disorders of temperature regulation bryan e. bledsoe, facep midlothian, tx
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Disorders of Disorders of Temperature Temperature RegulationRegulation
Bryan E. Bledsoe, FACEPBryan E. Bledsoe, FACEPMidlothian, TXMidlothian, TX
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Temperature RegulationTemperature Regulation
HypothermiaHypothermia HyperthermiaHyperthermia
Heat CrampsHeat Cramps Heat TetanyHeat Tetany Heat ExhaustionHeat Exhaustion Heat SyncopeHeat Syncope Heat StrokeHeat Stroke
FeverFever
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Temperature RegulationTemperature Regulation
Humans are Humans are warm-blooded warm-blooded mammals who mammals who maintain a maintain a constant body constant body temperature temperature ((euthermiaeuthermia).).
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Temperature RegulationTemperature Regulation
Temperature Temperature regulation is regulation is controlled by controlled by the the hypothalamhypothalamusus in the in the base of the base of the brain.brain.
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Temperature RegulationTemperature Regulation
The hypothalamus functions as The hypothalamus functions as a thermostat for the body.a thermostat for the body.
Temperature receptors Temperature receptors (thermoreceptors) are located (thermoreceptors) are located in the skin, certain mucous in the skin, certain mucous membranes, and in the deeper membranes, and in the deeper tissues of the body.tissues of the body.
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Temperature RegulationTemperature Regulation
When an increase in body temperature When an increase in body temperature is detected, the hypothalamus shuts is detected, the hypothalamus shuts off body mechanisms that generate off body mechanisms that generate heat (for example, shivering).heat (for example, shivering).
When a decrease in body temperature When a decrease in body temperature is detected, the hypothalamus shuts is detected, the hypothalamus shuts off body mechanisms designed to cool off body mechanisms designed to cool the body (for example, sweating).the body (for example, sweating).
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Temperature RegulationTemperature Regulation
Body Temperature = Thermogenesis–Heat Body Temperature = Thermogenesis–Heat LossLoss
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Temperature RegulationTemperature Regulation
Basal Metabolic Rate:Basal Metabolic Rate: The metabolism that occurs The metabolism that occurs
when the body is completely at when the body is completely at rest.rest.
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Temperature RegulationTemperature Regulation
Metabolic Rate:Metabolic Rate: The body continuously adjusts The body continuously adjusts
the metabolic rate in order to the metabolic rate in order to maintain a constant CORE maintain a constant CORE temperature.temperature.
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Temperature RegulationTemperature Regulation
Normal body Normal body temperature is temperature is approximately approximately 3737º º C (98.6C (98.6º º F).F).
However, what However, what is normal for an is normal for an individual may individual may vary somewhat.vary somewhat.
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HypothermiaHypothermia
Definition of HypothermiaDefinition of Hypothermia:: CLASSIC DEFINITION: A state of low CLASSIC DEFINITION: A state of low
body temperature, specifically a low body temperature, specifically a low CORE temperature (< 35CORE temperature (< 35º C or < 95º º C or < 95º F)F)..
ALTERNATIVE DEFINITION: It is best ALTERNATIVE DEFINITION: It is best defined as the unintentional decrease defined as the unintentional decrease of around 2of around 2º C (3.6º F) from the º C (3.6º F) from the “normal” CORE temperature“normal” CORE temperature
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HypothermiaHypothermia
What is the What is the CORE CORE temperature?temperature? The deep The deep
internal internal temperature of temperature of normothermicnormothermic humans.humans.
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HypothermiaHypothermia
How is the CORE How is the CORE temperature temperature measured?measured? There is little variance in There is little variance in
CORE temperature CORE temperature because of perfusion.because of perfusion.
Esophageal and Esophageal and tympanic temperatures tympanic temperatures are essentially the same are essentially the same as the temperature of as the temperature of the pulmonary artery.the pulmonary artery.
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HypothermiaHypothermia
In steady-state In steady-state conditions, the conditions, the rectal rectal temperature is a temperature is a good index of good index of CORE CORE temperature.temperature.
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HypothermiaHypothermia
Oral Oral temperature is temperature is an excellent an excellent index of CORE index of CORE temperature, temperature, provided the provided the mouth is kept mouth is kept closed.closed.
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HypothermiaHypothermia
The type of The type of temperature temperature measurement measurement utilized is less utilized is less important than important than using the same using the same device and device and measurement site to measurement site to detect trends.detect trends.
Thermometer must Thermometer must be able to read low be able to read low temperatures.temperatures.
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Heat loss Heat loss results from:results from: ConductionConduction ConvectionConvection RadiationRadiation EvaporationEvaporation RespirationRespiration
HypothermiaHypothermia
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Heat = Molecular MotionHeat = Molecular Motion
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HypothermiaHypothermia
Conduction:Conduction: Heat loss occurs Heat loss occurs
due to direct due to direct contact of the body contact of the body with a cooler object.with a cooler object.
Heat flows from Heat flows from higher temperature higher temperature matter to lower matter to lower temperature matter.temperature matter.
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HypothermiaHypothermia
Convection:Convection: Heat loss occurs Heat loss occurs
due to air currents due to air currents passing over the passing over the body.body.
Heat must first be Heat must first be conducted to the conducted to the air before air before convection can convection can occur.occur.
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HypothermiaHypothermia
Radiation:Radiation: Heat loss Heat loss
results from results from infrared rays.infrared rays.
All objects not All objects not at absolute zero at absolute zero will radiate heat will radiate heat to the to the atmosphere.atmosphere.
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RadiationRadiation
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RadiationRadiation
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HypothermiaHypothermia
Evaporation:Evaporation: Heat loss occurs Heat loss occurs
as water as water evaporates from evaporates from the skin.the skin.
Heat loss occurs Heat loss occurs as water as water evaporates from evaporates from the lungs during the lungs during respirationrespiration..
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HypothermiaHypothermia
Respiration:Respiration: Respiration combines the heat Respiration combines the heat
loss mechanisms of convection, loss mechanisms of convection, radiation, and evaporation.radiation, and evaporation.
Expired air is normally 98.6 Expired air is normally 98.6 degrees F. and 100% humidified.degrees F. and 100% humidified.
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Heat-conserving Heat-conserving MechanismsMechanisms
Vasoconstriction Vasoconstriction of blood vessels in of blood vessels in the skin.the skin.
Stimulated Stimulated through activation through activation of the sympathetic of the sympathetic nervous system.nervous system.
Causes pale, cool Causes pale, cool skin.skin.
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Heat-conserving Heat-conserving MechanismsMechanisms
Piloerection is more Piloerection is more commonly called commonly called “goose bumps” or “goose bumps” or “goose flesh.”“goose flesh.”
Evolutionary Evolutionary remnant.remnant.
Caused by Caused by sympathetic sympathetic stimulation of stimulation of arrector piliarrector pili muscles. muscles.
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Heat-conserving Heat-conserving MechanismsMechanisms
Increased heat Increased heat production:production: ShiveringShivering Activation of Activation of
futile cycles futile cycles (chemical (chemical thermogenesis)thermogenesis)
Increased Increased thyroxine releasethyroxine release
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HypothermiaHypothermia
When the core When the core temperature of temperature of the body drops the body drops below below
9595º º F, an F, an individual is individual is considered to considered to be be hypothermichypothermic..
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HypothermiaHypothermia
Clinically, hypothermia results Clinically, hypothermia results from:from: Inadequate heat generation by Inadequate heat generation by
the body (thermogenesis).the body (thermogenesis). Excessive cold stress.Excessive cold stress. A combination of both.A combination of both.
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HypothermiaHypothermia
Normal Range:Normal Range: 96-10096-100º º FF
Mild Mild Hypothermia:Hypothermia: 90-9590-95º º FF
Severe Severe HypothermiaHypothermia < 90< 90º º FF
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HypothermiaHypothermia
Predisposing Factors to Predisposing Factors to Hypothermia:Hypothermia: Patient AgePatient Age Patient HealthPatient Health MedicationsMedications Prolonged or Intense ExposureProlonged or Intense Exposure Co-existing Weather ConditionsCo-existing Weather Conditions
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HypothermiaHypothermia
Patient Age:Patient Age: Pediatric and geriatric patients Pediatric and geriatric patients
cannot tolerate cold environments cannot tolerate cold environments and have less capacity for heat and have less capacity for heat generation.generation.
Older patients often become Older patients often become hypothermic in environments that hypothermic in environments that seem only mildly cool to others.seem only mildly cool to others.
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HypothermiaHypothermia
Patient Health:Patient Health: Hypothyroidism (suppresses Hypothyroidism (suppresses
metabolic rate)metabolic rate) Malnutrition, hypoglycemia, Malnutrition, hypoglycemia,
Parkinson’s disease, fatigue, and Parkinson’s disease, fatigue, and other medical conditions can other medical conditions can interfere with the body’s ability interfere with the body’s ability to combat cold exposure.to combat cold exposure.
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HypothermiaHypothermia
Medications:Medications: Some drugs interfere with the Some drugs interfere with the
body’s heat-generating body’s heat-generating mechanisms.mechanisms.
These include: narcotics, alcohol, These include: narcotics, alcohol, antihistamines, antipsychotics, antihistamines, antipsychotics, antidepressants, and many antidepressants, and many others.others.
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HypothermiaHypothermia
Prolonged or Intense Prolonged or Intense Exposure:Exposure: The length and severity of cold The length and severity of cold
exposure have a direct effect on exposure have a direct effect on morbidity and mortality.morbidity and mortality.
The Wind Chill Index (WCI) must The Wind Chill Index (WCI) must be taken into consideration.be taken into consideration.
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HypothermiaHypothermia
Coexisting Coexisting Weather Weather Conditions:Conditions: High humidity, High humidity, brisk winds, brisk winds, accompanying rain accompanying rain
can all magnify the can all magnify the effect of cold effect of cold exposure on the body exposure on the body by accelerating heat by accelerating heat loss from the skin.loss from the skin.
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HypothermiaHypothermia
Degrees of Hypothermia:Degrees of Hypothermia: MildMild– Core temperature > 90 – Core temperature > 90
degrees F (32 degrees C)degrees F (32 degrees C) SevereSevere– Core temperature < 90 – Core temperature < 90
degrees F (32 degrees C)degrees F (32 degrees C)
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Signs and SymptomsSigns and Symptoms
MILD Hypothermia:MILD Hypothermia: LethargyLethargy ShiveringShivering Lack of CoordinationLack of Coordination Pale, cold, dry skinPale, cold, dry skin Early rise in blood pressure, Early rise in blood pressure,
heart, and respiratory rates.heart, and respiratory rates.
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Signs and SymptomsSigns and Symptoms
SEVERE Hypothermia:SEVERE Hypothermia: No shiveringNo shivering Heart rhythm problemsHeart rhythm problems Cardiac arrestCardiac arrest Loss of voluntary muscle controlLoss of voluntary muscle control Low blood pressureLow blood pressure Undetectable pulse and respirationsUndetectable pulse and respirations
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PreventionPrevention
Preventive Measures:Preventive Measures: Warm dressWarm dress Plenty of restPlenty of rest Adequate dietAdequate diet Limit ExposureLimit Exposure
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TreatmentTreatment
Treatment for Treatment for Hypothermia:Hypothermia:
1. Remove wet garments1. Remove wet garments
2. Protect against further heat 2. Protect against further heat loss and wind chill.loss and wind chill.
3. Maintain patient in 3. Maintain patient in horizontal position.horizontal position.
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TreatmentTreatment
Treatment for Treatment for Hypothermia:Hypothermia:
4. Avoid rough handling.4. Avoid rough handling.
5. Monitor the core 5. Monitor the core temperature.temperature.
6. Monitor the cardiac rhythm.6. Monitor the cardiac rhythm.
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TreatmentTreatment
ECG changes seen in hypothermia:ECG changes seen in hypothermia: Prolongation of first the PR interval, then the Prolongation of first the PR interval, then the
QRS, then the QTc interval.QRS, then the QTc interval. J waves (also called Osborne waves) can J waves (also called Osborne waves) can
occur at any temperature < 32.3occur at any temperature < 32.3º C (90º F).º C (90º F). Most frequently seen in Leads II and VMost frequently seen in Leads II and V66.. The size of the J waves increase with The size of the J waves increase with
temperature depressiontemperature depression..
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““J” or Osborne WavesJ” or Osborne Waves
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““J” or Osborne WavesJ” or Osborne Waves
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““J” or Osborne WavesJ” or Osborne Waves
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RewarmingRewarming
Methods of Rewarming:Methods of Rewarming: Active External RewarmingActive External Rewarming Active Internal RewarmingActive Internal Rewarming
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RewarmingRewarming
Active Rewarming of MILD Active Rewarming of MILD Hypothermia:Hypothermia: Active external methods:Active external methods:
Warm blanketsWarm blankets Heat packsHeat packs Warm water immersion (with caution)Warm water immersion (with caution)
Active internal methods:Active internal methods: Warmed IV fluidsWarmed IV fluids
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RewarmingRewarming
Active Rewarming of SEVERE Active Rewarming of SEVERE Hypothermia:Hypothermia: Active external methods:Active external methods:
Warm blanketsWarm blankets Heat packsHeat packs Warm water immersion (with Warm water immersion (with
caution)caution) Active internal methods:Active internal methods:
Warmed IV fluidsWarmed IV fluids Warmed, humidified oxygenWarmed, humidified oxygen
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RewarmingRewarming
Rewarming of the SEVERE Rewarming of the SEVERE hypothermia patient is best carried hypothermia patient is best carried out in the Emergency Department out in the Emergency Department using a pre-defined protocol, unless using a pre-defined protocol, unless travel time exceeds 15 minutes.travel time exceeds 15 minutes.
Most patients who die during active Most patients who die during active rewarming die from ventricular rewarming die from ventricular fibrillation.fibrillation.
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RewarmingRewarming
Application of external heat in the Application of external heat in the prehospital setting is usually not prehospital setting is usually not effective and not recommended effective and not recommended because:because: More heat transferrence is required More heat transferrence is required
than generally possible in the than generally possible in the prehospital setting.prehospital setting.
Application of external heat may cause Application of external heat may cause “rewarming shock.”“rewarming shock.”
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RewarmingRewarming
Rewarming Shock:Rewarming Shock: Occurs due to peripheral reflex Occurs due to peripheral reflex
vasodilation.vasodilation. Causes the return of cooled blood and Causes the return of cooled blood and
metabolic acids from the extremities.metabolic acids from the extremities. May cause a paradoxical afterdrop in May cause a paradoxical afterdrop in
the core temperature further the core temperature further worsening hypothermia.worsening hypothermia.
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RewarmingRewarming
Rewarming Shock:Rewarming Shock: Can be prevented in the Can be prevented in the
prehospital setting by using prehospital setting by using warmed IV fluids during active warmed IV fluids during active rewarming.rewarming.
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RewarmingRewarming
Portable IV fluid Portable IV fluid heaters are available heaters are available in the United States in the United States and Canada.and Canada.
Devices fit in-line Devices fit in-line and are powered by and are powered by DC power sources.DC power sources.
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RewarmingRewarming
The device is The device is single-use and single-use and remains with remains with the patient in the patient in the hospital the hospital (both the ED (both the ED and on the and on the floor).floor).
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RewarmingRewarming
The HOT IV is The HOT IV is powered from a powered from a Physio-Control Physio-Control battery or from battery or from a DC converter a DC converter plugged in to plugged in to an AC outlet.an AC outlet.
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Issues in HypothermiaIssues in Hypothermia
Benefits of IV Fluid Benefits of IV Fluid Warming:Warming: Maintains euthermiaMaintains euthermia Increases patient comfortIncreases patient comfort Prevents shiveringPrevents shivering
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Issues in HypothermiaIssues in Hypothermia
Benefits of IV Fluid WarmingBenefits of IV Fluid Warming:: Prevents cold-induced dysrhythmiasPrevents cold-induced dysrhythmias Decreases hemorrhage in abdominal Decreases hemorrhage in abdominal
trauma patientstrauma patients Decreases the incidence of Decreases the incidence of
infectious complications in infectious complications in abdominal trauma patientsabdominal trauma patients
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Issues in HypothermiaIssues in Hypothermia
Benefits of IV Fluid Benefits of IV Fluid WarmingWarming:: Allows active internal rewarming Allows active internal rewarming
to begin in the prehospital to begin in the prehospital setting.setting.
Less labor-intensive, freeing Less labor-intensive, freeing emergency personnel to manage emergency personnel to manage other, more pressing care needs.other, more pressing care needs.
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Cardiac ArrestCardiac Arrest
Other Clinical Concerns:Other Clinical Concerns: Resuscitation of cardiac arrest Resuscitation of cardiac arrest
due to hypothermia is only due to hypothermia is only successful when the patient is successful when the patient is being re-warmed.being re-warmed.
The hypothermic cardiac arrest The hypothermic cardiac arrest patient is not DEAD until he is patient is not DEAD until he is WARM and DEAD!WARM and DEAD!
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Survival from Survival from HypothermiaHypothermia
48.248.2º F (9º C)º F (9º C) - Lowest reported - Lowest reported survivor from therapeutic exposure.survivor from therapeutic exposure.
59.259.2º F (15.2º C) – Lowest reported º F (15.2º C) – Lowest reported infant survival from accidental infant survival from accidental exposure.exposure.
60.860.8º F (16º C) – Lowest reported º F (16º C) – Lowest reported adult survival from accidental adult survival from accidental exposure.exposure.
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Survival from Survival from HypothermiaHypothermia
64.464.4º F (18º C) – Asystole.º F (18º C) – Asystole. 66.266.2º F (19º C) – Flat EEG.º F (19º C) – Flat EEG. 71.671.6º F (22º C) – Maximum risk for º F (22º C) – Maximum risk for
ventricular fibrillation. ventricular fibrillation. 7777º F (25º C) – Cerebral blood flow º F (25º C) – Cerebral blood flow
decreased by 66%.decreased by 66%. 78.878.8º F (26º C) – No reflexes or º F (26º C) – No reflexes or
response to painful stimuli.response to painful stimuli.
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Issues in HypothermiaIssues in Hypothermia
Other Clinical Concerns:Other Clinical Concerns: Hypothermia is common, even in Hypothermia is common, even in
persons with minor trauma.persons with minor trauma. Hypothermia can worsen infectious Hypothermia can worsen infectious
complications of abdominal trauma.complications of abdominal trauma. Hypothermic trauma patients suffer Hypothermic trauma patients suffer
increased blood loss compared to increased blood loss compared to their normothermic cohorts.their normothermic cohorts.
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Issues in HypothermiaIssues in Hypothermia
Considerations in Emergency Considerations in Emergency Care:Care:““Most traditional methods of Most traditional methods of maintaining trauma patient maintaining trauma patient temperature during temperature during prehospital transport appear prehospital transport appear to be inadequate.”to be inadequate.”From: Watts DD, Roche M, et al. The utility of From: Watts DD, Roche M, et al. The utility of traditional prehospital interventions in maintaining traditional prehospital interventions in maintaining thermostasis. thermostasis. Prehosp Emerg CarePrehosp Emerg Care 1999;3(2)115- 1999;3(2)115-122122
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Issues in HypothermiaIssues in Hypothermia
Considerations in Emergency Considerations in Emergency Care:Care:
““Based upon our findings, accidental Based upon our findings, accidental hypothermia poses a relevant problem hypothermia poses a relevant problem in the prehospital treatment of trauma in the prehospital treatment of trauma patients. It is not limited to a special patients. It is not limited to a special season of the year.”season of the year.”From: Helm M, Lampl L, Hauke J, Bock KH. Accidental From: Helm M, Lampl L, Hauke J, Bock KH. Accidental hypothermia in trauma patients. Is it relevant to hypothermia in trauma patients. Is it relevant to preclinical emergency treatment? preclinical emergency treatment? Anaesthesist Anaesthesist 1995;44(2):101-1071995;44(2):101-107
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Issues in HypothermiaIssues in Hypothermia
Considerations in Emergency Considerations in Emergency Care:Care:““Thus, hypothermia is common in Thus, hypothermia is common in
patients undergoing a laparotomy patients undergoing a laparotomy for trauma. Hypothermic patients for trauma. Hypothermic patients with similar injury severity have with similar injury severity have greater blood loss.”greater blood loss.”From: Bernabei AF, Levision MA, Bender JS. The effects From: Bernabei AF, Levision MA, Bender JS. The effects of hypothermia and injury severity on blood loss during of hypothermia and injury severity on blood loss during trauma laparotomy. trauma laparotomy. J TraumaJ Trauma 1992;33(6):835-839 1992;33(6):835-839
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HyperthermiaHyperthermia
Heat crampsHeat cramps Heat tetanyHeat tetany Heat exhaustionHeat exhaustion Heat syncopeHeat syncope Heat strokeHeat stroke
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HyperthermiaHyperthermia
Abnormal Abnormal elevation in elevation in body body temperature.temperature.
Not a normal Not a normal physiological physiological response (such response (such as fever).as fever).
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HyperthermiaHyperthermia
Caused by Caused by environmental environmental temperature temperature increase.increase.
Increased Increased humidity.humidity.
Still air.Still air.
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HyperthermiaHyperthermia
Heat waves not Heat waves not uncommon.uncommon.
More devastating More devastating where heat waves where heat waves are uncommon.are uncommon.
600 heat-related 600 heat-related deaths in 1995 deaths in 1995 Chicago heat Chicago heat wave. wave.
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Heat CrampsHeat Cramps
Brief, painful muscle Brief, painful muscle contractions.contractions.
Frequent Frequent complication of heat complication of heat exhaustion.exhaustion.
Salt depletion and Salt depletion and other electrolyte other electrolyte problems commonly problems commonly associated.associated.
Self-limited.Self-limited. Symptomatic Symptomatic
treatment.treatment.
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Heat TetanyHeat Tetany
Carpopedal spasms Carpopedal spasms that occur in hot that occur in hot environments.environments.
Secondary to Secondary to hyperventilation hyperventilation from body’s from body’s attempt to cool.attempt to cool.
Resolves when Resolves when hyperventilation hyperventilation slows. slows.
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Heat ExhaustionHeat Exhaustion
Results from Results from cardiovascular cardiovascular strain as body strain as body attempts to attempts to maintain normal maintain normal temperature.temperature.
Usually develops Usually develops and continues and continues over several days.over several days.
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Heat ExhaustionHeat Exhaustion
Most common Most common between body between body temperature of temperature of 102.9° (39.4° C) 102.9° (39.4° C) and 104° (40° C).and 104° (40° C).
Finding is Finding is unreliable.unreliable.
Diagnosis should be Diagnosis should be made on physical made on physical assessment.assessment.
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Heat ExhaustionHeat Exhaustion
Firefighters at Firefighters at increased risk of increased risk of developing heat developing heat exhaustion.exhaustion.
Rehab sector Rehab sector essential for essential for major fires in major fires in warm weather.warm weather.
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Heat ExhaustionHeat Exhaustion
Symptoms:Symptoms: DizzinessDizziness HeadacheHeadache FatigueFatigue IrritabilityIrritability AnxietyAnxiety ChillsChills Nausea/vomitingNausea/vomiting Heat crampsHeat cramps
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Heat ExhaustionHeat Exhaustion
Signs:Signs: TachycardiaTachycardia HyperventilatioHyperventilatio
nn HypotensionHypotension SyncopeSyncope
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Heat ExhaustionHeat Exhaustion
Treatment:Treatment: Remove patient from warm Remove patient from warm
environment.environment. Remove bulky clothing.Remove bulky clothing. Fluids (IV or PO).Fluids (IV or PO). AntiemeticsAntiemetics Removal from duty.Removal from duty.
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Heat SyncopeHeat Syncope
Form of postural hypotension.Form of postural hypotension. Results from massive vasodilation.Results from massive vasodilation. Dehydration usually a contributing Dehydration usually a contributing
factor.factor. Most common in persons not Most common in persons not
acclimatized to the heat.acclimatized to the heat. Usually occurs during the early Usually occurs during the early
stages of heat exposure.stages of heat exposure.
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Heat SyncopeHeat Syncope
Treatment:Treatment: SymptomaticSymptomatic CoolCool FluidsFluids Rule out other Rule out other
causes of causes of syncope.syncope.
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Heat StrokeHeat Stroke
Heat stroke is a Heat stroke is a life-threatening life-threatening emergency!emergency!
Heat stroke is a Heat stroke is a total failure of total failure of temperature temperature regulation.regulation.
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Heat StrokeHeat Stroke
Core Core temperature temperature >104.9° (40.5° >104.9° (40.5° C).C).
Loss of sweating Loss of sweating (anhidrosis).(anhidrosis).
Altered mental Altered mental status.status.
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Heat StrokeHeat Stroke
Anhidrosis may or Anhidrosis may or may not be may not be present.present.
Just because a Just because a patient is patient is sweating does not sweating does not mean they are mean they are not suffering heat not suffering heat stroke.stroke.
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Heat StrokeHeat Stroke
Treatment Treatment must include:must include: CPR if required.CPR if required. Fluid and Fluid and
electrolyte electrolyte replacement.replacement.
Immediate Immediate cooling.cooling.
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Heat StrokeHeat Stroke
Goal of cooling is to get body Goal of cooling is to get body temperature down to 104° (40° C).temperature down to 104° (40° C).
Preferred method is immersion in cold Preferred method is immersion in cold water or ice-water bath.water or ice-water bath.
Evaporative cooling (moistened sheets) Evaporative cooling (moistened sheets) and ice packs) can be used but less and ice packs) can be used but less effective.effective.
Essential to remove from bath as soon Essential to remove from bath as soon as target temperature reached to avoid as target temperature reached to avoid overcooling and activation of reflex overcooling and activation of reflex mechanisms.mechanisms.
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FeverFever
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FeverFever
Fever is Fever is notnot an abnormal increase in an abnormal increase in body temperature.body temperature.
It is a resetting of the body’s set-point It is a resetting of the body’s set-point above normal.above normal.
Causes:Causes: Abnormalities within the brain (tumors, Abnormalities within the brain (tumors,
hemorrhage compress hypothalamus)hemorrhage compress hypothalamus) DehydrationDehydration Toxic substances within the body Toxic substances within the body
(pyrogens). (pyrogens).
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FeverFever
Definitions:Definitions: Any oral temp ≥ 98.9° (37.2° Any oral temp ≥ 98.9° (37.2°
C) in the early morning.C) in the early morning. Any oral temp ≥ 100° (37.8° Any oral temp ≥ 100° (37.8°
C) at any time.C) at any time.
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FeverFever
How hot is high?How hot is high? Human upper limit of fever is Human upper limit of fever is
105.8-107.6°F (41–42°C).105.8-107.6°F (41–42°C). Almost never exceeds 42° C Almost never exceeds 42° C
unless there’s a failure in unless there’s a failure in thermoregulation.thermoregulation.
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FeverFever
How hot is high?How hot is high? 104° (40° C) may be the upper 104° (40° C) may be the upper
limit of fever in infants <12 limit of fever in infants <12 weeks old.weeks old.
Remember that young infants Remember that young infants can have infections with normal can have infections with normal or lowered body temps.or lowered body temps.
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FeverFever
Can high fever can Can high fever can cause damage in cause damage in and of itself?and of itself? Seizures and Seizures and
complications.complications. Brain damage Brain damage
because of the because of the infection causing infection causing the fever the fever (meningitis or (meningitis or encephalitis).encephalitis).
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FeverFever
No human studies No human studies published.published.
Animal studies Animal studies suggest that a suggest that a body temp of ≥ body temp of ≥ 107.5° (42° C) in 107.5° (42° C) in humans may humans may trigger enough trigger enough adverse effects on adverse effects on a cellular level to a cellular level to cause death.cause death.
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FeverFever
Animal studies:Animal studies: Temperature >105° Temperature >105°
may cause may cause respiratory alkalosis respiratory alkalosis and occasional and occasional electrolyte electrolyte imbalancesimbalances
Temperature Temperature >105.8° >105.8° maymay cause cause cellular swelling and cellular swelling and damage in the damage in the brain, kidneys and brain, kidneys and liverliver
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FeverFever
When set-point in hypothalamus When set-point in hypothalamus changes, it usually takes several changes, it usually takes several hours to reach new set-point.hours to reach new set-point.
Signs and symptoms common Signs and symptoms common during this phase (blood during this phase (blood temperature lower than temperature lower than hypothalamic set-point). hypothalamic set-point).
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FeverFever
Fever is generally uncomfortable.Fever is generally uncomfortable. Signs and Symptoms:Signs and Symptoms:
ChillsChills Flushing of the skinFlushing of the skin Teeth chatteringTeeth chattering Feels coldFeels cold ShiveringShivering Skin cold to touch (phase-dependent)Skin cold to touch (phase-dependent)
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FeverFever
It is important to remember It is important to remember that fever is a that fever is a normalnormal response response to many diseases.to many diseases.
Although uncomfortable, it is Although uncomfortable, it is rarely harmful.rarely harmful.
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Febrile SeizuresFebrile Seizures
Incidence of 2-5% in US.Incidence of 2-5% in US. 6 months – 3 years (median 6 months – 3 years (median
18-22 months).18-22 months). Boys more often than girls.Boys more often than girls. Often occurs with the first Often occurs with the first
fever of an illness.fever of an illness.
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Febrile SeizuresFebrile Seizures
Characteristics:Characteristics: 85% of all febrile seizures last for 85% of all febrile seizures last for
<15 minutes and don’t recur <15 minutes and don’t recur within 24 hours.within 24 hours.
50% have temp between 39°-50% have temp between 39°-40°C.40°C.
25% have temp 25% have temp >> 40°C. 40°C.
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Febrile Seizures:Febrile Seizures:
Characteristics:Characteristics: 1/3 will have recurrence of febrile 1/3 will have recurrence of febrile
seizures.seizures. The younger the age at 1The younger the age at 1stst febrile seizure, febrile seizure,
the higher the incidence of recurrence.the higher the incidence of recurrence. El-Radhi, 1998El-Radhi, 1998
Presenting temp <39° for 1Presenting temp <39° for 1stst febrile seizure febrile seizure have 2.5x risk for recurrence within the same have 2.5x risk for recurrence within the same illness and 3x risk for recurrence with other illness and 3x risk for recurrence with other illnessesillnesses
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Febrile SeizuresFebrile Seizures
Simple febrile Simple febrile seizures are seizures are generalized tonic-generalized tonic-clonic with brief clonic with brief post-ictal period.post-ictal period.
Complex or Complex or atypical febrile atypical febrile seizures can be seizures can be focal, atonic, or focal, atonic, or prolongedprolonged
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Febrile SeizuresFebrile Seizures
Multiple studies Multiple studies have revealed have revealed several genetic several genetic loci that code loci that code for for susceptibility to susceptibility to febrile seizures.febrile seizures.
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Febrile SeizuresFebrile Seizures
Fever + Seizure ≠ “Febrile Fever + Seizure ≠ “Febrile Seizure”Seizure” Meningitis/SepsisMeningitis/Sepsis Seizure disorderSeizure disorder Medication/Poison-inducedMedication/Poison-induced
Febrile Seizure is NOT an EMS Febrile Seizure is NOT an EMS diagnosis!diagnosis!
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Febrile SeizureFebrile Seizure
Myths:Myths: Rate of temperature rise does Rate of temperature rise does
notnot appear to be a cause of appear to be a cause of febrile seizures.febrile seizures.
No studies have demonstrated No studies have demonstrated that febrile seizures without that febrile seizures without complicating hypoxia cause brain complicating hypoxia cause brain damage.damage.
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Febrile SeizuresFebrile Seizures
Myths:Myths: Febrile seizures cause epilepsy.Febrile seizures cause epilepsy.
Risk factors for afebrile seizure:Risk factors for afebrile seizure: Complex 1Complex 1stst Febrile Seizure. Febrile Seizure. Abnormal neuro state before 1Abnormal neuro state before 1stst Febrile Febrile
Seizure.Seizure. Afebrile seizure history in parents or Afebrile seizure history in parents or
siblingssiblings If If >>2 risk factors, 10% chance of 2 risk factors, 10% chance of
developing “epilepsy”developing “epilepsy”
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Febrile SeizuresFebrile Seizures
Myths:Myths: Treating the fever will prevent the Treating the fever will prevent the
seizure.seizure. Antipyretics are Antipyretics are notnot protective. protective. Rectal/oral diazepam at time of fever Rectal/oral diazepam at time of fever
isis protective. protective. Daily oral phenobarbital is protective Daily oral phenobarbital is protective
but has undesirable side effects.but has undesirable side effects.
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Febrile SeizuresFebrile Seizures
There is There is nono evidence that evidence that bringing the bringing the fever down by fever down by anyany means will means will stop or prevent stop or prevent a febrile a febrile seizure.seizure.
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Febrile SeizuresFebrile Seizures
Bottom line:Bottom line: They’re more scary than They’re more scary than
dangerous.dangerous. Most resolve without Most resolve without
anticonvulsant treatment.anticonvulsant treatment. Antipyretic treatment does not Antipyretic treatment does not
prevent or treat febrile seizures.prevent or treat febrile seizures. Not all seizures with fever are Not all seizures with fever are
febrile seizures.febrile seizures.
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FeverFever
Fever Fever treatment:treatment: Treatment of Treatment of
choice is choice is antipyretics antipyretics (acetaminophe(acetaminophen, n, ibuproprofen).ibuproprofen).
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FeverFever
There is no evidence to support one There is no evidence to support one antipyretic over another when antipyretic over another when considering effectivenessconsidering effectiveness
No delivery route (po/pr) has been No delivery route (po/pr) has been proven more effective than another, proven more effective than another, but there has been recent evidence but there has been recent evidence to suggest that higher doses may to suggest that higher doses may be needed when given rectally.be needed when given rectally.
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FeverFever
Acetaminophen 10-15 mg/kg Acetaminophen 10-15 mg/kg po/pr q4h.po/pr q4h.
Ibuprofen 10mg/kg po q6-8h.Ibuprofen 10mg/kg po q6-8h. No demonstrated benefit to No demonstrated benefit to
alternating the two meds but alternating the two meds but there is a significant chance of there is a significant chance of dosing error and possible dosing error and possible overdose.overdose.
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FeverFever
Other cooling methods:Other cooling methods: Never use ice, cold water or Never use ice, cold water or
alcohol.alcohol. Use tepid water or cool Use tepid water or cool
compresses over head and pulse compresses over head and pulse points.points.
Avoid inducing chills.Avoid inducing chills.
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FeverFever
Should we treat fever?Should we treat fever? AnimalAnimal studies suggest that the studies suggest that the
fever mechanism is a positive fever mechanism is a positive adaptive responseadaptive response Triggers host immune responsesTriggers host immune responses May stabilize cell membranesMay stabilize cell membranes
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FeverFever
Should we treat fever?Should we treat fever? Increased metabolic stress and Increased metabolic stress and
oxygen demand:oxygen demand: Patients with poor cardiac reservePatients with poor cardiac reserve Patients with poor pulmonary Patients with poor pulmonary
reservereserve Lowers the “seizure threshold”Lowers the “seizure threshold”
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FeverFever
Reasons to treat fever:Reasons to treat fever: Patient comfortPatient comfort Parent comfortParent comfort
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FeverFever
Should EMS Should EMS providers treat providers treat fever?fever?
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FeverFever
Should EMS providers treat fever?Should EMS providers treat fever? Pros:Pros:
Providing an additional service to our Providing an additional service to our customers.customers.
Comfort measure.Comfort measure. Cons:Cons:
Treat and release?Treat and release? Documentation of fever.Documentation of fever. Dosing of meds.Dosing of meds. Reinforcement of fears.Reinforcement of fears.
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FeverFever
Cultural Cultural considerations.considerations.
Relates to Relates to ancient beliefs ancient beliefs of “hot” and of “hot” and “cold” illnesses.“cold” illnesses.
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FeverFever
Summary:Summary: Fever is not the clearly defined Fever is not the clearly defined
concept many believe it to be.concept many believe it to be. Both the lay public and the medical Both the lay public and the medical
community need more education community need more education about fever.about fever.
““Fever Phobia” is unfounded.Fever Phobia” is unfounded. Fever treatment by EMS personnel is Fever treatment by EMS personnel is
controversial.controversial.
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Temperature RegulationTemperature Regulation
For more For more detailed detailed information on information on temperature temperature regulation and regulation and hypothermia, hypothermia, see the March see the March 2003 issue of 2003 issue of JEMSJEMS magazine. magazine.
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