Hypothermia, a potentially fatal condition, occurs when body temperature falls below 95°F (35°C).
Description
Although hypothermia is an obvious danger for people living in cold climates, many cases have occurred when the air temperature is well above the freezing mark. Elderly people, for instance, have succumbed to hypothermia after prolonged exposure to indoor air temperatures of 50–65°F (10–18.3°C). In the United States, hypothermia is primarily an urban phenomenon associated with alcoholism, drug addiction, mental illness, and cold—water immersion accidents. The victims are often homeless male alcoholics. Officially, 11,817 deaths were attributed to hypothermia in the United States from 1979 to 1994, but experts suspect that many fatal cases go unrecognized. Nearly half the victims were 65 or older, with males dominating every age group. Nonwhites were also overrepresented in the statistics. Among males 65 and older, nonwhites outnumbered whites by more than four to one.
Causes and symptoms
Measured orally, a healthy person's body temperature can fluctuate between 97°F (36.1°C) and 100°F (37.8°C). Survival depends on maintaining temperature stability within this range by balancing the heat produced by metabolism with the heat lost to the environment through (for the most part) the skin and lungs. When environmental or other changes cause heat loss to out-pace heat production, the brain triggers physiological and behavioral responses to restore the balance. The involuntary muscular activity of shivering, for example, aids heat production by accelerating metabolism. But if the cold stress is too great and the body's defenses are overwhelmed, body temperature begins to fall. Hypothermia is considered to begin once body temperature reaches 95°F (35°C), though even smaller drops in temperature can have an adverse effect.
Hypothermia is divided into two types: primary and secondary. Primary hypothermia occurs when the body's heat-balancing mechanisms are working properly but are subjected to extreme cold, whereas secondary hypothermia affects people whose heat-balancing mechanisms are impaired in some way and cannot respond adequately to moderate or perhaps even mild cold. Primary hypothermia typically involves exposure to cold air or immersion in cold water. The cold air variety usually takes at least several hours to develop, but immersion hypothermia will occur within about an hour of entering the water, since water draws heat away from the body much faster than air does. In secondary hypothermia, the body's heat-balancing mechanisms can fail for any number of reasons, including strokes, diabetes, malnutrition, bacterial infection, thyroid disease, spinal cord injuries (which prevent the brain from receiving crucial temperature-related information from other parts of the body), and the use of medications and other substances that affect the brain or spinal cord. Alcohol is one such substance. In smaller amounts it can put people at risk by interfering with their ability to recognize and avoid cold-weather dangers. In larger amounts it shuts down the body's heat-balancing mechanisms.
Secondary hypothermia is often a threat to the elderly, who may be on medications or suffering from illnesses that affect their ability to conserve heat. Malnutrition and immobility can also put the elderly at risk. Some medical research suggests as well that shivering and blood vessel narrowing—two of the body's defenses against cold—may not be triggered as quickly in older people. For these and other reasons, the elderly can, over a period of days or even weeks, fall victim to hypothermia in poorly insulated homes or other surroundings that family, friends, and care-givers may not recognize as life threatening. Another risk for the elderly is the fact that hypothermia can easily be misdiagnosed as a stroke or some other common illness of old age.
The signs and symptoms of hypothermia follow a typical course, though the body temperatures at which they occur vary from person to person depending on age, health, and other factors. The impact of hypothermia on the nervous system often becomes apparent quite early. Coordination, for instance, may begin to suffer as soon as body temperature reaches 95°F (35°C). The early signs of hypothermia also include cold and pale skin and intense shivering; the latter stops between 90°F (32.2°C) and 86°F (30°C). As body temperature continues to fall, speech becomes slurred, the muscles go rigid, and the victim becomes disoriented and experiences eyesight problems. Other harmful consequences include dehydration as well as liver and kidney failure. Heart rate, respiratory rate, and blood pressure rise during the first stages of hypothermia, but fall once the 90°F (32.2°C) mark is passed. Below 86°F (30°C) most victims are comatose, and below 82°F (27.8°C) the heart's rhythm becomes dangerously disordered. Yet even at very low body temperatures, people can survive for several hours and be successfully revived, though they may appear to be dead.
Diagnosis
Information on the patient's prior health and activities often helps doctors establish a correct diagnosis and treatment plan. Pulse, blood pressure, temperature, and respiration require immediate monitoring. Because the temperature of the mouth is not an accurate guide to the body's core temperature, readings are taken at one or two other sites, usually the ear, rectum, or esophagus. Other diagnostic tools include electrocardiography, which is used to evaluate heart rhythm, and blood and urine tests, which provide several kinds of key information; a chest x ray is also required. A computed tomography scan (CT scan) or magnetic resonance imaging (MRI) may be needed to check for head and other injuries.
Treatment
Emergency medical help should be summoned whenever a person appears hypothermic. The danger signs include intense shivering; stiffness and numbness in the arms and legs; stumbling and clumsiness; sleepiness, confusion, disorientation, amnesia, and irrational behavior; and difficulty speaking. Until emergency help arrives, a victim of outdoor hypothermia should be brought to shelter and warmed by removing wet clothing and footwear, drying the skin, and wrapping him or her in warm blankets or a sleeping bag. Gentle handling is necessary when moving the victim to avoid disturbing the heart. Rubbing the skin or giving the victim alcohol can be harmful, though warm drinks such as clear soup and tea are recommended for those who can swallow. Anyone who aids a victim of hypothermia should also look for signs of frostbite and be aware that attempting to rewarm a frostbitten area of the body before emergency help arrives can be extremely dangerous. For this reason, frostbitten areas must be kept away from heat sources such as campfires and car heaters.
Rewarming is the essence of hospital treatment for hypothermia. How rewarming proceeds depends on the body temperature. Different approaches are used for patients who are mildly hypothermic (the patient's body temperature is 90–95°F [32.2–35°C]), moderately hypothermic (86–90°F [30–32.2°C]), or severely hypothermic (less than 86°F [30°C]). Other considerations, such as the patient's age or the condition of the heart, can also influence treatment choices.
Mild hypothermia is reversed with passive rewarming. This technique relies on the patient's own metabolism to rewarm the body. Once wet clothing is removed and the skin is dried, the patient is covered with blankets and placed in a warm room. The goal is to raise the patient's temperature by 0.5–2°C an hour.
Moderate hypothermia is often treated first with active external rewarming and then with passive rewarming. Active external rewarming involves applying heat to the skin, for instance by placing the patient in a warm bath or wrapping the patient in electric heating blankets.
Severe hypothermia requires active internal rewarming, which is recommended for some cases of moderate hypothermia as well. There are several types of active internal rewarming. Cardiopulmonary bypass, in which the patient's blood is circulated through a rewarming device and then returned to the body, is considered the best, and can raise body temperature by 1–2°C every 3–5 minutes. However, many hospitals are not equipped to offer this treatment. The alternative is to introduce warm oxygen or fluids into the body.
Hypothermia treatment can also include, among other things, insulin, antibiotics, and fluid replacement therapy. When the heart has stopped, both cardiopulmonary resuscitation (CPR) and rewarming are necessary. Once a patient's condition has stabilized, he or she may need treatment for an underlying problem such as alcoholism or thyroid disease.
Prognosis
Victims of mild or moderate hypothermia usually enjoy a complete recovery. In regard to severely hypothermic patients, the prognosis for survival varies due to differences in people's physiological responses to cold.
Prevention
People who spend time outdoors in cold weather can reduce heat loss by wearing their clothing loosely and in layers and by keeping their hands, feet, and head well covered (30–50% of body heat is lost through the head). Because water draws heat away from the body so easily, staying dry is important, and wet clothing and footwear should be replaced as quickly as possible. Wind- and water-resistant outer garments are also crucial. Alcohol should be avoided because it promotes heat loss by expanding the blood vessels that carry body heat to the skin.
Preventing hypothermia among the elderly requires vigilance on the part of family, friends, and caregivers. An elderly person's home should be properly insulated and heated, with living areas kept at a temperature of 70°F (21.1°C). Warm clothing and bedding are essential, as are adequate food, rest, and exercise; warming the bed and bedroom before going to sleep is also recommended. Older people who live alone should be visited regularly—at least once a day during very cold weather—to ensure that their health remains sound and that they are taking good care of themselves. For help and advice, family members and others can turn to government and social service agencies. Meals on wheels and visiting nurse programs, for instance, may be available, and it may be possible to obtain financial aid for winterizing and heating homes.
BOOKS
Danzl, Daniel F. "Disturbances Due to Cold." In Conn's Current Therapy, 1996, ed. Robert E. Rakel. Philadelphia: W.B. Saunders Co., 1996.
Danzl, Daniel F., Robert S. Pozos, and Murray P. Hamlet. "Accidental Hypothermia." In Wilderness Medicine: Management of Wilderness and Environmental Emergencies, ed. Paul S. Auerbach. St. Louis: Mosby, 1995.
Mills Jr., W. J., and R. S. Pozos. "Low Temperature Effects on Humans." In Encyclopedia of Human Biology, ed. Renato Dulbecco. San Diego: Academic Press, 1997.
Petty, Kevin J. "Hypothermia." In Harrison's Principles of Internal Medicine, ed. Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.
Howard Baker
KEY TERMS
Antibiotics—Substances used against microorganisms that cause infection.
Computed tomography—A process that uses x rays to create three-dimensional images of structures inside the body.
Esophagus—A muscular tube through which food and liquids pass on their way to the stomach.
Magnetic resonance imaging—The use of electromagnetic energy to create images of structures inside the body.
Metabolism—The chemical changes by which the body breaks down food and other substances and builds new substances necessary for life.
Nervous system—The system that transmits information, in the form of electrochemical impulses, throughout the body. It comprises the brain, spinal cord, and nerves.
Rectum—The lower section of the large intestine. The intestines are part of the digestive system.
Stroke—A condition involving loss of blood flow to the brain.
Thyroid—A gland (fluid-secreting structure) in the neck. It plays an important role in metabolism.
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