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Thermoregulatory Disorders and Illness Related to Heat and Cold Stress View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Autonomic Neuroscience: Basic and Clinical 196 (2016) 91–104 Contents lists available at ScienceDirect Autonomic Neuroscience: Basic and Clinical journal homepage: www.elsevier.com/locate/autneu Review Thermoregulatory disorders and illness related to heat and cold stress William P. Cheshire Jr. Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, United States article info abstract Article history: Thermoregulation is a vital function of the autonomic nervous system in response to cold and heat stress. Ther- Received 22 October 2015 moregulatory physiology sustains health by keeping body core temperature within a degree or two of 37 °C, Received in revised form 17 December 2015 which enables normal cellular function. Heat production and dissipation are dependent on a coordinated set of Accepted 5 January 2016 autonomic responses. The clinical detection of thermoregulatory impairment provides important diagnostic and localizing information in the evaluation of disorders that impair thermoregulatory pathways, including au- Keywords: Thermoregulation tonomic neuropathies and ganglionopathies. Failure of neural thermoregulatory mechanisms or exposure to ex- Heat stroke treme or sustained temperatures that overwhelm the body's thermoregulatory capacity can also result in Heat exhaustion potentially life-threatening departures from normothermia. Hypothermia, defined as a core temperature of Hypothermia b35.0 °C, may present with shivering, respiratory depression, cardiac dysrhythmias, impaired mental function, Rewarming mydriasis, hypotension, and muscle dysfunction, which can progress to cardiac arrest or coma. Management in- Hypohidrosis cludes warming measures, hydration, and cardiovascular support. Deaths from hypothermia are twice as fre- fi Small ber neuropathy quent as deaths from hyperthermia. Hyperthermia, defined as a core temperature of N40.5 °C, may present with sweating, flushing, tachycardia, fatigue, lightheadedness, headache, and paresthesia, progressing to weak- ness, muscle cramps, oliguria, nausea, agitation, hypotension, syncope, confusion, delirium, seizures, and coma. Mental status changes and core temperature distinguish potentially fatal heat stroke from heat exhaustion. Man- agement requires the immediate reduction of core temperature. Ice water immersion has been shown to be su- perior to alternative cooling measures. Avoidance of thermal risk and early recognition of cold or heat stress are the cornerstones of preventive therapy. © 2016 The Author. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Contents 1. Introduction............................................................... 92 2. Measurementofbodytemperature..................................................... 92 2.1. Invasivetechniques........................................................ 92 2.2. Noninvasivetechniques....................................................... 92 3. Measurementofsweating......................................................... 93 3.1. Sympatheticskinresponse..................................................... 93 3.2. Thermoregulatorysweatingtest................................................... 94 3.3. Silasticimprinttest......................................................... 94 3.4. Quantitative sudomotor reflextest.................................................. 94 3.5. Epidermalbiopsy......................................................... 95 4. Thermoregulatorydisorders........................................................ 95 4.1. Small fiberneuropathies...................................................... 95 4.2. Disordersoftheresponsetocold.................................................. 95 4.3. Disordersoftheresponsetoheat.................................................. 95 5. Hypothermia............................................................... 97 5.1. Causesofhypothermia....................................................... 97 5.2. Diagnosisofhypothermia...................................................... 98 5.3. Managementofhypothermia.................................................... 98 6. Hyperthermia.............................................................. 99 E-mail address: [email protected]. http://dx.doi.org/10.1016/j.autneu.2016.01.001 1566-0702/© 2016 The Author. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 92 W.P. Cheshire Jr. / Autonomic Neuroscience: Basic and Clinical 196 (2016) 91–104 6.1. Causesofhyperthermia...................................................... 100 6.2. Diagnosisofhyperthermia..................................................... 100 6.3. Managementofhyperthermia................................................... 101 7. Whatmoremightbedone?....................................................... 101 8. Conclusion............................................................... 101 References.................................................................. 101 1. Introduction 2.1. Invasive techniques Temperature is a critical variable in health and disease. Constraint of Whereas direct measurement of brain temperature in clinical settings human body core temperature within a degree or two of 37 °C, which is is impractical, the pulmonary artery temperature, as measured by a the optimal temperature for normal cellular function, occurs in three thermistor in a pulmonary artery catheter, is considered the gold stan- ways. The first is stable climate, which maintains temperatures across dard for accurate determination of core temperature in clinical settings most of the surface of planet Earth within a range compatible with where invasive measurements are possible (Pearson et al., 2012; Lefrant human life. The second is the autonomic nervous system, which reacts et al., 2003). Other internal sites at which core temperature has been robustly to thermal challenges by orchestrating a complex array of neu- measured include the esophagus, intestines, rectum, and bladder ral responses below the level of conscious awareness. The autonomic re- (Lefrant et al., 2003; Robinson et al., 1998). Monitoring of esophageal sponses to cold stress include cutaneous vasoconstriction to retain temperature during left atrial radiofrequency procedures for atrial fibril- bodily heat as well as metabolic and shivering thermogenesis. The auto- lation, for example, has been shown to reduce the risk of thermal injury nomic responses to heat stress include cutaneous vasodilatation, which to the esophagus (Liu et al., 2012; Leite et al., 2011). liberates heat by radiant and convective heat loss, and sweating, which For the vast majority of patients who do not have indwelling cathe- liberates heat by evaporation. The third and perhaps least predictable is ters, rectal thermometry has evolved as the standard method for deter- human behavior, which responds to thermal sensory input by seeking mining core temperature (Lefrant et al., 2003; Robinson et al., 1998). warmth or coolness, but which also is responsible for getting people Rectal thermometry is not ideal, however, as rectal temperatures may into situations of cold or heat stress, some of which can threaten life lag changing temperatures in the blood and other deep organs or health. Another aspect to human behavior is the healthcare (Robinson et al., 1998; Eichna et al., 1951). Rectal thermometry also in- professional's response to thermoregulatory disorders, which draws volves physical and psychological discomfort, and there have been doc- from knowledge of autonomic physiology to treat patients who have umented cases of nosocomial transmission of stool-borne pathogens been rescued from circumstances that challenge their capacity for (Livornese et al., 1992; McAllister et al., 1986) and, very rarely, traumat- thermoregulation. ic injury to the rectum (Al-Qahanti et al., 2001). This clinical review has a dual emphasis. The first is thermoregulato- ry disorders, which are disorders of the autonomic nervous system that 2.2. Noninvasive techniques impair the pathways involved in thermoregulation. Whereas these dis- orders sometimes present with symptoms related to heat or cold stress, In common clinical practice, noninvasive methods approximate core more often the thermoregulatory deficit is incidental to symptoms and temperature indirectly. The traditional method of taking oral tempera- provides colocalizing information that is helpful to reaching an accurate ture with a sublingual mercury-in-glass thermometer has, in recent de- diagnosis. The second is illness related to heat stress or cold stress, cades, yielded to new technologies that avoid the potential hazards of which encompasses common clinical presentations in which autonomic broken glass and liquid mercury (Zhen et al., 2014; Apa et al., 2013; thermoregulatory function or dysfunction plays a role. Environmental Batra and Goyal, 2013; El-Radhi and Patel, 2006; Gasim et al., 2013; conditions of extreme or prolonged heat or cold stress can overwhelm Jefferies et al., 2011; Penning et al., 2011). The most sensitive tempera- human thermoregulatory capacity, even in healthy persons, but espe- ture sensors are thermistors, which are semiconductors, theelectricalre- cially for those whose capacity is impaired. Each year in the United sistance of which
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