Environmental Injuries:

Hypothermia &
Heat Emergency
Presenter: Dr. Yong MK
Moderator: Dr Zatul Rathiah
HYPOTHERMIA
• Body’s mechanism for temperature regulation is overwhelmed in the
face of a cold stressor

• Unintentional lowering of core body temperature below physiological

normal limits (<35oC/95oF)
• Quick Stats:

• Estimated deaths due to hypothermia (UK): 300, (Scotland): 150, (US): 700,
(Canada): 8000

• People of extreme ages (infants and elderly and homeless individuals) are
more susceptible to hypothermia induced/related death

• Commonly occurs from October to March

• Pathophysiology:
• Body temperature – balance of heat production & loss
• Generation - cellular metabolism

• Lost -
• Evaporization: vaporization of water through insensible losses and sweat
• Radiation: emission of infrared energy
• Conduction: direct transfer of heat to object
• Convection: direct transfer of heat to convective air currents
• Initial stage:
• Thermoreceptors at skin and subcutaneous tissue causes local
vasoconstriction
• Hypothalamus
• secretes ACTH & TSH to stimulate thyroid and adrenal glands
• Increases heat production by promoting shivering
• Prolonged vasoconstriction causes metabolic acidosis
• Subsequently:
• ECG starts to show ST elevation & prolonged QT interval
• Reduction in respiration rate and tidal volume leads to anatomical and
physiological dead space causing bronchiolar and alveolar edema
• Renal blood flow and GFR decrease which reflects on reduction of tubular
reabsorption causing cold induced natriuresis and diuresis
• Collectively causes CNS and cardiac depression
HYPOTHERMIA
• Core body temperature: <35oC
• Clinical signs:
• Mild (32oC - 35oC)
• Shivering

• Confusion

• Lethargy, fatigue

• Increased HR

• Increased RR
• Moderate (28oC – 32oC)
• Shivering stops < 32oC

• Disoriented, stupor

• Decreased HR, RR, BP

• Atrial arrythmias: bradycardia, J/Osborn waves

• Hypo-reflexic
• Severe: (<28oC)
• Coma

• Absent reflexes

• Dilated, unreactive pupils

• Oliguria

• Muscle rigidity

• Pulmonary edema

• Ventricular fibrillation

• Asystole
RISK FACTORS: STRONG
• Anesthetic use:
• Associated with 0.5-1.0 degree Celsius drop in core temperature per hour
• Substance abuse:
• Impairs judgement, vasodilation (alcohol), restrict shivering (marijuana)
• Impaired mental status
• Impairment of judgement
• Hypothyroidism
• Stroke
• Parkison’s disease
• Homelessness
• Extreme ages
• Gram negative septicaema
RISK FACTORS: weak
• Neuroleptic medication
• Vasodilation and suppression of sympathetic response
• Beta blockers medication
• Vasodilation and suppression of sympathetic response
• Sedative hypnotic medication
• Vasodilation and suppression of sympathetic response
• Impairs judgment
Investigations:
• Temperature
• 12 lead ECG
• Serum electrolytes
• Blood glucose
• ABG
• Coagulation profile
• CXR
Differential diagnosis:
• Sepsis
• Hypothyroidism
• Medication induce
• Airway:
• Indicated in the mildest form of hypothermia if indicated
• Breathing:
• Supplemental oxygen at 40oC during rewarming, to increases core
temperature by 1-2oC per hour decreasing evaporative heat during respiration
• Circulation:
• Warm IV crystalloid solution
• Hypothermic heart maybe unresponsive to cardiovascular drugs, pacemaker
stimulation and defibrillation
• Reduction in drug metabolism; to withhold drugs if core temperature < 30oC,
however drugs may be given but with increased interval between doses
• Defibrillation:
• Defibrillation is less effective in hypothermia. For ventricular fibrillation/ventricular
tachycardia (VF/VT) defibrillation may be tried up to three times but is then not tried
until the temperature reaches 30oC.
• Rewarming:
• External rewarming:
• Passive external rewarming (mild cases): REMOVE wet clothing and cover with warm
blanket
• Active external rewarming (moderate to severe): Passive external warming with forced
warm air to patient’s body
• Internal rewarming:
• Usage of warmed fluids (40-45oC)
• Best used with external rewarming
• Pleural or peritoneal irrigation with warm saline, continuous arteriovenous or
venovenous rewarming
• Extracorporeal rewarming: provides sufficient circulation and oxygenation (increase of 8-
12oC)
 DECISION TO RESUSCITATE
• Hypothermia decreases oxygen consumption by 6% with every 1oC drop
• At 28oC consumption is decreased to 50% and at 22oC around 75%
• At 18oC the brain can tolerate cardiac arrest 10 times longer than at 37oC
• Protective effect on brain and heart, hence neurological recovery is possible
• Careful to diagnose death in hypothermia
• Small volume, slow, irregular pulse and very low/unrecordable BP
• Look for signs of life for at least 1 min, use ECG monitoring
• Pre-hospital setting:
• Resuscitation to be withheld if cardiac arrest if not attributed to hypothermia
• i.e. Lethal injuries, prolonged asphyxia, fatal illnesses or if chest is not compressible
• In hospital setting:
• Involved senior doctors
• Use clinical judgement to determine resuscitation status
• Ensure use of all methods available for rewarming
In primary hypothermic cardiac arrests, death
should not be confirmed until:
Patient has been rewarmed
or
Other unrevivable injuries has been identified
or
Re-warming has failed despite all available measures

NO ONE IS DEAD UNTIL WARM AND DEAD!

HYPERTHERMIA
Definition: core temperature
exceeds that normally
maintained by homeostatic
mechanisms
Fever/pyrexia: elevation
of body temperature above the
normal range of 36.5–37.5 °C
(97.7–99.5 °F) due to an
increase in the temperature
regulatory set point
Malignant hyperthermia: body
temperature is elevated above
the theromoregulatory set
point due to excessive heat
production and/or insufficient
heat dissipation
• Epidemiology:

• Around 650 heat related deaths in the US yearly

• Russian heat wave (2010): 55,736 deaths (average temp: 39-40oC)

• People at greatest risk: extreme age groups

 HEAT STROKE
vs
HEAT EXHAUSTION
Definitions:
• Heat stroke:
• Hyperthermia with CNS dysfunction
• Core temperature: >40oC, usually 40oC – 44oC

• Heat exhaustion:
• Milder form of heat illness without profound CNS dysfunction
• Usually 37oC – 40oC
Clinical Classification:
• Classical heat stroke:
• Sedentary, often older or debilitated people under conditions of high heat
stress
• May be of insidious onset and can present with minimally elevated core
temperature

• Exertional heat stroke:

• Active, often young people
• under conditions that produce heat stress through either exertion alone or a
combination of environmental thermal loading combined with physical
activity
• Heat exhaustion:
• Milder form of heat illness
• Core temperature elevated to a smaller magnitude compared to heat stroke

• Heat syncope
• Heat edema:
• Self limited, mild swelling of dependent extremities
• Cutaneous vasodilation & pooling of interstitial fluid

• Heat rash (prickly heat, lichen tropicus, miliaria rubra):

• Vesiculopapular eruption over clothed areas
• Inflammation and obstruction of sweat ducts
Pathophysiology:
Clinical features:
• Heat exhaustion:
• Dizziness
• Headache
• Profuse sweating
• Irritability
• Nausea/vomiting
• Tachycardia
• Body weakness
• Body cramps
• Heat stroke:
• Hyperthermia: >40oC
CARDINAL FEATURES
• Altered mental status/neurological abnormalities
• Confusion, agitation, bizarre behavior, ataxia, seizures, obtundation, coma
• Anhidrosis/profuse sweating
• Hyperventilation
• Nausea/vomiting
• Muscle cramps
• Jaundice
• Tachycardia
• Tea colored urine
• Oliguria
• hypotension
Differential diagnosis:
• Infection
• Sepsis, meningitis, encephalitis, malaria, typhoid, tetanus
• Endocrine disorders
• DKA, thyroid storm
• Neurologic disorders
• CVA, status epilepticus
• Toxicologic
• Anticholinergics, sympathomimetics, salicylates, serotonin syndrome,
malignant hyperthermia, neuroleptic malignant syndrome, alcohol