- Email: [email protected]
Temperature – The forgotten vital sign
Accident and Emergency Nursing (2005) 13, 247–250
Accident and Emergency Nursing www.elsevierhealth.com/journals/aaen
Temperature – The forgotten vital sign Jason J. Smith (Surg Lt Cdr) Simon Mullett c a b c
a,*
, Steven A. Bland (Surg Lt Cdr) b,
TORC Laboratory, Department of Histopathology, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK Royal London Hospital, Whitechapel, London E1 1BB, UK Department of Accident and Emergency, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
Received 7 June 2005; accepted 2 August 2005
KEYWORDS
Summary Objective: To improve the measurement of core body temperature in the resuscitation room. Method: This work was undertaken in the Emergency Department (ED) of a large District General Hospital. The clinical notes for all admissions to the resuscitation suite during a 2 month period were reviewed to establish the frequency of temperature measurement. Following a simple educational program, performance was reaudited using the same methodology. Results: Of the first cohort 13.4% had had their temperature recorded. This improved to 71.6%. Conclusions: The measurement of body temperature in the resuscitation room is important as hypothermia has profound effects on the cardiovascular, pulmonary, neurological and haemostatic systems. Clinical audit highlights poor current performance and enables improvement of practice through simple education. c 2005 Elsevier Ltd. All rights reserved.
Core body temperature; Hypothermia; Resuscitation; Audit
Introduction
Patients arrive at the resuscitation suite of an emergency department (ED) with a large range of life threatening conditions. They may have suffered trauma, a cerebro-vascular accident or cardiac arrest. Hypothermia has profound effects
* Corresponding author. Tel.: +02392 286000x5355; fax: +02392 286379. E-mail address: [email protected] (J.J. Smith).
on the cardiovascular, pulmonary, neurological and haemostatic systems (Tsuei and Kearney, 2004). Procedures to reduce heat loss have become wide spread accepted practice. These may include administration of warmed intravenous fluids during the resuscitation, minimising patient exposure and actively warming the patient. Unlike other physiological parameters, however, which are carefully observed for changes during periods of intense medical care, core body temperature was observationally not well monitored. Therefore, an audit of current
0965-2302/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.aaen.2005.08.002
248
Method This work was undertaken in the ED of a large District General Hospital. A literature review highlighted the paramount importance of temperature measurement and monitoring in the resuscitation situation. From this review, the standard of care for all admissions to the resuscitation suite was established. It was felt that all those arriving at the resuscitation suite of an ED should have their temperature measured. Once measured it should be clearly recorded in the clinical notes. The initial assessment of performance was conducted over a two-month period. Patients recorded as having been admitted to the resuscitation suite in the departmental register were considered eligible. The clinical notes of these patients were reviewed to establish if the temperature had been clearly recorded. In addition, the patients’ history was compared with the Trauma Audit and Research Network (TARN, 2005) criteria of major trauma. The performance was compared to the standard of care. The first part of the audit cycle found that performance was low. Several measures were undertaken to heighten awareness and provide education. This involved presentations on the importance of temperature monitoring. The temperature monitoring areas on our trauma charts were highlighted. The equipment available in the resuscitation room for temperature monitoring was reviewed and several posters were put up to remind staff of temperature monitoring. A repeat assessment was conducted over a second two-month period. The patients recorded as having been admitted to the resuscitation suite in the departmental register were again considered eligible. The clinical notes were reviewed in the same way as for the initial audit to establish if the temperature had been clearly recorded in the second cohort. The patients’ histories were again compared with the TARN criteria of major trauma. The performance was again compared to the standard of care. The performance data gathered over the two different assessment periods was directly compared to identify any change.
Results The results of the audit are shown in Table 1. There were 77 admissions during the first twomonth period. Fifty-two patients’ notes were reviewed. 9 fitted TARN criteria. Patients (7[13.4%]) had had their temperature recorded. There were 97 admissions during the second two-month period. Seventy-four patients’ notes were reviewed. Fourteen fitted TARN criteria (23 trauma victims from history). Patients (53[71.6%]) had had their temperature recorded. The improvement in the measurement of core body temperature is shown in Chart 1.
Discussion Maintenance of the homoeothermic state is crucial to a person’s very existence. Exposure alone can disrupt the fine balance between heat loss and heat production leading to a fall in a person’s core body temperature. The resultant hypothermia is categorised as mild: 35–32 °C; moderate: 32–28 °C; severe: 28–20 °C; profound: 20–14 °C; and deep: <14 °C (Jenkins and Loscalzo, 1990). Hypothermia has a marked effect on the cardiovascular, neurological, pulmonary and haemostatic systems. Rutherford et al. (1998) reported that 9.4% of admissions to their Surgical Intensive Care Unit
Table 1
Summary of audit data
Number of admissions Notes reviewed (%) Met TARN criteria (%) Temperature measured (%)
1st Cycle
2nd Cycle
77 52 (67.5) 9 (17.3) 7 (13.4)
97 74 (76.3) 14 (18.9) 53 (71.6)
TEMPERATURE
Percentage (%)
practice was conducted, changes were implemented and the outcome of these changes assessed. The results of this audit are presented and discussed in the light of current literature, which emphasise the importance of body temperature as a physiological parameter.
J.J. Smith et al.
80 60 40
1st cycle 2nd cycle
20 0 Trauma
Non-trauma Combined Clinical subgroups
Chart 1 Improvement in measuring core body temperature in the resuscitation room of the ED following the education program.
Temperature – The forgotten vital sign had a core body temperature of less than 35 °C. Sixty percent of the hypothermic patients had suffered trauma injuries. This series showed 52% mortality. Lloyd (1996) states that temperature acts as no guide to survival, and there are many examples in the literature of survival from severe hypothermia and worse (Thomas and Cahill, 2000; Ko et al., 2002). Hypothermia’s neuro-protective role has been investigated since the 1950s. Safar (2002) cites Bigelow, Rosomoff and White & Albin as introducing moderate hypothermia (30°C) to heart surgery, brain surgery and spinal cord surgery, respectively. Frank (2001) reports a series of 20 patients undergoing aortic surgery who suffered no neurological deficits after cooling to 30 °C. After falling from favour for 25 years, there has recently been a resurgence of effort to investigate a role for hypothermia in the emergency setting. Hickey et al. (2000) concludes that it is prudent to avoid aggressive re-warming of haemodynamically stable patients who have developed mild–moderate hypothermia after cardiac arrest. Smith and Bleck (2002) comment on the statistically significant, positive outcomes of two separate trials reported by Holzer and by Bernard, which explored the role of hypothermia in patients following cardiac arrest. Felberg et al. (2001) published that external cooling to induce mild–moderate hypothermia after cardiac arrest is feasible and safe. In November 2005, the 2005 International Consensus on Cardiopulmonary (CPR) and Emergency Cardiovascular Care (ECC) Science and Treatment Recommendations (CoSTR2005) will be published simultaneously in the journals Circulation and Resuscitation. This will represent the scientific consensus of experts from a variety of countries, cultures and disciplines. The European Resuscitation Council (ERC) will then publish its new guidelines in the journal Resuscitation in December 2005, and the Resuscitation Council (UK) Guidelines (2005) will be published shortly afterwards. The reviewers’ worksheets are accessible on the web and active cooling for selected cardiac arrest patients after return of spontaneous circulation to a core temperature of 32–34 °C is supported (CoSTR2005,a,b). Hypothermia marked physiological effects can also be detrimental. The consequential triad of hypothermia, acidosis and coagulopathy, unless interrupted will invariably lead to death. FloresMaldonado et al. (2004) concluded that mild perioperative hypothermia is associated with infection of the surgical wound. Leslie and Sessler (2003) cites Lenhardt’s randomised study which showed recovery from anaesthesia was considerably dela-
249 yed in hypothermia patients compared to normothermic patients. Hildebrand et al. (2004) cites Winkler, who found that surgical patients with a core body temperature of 36.1 °C had greater blood loss than those who had a temperature of 36.6 °C. Tsuei and Kearney (2004) state that trauma itself blocks the normal central thermoregulation and blocks the shivering response. They proceed to cite Gentilello and Jurkovich’s modified classification of trauma with secondary hypothermia as mild: 36–34 °C; moderate: 34–32 °C; severe: <32 °C. Gentilello and Pierson (2001) state that where there is co-existing trauma, the effect is so deleterious, that it should be considered as a distinct entity from hypothermia due to other causes. It is clear, therefore, that there is evidence in the literature that hypothermia can have beneficial and deleterious effects. The only constant is that it is essential to measure and record the patient’s temperature. Morley (1996) showed that the Helicopter Emergency Medical Service do this using an aural probe to indicate initial hypothermia and monitor response to interventions. Peng and Bongard (1999) concluded that the patient’s temperature is as important as any other vital sign, prevention being the most important aspect of treatment, and monitoring the most important aspect of hypothermia management. Frank et al. (2000) and Lenhardt (2003) support measuring core temperature for any anaesthetic lasting longer than 30 minutes. The standard of care in this study is that every patient admitted to a resuscitation room in an ED should have their temperature measured and recorded appropriately in the clinical notes. Where the patient spends more than 1 hour in the department, the temperature should be recorded at least hourly. This study used a retrospective review of patients’ notes to evaluate whether patients had had their core body temperature measured. This methodology would fail to include those situations where the temperature was measured, but not recorded in the notes. With the transfer of patients through the hospital beyond the ED, it is important that information about care is transferred with the patient. It is as important to annotate the measurement in the notes as it is to take it initially. This study is limited by the inability to retrieve all patient notes. It was possible to review 67.5% of notes in the initial assessment period and 76% in the second. It is not felt that this limitation severely impacted on the results and the improvement in performance seen.
250
Conclusions The core body temperature of a severely ill patient is a valuable vital sign. All severely ill patients admitted to an accident and emergency department should have core body temperature recorded and, where appropriate, monitored alongside other vital signs. This work shows that performance can be easily improved by the use of simple education and informed, improved awareness.
References CoSTR2005., 2005a. International Consensus on Cardiopulmonary (CPR) and Emergency Cardiovascular Care (ECC) Science and Treatment Recommendations. Retrieved 6th April, 2005, from the American Heart Association website:. CoSTR2005., 2005b. International Consensus on Cardiopulmonary (CPR) and Emergency Cardiovascular Care (ECC) Science and Treatment Recommendations. Retrieved 6th April, 2005, from the American Heart Association website: . Felberg, R.A., Krieger, D.W., Chuang, R., Persse, D.E., Burgin, W.S., Hickenbottom, S.L., Morgenstern, L.B., Rosales, O., Grotta, J.C., 2001. Hypothermia after cardiac arrest: feasibility and safety of an external cooling protocol. Circulation 104, 1799–1804. Flores-Maldonado, A., Medina-Escobedo, C.E., Rios-Rodriguez, H.M.G., Fernandez-Dominguez, R., 2004. Mild perioperative hypothermia and the risk of wound infection. Arch. Med. Res. 32, 227. Frank, S.M., 2001. Consequences of hypothermia. Curr. Anaesthesia Crit. Care 12, 79. Frank, S.M., Tran, K.M., Fleisher, L.A., Elrahmany, H.K., 2000. Clinical importance of body temperature in the surgical patient. J. Thermal Biol. 25, 151.
J.J. Smith et al. Gentilello, L.M., Pierson, D.J., 2001. Trauma critical care. Am. J. Respir. Critt. Care Med. 163, 604–607. Hickey, R.W., Kochanek, P.M., Ferimer, H., Graham, S.H., Safar, P., 2000. Hypothermia and hyperthermia in children after resuscitation from cardiac arrest. Pediatrics 106, 118– 122. Hildebrand, F., Giannoudis, P.V., Van Griensven, M., Chawda, M., Pape, H.C., 2004. Pathophysiologic changes and effects of hypothermia on outcome in elective surgery and trauma patients. Am. J. Surg. 187, 363. Jenkins, L.L., Loscalzo, J., 1990. Manual of Emergency Medicine Diagnosis and Treatment. Little, Brown & Co., Boston. Ko, C.S., Alex, J., Jefferies, S., Parmar, J.M., 2002. Dead? Or just cold: profoundly hypothermic patient with no signs of life. Emerg. Med. J. 19, 478–479. Lenhardt, R., 2003. Monitoring and thermal management. Best Pract. Res. Clin. Anaesthesiol. 17, 569–581. Leslie, K., Sessler, DI, 2003. Perioperative hypothermia in the high-risk surgical patient. Best Pract. Res. Clin. Anaesthesiol. 17, 485. Lloyd, E.L., 1996. Accidental hypothermia. Resuscitation 32, 111. Morley, A.P., 1996. Pre-hospital monitoring of trauma patients: experience of a helicopter emergency medical service. Br. J. Anaesth. 76, 726–730. Peng, R.Y., Bongard, F.S., 1999. Hypothermia in trauma patients. J. Am. Coll. Surg. 188, 685. Resuscitation Council (UK), 2005. Available from:. Rutherford, E.J., Fusco, M.A., Nunn, C.R., Bass, J.G., Eddy, V.A., Morris Jr., J.A., 1998. Hypothermia in critically ill trauma patients. Injury 29 (8), 605–608. Safar, P., 2002. Development of cardiopulmonary-cerebral resuscitation in the twentieth century. Int. Cong. Series 1242, 215. Smith, T.L., Bleck, T.P., 2002. Hypothermia and neurologic outcome in patients following cardiac arrest: should we be hot to cool off our patients? Crit. Care 6, 377–380. Thomas, R., Cahill, C.J., 2000. Successful defibrillation in profound hypothermia. Resuscitation 47, 317. Trauma Audit and Research Network, 2005. TARN Procedures. Retrieved 22nd April, 2005 from the TARN website: . Tsuei, B.J., Kearney, P.A., 2004. Hypothermia in the trauma patient. Injury 35, 7.
Accident and Emergency Nursing www.elsevierhealth.com/journals/aaen
Temperature – The forgotten vital sign Jason J. Smith (Surg Lt Cdr) Simon Mullett c a b c
a,*
, Steven A. Bland (Surg Lt Cdr) b,
TORC Laboratory, Department of Histopathology, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK Royal London Hospital, Whitechapel, London E1 1BB, UK Department of Accident and Emergency, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
Received 7 June 2005; accepted 2 August 2005
KEYWORDS
Summary Objective: To improve the measurement of core body temperature in the resuscitation room. Method: This work was undertaken in the Emergency Department (ED) of a large District General Hospital. The clinical notes for all admissions to the resuscitation suite during a 2 month period were reviewed to establish the frequency of temperature measurement. Following a simple educational program, performance was reaudited using the same methodology. Results: Of the first cohort 13.4% had had their temperature recorded. This improved to 71.6%. Conclusions: The measurement of body temperature in the resuscitation room is important as hypothermia has profound effects on the cardiovascular, pulmonary, neurological and haemostatic systems. Clinical audit highlights poor current performance and enables improvement of practice through simple education. c 2005 Elsevier Ltd. All rights reserved.
Core body temperature; Hypothermia; Resuscitation; Audit
Introduction
Patients arrive at the resuscitation suite of an emergency department (ED) with a large range of life threatening conditions. They may have suffered trauma, a cerebro-vascular accident or cardiac arrest. Hypothermia has profound effects
* Corresponding author. Tel.: +02392 286000x5355; fax: +02392 286379. E-mail address: [email protected] (J.J. Smith).
on the cardiovascular, pulmonary, neurological and haemostatic systems (Tsuei and Kearney, 2004). Procedures to reduce heat loss have become wide spread accepted practice. These may include administration of warmed intravenous fluids during the resuscitation, minimising patient exposure and actively warming the patient. Unlike other physiological parameters, however, which are carefully observed for changes during periods of intense medical care, core body temperature was observationally not well monitored. Therefore, an audit of current
0965-2302/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.aaen.2005.08.002
248
Method This work was undertaken in the ED of a large District General Hospital. A literature review highlighted the paramount importance of temperature measurement and monitoring in the resuscitation situation. From this review, the standard of care for all admissions to the resuscitation suite was established. It was felt that all those arriving at the resuscitation suite of an ED should have their temperature measured. Once measured it should be clearly recorded in the clinical notes. The initial assessment of performance was conducted over a two-month period. Patients recorded as having been admitted to the resuscitation suite in the departmental register were considered eligible. The clinical notes of these patients were reviewed to establish if the temperature had been clearly recorded. In addition, the patients’ history was compared with the Trauma Audit and Research Network (TARN, 2005) criteria of major trauma. The performance was compared to the standard of care. The first part of the audit cycle found that performance was low. Several measures were undertaken to heighten awareness and provide education. This involved presentations on the importance of temperature monitoring. The temperature monitoring areas on our trauma charts were highlighted. The equipment available in the resuscitation room for temperature monitoring was reviewed and several posters were put up to remind staff of temperature monitoring. A repeat assessment was conducted over a second two-month period. The patients recorded as having been admitted to the resuscitation suite in the departmental register were again considered eligible. The clinical notes were reviewed in the same way as for the initial audit to establish if the temperature had been clearly recorded in the second cohort. The patients’ histories were again compared with the TARN criteria of major trauma. The performance was again compared to the standard of care. The performance data gathered over the two different assessment periods was directly compared to identify any change.
Results The results of the audit are shown in Table 1. There were 77 admissions during the first twomonth period. Fifty-two patients’ notes were reviewed. 9 fitted TARN criteria. Patients (7[13.4%]) had had their temperature recorded. There were 97 admissions during the second two-month period. Seventy-four patients’ notes were reviewed. Fourteen fitted TARN criteria (23 trauma victims from history). Patients (53[71.6%]) had had their temperature recorded. The improvement in the measurement of core body temperature is shown in Chart 1.
Discussion Maintenance of the homoeothermic state is crucial to a person’s very existence. Exposure alone can disrupt the fine balance between heat loss and heat production leading to a fall in a person’s core body temperature. The resultant hypothermia is categorised as mild: 35–32 °C; moderate: 32–28 °C; severe: 28–20 °C; profound: 20–14 °C; and deep: <14 °C (Jenkins and Loscalzo, 1990). Hypothermia has a marked effect on the cardiovascular, neurological, pulmonary and haemostatic systems. Rutherford et al. (1998) reported that 9.4% of admissions to their Surgical Intensive Care Unit
Table 1
Summary of audit data
Number of admissions Notes reviewed (%) Met TARN criteria (%) Temperature measured (%)
1st Cycle
2nd Cycle
77 52 (67.5) 9 (17.3) 7 (13.4)
97 74 (76.3) 14 (18.9) 53 (71.6)
TEMPERATURE
Percentage (%)
practice was conducted, changes were implemented and the outcome of these changes assessed. The results of this audit are presented and discussed in the light of current literature, which emphasise the importance of body temperature as a physiological parameter.
J.J. Smith et al.
80 60 40
1st cycle 2nd cycle
20 0 Trauma
Non-trauma Combined Clinical subgroups
Chart 1 Improvement in measuring core body temperature in the resuscitation room of the ED following the education program.
Temperature – The forgotten vital sign had a core body temperature of less than 35 °C. Sixty percent of the hypothermic patients had suffered trauma injuries. This series showed 52% mortality. Lloyd (1996) states that temperature acts as no guide to survival, and there are many examples in the literature of survival from severe hypothermia and worse (Thomas and Cahill, 2000; Ko et al., 2002). Hypothermia’s neuro-protective role has been investigated since the 1950s. Safar (2002) cites Bigelow, Rosomoff and White & Albin as introducing moderate hypothermia (30°C) to heart surgery, brain surgery and spinal cord surgery, respectively. Frank (2001) reports a series of 20 patients undergoing aortic surgery who suffered no neurological deficits after cooling to 30 °C. After falling from favour for 25 years, there has recently been a resurgence of effort to investigate a role for hypothermia in the emergency setting. Hickey et al. (2000) concludes that it is prudent to avoid aggressive re-warming of haemodynamically stable patients who have developed mild–moderate hypothermia after cardiac arrest. Smith and Bleck (2002) comment on the statistically significant, positive outcomes of two separate trials reported by Holzer and by Bernard, which explored the role of hypothermia in patients following cardiac arrest. Felberg et al. (2001) published that external cooling to induce mild–moderate hypothermia after cardiac arrest is feasible and safe. In November 2005, the 2005 International Consensus on Cardiopulmonary (CPR) and Emergency Cardiovascular Care (ECC) Science and Treatment Recommendations (CoSTR2005) will be published simultaneously in the journals Circulation and Resuscitation. This will represent the scientific consensus of experts from a variety of countries, cultures and disciplines. The European Resuscitation Council (ERC) will then publish its new guidelines in the journal Resuscitation in December 2005, and the Resuscitation Council (UK) Guidelines (2005) will be published shortly afterwards. The reviewers’ worksheets are accessible on the web and active cooling for selected cardiac arrest patients after return of spontaneous circulation to a core temperature of 32–34 °C is supported (CoSTR2005,a,b). Hypothermia marked physiological effects can also be detrimental. The consequential triad of hypothermia, acidosis and coagulopathy, unless interrupted will invariably lead to death. FloresMaldonado et al. (2004) concluded that mild perioperative hypothermia is associated with infection of the surgical wound. Leslie and Sessler (2003) cites Lenhardt’s randomised study which showed recovery from anaesthesia was considerably dela-
249 yed in hypothermia patients compared to normothermic patients. Hildebrand et al. (2004) cites Winkler, who found that surgical patients with a core body temperature of 36.1 °C had greater blood loss than those who had a temperature of 36.6 °C. Tsuei and Kearney (2004) state that trauma itself blocks the normal central thermoregulation and blocks the shivering response. They proceed to cite Gentilello and Jurkovich’s modified classification of trauma with secondary hypothermia as mild: 36–34 °C; moderate: 34–32 °C; severe: <32 °C. Gentilello and Pierson (2001) state that where there is co-existing trauma, the effect is so deleterious, that it should be considered as a distinct entity from hypothermia due to other causes. It is clear, therefore, that there is evidence in the literature that hypothermia can have beneficial and deleterious effects. The only constant is that it is essential to measure and record the patient’s temperature. Morley (1996) showed that the Helicopter Emergency Medical Service do this using an aural probe to indicate initial hypothermia and monitor response to interventions. Peng and Bongard (1999) concluded that the patient’s temperature is as important as any other vital sign, prevention being the most important aspect of treatment, and monitoring the most important aspect of hypothermia management. Frank et al. (2000) and Lenhardt (2003) support measuring core temperature for any anaesthetic lasting longer than 30 minutes. The standard of care in this study is that every patient admitted to a resuscitation room in an ED should have their temperature measured and recorded appropriately in the clinical notes. Where the patient spends more than 1 hour in the department, the temperature should be recorded at least hourly. This study used a retrospective review of patients’ notes to evaluate whether patients had had their core body temperature measured. This methodology would fail to include those situations where the temperature was measured, but not recorded in the notes. With the transfer of patients through the hospital beyond the ED, it is important that information about care is transferred with the patient. It is as important to annotate the measurement in the notes as it is to take it initially. This study is limited by the inability to retrieve all patient notes. It was possible to review 67.5% of notes in the initial assessment period and 76% in the second. It is not felt that this limitation severely impacted on the results and the improvement in performance seen.
250
Conclusions The core body temperature of a severely ill patient is a valuable vital sign. All severely ill patients admitted to an accident and emergency department should have core body temperature recorded and, where appropriate, monitored alongside other vital signs. This work shows that performance can be easily improved by the use of simple education and informed, improved awareness.
References CoSTR2005., 2005a. International Consensus on Cardiopulmonary (CPR) and Emergency Cardiovascular Care (ECC) Science and Treatment Recommendations. Retrieved 6th April, 2005, from the American Heart Association website:
J.J. Smith et al. Gentilello, L.M., Pierson, D.J., 2001. Trauma critical care. Am. J. Respir. Critt. Care Med. 163, 604–607. Hickey, R.W., Kochanek, P.M., Ferimer, H., Graham, S.H., Safar, P., 2000. Hypothermia and hyperthermia in children after resuscitation from cardiac arrest. Pediatrics 106, 118– 122. Hildebrand, F., Giannoudis, P.V., Van Griensven, M., Chawda, M., Pape, H.C., 2004. Pathophysiologic changes and effects of hypothermia on outcome in elective surgery and trauma patients. Am. J. Surg. 187, 363. Jenkins, L.L., Loscalzo, J., 1990. Manual of Emergency Medicine Diagnosis and Treatment. Little, Brown & Co., Boston. Ko, C.S., Alex, J., Jefferies, S., Parmar, J.M., 2002. Dead? Or just cold: profoundly hypothermic patient with no signs of life. Emerg. Med. J. 19, 478–479. Lenhardt, R., 2003. Monitoring and thermal management. Best Pract. Res. Clin. Anaesthesiol. 17, 569–581. Leslie, K., Sessler, DI, 2003. Perioperative hypothermia in the high-risk surgical patient. Best Pract. Res. Clin. Anaesthesiol. 17, 485. Lloyd, E.L., 1996. Accidental hypothermia. Resuscitation 32, 111. Morley, A.P., 1996. Pre-hospital monitoring of trauma patients: experience of a helicopter emergency medical service. Br. J. Anaesth. 76, 726–730. Peng, R.Y., Bongard, F.S., 1999. Hypothermia in trauma patients. J. Am. Coll. Surg. 188, 685. Resuscitation Council (UK), 2005. Available from: