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!LTHOUGHHYPOTHERMIAISMOSTCOMMONINPATIENTSWHOAREEXPOSED
TO A COLD ENVIRONMENT IT CAN DEVELOP SECONDARY TO TOXIN EXPOSURE
METABOLIC DERANGEMENTS INFECTIONS AND DYSFUNCTION OF THE CENTRAL
NERVOUS AND ENDOCRINE SYSTEMS 4HE CLINICAL PRESENTATION OF HYPO
THERMIA INCLUDES A SPECTRUM OF SYMPTOMS AND IS GROUPED INTO THE
FOLLOWINGTHREECATEGORIESMILDMODERATEANDSEVERE-ANAGEMENT
DEPENDSONTHEDEGREEOFHYPOTHERMIAPRESENT4REATMENTMODALITIES
RANGE FROM NONINVASIVE PASSIVE EXTERNAL WARMING TECHNIQUES EG
REMOVAL OF COLD WET CLOTHING MOVEMENT TO A WARM ENVIRONMENT
TO ACTIVE EXTERNAL REWARMING EG INSULATION WITH WARM BLANKETS
TO ACTIVE CORE REWARMING EG WARMED INTRAVENOUS FLUID INFUSIONS
HEATED HUMIDIFIED OXYGEN BODY CAVITY LAVAGE AND EXTRACORPOREAL
BLOODWARMING -ILDTOMODERATEHYPOTHERMIAISTREATEDEASILYWITH
SUPPORTIVE CARE IN MOST CLINICAL SETTINGS AND HAS GOOD PATIENT OUT
COMES 4HE TREATMENT OF SEVERE HYPOTHERMIA IS MORE COMPLEX AND
OUTCOMESDEPENDHEAVILYONCLINICALRESOURCES0REVENTIONANDREC
OGNITIONOFATYPICALPRESENTATIONSAREESSENTIALTOREDUCINGTHERATES
OFMORBIDITYANDMORTALITYASSOCIATEDWITHTHISCONDITION!M&AM
0HYSICIAN #OPYRIGHTÚ!MERICAN!CADEMYOF
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!
3EEPAGEFOR LTHOUGH FEVER IS THE MOST COM AND THOSE WITH SIGNIFICANT COMORBIDITIES
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RECOMMENDATIONLABELS
THERMOREGULATION HYPOTHER NESS EXPLORATION AND OUTDOOR AND WATER
MIA HAS PLAYED A MAJOR ROLE IN SPORTS THE INCIDENCE OF HYPOTHERMIA SEC
SHAPING HISTORY AND MEDICINE FOR MILLEN ONDARYTOACCIDENTALEXPOSUREMAYBECOME
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AGE OF APPROXIMATELY  PERSONS PER YEAR "ODYHEATISLOSTTOTHEENVIRONMENTVIAFIVE
!LMOST ONE HALF OF THESE DEATHS INVOLVED MECHANISMSRADIATIONCONDUCTIONCONVEC
PATIENTSOLDERTHANYEARSWITHANOVERALL TIONEVAPORATIONANDRESPIRATION2ADIATIVE
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RISKFACTORSTHATPREDISPOSETHEBODYTOPOOR SION OCCURS PRIMARILY FROM THE HEAD AND
TEMPERATURE REGULATION INCLUDE VERY YOUNG NONINSULATED AREAS OF THE BODY IS THE MOST
OR ADVANCED AGE THE PRESENCE OF COMORBID RAPIDANDACCOUNTSFORMORETHANPERCENT
CONDITIONSANDINTOXICATION OFHEATLOSS#ONDUCTIONWHICHISTHETRANS
)N URBAN AREAS HYPOTHERMIA FREQUENTLY FEROFHEATVIADIRECTCONTACTISANIMPORTANT
OCCURSWITHCHRONICCOLDEXPO MECHANISMINIMMERSIONINCIDENTSBECAUSE
SUREASWELLASWITHIMMERSION THETHERMALCONDUCTIVITYOFWATERISAPPROXI
0ERSONSWITHINDOORHYPO ACCIDENTSINVOLVINGINTOXICANTS MATELYTIMESTHATOFAIR
THERMIAHAVEAHIGHER OR MENTAL ILLNESS )N MORE #ONVECTIVE HEAT LOSS OCCURS WITH THE
MORTALITYRATETHANPERSONS RURAL ENVIRONMENTS THE INCI MOVEMENT OF FLUID OR GAS CARRYING SIG
WITHOUTDOORHYPOTHERMIA DENCEOFHYPOTHERMIAISHIGHER NIFICANTLY MORE HEAT AWAY FROM THE BODY
AMONGNONAMBULATORYPATIENTS IN WINDY CONDITIONS BY RAPIDLY REMOVING

$ECEMBER U6OLUME.UMBER WWWAAFPORGAFP !MERICAN&AMILY0HYSICIAN 

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 3TANDARDCLINICALTHERMOM THE WARM INSULATING LAYER OF ININDOORPATIENTSHOWEVERINDOORPATIENTS
ETERSDONOTREGISTERBELOW AIR THAT INITIALLY IS IN DIRECT HAVE A SIGNIFICANTLY HIGHER MORTALITY RATE
ª#ª& 
CONTACT WITH THE SKIN 4HIS THANTHEIROUTDOORCOUNTERPARTSMOSTLIKELY
MECHANISM ALSO EXPLAINS THE SECONDARYTOINCREASEDAGEANDLATERTIMEOF
SIGNIFICANCE OF WIND CHILL DISCOVERYANDDIAGNOSIS
BECAUSE THE AMOUNT OF HEAT CARRIED AWAY /THER CAUSES OF HYPOTHERMIA INCLUDE
FROM THE BODY IS PROPORTIONAL TO WIND METABOLIC DISORDERS THAT ARE LINKED TO A
SPEED%VAPORATIONANDRESPIRATIONWORKVIA DECREASED BASAL METABOLIC RATE AND CAN BE
THESAMEMECHANISMINVOLVINGWATERDROP RELATED TO DYSFUNCTION OF THE THYROID ADRE
LETSANDCONTRIBUTETOHYPOTHERMIAMOSTLY NAL OR PITUITARY GLANDS )N ADDITION ETHA
IN COOL DRY WINDY ENVIRONMENTS BECAUSE NOL CAN CAUSE HYPOTHERMIA BY INCREASING
ALLLIQUIDWILLVAPORIZEASTHEHUMIDITYGRA HEAT LOSS VIA VASODILATION AND BY IMPAIRING
DIENTDECREASES BEHAVIORAL RESPONSES TO COLD 3EPSIS MAY
4O MAINTAIN TEMPERATURE HOMEOSTASIS PRESENT WITH A LOW TEMPERATURE ESPECIALLY
THE HYPOTHALAMUS ORCHESTRATES A COUNTER AT THE EXTREMES OF AGE AND HERALDS A POOR
ATTACK AGAINST HEAT LOSS VIA HEAT CONSERVA OUTCOMEFROMBACTEREMIA
TIONANDHEATPRODUCTION(EATCONSERVATION
IS ACHIEVED BY PERIPHERAL VASOCONSTRICTION
REDUCING HEAT CONDUCTION TO THE SKIN AND 4!",%
BEHAVIORALRESPONSESSUCHASTHELAYERINGOF #OMMON#AUSESOF(YPOTHERMIA
WARMCLOTHINGTOINCREASEINSULATION(EAT
PRODUCTION IS ACCOMPLISHED BY SHIVERING $ERMALDISEASE
WHICH CAN INCREASE THE NORMAL BASAL META "URNS
BOLICRATEBYTWOTOFIVETIMESANDTHROUGH %XFOLIATIVEDERMATITIS
NONSHIVERING THERMOGENESIS VIA INCREASED 3EVEREPSORIASIS
LEVELS OF THYROXINE AND EPINEPHRINE )N A $RUGINDUCED
COLDENVIRONMENTHOMEOSTASISCANBEOVER %THANOL
WHELMED HEAT PRODUCTION CAN CEASE AND 0HENOTHIAZINES
THE CORE BODY TEMPERATURE CAN DROP AFTER 3EDATIVE HYPNOTICS
ONLY A FEW HOURS SECONDARY TO FATIGUE AND %NVIRONMENTAL
GLYCOGENDEPLETION )MMERSION
.ONIMMERSION
%TIOLOGY )ATROGENIC
4HE CAUSES OF HYPOTHERMIA ARE NUMEROUS !GGRESSIVEFLUIDRESUSCITATION
4ABLE BUTAFEWDESERVESPECIALMENTION (EATSTROKETREATMENT
BECAUSEFAILURETORECOGNIZEATYPICALPRESEN -ETABOLIC
TATIONSANDINITIATEEARLYTREATMENTOFSPECIFIC (YPOADRENALISM
CAUSES INCREASES THE RATES OF MORBIDITY AND (YPOPITUITARISM
MORTALITY 4HE DIAGNOSIS OF ENVIRONMENTAL (YPOTHYROIDISM
HYPOTHERMIA IS OBVIOUS IN PATIENTS FOUND .EUROLOGIC
OUTDOORSINCOLDCLIMATESBUTMAYBEOVER !CUTESPINALCORDTRANSECTION
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0ATIENTS WHO ARE INDOORS IN WARM ENVI 3TROKE
RONMENTSMAYDEVELOPHYPOTHERMIASECOND 4UMOR
ARY TO AIR CONDITIONING OR ICE BATHS 4HESE 7ERNICKESDISEASE
INDOOR PATIENTS WITH HYPOTHERMIA TEND TO .EUROMUSCULARINEFFICIENCY
BE ELDERLY AND THEY MAY PRESENT INITIALLY !GEEXTREME
TO THEIR REGULAR PHYSICIAN WITH VAGUE COM )MPAIREDSHIVERING
PLAINTSOFMENTALANDORMOTORSKILLDETERIO ,ACKOFACCLIMATIZATION
RATION 4HE SUBTLE SYMPTOMS OF EARLY MILD 3EPSIS
TO MODERATE HYPOTHERMIA ARE LESS OBVIOUS

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 (YPOTHERMIA

$IAGNOSIS -ANAGEMENT
!LTHOUGH THE PATHOPHYSIOLOGY AND CLINICAL )N ADDITION TO THE CASE SPECIFIC THERAPIES
FINDINGSOFHYPOTHERMIAOCCURALONGACON MENTIONED ABOVE SOME GENERAL PRINCIPLES
TINUUM THE GENERALLY ACCEPTED DEFINITION APPLYTOALLPATIENTS)FBEDSIDEGLUCOSETEST
DIVIDESTHESPECTRUMINTOTHREEZONESMILD ING IS UNAVAILABLE A TRIAL OF GLUCOSE IS WAR
MODERATE AND SEVERE 4ABLE   !S MEN RANTED BECAUSE MOST PATIENTS HAVE DEPLETED
TIONED PREVIOUSLY MILD HYPOTHERMIA MAY THEIR GLYCOGEN STORES AND HYPOTHERMIA
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7HENCONSIDERINGTHEDIAGNOSISAFALSESENSE 4HIAMINEALSOMAYBEGIVENEMPIRICALLYTOALL
OF REASSURANCE MAY BE GIVEN BY STANDARD PATIENTSBECAUSEAPATIENTSHISTORYOFALCOHOL
CLINICAL THERMOMETERS WHICH MEASURE ONLY ABUSEMAYNOTBEAVAILABLEANDTHIAMINEHAS
AS LOW AS —# —&  )T IS IMPORTANT TO
USESPECIALLOW READINGRECTALTHERMOMETERS
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4!",%
4YMPANICTHERMOMETRYANDBLADDERPROBES
ALSO HAVE BEEN USED FREQUENTLY IN RESEARCH 3TAGESOF(YPOTHERMIAAND#LINICAL&EATURES
BUT FURTHER STUDIES ARE NEEDED TO DETER
(YPOTHERMIA "ODY
MINE THEIR ACCURACY IN PATIENTS WITH HYPO
ZONE TEMPERATURE #LINICALFEATURES
THERMIA !LTHOUGH THE IDEAL MODE OF CORE
TEMPERATURE MEASUREMENT IS CONTROVERSIAL -ILD ª#TOª# )NITIALEXCITATIONPHASETOCOMBAT
THEBESTSTRATEGYISTOSIMULTANEOUSLYUSEAS ª&TOª& COLD
MANY METHODS AS ARE AVAILABLE BECAUSE THE (YPERTENSION
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REWARMING 4ACHYCARDIA
4ACHYPNEA
,ABORATORY 6ASOCONSTRICTION
7ITHTIMEANDONSETOFFATIGUE
2ENAL FAILURE SECONDARY TO RHABDOMYOLY
!PATHY
SIS OR ACUTE TUBULAR NECROSIS MAY OCCUR
!TAXIA
%LECTROLYTE LEVELS MAY CHANGE RAPIDLY DUR
#OLDDIURESISˆKIDNEYSLOSE
ING RESUSCITATION AND SHOULD BE CHECKED CONCENTRATINGABILITY
FREQUENTLY 0OTASSIUM LEVELS IN PARTICULAR (YPOVOLEMIA
FLUCTUATE BECAUSE OF ACID BASE CHANGES THAT )MPAIREDJUDGMENT
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THERMIA TYPICALLY ARE COAGULOPATHIC BECAUSE TOª# $ECREASEDHEARTRATE
OF TEMPERATURE DEPENDENT ENZYMES IN THE $ECREASEDLEVELOFCONSCIOUSNESS
COAGULATION CASCADE ALTHOUGH THE RESULTS OF $ECREASEDRESPIRATORYRATE
COAGULATIONSTUDIESAREFREQUENTLYNORMALAS $ILATEDPUPILS
THEBLOODSAMPLEISHEATEDTO—#—& $IMINISHEDGAGREFLEX
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#OAGULOPATHIES TYPICALLY ARE SELF LIMITED (YPOREFLEXIA
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USE OF UNCORRECTED VALUES OF ARTERIAL BLOOD 3EVERE ª# !PNEA
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ING "ECAUSE THE WHITE BLOOD CELL COUNT $ECREASEDORNOACTIVITYON
IS INACCURATE IN IDENTIFYING THE PRESENCE OF ELECTROENCEPHALOGRAPHY
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 MINIMALADVERSEEFFECTS7ETCLOTHINGSHOULD VENTRICULARFIBRILLATIONANDASYSTOLE0ROLON

BE REMOVED AND REPLACED WITH BLANKETS FOR GATIONOF02123AND14INTERVALS*WAVES
INSULATION %XCESSIVE MOVEMENT AND NASO
&IGURE ANDMIMICKINGOFACUTECORONARY
GASTRIC TUBE PLACEMENT SHOULD BE AVOIDED SYNDROMESALSOMAYBESEEN
BECAUSETHESEHAVEBEENSHOWNTOPRECIPITATE !LTHOUGHMOSTDYSRHYTHMIASWILLCORRECT
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WITH WARMING ALONE VENTRICULAR FIBRILLA

TION WITH WARMED FLUID HELPS TO OVERCOME TIONSHOULDBETREATEDWITHDEFIBRILLATION)F
DEHYDRATIONCAUSEDBYCOLDDIURESIS INITIALLYUNSUCCESSFULADDITIONALATTEMPTSAT
)NGENERALSTEROIDSUPPLEMENTATIONSHOULD
NOT BE GIVEN EMPIRICALLY TO ALL PATIENTS
3TRESS DOSE STEROIDS SHOULD BE RESTRICTED TO
PATIENTS WITH A HISTORY OF KNOWN ADRENAL
INSUFFICIENCY AND THOSE WHOSE BODY TEM
RHYTHMIASDONOTREQUIRESPECIFICTREATMENT
PERATUREFAILSTONORMALIZEDESPITETHEUSEOF
APPROPRIATEWARMINGTECHNIQUES
DEFIBRILLATION AND USE OF INTRAVENOUS MEDI
CATIONSSHOULDBEWITHHELDUNTILTHEPATIENT
ISWARMEDTOABOVE—#—& WHILEBASIC
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PHYTHE!MERICAN(EART!SSOCIATION!(! )N PATIENTS WITH HYPOTHERMIA THE DECISION
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NIQUES SHOULD BE BASED ON SEVERAL CLINICAL
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HAVE INTACT THERMOREGULATORY MECHANISMS EXTERNALREWARMING!RELATIVELYNEWTECH
NORMAL ENDOCRINE FUNCTION AND ADEQUATE NIQUEOFACTIVEEXTERNALREWARMINGISTHEUSE
ENERGY STORES TO CREATE ENDOGENOUS HEAT ! OFARTERIOVENOUSANASTOMOSES7HENOPENED
DISADVANTAGEOFPASSIVEREWARMINGISTHATTHE ANDHEATEDTHESESMALLORGANS
BODYSCORETEMPERATURERISESVERYSLOWLY LOCATED BELOW THE SKIN CARRY
!CTIVE EXTERNAL REWARMING IS SIMPLY THE WARMED SUBCUTANEOUS VENOUS !CTIVECOREREWARMINGMAY
APPLICATION OF HEAT DIRECTLY TO THE SKIN BLOODTOTHEBODYSCORE/PEN BEACCOMPLISHEDBYWARM
AND IS ONLY EFFECTIVE IN THE PRESENCE OF ING CAN BE ACCOMPLISHED BY LAVAGEOFSEVERALBODY
INTACT CIRCULATION THAT CAN RETURN PERIPHER IMMERSIONOFTHEHANDSORTHE CAVITIES
ALLYREWARMEDBLOODTOTHECORE(OTWATER FEET IN —# —& WATER OR
BOTTLES AND HEATING PADS APPLIED TO TRUN BY APPLYING NEGATIVE PRESSURE
CAL AREAS ONLY MAY CAUSE BURNS TO COLD WHEN THE FOREARM IS INSERTED IN A SPECIAL
ANDVASOCONSTRICTEDSKIN&ORCED AIRWARM DEVICECONTAININGHEATEDAIRINAVACUUMOF
ING SYSTEMS EG "AIR (UGGER TEMPERATURE nMM(G4HECLINICALUSEFULNESSOFTHIS
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 ! MAJOR COMPLICATION OF ACTIVE EXTERNAL VENOUSFLUIDSPREFERABLYPERCENTDEXTROSE
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WHICH RESULTS WHEN COLD PERIPHERAL BLOOD TO —# (EATING INTRAVENOUS FLUIDS CAN
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USING MINIMALLY INVASIVE CORE REWARMING ALLPATIENTSEXCEPTTHOSEWHOREQUIREPASSIVE
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ERY JOINS THE CENTRAL CIRCULATION 0ERIPHERAL ING ACCOMPLISHED BY CARDIOPULMONARY
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BYPASS ARTERIOVENOUS REWARMING VENOVE

NAL REWARMING MAY CAUSE VENOUS POOLING NOUS REWARMING OR HEMODIALYSIS 4HESE
AND hREWARMING SHOCKv "ECAUSE OF THESE TECHNIQUESAREHIGHLYEFFECTIVEANDINCREASE
COMPLICATIONS PATIENTS MAY CORE TEMPERATURE BY —# TO —# —&
DETERIORATE BRIEFLY BEFORE THEY EVERYTHREETOFIVEMINUTES!RETROSPECTIVE
!IRWAYREWARMINGCANBE
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FIED OXYGEN AT —# —& IS DONE EASILY SOLUTIONHEATEDTO—#TO—#ATARATEOF
INCREASES CORE TEMPERATURE BY —# —& TO,PERHOURHASBEENSHOWNTOINCREASE
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,9..%-##5,,/5'(-$ISASSISTANTPROFESSORATTHE5NIVERSITYOF#ALIFORNIA
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