HYPOTHERMIA

& COLD INJURIES

 Background
• Definition: Core Temp <35°C
• Severity:
– Mild hypothermia: 32-35°C
• Shivering thermogenesis, amnesia, dysarthria
– Moderate hypothermia: 28-32°C
• Stupor, extinguished shivering, dysrhythmias
– Severe hypothermia: <28°C
• V-fib risk, acid base disturbance, decreased CO and CBF
 DDx
• Accidental • Drugs
(environmental) exposure – Ethanol
• Metabolic disorders – Sedatives-hypnotics
– Hypoglycemia • Sepsis
– Hypothyroidism • Dermal disease
– Hypoadrenalism – Burns
– Hypopituitarism – Exfoliative dermatitis
• Hypothalamic and CNS • Acute incapacitating
– Head trauma illness
– Tumor • Massive fluid or blood
– Stroke resuscitation
– Wernicke encephalopathy • Malnutrition
 ECG
• Typical sequence is sinus brady > a fib w/ slow
ventricular response > v-fib > asystole
• Other ECG findings:
– Osborn (J) wave
– T-wave inversions
– PR, QRS, QT prolongation
– Muscle tremor artifact
– AV block
– PVCs
Typical ECG

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 Supportive measures
• Handle pt gently
– V-fib may be induced by rough handling of pt due to
irritable myocardium (anecdotal)
• O2
– Hypothermia causes leftward shift of oxyhemoglobin
dissociation curve
• IVF
– Hypothermia > impaired renal concentrating ability >
cold diuresis
– Pts are prone to rhabdo
– Intravascular volume is lost due to extravascular shift
 Specific therapies
• Abx
– Give if suspect sepsis (e.g. hypothermia fails to correct w/
rewarming measures)
• Thiamine
– Consider if Wernicke disease is possible cause of
hypothermia (e.g. alcoholic pt)
• Hydrocortisone
– Consider if pt has history of adrenal suppression or
insufficiency
• Thyroxine
– Consider if any suspicion for hypothyroidism/myxedema
coma
 Passive Rewarming
• Consider in pt w/ mild hypothermia (>32°C)
who is able to generate intrinsic heat
• Techniques
– Removal from cold environment
– Remove wet clothing
– Insulation with blankets
 Active rewarming
• Indications
– Cardiovascular instability
– Moderate to severe hypothermia (<32°C)
– Inadequate rate or failure to rewarm
– Endocrine insufficiency
– Traumatic or toxicologic peripheral vasodilation
– Secondary hypothermia impairing thermoregulation
• Rewarm trunk BEFORE the extremities
– Otherwise may lead to hypotension ("core temperature
afterdrop")
• Warmed vasodilated peripheral tissue allows cooler blood in
extremities to circulate back to core
 Active External Rewarming
• Consider in: • Techniques
– Moderate-severe – Warm IV bags applied
hypothermia to skin
– Mild hypothermia in pt – Heating blankets
who is unstable or – Radiant heat
cannot generate – Forced air - Bair hugger
intrinsic heat
– Failure to respond to
passive external
rewarming
– May be ineffective in
pts w/ poor perfusion
or in cardiac arrest
 Active Internal Rewarming
• Consider alone or • Techniques
along with active – Warm humidified O2 –
external warming in: Heated IV fluids: 40-42°C
• Level 1 infuser
– Cardiovascular • Microwave on high x 2min
instability / life- – Peritoneal lavage
threatening • Encourages liver function
dysrhythmias – Pleural lavage
– Severe hypothermia • 2 large chest tubes
– Moderate – GI tract lavage and
hypothermia which bladder lavage
• Limited area for heat exchange
fails to respond to less and can cause Electrolyte shifts
aggressive measures – Bypass/ECMO/AV
Dialysis
 ACLS
• CPR
– Only perform if pt truly does not have a pulse
(unnecessary CPR may lead to V-fib)
– Spend 30-45s attempting to detect respiratory
activity and pulse before starting CPR
• Pt not dead until warm and dead: 30-32°C
• Active internal rewarming indicated for
cardiac arrest
– Mediastinal and direct cardiac lavage
 ACLS
• Dysrhythmias (Occur <30°C)
– Active rewarming is treatment of choice
• Most dysrhythmias (e.g. sinus brady, a-fib/flutter) require no
other therapy
• Activity of antiarrhythmics is unpredictable in hypothermia •
Hypothermic heart is relatively resistant to atropine, pacing,
and countershock
– V-fib
• May be refractory to therapy until pt is rewarmed
• Attempt a single defibrillation attempt
– If unsuccessful continue CPR and attempt defibrillation again
once temp >30C (86F)
– IV medications: increase interval between doses
FREEZING INJURIES
 Background
• Results from the freezing of tissue
• It is a disease of morbidity, not mortality
• Risk correlated with temperature and wind speed
– Risk is <5% when ambient temperature (includes wind
chill) is > –15°C
– Most often occurs at ambient temp < –20°C
• Can develop w/in 2-3sec when metal surfaces
that are at or below –15°C are touched
• Most commonly affects distal part of extremities,
face, nose, and ears
 Pathophysiology
• Freezing alone is usually not sufficient to
cause tissue death
– Thawing contributes markedly to the degree of
injury
– Endothelial damage, beginning at the point of
thaw, is the critical event in frostbite
• Resulting damage results in swelling, platelet
aggregation, vessel thrombosis
 Zones of Injury
• Zone of Coagulation
• Most severe and usually most distal
• Damage is irreversible
• Zone of Hyperemia
• Least severe and usually most proximal
• Generally recovers w/o treatment in <10d
• Zone of Stasis
• Middle zone characterized by severe, but possibly
reversible, cell damage
• It is this zone for which treatment may have benefit
 Classification
• First degree (frostnip)
– Partial-skin freezing
– Stinging and burning, followed by throbbing
– Numbness, erythema, swelling, dysesthesia,
desquamation (days later)
– Prognosis excellent
 Classification
• Second degree
– Full-thickness skin freezing
– Numbness followed by aching and throbbing
– Skin blisters form w/in 6-24hr
• Desquamate and form hard black eschars over several
days
– Prognosis is good
 Classification
• Third degree
– Damage extends into subdermal plexus
– Extremity feels like a "block of wood" followed by
burning, throbbing, shooting pains
– Hemorrhagic blisters form and are a/w skin
necrosis and blue-gray discoloration
– Prognosis is often poor
– Tissue loss involving entire thickness of skin
 Classification
• Fourth degree
– Extension into subcutaneous tissues, muscle,
bone, and tendon; little edema
– Deep, aching joint pain
– Skin is mottled w/ nonblanching cyanosis and
formation of deep, dry, black eschar
– Prognosis is extremely poor
 Pre-thaw
• Assess Doppler pulse and appearance
• Protect part – no friction massage
• Stabilize core temperature
• Address medical and surgical conditions
• Rehydrate patient
• Prevent partial thaw and refreeze
– Refreezing will cause even more severe damage
 Thaw
• Analgesia
– Provide parenteral opiates
• Blocking prostaglandin, thromboxane, and arachidonic
cascade
• Ibuprofen 400mg po q8h
• Rapid rewarming is the core of therapy and should be
initiated as soon as possible
– Extremities
• Place in water w/ temperature of 37- 40°C (do not exceed 42°C) •
Leave in for 20-30min, when the extremity should become pliable
and erythematous
– Face
• Apply moistened compresses soaked in warm water
 Post-thaw
• Tetanus prophylaxis
• Local wound care
– Apply topical aloe vera cream q6hr (interrupts
arachidonic acid cascade)
– Affected digits should be separated w/ cotton and
wrapped w/ sterile, dry gauze
– Dry, elevate and splint
– Blister removal is controversial
• Consider drainage of nonhemorrhagic bullae that interfere
w/ movement
• Never debride hemorrhagic bullae
 Post-thaw
• Systemic care
– Hydrotherapy at 37°C tid
– Streptococcal prophylactic Pen G 500kU IV q6hr
– Intra-arterial tPA reduces digit amputation rate
– Phenoxybenzamine to reduce vasospasm
• Surgery
– Monitor compartment pressures
– Amputation
• May be required if wet gangrene or infection occurs
• Usually not performed until full demarcation occurs (3-4 wk)
 Sequelae
• Acute
– Rhabdomyolysis, ATN, Electrolyte fluxes
– Core temperature afterdrop
– Compartment syndrome
• Chronic
– Neuropathic pain/dysesthesias, thermal sensitivity
– Autonomic dysfunction (Hyperhidrosis, Raynaud’s)
– MSK (atrophy, tenosynovitis, strictures, OA)
– Derm (edema, ulcers, delayed cancers)
NON-FREEZING INJURIES
 Pernio (Chillblains)
• Background
• Mild but uncomfortable inflammatory lesions
of skin
– Caused by long-term intermittent exposure to
damp, nonfreezing ambient temperatures
 Pernio
• Symptoms • Treatment
– Tingling, numbness, pruritus, • Affected skin should be
burning paresthesias rewarmed, gently bandaged,
– Cutaneous manifestations and elevated
appear up to 12hr after acute • Nifedipine 20mg PO TID may be
exposure: helpful as both prophylactic and
– Localized edema, erythema, therapeutic tx
cyanosis, plaques, nodules
• May progress in rare cases to • Topical corticosteroids and oral
ulcerations, vesicles, and bullae steroid burst have been shown
– Rewarming may result in to be useful
formation of tender blue
nodules which may persist for
days
 Cold Panniculitis
• Prolonged exposure to temp >freezing leads to
mild necrosis of subcutaneous fat tissue
• Seen in children (popsicles) and women
involved in equestrian activities
• Resolution may result in adipose fibrosis w/
cosmetic defects
– There is no treatment
 Trench Foot (Immersion Foot)
• Background
• Develops slowly over hours-days when foot is
exposed to cold/wet conditions
• Reversible injury may progress to irreversible
injury
 Trench Foot
• Clinical Features
– Tingling/numbness is initial symptom
– Foot appears pale, mottled, anesthetic, pulseless, and immobile
• Initially does not change after rewarming
– Hyperemic phase begins w/in hr after rewarming
• Assoc w/ severe burning pain and reappearance of proximal sensation
– As perfusion returns to foot over 2-3d edema and possibly
bullae may form
– Anesthesia persists for weeks and may be permanent; gangrene
may occur

• Treatment
– Keep feet clean, warm, dryly bandaged, elevated
– Monitor for signs of infection
 Sources
• Tintinalli
• Rosen
• WikEM: Jordan Swartz, Manpreet Singh, Ross
Donaldson