Hypothermia and Cold Weather Injuries

 

Am Fam Physician. 2019 Dec 1;100(11):680-686.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/hypothermia.

Author disclosure: No relevant financial affiliations.

Hypothermia, frostbite, and nonfreezing cold injuries predominantly affect older adults, homeless or intoxicated people, adventurers, and military personnel. Prevention begins with clothing that is clean, layered, and loose to promote circulation. Base layers made of moisture-wicking materials are favored over wool or cotton. Wool or fleece garments are ideal for middle layers, whereas outer layers should repel moisture. Hypothermia occurs when core body temperature drops below 95°F and can be staged by clinical symptoms when core temperature measurement is unavailable. Initial treatment includes external and internal rewarming. Warmed normal saline is favored over lactated Ringer solution. Frostbite is a freezing injury that usually affects the extremities. After rapid rewarming, prognosis is best determined with technetium 99mTc pyrophosphate scintigraphy or magnetic resonance angiography. Initial treatment includes protecting tissue from further trauma, preventing refreezing, and avoiding dry heat sources. Ideally, patients should be transported to facilities where rapid rewarming, imaging, and thrombolytic treatment are available. Tissue plasminogen activator significantly decreases amputation rates for severe injuries if started within 24 hours of rewarming. Immersion foot occurs during damp nonfreezing conditions. Rapid rewarming should be avoided, and amitriptyline should be considered for pain control.

Hypothermia, frostbite, and nonfreezing cold injuries predominantly affect older adults, homeless or intoxicated people, adventurers, and military personnel.1,2 Alcohol consumption is an important risk factor and was associated with 68% of accidental hypothermia cases in one retrospective study.35 From 2006 to 2010, there were 10,649 deaths in the United States attributed to natural weather causes; two-thirds of these were associated with excessive cold.5 Cold-related mortality was substantially higher in older adults and in rural or low-income areas.

WHAT'S NEW ON THIS TOPIC

Hypothermia

From 2006 to 2010, two-thirds of the 10,649 deaths in the United States attributed to natural weather causes were associated with excessive cold.

In one retrospective study, 68% of cases of accidental hypothermia were associated with alcohol consumption.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Rewarming frostbitten tissue should be avoided if there is a risk of refreezing.16

C

Consensus guidelines in the absence of clinical trials

Ibuprofen (12 mg per kg divided into two daily doses) should be given for frostbite until the wound heals or surgery is performed.16

C

Consensus guidelines in the absence of clinical trials

Tissue plasminogen activator decreases the risk of amputation if started within 24 hours of rewarming in patients with grade III/IV or deep frostbite.16,19,22,27

B

Limited clinical trials with outcomes of reducing amputation

Rapid rewarming of nonfreezing cold injuries (i.e., immersion foot) should be avoided.24,31

C

Consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Rewarming frostbitten tissue should be avoided if there is a risk of refreezing.16

C

Consensus guidelines in the absence of clinical trials

Ibuprofen (12 mg per kg divided into two daily doses) should be given for frostbite until the wound heals or surgery is performed.16

C

Consensus guidelines in the absence of clinical trials

Tissue plasminogen activator decreases the risk of amputation if started within 24 hours of rewarming in patients with grade III/IV or deep frostbite.16,19,22,27

B

Limited clinical trials with outcomes of reducing amputation

Rapid rewarming of nonfreezing cold injuries (i.e., immersion foot) should be avoided.24,31

C

Consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Optimal human thermoregulation requires a core temperature within 2 to 3 degrees of 98.6°F (37°C).6 The five mechanisms of heat loss are radiation, conduction, convection, evaporation, and respiration.7 The skin is the main mechanism of heat exchange and is responsible for approximately 90% of total heat loss,3 which can be exacerbated by vasodilation secondary to alcohol consumption or medication use.3,7,8 Conduction is the direct transfer of heat between objects.

The Authors

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NICHOLAS A. RATHJEN, DO, is a family physician at William Beaumont Army Medical Center, Fort Bliss, Tex....

S. DAVID SHAHBODAGHI, MD, MPH, is medical director of the Soldier and Family Medical Clinic and a family physician at William Beaumont Army Medical Center.

JENNIFER A. BROWN, MD, is the brigade surgeon for the 4th Security Force Assistance Brigade at Evans Army Community Hospital, Fort Carson, Colo.

Address correspondence to Nicholas A. Rathjen, DO, William Beaumont Army Medical Center, 5005 N. Piedras St., Fort Bliss, TX 79920 (email: nicholas.a.rathjen@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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