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Heat Loss
Heat Loss
Radiation infrared heat rays (60% total heat loss) Conduction to solid objects (3%)
Respiration evaporation (water droplets evaporated) contribute to hypothermia in cool, windy, and dry environments
Sweating Stimulation of the anterior hypothalamus-preoptic area sympathetic nerves cholinergic sweat glands
Sweat secretion
coiled/ glandular portion primary secretion plasma (except protein); Na = 142 mEq/L, Cl = 104 mEq/L duct portion slight stimulation low level salt strong stimulation high level salt (50 60 mEq/L) Aldosterone 15 30 g/day salt excreted (unacclimatized) 3 5 g/day salt
Anterior hypothalamic-preoptic area heat-sensitive neurons & 1/3 cold-sensitive neurons (temperature sensors) Skin receptors: 10x cold receptors > warmth receptors preventing hypothermia Chilled body causes: 1. shivering 2. sweating inhibition 3. skin vasoconstriction Deep tissue receptors (spinal cord, abdominal viscera, great veins around upper abdomen & thorax) Posterior hypothalamus combine & integrate temperature sensory signals
Sympathetic excitation
Thyroxine
Shivering Heat center (anterior hypothalamic-preoptic area) inhibition Primary motor center for shivering (dorsomedial portion of posterior hypothalamus) stimulation
Sympathetic excitation of heat production Sympathetic stimulation the rate of cellular metabolism
Behavioral Control of Body Temperature Feeling hot or cold due to the changes of internal body temperature moving into heated room or wearing wellinsulated clothing Local Skin Temperature Reflexes Local vasodilatation or sweating
Skin & deep body tissues (spinal cord & abdominal viscera)
also affect body temperature regulation change of hypothalamic set point
Abnormalities of Body Temperature Regulation Fever Abnormalities in the brain (brain tumor) increase body temperature Toxic substances on temperature-regulating centers (pyrogens) rising the set-point Pyrogens: proteins, breakdown products of proteins, lipopolysaccharide toxins of bacteria or degenerating body
tissues The increase of set-point heat conservation & heat production increase
Bacterial pyrogens (endotoxins of gram-negative bacteria) several hours Bacteria Leukocytes, macrophages, large granular killer lymphocytes Interleukin 1 (leukocyte pyrogen/ endogenous pyrogen)
hypothalamic set-point
Neither feel cold or hot
The factor (e.g. pyrogens) removed The set-point reduced to a lower value Hypothalamus attempt to reduce body temperature Intense sweating, hot skin (vasodilatation) = flush/crisis
Causes of Hyperthermia
Excessive heat production:
Exertional hyperthermia Heat stroke (exertional)* Malignant hyperthermia of anesthesia Neuroleptic malignant syndrome* Lethal catatonia Thyrotoxicosis Pheochromocytoma Salicylate intoxication Drug abuse (cocaine, amphetamine)
Delirium tremens
Status epilepticus Generalized tetanus
Encephalitis
Sarcoidosis & granulomatous infections Trauma
* Mixed pathogenesis
Exertional Hyperthermia
Acclimatized athletes 2 L sweat/ hour evaporation of 900 kcal/ hour Heat dissipation skin vasodilatation & sweating limited by volume depletion, ambient temperature & humidity Intense, prolonged exercise in humid weather hyperthermia Exertional hyperthermia usually self-limited & asymptomatic Adverse effects: muscle cramps, heat exhaustion, heatstroke Prevention: Acclimatization (athlete), light clothing, avoid direct sunlight, hydration Treatment: Rest, oral rehydration, IV fluids, evacuation to cool environment
Heatstroke One can withstand several hours 130F in dry air (convection) One can only tolerate up to 94F in 100% humidified air
Heatstroke Heatstroke: - Exertional heat stroke (athletes & military) - Classic heat stroke (sedentary, elderly) Exertional heat stroke: Lack of acclimatization, lack of cardiovascular conditioning, dehydration, heavy clothing, excessive exertion Classic heat stroke: Impaired heat dissipation (anhidrosis), cardiovascular diseases, neurologic disorders, impaired consciousness, obesity, anticholinergic or diuretic agents,
Symptoms & signs: Dizziness, abdominal distress, vomiting, delirium/ stupor/ coma, hypotension, tachycardia, hyperventilation, hemorrhages, degeneration, in brain, liver, kidneys Laboratory findings: Hemoconcentration, proteinuria, microscopic hematuria, abnormal liver function, elevated muscle enzymes levels, rhabdomyolysis (exertional), disseminated intravascular coagulation (exertional),
Treatment:
- Removal of clothing - Sponge/ spray cooling/ cold water bath/ ice body surface
- Oral hydration
- Intravenous hydration with room temperature fluids - Correction of electrolyte/ acid-base disturbance - Cardiovascular monitoring & support
Neuroleptic Malignant Syndrome Neuroleptic agents: phenotiazines, butyrophenones, thioxanthenes, haloperidol (most often) Blockade of dopaminergic receptors in the corpus striatum Symptoms & signs: > 41C, skeletal muscle rigidity excessive heat impairs hypothalamic thermoregulation, extrapyramidal abnormalities, altered consciousness, autonomic dysfunction (labile blood pressure, tachyarrhythmias, incontinence) impairs heat dissipation Laboratory findings: Hemoconcentration, leukocytosis, hypernatremia, acidosis, electrolyte disturbances, rhabdomyolysis, abnormal renal & hepatic functions Treatment: Neuroleptic withdrawal, metabolic & cardiovascular support, dantrolene sodium, bromocriptine mesylate (dopamine agonist)
Hormonal Hyperthermia
Thyrotoxicosis (most common) Pheochromocytoma crisis: High level of norepinephrine skin vasoconstriction & hypermetabolism Adrenal insufficiency Hypoglycemia Hyperparathyroidism
Infections
Anticholinergic drugs Cocaine
Amphetamine
Alcohol abuse & withdrawal Salicylate intoxication Therapeutic Hyperthermia Nasal hyperthermia for viral nasopharyngitis
The Consequences of Hyperthermia Extreme hyperthermia: Confusion, delirium, stupor, coma Metabolic abnormalities: Hypoxia, respiratory alkalosis,
Management of Hyperthermia 1. Diagnose & treat underlying disoder 2. Cardiovascular & metabolic support 3. Antipyretic therapy (39C, young, elderly, underlying diseases) mandatory in heat stroke, malignant hyperthermia; indicated in neuroleptic malignat syndrome, thyrotoxic crisis 4. Pharmacologic agents to lower hypothalamic set-point (in fever) acetaminophen, aspirin 5. Physical cooling (in hyperthermia) removing bedclothes, bedside fans, sponging with tepid water/ alcohol, hypothermic mattresses, ice packs, ice water immersion (most effective) 6. IP cool fluid, gastric lavage or ice water enema, extracorporeal circulation
Frostbite
Temperature regulation greatly impaired < 94F; lost < 85F due to the depression of the rate of chemical heat production,
- Sedative-hypnotics
Environmental:
-
- Stroke
- Tumor - Wernickes disease Neuromuscular inefficiency: - Age extreme - Impaired shivering - Lack of acclimatization Sepsis
Immersion Nonimmersion
32.2C - 35C Initial excitation phase to combat cold: Hypertension Shivering Tachycardia Tachypnea
Vasoconstriction
With time and onset of fatigue: Apathy Ataxia Cold diuresis kidneys lose concentrating ability Hypovolemia Impaired judgment
Moderate
Dilated pupils
Diminished gag reflex Extinction on shivering Hyporeflexia Hypotension J wave (electrocardiogram)
necrosis
2. Rapid changes of electrolyte levels (potassium, due to rewarming) 3. Coagulopathies self limited 4. Inaccurate leukocytes count antibiotics in neonates, elderly, immunocompromised patients
Management of Hypothermia
1. Glucose (most patients depleted glycogen stores) 2. Thiamine (a possibility of alcohol abuse)
Rewarming
1. Mild hypothermia, intact thermoregulatory mechanisms, normal endocrine function, adequate energy stores
to 40C - 45C
c. Extracorporeal blood rewarming most effective (cardiopulmonary bypass, arteriovenous rewarming,
- 3C/ hour
Hypothermia
Cardiopulmonary arrest?
No
Core body temperature > 32C? Intact energy stores? Intact thermoregulatory mechanisms? No Yes
Yes
Secure airway Defibrillate ventricular fibrillation only Initiate CPR Bedside glucose, thiamine Warmed IV fluids Heated humidified O2 Treat underlying etiology Antibiotics and/or steroids as appropriate Is extracorporeal rewarming available? No Active core rewarming Rewarm to > 30C - 32C Yes