Hypothermia

Hypothermia
During Napoleon Bonaparte's retreat from Russia in the winter of 1812, many troops died from hypothermia.[1]
Classification and external resources
Specialty Critical care medicine
ICD-10 T68
ICD-9-CM 991.6
DiseasesDB 6542
MedlinePlus 000038
eMedicine med/1144
Patient UK Hypothermia
MeSH D007035

Hypothermia is defined as a body core temperature below 35.0 °C (95.0 °F). Symptoms depend on the temperature. In mild hypothermia there is shivering and mental confusion. In moderate hypothermia shivering stops and confusion increases. In severe hypothermia there may be paradoxical undressing, in which a person removes his or her clothing, as well as an increased risk of the heart stopping.[2]

Hypothermia has two main types of causes. It classically occurs from exposure to extreme cold.[1] It may also occur from any condition that decreases heat production or increases heat loss.[1] Commonly this includes alcohol intoxication but may also include low blood sugar, anorexia, and advanced age, among others.[1][2] Body temperature is usually maintained near a constant level of 36.5–37.5 °C (97.7–99.5 °F) through thermoregulation.[2] Efforts to increase body temperature involve shivering, increased voluntary activity, and putting on warmer clothing.[2][3] Hypothermia may be diagnosed based on either a person's symptoms in the presence of risk factors or by measuring a person's core temperature.[2]

The treatment of mild hypothermia involves warm drinks, warm clothing and physical activity. In those with moderate hypothermia heating blankets and warmed intravenous fluids are recommended. People with moderate or severe hypothermia should be moved gently. In severe hypothermia extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass may be useful. In those without a pulse cardiopulmonary resuscitation (CPR) is indicated along with the above measures. Rewarming is typically continued until a person's temperature is greater than 32 °C (90 °F). If there is no improvement at this point or the blood potassium level is greater than 12 mmol/liter at any time resuscitation may be discontinued.[2]

Hypothermia is the cause of at least 1500 deaths a year in the United States.[2] It is more common in older people and males.[4] One of the lowest documented body temperatures from which someone with accidental hypothermia has survived is 13.0 °C (55.4 °F) in a near-drowning of a 7-year-old girl in Sweden.[5] Survival after more than six hours of CPR has been described.[2] In those in whom ECMO or bypass is used survival is around 50%.[2] Deaths due to hypothermia have played an important role in many wars.[1] Hyperthermia is the opposite of hypothermia, being an increased body temperature due to failed thermoregulation.[6][7] The term is from Greek ὑπο meaning under and θερμία meaning heat.

Classification

Hypothermia is often defined as any body temperature below 35.0 °C (95.0 °F).[8] With this method it is divided into degrees of severity based on the core temperature.[8]

Another classification system, the Swiss staging system, divides hypothermia based on the presenting symptoms which is preferred when it is not possible to determine an accurate core temperature.[2]

Other cold-related injuries that can be present either alone or in combination with hypothermia include:

The normal human body temperature is often stated as 36.5–37.5 °C (97.7–99.5 °F).[11] Hyperthermia and fever, are defined as a temperature of greater than 37.5–38.3 °C (99.5–100.9 °F).[7]

Signs and symptoms

Signs and symptoms vary depending on the degree of hypothermia, and may be divided by the three stages of severity. Infants with hypothermia may feel cold when touched, with bright red skin and unusual lack of energy.[12]

Mild

Symptoms of mild hypothermia may be vague,[13] with sympathetic nervous system excitation (shivering, high blood pressure, fast heart rate, fast respiratory rate, and contraction of blood vessels). These are all physiological responses to preserve heat.[14] Increased urine production due to cold, mental confusion, and hepatic dysfunction may also be present.[15] Hyperglycemia may be present, as glucose consumption by cells and insulin secretion both decrease, and tissue sensitivity to insulin may be blunted.[16] Sympathetic activation also releases glucose from the liver. In many cases, however, especially in alcoholic patients, hypoglycemia appears to be a more common presentation.[16] Hypoglycemia is also found in many hypothermic patients, because hypothermia may be a result of hypoglycemia.[17]

Moderate

Low body temperature results in shivering becoming more violent. Muscle mis-coordination becomes apparent.[18][19][20] Movements are slow and labored, accompanied by a stumbling pace and mild confusion, although the person may appear alert. Surface blood vessels contract further as the body focuses its remaining resources on keeping the vital organs warm. The subject becomes pale. Lips, ears, fingers, and toes may become blue.

Severe

As the temperature decreases, further physiological systems falter and heart rate, respiratory rate, and blood pressure all decrease. This results in an expected heart rate in the 30s at a temperature of 28 °C (82 °F).[15]

Difficulty speaking, sluggish thinking, and amnesia start to appear; inability to use hands and stumbling are also usually present. Cellular metabolic processes shut down. Below 30 °C (86 °F), the exposed skin becomes blue and puffy, muscle coordination very poor, and walking almost impossible, and the person exhibits incoherent/irrational behavior, including terminal burrowing (see below) or even stupor. Pulse and respiration rates decrease significantly, but fast heart rates (ventricular tachycardia, atrial fibrillation) can also occur. Atrial fibrillation is not typically a concern in and of itself.[2] Major organs fail. Clinical death occurs.

Paradoxical undressing

Twenty to fifty percent of hypothermia deaths are associated with paradoxical undressing. This typically occurs during moderate to severe hypothermia, as the person becomes disoriented, confused, and combative. They may begin discarding their clothing, which, in turn, increases the rate of heat loss.[21][22]

Rescuers who are trained in mountain survival techniques are taught to expect this; however, some may assume incorrectly that urban victims of hypothermia have been subjected to a sexual assault.[23]

One explanation for the effect is a cold-induced malfunction of the hypothalamus, the part of the brain that regulates body temperature. Another explanation is that the muscles contracting peripheral blood vessels become exhausted (known as a loss of vasomotor tone) and relax, leading to a sudden surge of blood (and heat) to the extremities, fooling the person into feeling overheated.[23][24]

Terminal burrowing

An apparent self-protective behaviour known as terminal burrowing, or hide-and-die syndrome,[25] occurs in the final stages of hypothermia. The afflicted will enter small, enclosed spaces, such as underneath beds or behind wardrobes. It is often associated with paradoxical undressing.[26] Researchers in Germany claim this is "obviously an autonomous process of the brain stem, which is triggered in the final state of hypothermia and produces a primitive and burrowing-like behavior of protection, as seen in hibernating animals."[27] This happens mostly in cases where temperature drops slowly.[24]

Causes

The rate of hypothermia is strongly related to age in the United States.

Hypothermia usually occurs from exposure to low temperatures, and is frequently complicated by alcohol consumption.[1] Any condition that decreases heat production, increases heat loss, or impairs thermoregulation, however, may contribute.[1] Thus, hypothermia risk factors include: substance abuse (including alcohol abuse), homelessness, any condition that affects judgment (such as hypoglycemia), the extremes of age, poor clothing, chronic medical conditions (such as hypothyroidism and sepsis), and living in a cold environment.[28][29] Hypothermia occurs frequently in major trauma, and is also observed in severe cases of anorexia nervosa.

Alcohol

Alcohol consumption increases the risk of hypothermia by its action as a vasodilator. It increases blood flow to the skin and extremities, making a person feel warm, while increasing heat loss.[30] Between 33% and 73% of hypothermia cases are complicated by alcohol.[1]

Poverty

In the UK, 28,354 cases of hypothermia were treated in 2012/13 – an increase of 25% from the previous year.[31] Some cases of hypothermia death, as well as other preventable deaths, happen because poor people cannot easily afford to keep warm. Rising fuel bills have increased the numbers who have difficulty paying for adequate heating in the UK. Some pensioners and disabled people are at risk because they do not work and cannot easily get out of their homes. Better heat insulation can help.[32][33][34]

Water immersion

Two American marines participating in an immersion hypothermia exercise

Hypothermia continues to be a major limitation to swimming or diving in cold water.[18] The reduction in finger dexterity due to pain or numbness decreases general safety and work capacity, which consequently increases the risk of other injuries.[18][20]

Other factors predisposing to immersion hypothermia include dehydration, inadequate rewarming between repetitive dives, starting a dive while wearing cold, wet dry suit undergarments, sweating with work, inadequate thermal insulation (for example, thin dry suit undergarment), and poor physical conditioning.[18]

Heat is lost much more quickly in water[18] than in air. Thus, water temperatures that would be quite reasonable as outdoor air temperatures can lead to hypothermia in survivors, although this is not usually the direct clinical cause of death for those who are not rescued. A water temperature of 10 °C (50 °F) can lead to death in as little as one hour, and water temperatures near freezing can cause death in as little as 15 minutes.[35] A notable example of this occurred during the sinking of the Titanic, when most people who entered the −2 °C (28 °F) water died in 15–30 minutes.[36]

The actual cause of death in cold water is usually the bodily reactions to heat loss and to freezing water, rather than hypothermia (loss of core temperature) itself. For example, plunged into freezing seas, around 20% of victims die within 2 minutes from cold shock (uncontrolled rapid breathing, and gasping, causing water inhalation, massive increase in blood pressure and cardiac strain leading to cardiac arrest, and panic); another 50% die within 15–30 minutes from cold incapacitation (inability to use or control limbs and hands for swimming or gripping, as the body "protectively" shuts down the peripheral muscles of the limbs to protect its core).[37] Exhaustion and unconsciousness cause drowning, claiming the rest within a similar time.[35]

Pathophysiology

Heat is primarily generated in muscle tissue, including the heart, and in the liver, while it is lost through the skin (90%) and lungs (10%).[13] Heat production may be increased 2 to 4 fold through muscle contractions (i.e. exercise and shivering).[13] The rate of heat loss is determined, as with any object, by convection, conduction, and radiation.[13] The rates of these can be affected by body mass index, body surface area to volume ratios, clothing and other environmental conditions.[42]

Many changes to physiology occur as body temperature decreases. These occur in the cardiovascular system leading to the Osborn J wave and other dysrhythmias, decreased CNS electrical activity, cold diuresis, and non-cardiogenic pulmonary edema.[43]

Research has shown that glomerular filtration rate (GFR) decreases as a result of hypothermia.[44] In essence, Hypothermia increases preglomerular vasoconstriction, thus decreasing both renal blood flow (RBF) and GFR.[45]

Diagnosis

Atrial fibrillation and Osborn J waves in a person with hypothermia. Note what could be mistaken for ST elevation.

Accurate determination of core temperature often requires a special low temperature thermometer, as most clinical thermometers do not measure accurately below 34.4 °C (93.9 °F).[14] A low temperature thermometer can be placed in the rectum, esophagus or the bladder. Esophageal measurements are the most accurate and are recommended once a person is intubated.[2] Other methods of measurement such as in the mouth, under the arm, or using an infrared ear thermometer are often not accurate.[2]

As a hypothermic person's heart rate may be very slow, prolonged feeling for a pulse could be required before detecting. In 2005, the American Heart Association recommended at least 30–45 seconds to verify the absence of a pulse before initiating CPR.[46] Others recommend a 60-second check.[2]

The classical ECG finding of hypothermia is the Osborn J wave. Also, ventricular fibrillation frequently occurs below 28 °C (82 °F) and asystole below 20 °C (68 °F).[13] The Osborn J may look very similar to those of an acute ST elevation myocardial infarction.[15] Thrombolysis as a reaction to the presence of Osborn J waves is not indicated, as it would only worsen the underlying coagulopathy caused by hypothermia.

Prevention

Appropriate clothing helps to prevent hypothermia. Synthetic and wool fabrics are superior to cotton as they provide better insulation when wet and dry. Some synthetic fabrics, such as polypropylene and polyester, are used in clothing designed to wick perspiration away from the body, such as liner socks and moisture-wicking undergarments. Clothing should be loose fitting, as tight clothing reduces the circulation of warm blood.[47] In planning outdoor activity, prepare appropriately for possible cold weather. Those who drink alcohol before or during outdoor activity should ensure at least one sober person is present responsible for safety.

Covering the head is effective, but no more effective than covering any other part of the body. While common folklore says that people lose most of their heat through their heads, heat loss from the head is no more significant than that from other uncovered parts of the body.[48][49] However, heat loss from the head is significant in infants, whose head is larger relative to the rest of the body than in adults. Several studies have shown that for uncovered infants, lined hats significantly reduce heat loss and thermal stress.[50][51][52] Children have a larger surface area per unit mass, and other things being equal should have one more layer of clothing than adults in similar conditions, and the time they spend in cold environments should be limited. However children are often more active than adults, and may generate more heat. In both adults and children, overexertion causes sweating and thus increases heat loss.[53]

Building a shelter can aid survival where there is danger of death from exposure. Shelters can be of many different types, metal can conduct heat away from the occupants and is sometimes best avoided. The shelter should not be too big so body warmth stays near the occupants. Good ventilation is essential especially if a fire will be lit in the shelter. Fires should be put out before the occupants sleep to prevent carbon monoxide poisoning. People caught in very cold, snowy conditions can build an igloo or snow cave to shelter.[54][55]

The United States Coast Guard promotes using life vests to protect against hypothermia through the 50/50/50 rule: If someone is in 50 °F (10 °C) water for 50 minutes, he/she has a 50 percent better chance of survival if wearing a life jacket.[56] A heat escape lessening position can be used to increase survival in cold water.

Babies should sleep at 16-20 °C (61-68 °F) and housebound people should be checked regularly to make sure the temperature of the home is sufficient.[27][53][57] [58]

Management

Degree[2][46] Rewarming technique
Mild (stage 1) Passive rewarming
Moderate (stage 2) Active external rewarming
Severe (stage 3 and 4) Active internal rewarming

Aggressiveness of treatment is matched to the degree of hypothermia.[2] Treatment ranges from noninvasive, passive external warming to active external rewarming, to active core rewarming.[14] In severe cases resuscitation begins with simultaneous removal from the cold environment and management of the airway, breathing, and circulation. Rapid rewarming is then commenced. Moving the person as little and as gently as possible is recommended as aggressive handling may increase risks of a dysrhythmia.[46]

Hypoglycemia is a frequent complication and needs to be tested for and treated. Intravenous thiamine and glucose is often recommended, as many causes of hypothermia are complicated by Wernicke's encephalopathy.[59]

The UK National Health Service advises the lay public against putting a person in a hot bath, massaging their arms and legs, using a heating pad, or giving them alcohol. These measures can cause blood to be directed to the skin, causing a fall in blood pressure to vital organs, potentially resulting in death.[60]

Rewarming

Rewarming can be done with a number of methods including passive external rewarming, active external rewarming, and active internal rewarming.[61] Passive external rewarming involves the use of a person's own ability to generate heat by providing properly insulated dry clothing and moving to a warm environment.[62] It is recommended for those with mild hypothermia.[62]

Active external rewarming involves applying warming devices externally, such as a heating blanket.[2] These may function by warmed forced air (Bair Hugger is a commonly used device), chemical reactions, or electricity.[2][62] In wilderness environments, hypothermia may be helped by placing a hot water bottle in both armpits and groin.[63] These methods are recommended for moderate hypothermia.[62] Active core rewarming involves the use of intravenous warmed fluids, irrigation of body cavities with warmed fluids (the chest or abdomen), use of warm humidified inhaled air, or use of extracorporeal rewarming such as via a heart lung machine or extracorporeal membrane oxygenation (ECMO).[61] Extracorporeal rewarming is the fastest method for those with severe hypothermia.[62] Survival rates with normal mental functioning have been reported at around 50%.[2] Chest irrigation is recommended if bypass or ECMO is not possible.[2]

Rewarming shock (or rewarming collapse) is a sudden drop in blood pressure in combination with a low cardiac output which may occur during active treatment of a severely hypothermic person.[64][65] There was a theoretical concern that external rewarming rather than internal rewarming may increase the risk.[2] These concerns were partly believed to be due to afterdrop, a situation detected during laboratory experiments where there is a continued decrease in core temperature after rewarming has been started.[2] Recent studies have not supported these concerns, and problems are not found with active external rewarming.[2][46]

Fluids

Warm sweetened liquids can be given provided the person is alert and can swallow. Many recommend that alcohol[27][57] and drinks with lots of caffeine be avoided.[66] As most people are moderately dehydrated due to cold-induced diuresis, warmed intravenous fluids to a temperature of 38–45 °C (100–113 °F) are often recommended.[2][14]

Cardiac arrest

In those without signs of life cardiopulmonary resuscitation (CPR) should be continued during active rewarming.[2] For ventricular fibrillation or ventricular tachycardia, a single defibrillation should be attempted.[67] People with severe hypothermia however may not respond to pacing or defibrillation.[67] It is not known if further defibrillation should be withheld until the core temperature reaches 30 °C (86 °F).[67] In Europe epinephrine is not recommended until the temperature reaches 30 °C (86 °F) while the American Heart Association recommended up to three doses of epinephrine before 30 °C (86 °F) is reached.[2] Once a temperature of 30 °C (86 °F) is reached, normal ACLS protocols should be followed.[46]

Prognosis

It is usually recommended not to declare a person dead until their body is warmed to a near normal body temperature of greater than 32 °C (90 °F),[2] since extreme hypothermia can suppress heart and brain function.[68] Exceptions include if there is an obvious fatal injuries or the chest is frozen so that it cannot be compressed.[46] If a person was buried in an avalanche for more than 35 minutes and is found with a mouth packed full of snow without a pulse stopping early may also be reasonable.[2] This is also the case if a person's blood potassium is greater than 12 mmol/l.[2]

Those who are stiff with pupils that do not move may survive if treated aggressively.[2] Survival with good function also occasionally occurs even after the need for hours of CPR.[2] Children who have a near-drowning accidents in water near 0 °C (32 °F) can occasionally be revived even over an hour after losing consciousness.[69] The cold water lowers metabolism, allowing the brain to withstand a much longer period of hypoxia. While survival is possible, mortality from severe or profound hypothermia remains high despite optimal treatment. Studies estimate mortality at between 38%[70][71] and 75%.[13]

In those who have hypothermia due to another underlying health problem, when death occurs it is frequently from that underlying health problem.[2]

Epidemiology

In the past, hypothermia occurred most frequently in homeless people, but recreational exposure to cold environments is now the main cause of hypothermia. Between 1995 and 2004 in the United States, an average of 1560 cold-related emergency department visits occurred per year and in the years 1999 to 2004, an average of 647 people died per year due to hypothermia.[28][72]

History

The armies of Napoleon retreat from Russia in 1812.
Snow-storm: Hannibal and His Army Crossing the Alps, J. M. W. Turner

Hypothermia has played a major role in the success or failure of many military campaigns, from Hannibal's loss of nearly half his men in the Second Punic War (218 B.C.) to the near destruction of Napoleon's armies in Russia in 1812. Men wandered around confused by hypothermia, some lost consciousness and died, others shivered, later developed torpor, and tended to sleep. Others too weak to walk fell on their knees; some stayed that way some time resisting death. The pulse of some was weak and hard to detect; others groaned; yet others had eyes open and wild with quiet delirium.[73] Loss of life to hypothermia in Russian regions continued through the first and second world wars, especially in the Battle of Stalingrad.[74]

Civilian examples of deaths caused by hypothermia occurred during the sinkings of the RMS Titanic and RMS Lusitania, and more recently of the MS Estonia.[75][76][77]

Antarctic explorers developed hypothermia; Ernest Shackleton and his team measured body temperatures "below 94.2°, which spells death at home", though this probably referred to oral temperatures rather than core temperature and corresponded to mild hypothermia. One of Scott's team, Atkinson, became confused through hypothermia.[73]

Nazi human experimentation during World War II amounting to medical torture included hypothermia experiments, which killed many victims. There were 360 to 400 experiments and 280 to 300 subjects, indicating some had more than one experiment performed on them. Various methods of rewarming were attempted, "One assistant later testified that some victims were thrown into boiling water for rewarming".[78]

Other animals

Many animals other than humans often induce hypothermia during hibernation or torpor.

Water bears (Tardigrade), microscopic multicellular organisms, can survive freezing at low temperatures by replacing most of their internal water with the sugar trehalose, preventing the crystallization that otherwise damages cell membranes.

See also

References

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  32. ↑ Excess winter deaths
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  34. ↑ Fuel poverty
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  53. 1 2 hypothermia Prevention
  54. ↑ How to build an Igloo, survive a blizzard, finish your mission on time This web page gives basic instructions for westerners.
  55. ↑ Cold Weather Survival, Shelkters This has instructions about building different types of shelter
  56. ↑ United States Coast Guard. "Recreational Boating Safety Information". United States Coast Guard. Retrieved 2008-06-18.
  57. 1 2 Preventing hypothermia
  58. ↑ Can hypothermia be prevented?
  59. ↑ Tintinalli, Judith (2004). Emergency Medicine: A Comprehensive Study Guide, Sixth edition. McGraw-Hill Professional. p. 1181. ISBN 0-07-138875-3.
  60. ↑ "Treating hypothermia". NHS. Archived from the original on Sep 14, 2014.
  61. 1 2 McCullough L, Arora S (Dec 2004). "Diagnosis and treatment of hypothermia". Am Fam Physician. 70 (12): 2325–32. PMID 15617296.
  62. 1 2 3 4 5 Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A (2010-11-02). "Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S829–61. doi:10.1161/CIRCULATIONAHA.110.971069. PMID 20956228.
  63. ↑ Auerbach, [edited by] Paul S. (2007). Wilderness medicine. (5th ed.). St. Louis, Mo.: Elsevier Mosby. pp. Chapter 5. ISBN 978-0-323-03228-5.
  64. ↑ Tveita T (October 2000). "Rewarming from hypothermia. Newer aspects on the pathophysiology of rewarming shock". Int J Circumpolar Health. 59 (3–4): 260–6. PMID 11209678.
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  66. ↑ Auerbach, [edited by] Paul S. (2011). "Accidental Hypothermia". Wilderness medicine (6th ed.). Philadelphia, PA: Elsevier/Mosby. pp. Chapter 5. ISBN 1437716784.
  67. 1 2 3 Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A (2010). "Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S829–61. doi:10.1161/CIRCULATIONAHA.110.971069. PMID 20956228. Archived from the original on Aug 20, 2014.
  68. ↑ Iyer A, Rajkumar V, Sadasivan D, Bruce J, Gilfillan I (2007). "No one is dead until warm and dead". The Journal of thoracic and cardiovascular surgery. 134 (4): 1042–3. doi:10.1016/j.jtcvs.2007.05.028. PMID 17903527.
  69. ↑ Bolte RG, Black PG, Bowers RS, Thorne JK, Corneli HM (1988). "The use of extracorporeal rewarming in a child submerged for 66 minutes". Journal of the American Medical Association. 260 (3): 377–379. doi:10.1001/jama.260.3.377. PMID 3379747.
  70. ↑ Morita S, Seiji M, Inokuchi S, Sadaki I, Inoue S, Shigeaki I, Akieda K, Kazuki A, Umezawa K, Kazuo U, Nakagawa Y, Yoshihide N, Yamamoto I, Isotoshi Y (December 2008). "The efficacy of rewarming with a portable and percutaneous cardiopulmonary bypass system in accidental deep hypothermia patients with hemodynamic instability". J Trauma. 65 (6): 1391–5. doi:10.1097/TA.0b013e3181485490. PMID 19077632.
  71. ↑ Vassal T, Benoit-Gonin B, Carrat F, Guidet B, Maury E, Offenstadt G (December 2001). "Severe accidental hypothermia treated in an ICU: prognosis and outcome". Chest. 120 (6): 1998–2003. doi:10.1378/chest.120.6.1998. PMID 11742934.
  72. ↑ "Hypothermia-Related Mortality – Montana, 1999–2004".
  73. 1 2 Guly, H (Jan 2011). "History of accidental hypothermia.". Resuscitation. 82 (1): 122–5. doi:10.1016/j.resuscitation.2010.09.465. PMC 3060344Freely accessible. PMID 21036455.
  74. ↑ Marx, John (2010). Rosen's emergency medicine: concepts and clinical practice 7th edition. Philadelphia, PA: Mosby/Elsevier. p. 1868. ISBN 978-0-323-05472-0.
  75. ↑ "Findings: Titanic victims in 'cold shock'". p. 24 May 2002. Retrieved 22 November 2014.
  76. ↑ John Updike (1 July 2002). "Remember the Lusitania". Retrieved 22 November 2014.
  77. ↑ Soomer H, Ranta H, Penttilä A (2001). "Identification of victims from the M/S Estonia". International Journal of Legal Medicine. 114 (4–5): 259–262. doi:10.1007/s004140000180. PMID 11355406.
  78. ↑ Berger, RL (May 17, 1990). "Nazi science--the Dachau hypothermia experiments.". The New England Journal of Medicine. 322 (20): 1435–40. doi:10.1056/NEJM199005173222006. PMID 2184357.
Bibliography
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