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Hypothermia

and
Cold Weather Injuries
Recognizing, Preventing and Treating

Shawn F. Kane, M.D.


Kevin deWeber, MD, FAAFP

Outline

History
Cold Injury v Heat Injury
Definitions
Physiology/Effects on Organ Systems
Non-Freezing and Freezing cold injuries
Treatment
Field Management

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Historical Perspective
French invasion of Russia in 1812. Baron
de Larrey, chief surgeon, noted mental
and physical hardships by Soldiers
exposed to the cold
Freeze-thaw-refreeze phenomenon.

George Washington 10% of his troops


perished in the winter of 1777-78 due to
cold.
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Historical Perspective
WWII 200,000 Allied and German troops
suffer cold related injuries or deaths

Korea 10% of all US fatalities were cold


related.
1950 Battle of Chosin Reservoir. 30K UN troops
held off and repelled 60K Chinese
UN: 2.5K KIA, 5K WIA, 7.5K Frostbite/cold weather injuries
Chinese: 25K KIA, 12.5K WIA, 30K Frostbite/cold weather injuries

Cold Injury v Heat Injury


Heat Injuries: CDC 1999-2003. 3,442
deaths due to heat. Mean 688/yr
Cold Injuries: CDC 1999-2002. 4,407
deaths due to cold. Mean 689/yr
60%/40% - underlying cause/contributing
factor
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Definitions
Accidental Hypothermia: the unintentional
drop in core body temperature to <35C
(95F)
Intentional Hypothermia:
controlled cooling of core
body temperature for
specific medical
indications (CVA, MI, TBI)
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Definitions
Types of Heat Loss
Radiation: dispersal of heat energy from
uncovered skin to nearby objects
>50% of our heat loss

Evaporation: loss of heat via the


transformation of liquid water into water
vapor.
20-30% of heat loss
Insensible heat loss can lead to dehydration if
not accounted for.
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Definitions
Types of Heat Loss
Conduction: transfer of heat from one
object to another through physical contact
Conductivity of water is 23X that of air!!
Immersion injury reduces body temp more
rapidly than convective loss

Convection: loss of heat to the air moving


next to the body
Windy days
Cycling, running
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Hypothermia
Stages/Classifications
ACCIDENTAL
MILD: 32C 35C
Shivering

90F - 95F

Hypothermia of TRAUMA

MILD: 34C 36C


93F - 97F

MODERATE: 28C 32C


MODERATE: 32C 34C
Reduced
82F 90F
shivering
90F - 93F
SEVERE: <28C
NO shivering
<82F

33-35(91-95), 31-32(88-90)
<31(<88)

SEVERE: <32C
<90F
Jurkovich GJ. Surg Clin N AM
87(2007) 247-267

Human Physiology
Range of 34-40.5C(95-105F) to retain
normal organ function
Thermoregulatory drive is so important
that it takes precedence over many other
homeostatic functions
Human body can compensate for
hyperthermia better than hypothermia

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Heat Loss

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Heat Gain

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Physiology/Effects on Organ
Systems
Initial effects mimic those of sympathetic
stimulation
Tremor
Vasoconstriction
Increased O2 consumption
Increased Heart Rate
Increased Minute Ventilation

Continued cold exposure results in inability to


compensate
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Physiology/Effects on Organ
Systems
Cardiovascular:
Initial tachycardia progresses to bradycardia
starting at 34C
CO initially increased despite a drop in BP
50% decrease in HR

<30C atrial fibrillation, bradycardia and


ventricular dysrhythmias
<25C asystole
At temperature <30C decreased effects of
cardiac medications

Physiology/Effects on Organ
Systems
Cardiovascular:
Conduction system is VERY sensitive to
decrease temperatures.
PR interval, QRS and QT interval prolong as
temperature decreases or stays below normal
J or Osborn wave in 80% of hypothermic
patients
Bretylium is the only CV drug that works at
decreased temperatures
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Osborn or J wave

Colder the temperature the larger the J wave

Physiology/Effects on Organ
Systems
Respiratory:
Initially increased but becomes depressed at
temperature <33C
Increased mucous production (bronchorrhea)
Left shift in oxyhemoglobin curve impairing
oxygen delivery

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Physiology/Effects on Organ
Systems
GI:
Ileus, bowel wall edema, shallow gastric
ulcers (Wischnevskys Ulcers)
Decrease hepatic function drug metabolism
Hemorrhagic pancreatitis, elevated amylase

RENAL:
Initial vasoconstriction contributes to diuresis
Later loss of distal tubular water reabsorption
due to dec ADH sensitivity and inc electrolyte
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excretion
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Physiology/Effects on Organ
Systems
HEME:
Cold platelets DO NOT work
34C 40% decrease in coagulation enzyme
function
Hemoconcentration
1C drop in temp 2% increase in hematocrit
Normal hematocrit in moderate to severe
hypothermia: need to be concerned about blood
loss.

Decreased WBC function, increased infection


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risk

Physiology/Effects on Organ
Systems
NEUROLOGICAL:
Decreased neural transmission
Incoordination and cognition, numbness

DTRs decrease and eventually flaccid


paralysis
<32C = amnesia
31C-27C lose consciousness
paradoxical undressing
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Hypothermia
Standard clinical thermometers and a
false sense of security
Only go down to 34C(94F) need low-reading
rectal thermometers (<32/90C/F)
Best accuracy thermometer in place for 3
minutes at a depth of 10 cm

Treat the patient clinically not the


classification of hypothermia
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NOT DEAD UNTIL THEY ARE


WARM AND DEAD
(unless they are really dead)

Hypothermia Treatment

RECOGNIZE THE CONDITION!


Removal from nasty conditions
Removal of wet clothing
Handle with care (testy heart)
Insulate and warm up

Rewarming Methods
External
blankets
hot water bottle
heater
another body
Immersion

Internal
Warm IV fluids
Warmed air

Exercise is BAD
Depletes glycogen,
reduces shivering
Increases heat loss

Hypothermia in Sport
High risk sports
Water sports
Running, cycling
Alpine & cold weather sports

Mild Hypothermia in Sports


91-95 F
Remove from cold
Insulate
Warm, sweet drink
No alcohol

Minimal to mild activity if improving

Moderate Hypothermia
88-90 F
Passive rewarming
In field, no active rewarming until rectalT >93F

Monitor rectal temp


Transport to ER for observation

Severe Hypothermia
<88 T
Handle with care!
Gentle passive rewarming only
Transport immediately, ERICU

Non-Freezing Cold Injuries


(NFCI)
A clinical syndrome defined as:
Injury to soft tissues of the extremities that result from
prolonged cooling and/or constant exposure to wet/damp
conditions.

Peripheral nerves (then muscle) are most


susceptible to cold related injuries.
Sequelae to NFCI may arise immediately
after the incident or may not demonstrate
themselves for up to 18 months post
exposure

Non-Freezing Cold Injuries


Wet

Trenchfoot
Prolonged exposure to temps
between 0-32C(32-60F) for hours
to 3-4 days

Swollen, edematous, numb


foot
Initially red then becomes
pale and cyanotic
Increased sensitivity to pain
and infections
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Dry

Chilblains or Pernio
Exposure to temps <32C(60F)

Bare skin exposed to dry


environment
Erythematous, tender, swollen,
itchy and painful papules
After rewarming inflamed,
red and hot to the touch for
hours

Non-Freezing Cold Injuries


Wet

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Dry

Non-Freezing Cold Injuries


(NFCI)
Transient Sequelae:

Late Sequelae:

Hyperhidrosis
Hyperesthesia/Anesthesia
of digits
Dec ROM and joint swelling
Edema
Fat pad loss, transient
muscle atrophy
Pain from injury to
peripheral nerves or small
vessels as a result of
ischemia

ACSM 2005

Hyperesthesia of distal
digits
Increased sensitivity to
heat and cold
Nail bed deformities
Hyperhidrosis,
hypohidrosis or anhidrosis
Decreased proprioception
Pain
Loss of fibrocartilage in ear
AVN, growth plate injuries

Freezing Cold Injuries (FCI)


A clinical syndrome of temporary or permanent tissue
damage that results from the formation of
extra/intracellular crystals due to prolonged exposure
to sub-freezing temperatures
Extent of damage can be superficial (frostnip) to full
thickness (bones and muscles)
Grade 1 through 4

FCI composed of two parts: immediate and


reperfusion

Freezing Cold Injuries (FCI)


Initial Freeze Injury

Hyperosmolarity disrupts
cell function
Rapid freezing leads to
intracellular crystals and
immediate cell death
Loss of pain sensation

Reperfusion Injury
RBC, WBC and platelet
aggregation leads to
patchy thrombosis in
microcirculation
Oxygen free radicals,
prostaglandins and
thromboxane worsen
vasoconstriction and
thrombosis
MAJORITY of damage
occurs during
REWARMING

ACSM 2005

Freezing Cold Injuries (FCI)

Cold Weather Injury Treatment


Low index of suspicion in an athlete who
complains of being cold during or after
exercise with a change in sensorium.
ABCs
FIRST priority is to prevent further HEAT
LOSS! (shelter from wet, cold, windy
environments, dry off)

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Cold Weather Injury Treatment


DO NOT thaw tissue if there is a risk of refreezing
DO NOT RUB the affected area
Minimize motion, move horizontally to
minimize cardiac irritability
Safety of rescuers

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Rewarming
PASSIVE: involves the use of blankets to
cover body and head to trap heat being
lost.
ACTIVE: the application of outside heat to
raise body temperature
External heat blanket/forced hot air system
Internal introduction of warm fluids into the
body
Warm IVF, body cavity lavage, extracorporeal
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NFCI and FCI TREATMENT


RAPID rewarming is the goal. Trunk>Limbs
Immersion of limb in 40-42C (102-106F)
water bath
30-45 minutes area appears flushed with
good circulation when circulation is reestablished
Tetanus Toxoid
Benzyl penicillin 600mg q6 for 48-72 hours
Narcotic Pain Relief

very painful!!!
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HFCI and FCI TREATMENT


Dry skin to prevent maceration.
Prevent further injury (prostaglandins)
Serous blisters unroof; topical aloe vera
NSAIDS

Prevent Thrombosis
tPA a few studies demonstrate the benefit of tPA in
preventing/minimizing amputations or the amount of
amputated tissue
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TREATMENT
Amputation should be
delayed 2-3 months

MRI/MRA
Technetium 99m methylene diphosphonate bone scan
(triple phase 1 minute, 2 hours and 7 hours) as early
as 48 hours after admission may help identify viable
(hibernating) tissue
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NFCI and FCI Sequelae


Transient Sequelae:

Late Sequelae:

Hyperesthesia of distal
Hyperhidrosis
digits
Hyperesthesia/Anesthesia
Increased sensitivity to
of digits
heat and cold
Dec ROM and joint
Nail bed deformities
swelling
Hyperhidrosis,
Edema
hypohidrosis or
anhidrosis
Fat pad loss, transient
Decreased
muscle atrophy
proprioception
Pain from injury to
Pain
peripheral nerves or small
vessels as a result of
Loss of fibrocartilage in
ischemia
ear
AMPUTATION IS THE ULTIMATE LONG-TERM AVN, growth plate
injuries
SEQUELAE TO A FCI
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How much do you amputate?

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FIELD PASSIVE
REWARMING EQPT

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FIELD ACTIVE
REWARMING EQPT

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Prevention of Cold Injuries


Layered clothing
Cotton BAD
Wetsuits in water sports

Adequate nutrition & hydration


Cancel events if too cold
ACSM: dry bulb <-4F at coldest place

Review

Moderate hypothermia: 91-95F


Avoid active rewarming if <93F in field
Dry NFCI: chilblains, pernio
Wet NFCI: trenchfoot
Frostbite: drain SEROUS blisters; give
Pcn, NSAID, Tetanus toxoid, pain meds
Cancel events if low Temp <-4F

Questions