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On a cold night last winter I received a call from the local EMS associated with my hospital. They were bringing us a 50ish white male found sleeping in an apartment lobby. He was slightly responsive but not making sense—and he had the classic caustic, sweet-sour breath diagnostic of alcohol intake. When the ambulance arrived, he appeared lethargic and cool. His clothes were removed, and after a brief primary survey, it was clear he was more than just intoxicated: He was showing multiple hypothermia symptoms.
Specifically, the patient had a purplish-gray hue to his fingertips and toes (cyanosis), and his torso was cool and somewhat pale. He was only able to mumble, but he appeared to be uninjured and was moving all his extremities aimlessly. Initial exam demonstrated he was intact and uninjured.
Quick vital signs demonstrated a core body temperature of 33.3 degrees C (92 F), blood pressure of 105/62, and a heart rate of about 110 beats per minute. He was confused, lethargic, and cool to the touch.
Emergency Hypothermia Treatment
We stripped off the patient’s clothes and immediately covered him with heated blankets and wheeled him into one of the warmer Emergency Department rooms. The weather had been cold and damp, and was hovering around freezing with some residual ice and snow present. It was clear that I was dealing with a case of hypothermia in an adult, complicated by alcohol intoxication.
This patient was in serious danger, yet he was only one of many patients on the spectrum of hypothermic injury seen each year in hospitals around the nation. He was obviously ill and in danger, yet my training told me there were certain steps I could take that could quickly mitigate his mortality or further injury.
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A Primer on Hypothermia: Diagnosis
Hypothermia is an interesting and complicated condition because it varies, as to degree, along a continuous spectrum of disease, from the mildest cold-induced injury to extremely serious, life-threatening exposure. It is common sense to realize that the human body will become colder the longer it is exposed to a cold environment. It is also common sense to realize that variations in our protection—shelter and clothing—will also make an impact as to how cold we get.
Mild hypothermia is defined as a body temperature of 32 to 35 C (90 to 95 F), while moderate hypothermia is a core temperature of 28 to 32 C (82 to 90 F). And, finally, severe hypothermia is defined by a core body temperature below 28 C (82 F). These are fluid and rough guidelines, because there are also physiological and individual factors affecting each patient that have an impact on the degree or seriousness of injury.
For example: a patient who is a conditioned runner will have a different clinical response to a core temperature of 32 C. than a sickly or elderly individual with a similar body temperature. The degree of “bounce back” or recovery will vary widely in patients of different states of health, age or body tone.
Core temperature is typically taken the old-fashioned way your mom took it—with a glass thermometer. Rectal temps provide a quick adequate measurement, however, for more seriously cold patients other methods may be necessary, such as an esophageal probe, bladder probe, or intraperitoneal probe. Oral temperatures are not considered adequate to measure the core body temperature.
Reading Hypothermia Symptoms: What They Mean
Not only is there a rough ranking of hypothermia by temperature, but also it is classified “mild, moderate, to severe” by clinical signs and symptoms that roughly follow core body temperature.
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The following clinical signs demonstrate some of the ways a person with hypothermia may look should you find them, rescue them, or see them in an emergency setting:
- Mild hypothermia is demonstrated by rapid breathing, dizziness, clumsy speech, impaired judgment and often, shivering. These patients will often be anxious and active on stimulation or examination. They can answer basic questions and will usually be fully oriented and appropriate within minutes of warming.
- With moderate hypothermia, patients will be lethargic and slow-moving. They have lost their shivering response and will usually have a reduced respiratory rate (slow breathing) and a slow heart rate. They will appear sleepy and unfocused. They are often mistaken for being intoxicated or drunk; this is a “pitfall” that any good ER doctor will try not to step in.
- Severe hypothermia is characterized by an unresponsive patient who will have a severely slowing heartbeat and breathing rate. The heart often becomes irregular and will soon stop beating, along with the patient’s breathing and other life functions. The patient will not have measurable vital signs, and his metabolic functions will also cease. At this point, death is inevitable, except in the most extremely rare cases where intervention is rapid, extreme, and highly directed by proper medical care.
Severe hypothermia can occur within hours in most common exposures—or within minutes in very extreme conditions, such as cold water immersion or, for example, on the slopes of Mt. Everest. Falling through an icy lake or being stuck on the side of a mountain in sub-zero weather are not likely scenarios for most people, luckily.
My patient, however, passed out drunk in cold weather—which describes a rather common event, relatively speaking. We live in a society with homelessness and substance abuse, and our weather, wherever we are in the U.S., can be variable. Cold exposure in these types of circumstances can happens in any part of the nation, depending on the time of year.
Hypothermia Symptoms Spark a Quick ER Response
Let’s get back to my patient: His core temperature measured approximately 92 degrees F, which put him in the mild hypothermia group. However, he was not shivering, although he was lethargic and confused.
In this scenario, not only was his alcohol intoxication impairing his response to cold conditions, but it was also blurring my clinical assessment of him and confusing the picture of mild hypothermia. In these types of cases, a good clinician integrates the various factors that create the clinical picture of a patient. In this specific case, it was alcohol intoxication along with prolonged cold exposure.
The obvious plan was apparent, and my team embarked on it most efficiently. “Warm him up” was the first step: We placed him under a Bair Hugger blanket, a device made of soft plastic pumped with heated air.
When placed on the patient, a Bair Hugger provides a continuous warming environment that’s adequate for most cases of mild hypothermia. This method is called an “external warming” technique. By providing a warm environment, we warm the organism and prevent further heat loss. Hot blankets, a warm bath, warm forced air, heating pads, and heating blankets are other external warming techniques.
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Treating Hypothermia Symptoms with “Internal Warming”
In more severe cases of hypothermia, clinicians may need to use internal warming techniques. In fact, internal warming is usually required in more critical levels (moderate to severe) of hypothermia. Such techniques are more invasive and sometimes require a procedure or sterile technique. They include:
- Warm intravenous fluids (saline and dextrose)
- Infusion of warm
- Sterile fluids into the bladder
- Rectum or even peritoneal cavity
A patient placed on a ventilator, for example, and ventilated with warm air, is undergoing a form of internal warming. In some severe patients it may be necessary to use warm dialysis fluids or even place the patient on cardiopulmonary bypass machine.
These latter techniques are extreme, but have often been used in extreme cases of cold exposure or cold water immersion accidents. The core temperature in such patients is so low, that there is little ability to generate adequate calories from the metabolic function of the patient.
Even in my cold, lethargic, drunken patient, he is burning calories and creating some fire within, by metabolizing the alcohol he consumed. By keeping him warm for a number of hours, and allowing him to stabilize, he will warm from within.
This is exactly what happened to my accidental visitor. After a fitful night under the Bair Hugger and several liters of warmed intravenous Ringers Lactate solution, he awoke looking for his shoes, and asking for something to eat. He made short work of the ubiquitous dry turkey sandwiches that we always have in the ER fridge. He polished them off, along with several servings of “cup a soup” and a small container of chocolate pudding.
By morning, he was voiding voluminously into the bedside urinal, and soon was walking, however unsteadily, to the bathroom. By morning sign-out, the patient was becoming somewhat of a nuisance, and demanding his rights, his wallet, shoes, clothing, etc. He was significantly oblivious to the resources, energy, and efforts expended to save his life.
A job well-done. So it goes for an Emergency Physician.
A MATTER OF LIFE: QUICK RESPONSE TO HYPOTHERMIA SYMPTOMS
I wrote this case to illustrate a typical “cold exposure,” knowing that it encompasses many of the concepts relevant to hypothermia and allowing me to give a brief overview of serious life-threatening hypothermia. In a companion piece, I’ll touch on mild cold exposure cases that will get into minor cold-induced injuries such as frostbite, frostnip, or Pernio (chilblain).
Whatever the cold-exposure is—mild, moderate, or severe—it is elementary that proper clothing, adequate caloric intake, and limiting one’s exposure to extremely cold environments will protect one from most cases of hypothermia.
In rare cases of accidental exposure, I stress to the readers to anticipate environmental conditions, weather, upcoming storms, and appropriate attire, so as to avoid freezing—and an unscheduled trip to the ER.