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Accidental hypothermia

Definition
Accidental hypothermia is defined as an unintentional decline in the core body temperature to < 35 °C due to environmental exposure.
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Pathophysiology
The pathophysiology of accidental hypothermia involves a combination of heat loss and impaired thermoregulation. Heat loss can occur through radiation, conduction, convection, and evaporation. Impaired thermoregulation can result from factors such as sepsis, which can disrupt the body's normal temperature control mechanisms.
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Epidemiology
In the US, accidental hypothermia is responsible for at least 1,500 deaths each year. The incidence of accidental hypothermia in the Netherlands is estimated at 1.1 per 100,000 person-years.
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Disease course
Clinical manifestations of accidental hypothermia can vary depending on the severity. Mild hypothermia may present with shivering and altered mental status. As the condition worsens, patients may exhibit detectable vital signs even with core temperatures < 24 °C. Severe hypothermia can lead to cardiac arrhythmias, hypoventilation, and in extreme cases, cardiac arrest.
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Prognosis and risk of recurrence
The overall mortality rate of accidental hypothermia is significant. In a study conducted in Japan, the overall proportion of cases resulting in in-hospital death was 24.4%.
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Key sources
The following summarized guidelines for the evaluation and management of accidental hypothermia are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2020) and the Wilderness Medical Society (WMS 2019).
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Guidelines

1.Diagnostic investigations

Field assessment: classify hypothermia as mild, moderate, severe and profound on the bases of clinical observations, recognizing that:
shivering can occur below 32 °C, usually with altered mental status
patients can have detectable vital signs with core temperatures below 24 °C
core temperature can overlap between classification categories
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  • Core temperature measurement

2.Respiratory support

Airway management
Recognize that advantages of advanced airway management outweigh the risk of causing VF.
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Place a nasogastric or orogastric tube after the airway is secured to decompress the stomach.
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  • Ventilation

3.Medical management

Fluid resuscitation: place intraosseous catheter, if immediate peripheral IV catheter cannot be placed. Use femoral line for the central venous access, if no other option is available.
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  • Vasopressors

  • Glucose and insulin

4.Nonpharmacologic interventions

Out-of-hospital management, safety of the rescuer: ensure that the scene is secure and safe to enter and make an evaluation before the decision to rescue or resuscitate a patient.
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  • Out-of-hospital management (patient handling)

  • Out-of-hospital management (protection from cold)

  • Out-of-hospital management (passive rewarming)

  • Out-of-hospital management (active rewarming)

  • Out-of-hospital management (rewarming during transport)

  • Out-of-hospital management (non-hypothermic cold-stressed patients)

  • Out-of-hospital management (patients with severe trauma)

  • Transportation

5.Therapeutic procedures

Cardiopulmonary resuscitation: attempt CPR unless contraindications exist. Recognize that fixed, dilated pupils, apparent rigor mortis, and dependent lividity are not contraindications to resuscitation in patients with severe hypothermia.
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  • Automated external defibrillation

  • Transcutaneous pacing

6.Specific circumstances

Patients in cardiac arrest: undertake full resuscitative measures, including extracorporeal rewarming when available, in all victims of accidental hypothermia without characteristics suggesting that they are unlikely to survive and without any obviously lethal traumatic injury.
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