat Tetany

 Carpopedal spasms
that occur in hot
environments.
 Secondary to
hyperventilation
from body’s attempt
to cool.
 Resolves when
hyperventilation
slows.
Heat Exhaustion

 Results from
cardiovascular strain
as body attempts to
maintain normal
temperature.
 Usually develops
and continues over
several days.
Heat Exhaustion

 Most common
between body
temperature of
102.9°° (39.4
102.9 (39.4°° C) and
104°° (40
104 (40°° C).
 Finding is unreliable.
 Diagnosis should be
made on physical
assessment.
Heat Exhaustion

 Firefighters at
increased risk of
developing heat
exhaustion.
 Rehab sector
essential for
major fires in
warm weather.
Heat Exhaustion

 Symptoms:
 Dizziness
 Headache
 Fatigue
 Irritability
 Anxiety
 Chills
 Nausea/vomiting
 Heat cramps
Heat Exhaustion

 Signs:
 Tachycardia
 Hyperventilation

 Hypotension

 Syncope
Heat Exhaustion

 Treatment:
 Remove patient from warm
environment.
 Remove bulky clothing.

 Fluids (IV or PO).

 Antiemetics

 Removal from duty.

Heat Syncope

 Form of postural hypotension.

 Results from massive vasodilation.
 Dehydration usually a contributing
factor.
 Most common in persons not
acclimatized to the heat.
 Usually occurs during the early stages
of heat exposure.
Heat Syncope

 Treatment:
 Symptomatic
 Cool

 Fluids

 Rule out other

causes of
syncope.
Heat Stroke

 Heat stroke is a
life--threatening
life
emergency!
 Heat stroke is a
total failure of
temperature
regulation.
Heat Stroke

 Core temperature
>104.9°° (40.5
>104.9 (40.5°° C).
 Loss of sweating
(anhidrosis).
 Altered mental
status.
Heat Stroke

 Anhidrosis may or
may not be present.
 Just because a
patient is sweating
does not mean they
are not suffering
heat stroke.
Heat Stroke

 Treatment must
include:
 CPR if required.
 Fluid and
electrolyte
replacement.
 Immediate
cooling.
Heat Stroke

 Goal of cooling is to get body temperature

down to 104°
104° (40
(40°° C).
 Preferred method is immersion in cold water
or ice-
ice-water bath.
 Evaporative cooling (moistened sheets) and
ice packs) can be used but less effective.
 Essential to remove from bath as soon as
target temperature reached to avoid
overcooling and activation of reflex
mechanisms.
Fever
Fever

 Fever is not an abnormal increase in body

temperature.
 It is a resetting of the body’s set-
set-point above
normal.
 Causes:
 Abnormalities within the brain (tumors,
hemorrhage compress hypothalamus)
 Dehydration
 Toxic substances within the body (pyrogens).
Fever

 Definitions:
 Any oral temp ≥ 98.9°
98.9° (37.2
(37.2°° C) in
the early morning.
 Any oral temp ≥ 100°
100° (37.8
(37.8°° C) at
any time.
Fever

 How hot is high?

 Human upper limit of fever is 105.8-
105.8-
107.6°°F (41–
107.6 (41–42
42°°C).
 Almost never exceeds 42° 42° C unless
there’s a failure in thermoregulation.
Fever

 How hot is high?

 104
104°°(40° C) may be the upper limit of
(40°
fever in infants <12 weeks old.
 Remember that young infants can
have infections with normal or
lowered body temps.
Fever

 Can high fever can

cause damage in
and of itself?
 Seizures and
complications.
 Brain damage
because of the
infection causing the
fever (meningitis or
encephalitis).
Fever

 No human studies
published.
 Animal studies
suggest that a body
temp of ≥ 107.5°
107.5°
(42°° C) in humans
(42
may trigger enough
adverse effects on a
cellular level to
cause death.
Fever

 Animal studies:
 Temperature >105°
>105°
may cause
respiratory alkalosis
and occasional
electrolyte
imbalances
 Temperature
>105.8°° may cause
>105.8
cellular swelling and
damage in the brain,
kidneys and liver
Fever

 When set--point in hypothalamus

set
changes, it usually takes several
hours to reach new set-
set-point.
 Signs and symptoms common
during this phase (blood
temperature lower than
hypothalamic set-
set-point).
Fever

 Fever is generally uncomfortable.

 Signs and Symptoms:
 Chills
 Flushing of the skin
 Teeth chattering
 Feels cold
 Shivering
 Skin cold to touch (phase-
(phase-dependent)
Fever

 Itis important to remember that

fever is a normal response to many
diseases.
 Although uncomfortable, it is rarely
harmful.
Febrile Seizures

 Incidence of 2-
2-5% in US.
 6 months – 3 years (median 18- 18-22
months).
 Boys more often than girls.
 Often occurs with the first fever of
an illness.
Febrile Seizures

 Characteristics:
 85% of all febrile seizures last for <15
minutes and don’t recur within 24
hours.
 50% have temp between 39° 39°-40
40°°C.
 25% have temp > 40 40°°C.
Febrile Seizures:

 Characteristics:
 1/3 will have recurrence of febrile seizures.
 The younger the age at 1 st febrile seizure,
the higher the incidence of recurrence.
 El
El--Radhi, 1998
 <39° for 1st febrile seizure
Presenting temp <39°
have 2.5x risk for recurrence within the same
illness and 3x risk for recurrence with other
illnesses
Febrile Seizures

 Simple febrile
seizures are
generalized tonic-
tonic-
clonic with brief
post--ictal period.
post
 Complex or atypical
febrile seizures can
be focal, atonic, or
prolonged
Febrile Seizures

 Multiple studies
have revealed
several genetic
loci that code
for susceptibility
to febrile
seizures.
Febrile Seizures

 Fever + Seizure ≠ “Febrile Seizure”

 Meningitis/Sepsis

 Seizure disorder
 Medication/Poison
Medication/Poison--induced
 Febrile
Seizure is NOT an EMS
diagnosis!
Febrile Seizure

 Myths:
 Rate of temperature rise does not
appear to be a cause of febrile
seizures.
 No studies have demonstrated that
febrile seizures without complicating
hypoxia cause brain damage.
Febrile Seizures

 Myths:
 Febrile seizures cause epilepsy.
 Risk factors for afebrile seizure:
 Complex 1st Febrile Seizure.
 Abnormal neuro state before 1st Febrile
Seizure.
 Afebrile seizure history in parents or siblings
 If
>2 risk factors, 10% chance of
developing “epilepsy”
Febrile Seizures

 Myths:
 Treating the fever will prevent the
seizure.
 Antipyretics are not protective.
 Rectal/oral diazepam at time of fever is
protective.
 Daily oral phenobarbital is protective but
has undesirable side effects.
Febrile Seizures

 There is no
evidence that
bringing the fever
down by any
means will stop or
prevent a febrile
seizure.
Febrile Seizures

 Bottom line:
 They’re more scary than dangerous.
 Most resolve without anticonvulsant
treatment.
 Antipyretic treatment does not
prevent or treat febrile seizures.
 Not all seizures with fever are febrile
seizures.
Fever

 Fever treatment:
 Treatment of
choice is
antipyretics
(acetaminophen,
ibuproprofen).
Fever

 There is no evidence to support one

antipyretic over another when
considering effectiveness
 No delivery route (po/pr) has been
proven more effective than another, but
there has been recent evidence to
suggest that higher doses may be
needed when given rectally.
Fever

 Acetaminophen 10-15 mg/kg po/pr

10-
q4h.
 Ibuprofen 10mg/kg po q6-q6-8h.
 No demonstrated benefit to
alternating the two meds but there
is a significant chance of dosing
error and possible overdose.
Fever

 Other cooling methods:

 Never use ice, cold water or alcohol.
 Use tepid water or cool compresses
over head and pulse points.
 Avoid inducing chills.
Fever

 Should we treat fever?

 Animalstudies suggest that the fever
mechanism is a positive adaptive
response
 Triggershost immune responses
 May stabilize cell membranes
Fever

 Should we treat fever?

 Increased
metabolic stress and
oxygen demand:
 Patients with poor cardiac reserve
 Patients with poor pulmonary reserve

 Lowers the “seizure threshold”

Fever

 Reasons to treat fever:

 Patientcomfort
 Parent comfort
Fever

 Should EMS
providers treat
fever?
Fever

 Should EMS providers treat fever?

 Pros:
 Providing an additional service to our
customers.
 Comfort measure.

 Cons:
 Treat and release?

 Documentation of fever.

 Dosing of meds.

 Reinforcement of fears.
Fever

 Cultural
considerations.
 Relates to ancient
beliefs of “hot”
and “cold”
illnesses.
Fever

 Summary:
 Fever is not the clearly defined concept
many believe it to be.
 Both the lay public and the medical
community need more education about
fever.
 “Fever Phobia” is unfounded.
 Fever treatment by EMS personnel is
controversial.