impaired thermoregulation is a known complication of high level spinal cord injury and side effects of hypothermia induced by such an injury may complicate trauma resuscitation .
hypothermia defined as a core temperature of < 35c are seen frequently in emergency departments ( eds ) throughout the united states .
visits occurs mostly in a geographical and seasonal distribution but may also occur in the summer months without exposure to extreme temperatures .  
the mortality rate for hypothermia in the united states approaches 700 per year with florida accounting for on average six deaths per year .
about 99% of the deaths occur in the months of november through february .   primary hypothermia caused by environmental cold water immersion and extreme cold temperatures
secondary hypothermia is a low core temperature attributed to a variety of medical conditions , including spinal cord injury , and is overall more common than primary hypothermia .
studies have shown that secondary hypothermia in trauma patients with a core temperature of less than 32c ( 89.6f ) were ten times more likely to die than those with normothermia .  
this case illustrates a multifaceted and complex situation in which a trauma patient presents with multiple potential life - threatening injuries but also in full cardiac arrest due to secondary hypothermia from a rather rare cause of hypothermia , occult spinal cord injury .
a 64-year - old caucasian male with an unknown past medical history presented to the bayfront hospital ed in st .
the patient was initially found by local police officers lying unconscious in a ditch next to his bicycle .
when ems arrived on scene the patient was cold , unresponsive , gcs 3 , covered in ants and without any other obvious signs of skeletal or traumatic injury .
the patient was fully immobilized in a cervical collar and on a backboard prior to transport to the ed and was intubated secondary to his low gcs .
the patient 's vitals at the time showed sinus bradycardia at a rate of 30 - 40s , palpable pulse but an unobtainable blood pressure on multiple attempts . at 08:22
the patient arrived at the ed and upon transfer to the trauma bed was noted to be in ventricular fibrillation . at that time aed pads were attached and advanced cardiac life support ( acls ) protocol was initiated .
trauma protocol labs were sent which consisted of cbc , cmp , serum cortisol , serum etoh , amylase , tsh , cardiac enzymes , and a coagulation profile . during the resuscitation the emergency room physician and trauma surgeon noted that the patient was very cold to the touch . a rectal temperature was performed but the temperature did not register . per trauma protocol ,
the patient was being given warm iv fluids as well as warm humidified air via mechanical ventilation .
it was not until 09:06 that the patient 's temperature was accurately recorded to be 24.9c ( 76.9f ) . at
approximately 09:22 the patient had been undergoing acls protocol for one hour and had been defibrillated 13 times and given five rounds of epinephrine , two rounds of atropine , and two rounds of amiodarone . with the patient still in ventricular fibrillation ,
it was decided to continue cardiopulmonary resuscitation with chest compressions and mechanical ventilation until the patient 's core temperature increased .
supplemental active re - warming interventions including warm water lavage via og tube and foley catheter were started at that time .
the patient remained in ventricular fibrillation for more than three hours until 11:45 , when his rectal temperature was 30.1c ( 86.2f ) he was successfully converted into normal sinus rhythm at 66 bpm with a manual blood pressure of 180/120 .
as the patient 's temperature continued to rise he went in and out of atrial fibrillation and sinus tachycardia but eventually returned and remained in normal sinus rhythm .
after cardiac stabilization , a complete secondary survey was performed that showed no other obvious signs of trauma or skeletal injury .
a central line and arterial line was placed and he was started on a dopamine drip as his blood pressure decreased to 88/56 .
once the patient 's temperature reached 31.2c ( 88.2f ) his og and foley catheter lavage were discontinued .
although unable to remember the accident , or any events leading up to the accident , he did appropriately respond to some basic questions .
it was at this that the patient 's motor deficits were noticed as he was unable to feel anything from the neck down or move any of his extremities .
the patient underwent a scan of his head , neck , abdomen , and pelvis .
the scans showed no head injury or c - spine fractures and noted only a small 1 mm broad - based disc bulge at the level of c5 - 6 and c6 - 7 , moderately dilated loops of bowel consistent with an ileus and two small bilateral pleural effusions .
although a toxicology screen was not obtained , he did have an etoh of 0.183 g / dl .
the patient was transferred to the icu , and subsequently underwent an mri of his c - spine which demonstrated diffuse edema of his cervical spine . after a prolonged hospital
stay the patient 's mental status did improve to baseline but his paralysis did not as he remained a tetraplegic .
mild hypothermia is defined as a temperature 32 - 35c , moderate 28 - 32c , and severe < 28c .
primary hypothermia is caused by accidental or environmental exposure such as cold water immersion and extreme cold outdoor temperatures .
secondary hypothermia is seen more commonly in the general population and can be caused by medical conditions that lowers the body 's temperature set point , i.e. severe cerebrovascular disease , infection , endocrine dysfunction , hypothalamic dysfunction , peritonitis , pancreatitis , medications , and in our case spinal cord injury .
[ 15 ] thermoregulatory dysfunction has been reported in high spinal cord injuries but the reports referencing immediate autonomic dysreflexia following trauma are not well described in the literature .
most of the reported cases discussing thermoregulatory dysfunction and autonomic dysreflexia in patients with high spinal cord injury mostly discuss observed temperature elevations .   after a spinal cord injury above the major splanchnic sympathetic outflow ( t4-t6 ) ,
it is common for partial poikilothermia to occur secondary to the lack of hypothalamic control over the sympathetic nervous system .
this impairment occurs because of the interruption of neuronal pathways between the periphery and the hypothalamus , the resultant deficit is the inability to shiver when it is cold and the lack of proper blood vessel vasodilation or vasoconstriction to certain environmental stimuli , which normally keeps the body at an ambient temperature .   the lack of hypothalamic control results in depressed heat regulation , accounting for only a 10 - 15% increase in core temperature compared to a normal increase of 200 - 500% .   due to our patient 's high spinal cord injury and complete tetraplegia ,
he most likely lost all form of heat regulation usually governed by an intact spinal cord pathway and hypothalamic feedback .
this explains our patient 's partial poikilothermia and resultant inability to keep his core body temperature above the ambient temperature which was in the mid to upper sixties that night .
re - warming the hypothermic patient is the mainstay of treatment regardless of the primary cause and is the only means to return cardiac stabilization following dysrhythmias such as ventricular fibrillation .
re - warming can take place by using three different mechanisms ; passive external , active external , and active internal warming .
active external warming with blankets has been shown to increase temperatures by 1c-2c / h , active internal warming with warm humidified air by 1c-1.5c / h and active internal warming with infusion of warm fluid into gastric , colonic , pleural , peritoneal or pericardial cavities by 2c-2.5c / h .   from initial presentation to cardiac stabilization , our patient was re - warmed at a rate of 2.13c / h using the described passive and active re - warming methods stated earlier .
another option to re - warming that was not addressed in our case was the use of cardiopulmonary bypass in the setting of prolonged cpr .
this option can increase re - warming at rates up to 10c per hour . in the case of all resuscitations in the hypothermic patient
, they should not be considered unsuccessful until the patient has a core temperature of 32c .  
sometimes it is difficult to determine who is deemed appropriate to re - warm to a core temperature of 32c before terminating resuscitation efforts .
current recommendations suggest that all lifesaving procedures should be initiated unless the victim is obviously dead ( eg , rigor mortis , decomposition , hemisection , decapitation ) or have ominous signs of a grave prognosis regardless of efforts which include potassium levels > 10
meq / l , temperature < 12c , ph < 6.5 and a fibrinogen level < 50 mg / dl .  
the evidence of the patient 's paralysis was not apparent until he woke up following successful cardioversion and re - warming .
no radiologic abnormalities were seen except the small 1-mm broad - based bulge seen at level c5 - 6 and c6 - 7 .
the mri done later that day demonstrated diffuse spinal cord edema which finally explained his injuries .
this type of injury is most commonly seen in children and is termed a spinal cord injury without radiological abnormality or spinal cord injury without radiological abnormality ( sciwora ) .
sciwora is defined as the occurrence of acute traumatic myelopathy despite normal plain radiographs and normal computed tomographic ( ct ) studies .
it is most described and discovered in the pediatric population and thought to be due to the mismatch in the elasticity of the tissue of the vertebral column and spinal cord .  
sciwora in adults is very rare and most of these injuries are often missed initially and diagnosis is often delayed because these injuries tend to occur in the multi - trauma patient .  
for the most part , sciwora in adolescents and adults are less severe because most of them present as incomplete paralysis with transient symptoms and a delayed onset and should always be suspected in patients that have a neurological deficits and apparently normal x - rays and/or ct scans .  
the use of steroids is controversial but has shown some long - term benefit and is recommended as a treatment  option .
 the national acute spinal cord injury study ( nascis ) trials showed no statistical difference between methylprednisolone sodium succinate ( mpss ) and placebo in terms of neurological recovery at one year , but the post - hoc analyses of subgroups did .
the nascis iii study found that in patients treated earlier than 3 hours after injury , the administration of methylprednisolone for 24 h was best .
the dose , if considered , consists of a high dose methylprednisone bolus of 30 mg / kg iv within 8 h of the injury as well as an infusion of 5.4 mg / kg / h for the next 23 h. [ 1517 ]
it is evident from this case report that even though hypothermia can occur from many different causes , it is still treated the same until its underlying cause can be identified .
current trauma protocol , using warm saline and warm humidified air during mechanical ventilation , allows prompt treatment in those patients who are not initially discovered to be hypothermic .
this case also highlights the complexity of the trauma patient and the multiple conditions that can present and mask other conditions .
this case was ultimately caused by an occult spinal cord injury after the patient fell from his bicycle .
this injury is classified as a sciwora and in adults is a condition that is rare . to have this condition causing severe hypothermia with cardiopulmonary arrest
 we report a case of a 64-year - old caucasian male who was transported to the emergency department ( ed ) after being found unconscious on the side of the road . on arrival to the ed the patient went into ventricular 
 fibrillation and advanced cardiac life support was started at that time . 
 thirty minutes into the resuscitation , after multiple rounds of code drugs and defibrillation attempts , the patient was found to be severely hypothermic with a rectal temperature of 24.9c ( 76.9f ) . through the use of passive and active re - warming measures the patient 's temperature increased enough to allow successful cardioversion and stabilization . within minutes of cardiac stabilization 
 the patient regained consciousness and was able to follow commands , but was found to be paralyzed from the neck down . 
 subsequent ct scans revealed no acute fractures , subluxations or acute spinal cord injury . 
 this case represents the rare finding of severe hypothermia secondary to occult spinal cord injury . 
 case report was taken from case at bayfront hospital , st . 
 petersburg , florida . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION