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1、Hypothermia Why Am I So Cold?,David Feldstein, MD Primary Care Conference 5/26/04,Objectives,Etiologies of hypothermia Clinical manifestations of hypothermia Causes of hypothermia in psychiatric patients I have not received any financial compensation for this talk,Case,CC: Delerium HPI: 48 y.o. inst
2、itutionalized man with hx schizophrenia behavioral changes X 2 weeks slurring of speech and decrease in ambulation and eating labored breathing day of admission. temperature 33.3 orally at his institution.,Case (cont),PMH Gunshot wound to the head Paranoid schizophrenia HTN NMS secondary to Clozaril
3、 Meds: Aripiprazole (Abilify), Clonazepam SH Institutionalized for 20 years No access to tobacco, alcohol or illicit drugs,Case (cont),PE: T 33.2 rectal; HR 60; 129/76; RR 16; 95% RA Gen: Spontaneously opening eyes and moving extremities. NAD HEENT: Pupils 1mm and sluggish Neck: Nonpalpable thyroid
4、Lungs: Bibasilar crackles with poor effort CVS/Abd WNL Neuro: Not following commands, Nml tone, 1+ DTRs, No clonus Skin: Cool to touch, no rashes Ext: 1+ pitting edema to knees bilaterally,Hospital Course,Head CT and LP were performed Blood cultures sent Vancomycin and Zosyn started empirically 12 h
5、ours after arrival in ED patient was found to be completely unresponsive to painful stimuli Temp 33.3 rectal; HR 52; BP 125/72,Definition of Hypothermia,Mild 32-35C (90-95F) Moderate 28-32C (82-90F) Severe 28C (82F),Causes of Hypothermia,Decreased Heat Production Increased Heat Loss Impaired Thermor
6、egulation Miscellaneous,Decreased Heat Production,Endocrine Hypopituitarism Hypoadrenalism Hypothyroidism Insufficient Fuel Hypoglycemia Malnutrition Neuromuscular Inefficiency Extreme Age Impaired Shivering Inactivity,Increased Heat Loss,Environmental Exposure Induced Vasodilation EtOH Drugs Skin B
7、urns Psoriasis Iatrogenic Cold Infusions,Impaired Thermoregulation,Peripheral Failure Neuropathies Central Failure Metabolic Drugs Trauma CVA Hypothalamic dysfunction MS Wernickes,Miscellaneous,Sepsis Pancreatitis Carcinomatosis Uremia,Kramer et al.,Retrospective screening of patients over 60 with h
8、ypothermia in a community hospital in Jerusalem (1983-86),Prognosis of Hypothermia (Kramer),In hospital mortality 74% Acute renal failure 12% DIC 9%,Back To My Patient,WBC 1.9 nml diff Hct 37 Plts 65 INR 1.1 / PTT 48.5 Na 140 K 5.7 Cl 110 CO2 25 Bun/Cr 23/1.0 Glucose 67,AST 62/ ALT 132 GGT 63 Tbili
9、0.4 TSH 5.16 / Free T4 0.8 Cortisol 18.6 Tox Screen + benzos Head Ct old trauma LP 2 nucleated cells CXR- mild pulm edema ABG 7.26/61/105/26,Further Hospital Course,Transferred to TLC Went for Head CT with contrast Woke up in scanner and combatative Temp 35.3 and patient back to baseline per caregiv
10、ers Given 10mg Haldol for outbursts 1 hour after Haldol was again unresponsive with Temp 33.9,Clinical Manifestations,CNS amnesia, apathy decr level of consciousness coma CVS Tachy brady atrial/ventricular arrythmias decreased co asystole Resp Tachypnea decr ventilation with bronchorrhea/bronchospas
11、m loss of airway protection pulm congestion apnea Renal Cold diuresis decrease urine output Endocrine Incr catechols, adrenal steroids and thyroxine decr insulin activity decr BMR Neuromuscular Incr muscle tone shivering loss of shivering rigidity decr nerve-conduction and areflexia,Laboratory Manif
12、estations,CBC hemoconcentration/thrombocytopenia Lytes hyperkalemia/hypernatremia Bun/Cr increased Glucose intially increased then can be decreased Coags increased ABG hypercarbia/hypoxia/acidosis EKG bradycardia/Osborne waves/atrial or ventricular arrythmias,Osborne Waves,Antipsychotics in Hypother
13、mia,Chlorpromazine (Thorazine) attempts to use to induce hypothermia in 1950s Multiple case reports of typical and atypical antipsychotics causing hypothermia Heh 1988 8 institutionalized patients with schizophrenia Measured oral temp off antipsychotics then on Haloperidol and then on Clozapine Oral
14、 temp dropped on both antipsychotics Greater drop with clozapine,Antipsychotics in Hypothermia (cont),Scwaninger 1998 Describes 10 cases of hypothermia secondary to atypical antipsychotics reported to German Federal Institute for Drugs and Medical Devices Kramer 1989 Found 22% of older patients with
15、 hypothermia in one hospital were on antipsychotics (thioridazine most common),Possible Mechanism,Hypothalamus Dopamine receptor antagonism Serotonin (5-HT2) antagonism Periphery Alpha receptor antagonism Preventing vasoconstriction,Take Home,Hypothermia can occur without “cold” exposure Antipsychot
16、ics may cause hypothermia much more commonly than we are aware In the elderly hypothermia has a very poor prognosis Without treatment hypothermia will progress with significant morbidity and mortality,References:,Danzl DF, Prozoz RS. Accidental Hypothermia. NEJM 1994; 331(26):1756-60. Hanania NA, Zimmerman JL. Environmental Emergencies: Accidental Hypothermia. Critical Care Clincs 1999; 15(2):235-49. Kramer
