Which patients are at high risk for hypothermia?
During the winter months, EDs in colder climates see increasing numbers of patients with hypothermia.
"Anyone is susceptible to it and not just in the dead of winter," cautions Timothy Erickson, MD, FACEP, director for the emergency medicine residency program at the University of Illinois at Chicago Medical Center. "People think they’re hardy and can handle the cold, but they can end up losing fingers and toes."
ED nurses should know which patients are especially susceptible to hypothermia, since the condition is sometimes overlooked, says Edward Otten, MD, professor of emergency medicine at the University of Cincinnati and president of the Wilderness Medical Society, based in Indianapolis. Here are seven patient populations at high risk for hypothermia:
1. Homeless.
A lot of them come in with a garden-variety complaint, and all they really want is a warm place to sleep, but others have severe hypothermia, Erickson says.
When it just starts to turn cold, homeless shelters may not be open yet, he notes. "Once it turns really frigid and plummets below zero, awareness is heightened, so there are more available shelters."
In the winter, homeless patients at University of Illinois’ ED are usually allowed to remain in the ED overnight, then given a bus token and directed to a shelter. "If you just send them out without some sort of assistance, the problem will happen again and again all winter," Erickson advises. The ED also keeps a closet filled with warm clothing donated by staff members to give the homeless.
2. Hypoglycemics.
The link between hypothermia and hypoglycemia is often missed by ED nurses, according to Otten. "When you see hypothermia and it isn’t really cold outside, hypoglycemia should go through your mind," he says.
If an elderly patient presents with a temperature of 92° in the middle of August, check the glucose. "If you don’t have the substrate to metabolize, you won’t be able to get your body temperature up, and you’ll eventually become room temperature," says Otten.
The patient’s temperature isn’t the only factor to consider, he stresses. "If a 10-year-old patient comes in with a temperature of 85°, he or she will do great. But if it’s a patient in his or her 70s with heart and kidney disease and a temperature of 92°, he or she might die," says Otten. "The most important thing is what underlying medical problems they have that caused them to go into hypothermia."
3. Trauma patients.
Temperature is probably the most commonly missed vital sign in trauma patients, says Otten.
"If you have a patient in the wintertime who is trapped inside a car, it might be raining or snowing, and you put the patient on a backboard with wet clothes on and maybe cut the clothes off in the field and bring that patient into the ER. You take blood pressure, pulse, and respiration but don’t get the temperature. By the time you do, you’ve already given the patient cold IV fluids and blood, and next thing you know the patient is up in the OR with a temperature of 89°."
ED nurses need to be diligent in getting the temperature from trauma patients, he urges." The rectal temperature is probably the best way to go, because a lot of the time the patient’s skin may be cold, but the core temperature may be OK," says Otten. "Tympanic membrane temperatures are OK, but you need a low reading thermometer because most don’t go below 35° C."
4. Outdoor lovers.
"A lot of times, young healthy people think they’re indestructible and wind up with extremity frostbite or hypothermia," says Erickson. Each winter, the ED treats hypothermia patients who have accidentally been immersed in freezing water after walking on the frozen lake or driving snowmobiles over it, he reports.
5. Intoxicated people.
"Alcohol lowers your glucose and also gives you bad judgment so you think it’s OK to lie on the ground and go to sleep in the snow," says Otten. "Tobacco also makes you susceptible. People think if they’re cold they’ll have a cigarette to warm them up, but it has the opposite effect because of the vasoconstrictive effects of nicotine."
6. Impoverished.
Families without heat during the winter are at high risk for hypothermia. "Patients in the lower socioeconomic class may not have good central heating or may have the power turned off because they can’t pay their bills," notes Otten.
7. Very old and very young.
The elderly are prone to hypothermia because their hypothalamus doesn’t work as well, Otten says. "So they can’t metabolize a lot of their glucose stores because they don’t have as many and are more likely to have problems maintaining temperature. With babies, the surface area of their bodies are so much greater compared to their volume, so they can lose heat a lot faster."
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