Hypothermia-related death

Last revised by Daniel J Bell on 12 Mar 2019

Hypothermia-related death refers to the endpoint of behavioral and physiological changes caused by a reduction in body temperature.

Hypothermia can affect anyone in extreme cold, but in the presence of helplessness promoting factors also occurs in temperate climates, indoors and in summer 1-3. These factors include advanced age, homelessness, substance abuse and medical conditions, such as trauma, decreased mobility, chronic cardiac or respiratory diseases and altered mental state. In infants, the relatively large body surface further increases the potential of rapid heat loss 2,4.

The most common cause of hypothermia-related death is acute intoxication. While accidental hypothermia is the most common scenario, it can be difficult to exclude suicide or even homicide 2,4. When the time between onset of hypothermia and death is short, macroscopic and microscopic features of hypothermia will be less pronounced. Alcohol, in particular, is known to accelerate this process and result in a diagnostic challenge 5.

Hypothermia is associated with peculiar, irrational behavior reflecting disorientation and general confusion. Uncoordinated movements and paradoxical undressing lead to further injury and heat loss and may even give the false impression of a sexual offence. The final stages of hypothermia may involve entering a small, enclosed space, likened to the primitive protective behavior of hibernating animals 2,6.

  • spot-like hemorrhages in the gastric mucosa (Wischnewski spots): described in 14-100% of hypothermia-related deaths 2,3
  • purple-red spot-like skin blotches in non-hypostatic areas
  • pink livores
  • paradoxical undressing
  • 'hide-and-die' syndrome or 'terminal burrowing' 
  • pulmonary edema - non-specific
  • muscular hemorrhages - less frequently present, but can be detected with MRI, especially in the iliopsoas and back muscles 1,5
  • Wischnewski spots are too small to be detected with MRI

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