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Cold tolerance varies considerably among individuals Factors that increase the likelihood of injury from exposure to cold include poor general physical conditioning, nonacclimatization, advanced age, altered mental status, systemic illness, poor tissue oxygenation, wet or insufficient clothing, previous cold weather injury, smoking, and the use of alcohol or other sedative drugs High wind velocity ( windchill factor ) increases the severity of cold injury at low temperatures

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An esophageal or rectal probe that measures as low as 25 C is required; oral temperatures are inaccurate

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Systemic hypothermia may result from exposure (atmospheric or immersion) to prolonged or extreme cold The condition may arise in healthy individuals in the course of occupational or recreational exposure or in victims of accidents Systemic hypothermia may follow exposure to cool but not cold temperatures when there is altered homeostasis due to debility or disease In colder climates, elderly and inactive individuals living in inadequately heated housing are particularly susceptible Patients with cardiovascular or cerebrovascular disease, mental retardation, acute alcoholism, malnutrition, myxedema, hypopituitarism, or use of sedating or tranquilizing drugs are more vulnerable to accidental hypothermia Prolonged postoperative hypothermia or administration of large amounts of refrigerated stored blood (without rewarming) can cause systemic hypothermia Systemic hypothermia causes reduced physiologic function with decreased oxygen consumption and slowed myocardial repolarization, peripheral nerve conduction, gastrointestinal motility, and respirations as well as hemoconcentration and pancreatitis Defenses against cold exposure are superficial blood vessel constriction and increased metabolic heat production

Some persons have a familial or acquired hypersensitivity to cold, and urticaria may develop upon even limited exposure to a cold (eg, wind, freezer compartments) The urticaria usually occurs only on exposed areas, but in markedly sensitive individuals the response can be generalized and fatal Immersion in cold water may result in severe systemic reactions from histamine release, including shock Familial cold urticaria is an autosomal dominant inflammatory disorder (including the Muckle-Wells syndrome), manifested as a burning sensation of the skin occurring about 30 minutes after exposure to cold Acquired cold urticaria may be associated with medication (eg, griseofulvin) or with infection Cold urticaria may occur secondarily to cryoglobulinemia or as a complication of syphilis Most cases of acquired cold urticaria are idiopathic For diagnosis, an ice cube is usually applied to the skin of the forearm for 4 5 minutes, then removed, and the area is observed for 10 minutes As the skin rewarms, an urticarial wheal appears at the site and may be accompanied by itching The clinical use of antileukotrienes in cold urticaria is anecdotal

Early manifestations of hypothermia include weakness, drowsiness, lethargy, irritability, confusion, shivering, and impaired coordination A lowered body temperature may be the sole finding; the skin may appear blue or puffy With extended exposure, apathy, impaired judgment, and ataxia appear The internal (core) body temperature in accidental hypothermia may range from 25 C to 35 C At core temperatures below 35 C, the patient may become delirious, drowsy, or comatose and may stop breathing The pulse and blood pressure may be unobtainable, leading clinicians to believe the patient is dead Metabolic acidosis, hyperkalemia, pneumonia, pancreatitis, ventricular fibrillation, hypoglycemia or

and laboratory monitoring during the rapid rewarming process Essential laboratory tests include electrocardiogram (ECG), chest radiograph, complete blood count, prothrombin time, partial thromboplastin time, electrolytes, blood urea nitrogen (BUN), serum creatinine, liver function tests, amylase, glucose, pH, blood gases, urinalysis, and urine volume Cardiac rhythm should be monitored, and cardiac, central vascular, or chest trauma or stimulation (catheter, cannulas, etc) should be avoided unless essential because of the risk of inducing ventricular fibrillation However, patients who are comatose or in respiratory failure should be tracheally intubated The patient should be evaluated for trauma and peripheral cold injury (eg, frostbite) Antibiotics are not routinely given and should be used only if indicated (neonate, elderly, or immunocompromised patient) Core temperature (esophageal preferred over rectal) should be monitored frequently during and after initial rewarming because of reports of recurrent hypothermia

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