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Accidental Hypothermia
Gregory Gafni-Pappas, DO
Assistant Program Director
UM/SJMH Emergency Medicine Residency
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Conflicts of Interest
NOTHING TO
DISCLOSE
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Brief History
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Epidemiology
>650 deaths per year
Hypothermia-related deaths — United States, 1999-2002 and 2005.
MMWR Morb Mortal Wkly Rep. Mar 17 2006;55(10):282-284.
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Epidemiology
Hypothermia-related deaths--United States, 2003-2004. MMWR Morb
Mortal Wkly Rep. Feb 25 2005;54(7):173-175.
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The Old Adage
“A person is not dead until they
are warm and dead”
Lowest initial temperature recorded in patients who
survived from hypothermia:
Child 14.2°C (57.6°F)
Adult 13.7°C (56.7°F)
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Caveat
Very little medical literature in regards
to large scale prospective or
randomized clinical studies
However, there is an abundance of
survival stories, case reports, and
retrospective reviews
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Coldest Places on Earth
Verkhoyansk, Russia
-50.6 F average in January
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Classification
n Hypothermia
n Classified
= Temperature < 35°C
by severity
n  Mild
32-35°C (89.6-95°F)
n  Moderate 28-32°C (82.4-89.6°F)
n  Severe <28°C (<82.4°F)
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Physiologic Effects
Cardiovascular
Respiratory
Neurologic
↓ HR, ↓ BP, ↓ CO
Osborn waves
Vfib (most common
arrhythmia) → Asystole
Hypotension
↓ RR
Bronchorrhea
↓ Cough reflex
↓ Ciliary function
Pulmonary Edema
Ataxia, Dysarthria
Pupils dilate
Paradoxical undressing
Stupor
↓ LOC
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Physiologic Effects
Renal
Metabolic
GI
Cold Diuresis
↓ GFR
Metabolic acidosis
Electrolyte imbalance
Oliguria
↓ Insulin release/uptake
leads to Hyperglycemia
↓ GI motility
Pancreatitis
Ileus
Constipation
↓ Rectal tone
↓ Shivering
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Core Temperature Afterdrop
1. 
Possibly related to peripheral cold blood
returning to central circulation
2. 
Inadequate fluid resuscitation causes
vasoconstriction, circulatory collapse, and
subsequent shock
Coldest Places on Earth
International Falls, MN
Average temperature in
January around 2.7 F
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Risk Factors
Wide Open Differential Diagnoses
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When is it ok to withhold care?
State of Alaska Cold Injury Guidelines
(2014)
n  Core
temperature <10°C
n  Frozen chest or ice in the airway
n  Victim submersed in water >1hr
n  Obvious lethal injury
n  Avalanche burial >35 minutes
n  Procedures significantly delay evacuation to
controlled rewarming
n  Procedures put rescuers at risk
Services DoHaS, Health DoP, EMS SoCHa. State of Alaska Cold Injuries Guidelines.
Juneau, Alaska (Guideline) 2014.
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Initial Care Differences
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Initial Care
Diagnostics
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Coldest Places on Earth
Barrow, Alaska
Average mean temp in July is 40.4 F
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Methods to Rewarm
n 
Passive rewarming (32-35°C)
n 
Active Rewarming (<32°C or AMS)
External
Internal
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Coldest Places on Earth
North Ice, Greenland
Lowest recorded temperature
minus 66 F
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Special Situations
n Drowning
n 
Longest period of submersion before survival:
n 66
n 
minutes
How old?
n 2.5
n 
years
What was the core temperature?
n 19°C
(66°F)
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“Should I continue CPR per ACLS
guidelines?”
+ “When should I intubate the patient?”
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+ “3 Rounds of ACLS drugs were given and the patient was
defibrillated without response…should I call the code?”
“The patient is not dead until they are
warm and dead”
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“I’m warming the patient but the
temp won’t budge…what should I
do?”
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+ “The patient was warming up but all of a sudden
became hypotensive…what happened?”
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Therapeutic Hypothermia
Consideration
n  Should
we keep patients hypothermic?
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Coldest Places on Earth
Vostok, Antarctica
Minus 128.6 F
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References
1. 
Hypothermia-related deaths — United States, 1999-2002 and 2005.
MMWR Morb Mortal Wkly Rep. Mar 17 2006;55(10):282-284.
2. 
Hypothermia-related deaths--United States, 2003-2004. MMWR Morb
Mortal Wkly Rep. Feb 25 2005;54(7):173-175.
3. 
Brown DJ, Brugger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J
Med. Nov 2012;367(20):1930-8.
4. 
Mulcahy A, Watts M. Accidental Hypothermia: An Evidence-Based
Approach. Emergency Medicine Practice. Jan 2009:11.
5. 
Services DoHaS, Health DoP, EMS SoCHa. State of Alaska Cold Injuries
Guidelines. Juneau, Alaska (Guideline) 2014.
6. 
AHA. Hypothermia. Circulation: Journal of the American Heart Association. 2005;Part 10.4(112):IV-136 - IV -138. (Guideline; Consensus
Paper)
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