Treating Mild, Moderate & Severe Hypothermia In The Emergency Room: Rewarming Techniques, Active Rewarming | EB Medicine 2016

Evidence-Based Management Of Accidental Hypothermia In The Emergency Department

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
    1. Field Assessment
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Mental Status
      2. Vital Signs
        • Temperature
        • Pulse
        • Blood Pressure
        • Respiratory Rate
        • Pulse Oximetry
      3. Neurologic Examination
      4. Other Physical Examination Findings
  9. Diagnostic Studies
    1. Laboratory Studies
      1. Fingerstick Glucose
      2. Chemistry Panel
      3. Complete Blood Count
      4. Coagulation Studies
      5. Blood Gases
      6. Other Laboratory Testing
    2. Imaging Studies
      1. Plain Films
      2. Ultrasound
      3. Computed Tomography
    3. Other Diagnostic Studies
      1. Electrocardiography
  10. Treatment
  11. Controversies
    1. Core Afterdrop
  12. Disposition
  13. Special Circumstances
    1. Hypothermia In Trauma Patients
  14. Summary
  15. Risk Management Pitfalls For Accidental Hypothermia
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Managing Accidental Hypothermia
  19. Tables and Figures
    1. Table 1. Risk Factors For Thermoinstability And Secondary Hypothermia
    2. Figure 1. Electrocardiogram Of A Hypothermic Patient With Prominent J Waves (Osborn Waves)
  20. References


Accidental hypothermia is defined as an unintentional drop in core body temperature below 35°C. It can present in any climate and in any season, as it is not always a result of environmental exposure; underlying illnesses or coexisting pathology can play important roles. Although there is some variability in clinical presentation, hypothermia produces a predictable pattern of physiologic responses and clinical manifestations, and effective treatment has yielded many impressive survival case reports. Treatment strategies focus on prevention of further heat loss, volume resuscitation, implementation of appropriate rewarming techniques, and management of cardiac dysrhythmia. Rewarming may be passive or active and/or internal or external, depending on severity and available resources. This issue focuses on methods of effective rewarming and prevention of further morbidity and mortality.

Case Presentations

Emergency physicians in 3 different cities encounter 3 distinct patients with 1 thing in common: a low core body temperature.

Minneapolis, Minnesota: On a cold winter day, an emergency physician receives a call from EMS asking for advice: They were called to a nearby park where an unidentified middle-aged woman was found on the ground near a park bench. She has no palpable pulse, and there is an unknown downtime. On exam, her pupils are fixed and dilated, and her body feels cold to the touch. The paramedic is concerned that any resuscitation efforts would be futile and asks if any interventions should be made.

Portland, Oregon: A 22-year-old woman is brought to the ED after being rescued from a hiking expedition gone awry. The rescue team reports that she was lost on a mountain overnight without proper equipment or clothing. She was found lethargic, bradycardic, and hypotensive, but pulses were present. When she arrives in the ED, her condition is unchanged. You wonder what the best rewarming strategy would be.

Phoenix, Arizona: An 82-year-old man with multiple medical problems is transported to the ED from his nursing home due to altered mental status. Initial vital signs show that he is tachycardic, hypotensive, and has a rectal temperature of 33°C. There is no history of known cold exposure, and nursing home staff assures the doctor that he has been in bed for days with plenty of blankets. What is the differential diagnosis, and how should this patient be treated?


Accidental hypothermia is defined as the unintentional drop in core body temperature below 35°C (95°F).1 While accidental hypothermia is most common in cool climates during winter months, it can also occur in warm climates, in any season, and in individuals without a history of outdoor exposure. Accidental hypothermia can occur in a variety of populations, including those in an urban environment. Those at highest risk include homeless individuals, the very young and very old, and individuals with psychiatric disease, serious underlying medical conditions, traumatic injuries, or drug or alcohol intoxication.2,3 These groups often have impaired thermoregulation, but they also lack the ability to perform the behavioral adaptations to protect themselves from the cold, such as seeking shelter and putting on extra clothing.

The United States Centers for Disease Control and Prevention (CDC) reported that in the United States during the years of 1999 to 2011, there were an average of 1301 deaths from environmental cold exposure per year.4 Approximately half of the deaths attributed to hypothermia occur in patients over the age of 65. Inhospital mortality of patients with moderate or severe hypothermia is as high as 40%.3 Despite the high mortality rate, there have been survivors with good neurologic outcomes who were resuscitated from extremely low temperatures, the lowest of which was 13.7°C.5 There have also been case reports of individuals surviving neurologically intact after prolonged cardiac arrest, the longest being in cardiac arrest for 8 hours and 40 minutes.6

In this issue of Emergency Medicine Practice, we will review the definition, pathophysiology, differential diagnosis, prehospital management, and emergency department (ED) evaluation and management of patients presenting with accidental hypothermia.

Critical Appraisal Of The Literature

The literature is full of extraordinary survival stories of patients with accidental hypothermia. These case reports and retrospective reviews have expanded our understanding of what the human body can endure. The sheer number of rewarming methods described in the literature provides the emergency clinician with seemingly countless options. Unfortunately, there is a paucity of randomized controlled trials comparing various treatments and rewarming techniques, likely due to the rarity of this condition. Ethical limitations preclude simulating severe accidental hypothermia in healthy individuals in the laboratory setting. Canine and porcine models offer some additional data, but clinical translatability is always a question. Because of the lack of quality clinical evidence, it is not possible to provide strong recommendations on management of patients with accidental hypothermia.

Searches of numerous evidence-based medicine sources were performed, including PubMed, MEDLINE®, Cochrane Database of Systemic Reviews, Database of Abstracts of Reviews of Effectiveness (DARE), and the National Guideline Clearinghouse, using the key terms accidental hypothermia and accidental hypothermic arrest. A systematic review published in 2014 describing the use of extracorporeal-assisted rewarming in the management of accidental deep hypothermic cardiac arrest was the sole review that met criteria for inclusion on DARE.7

Several sets of guidelines for the treatment of accidental hypothermia exist. In 2010, the American Heart Association and European Resuscitation Council both published guidelines on treatment of accidental hypothermia within the larger context of general guidelines for cardiopulmonary resuscitation (CPR).8,9 The State of Alaska Cold Injuries Guidelines were last updated in 2014 and include a section on accidental hypothermia.10 In 2013, the International Commission for Alpine Rescue- International Commission for Mountain Emergency Medicine (ICAR-MEDCOM) also developed recommendations for on-site medical treatment for acci dental hypothermia.11

Additionally, in 2014, the Wilderness Medical Society developed practice guidelines for out-of-hospital care of accidental hypothermia.12 These guidelines are based on the available literature as described above. Although the literature is not strong, the volume of data, available guidelines, and expert opinion do allow a treating physician to make a logical treatment plan for a patient with hypothermia according to available resources.

Risk Management Pitfalls For Accidental Hypothermia

  1. “I work in Florida, not Alaska. I didn’t think I’d ever see a hypothermic patient.”
    While most cases of accidental hypothermia occur in colder climates during the winter months, hypothermia can occur anywhere, including mild climates. All emergency clinicians should have the skills to identify and treat these patients.
  2. “The nurse couldn’t get a temperature.”
    Normal thermometers only read down to 34°C. If a thermometer is not reading appropriately, it may be because the patient’s core body temperature is below that level. A low-reading thermometer should be used to obtain a core body temperature and assess for hypothermia.
  3. “I couldn’t feel a pulse, so we started CPR.”
    Pulses are extremely difficult to palpate in hypothermic patients. Additionally, initiating CPR in hypothermic patients with a perfusing rhythm runs the theoretical risk of precipitating a nonperfusing dysrhythmia that is refractory to treatment. If possible, bedside cardiac ultrasound or cardiac monitoring should be used to evaluate for organized cardiac activity. If that is not available, the emergency clinician should palpate for a pulse for a full minute before initiating CPR.
  4. “I started rewarming the patient and then admitted him to the ICU. As the patient was going upstairs, he arrested in the elevator.”
    A moderately or severely hypothermic patient’s clinical status is extremely tenuous. Dysrhythmias and cardiovascular collapse can occur at any time, often after rewarming has been initiated. Strongly consider limiting any transport within the hospital until the patient is rewarmed to 30°C to 32°C (with the clear exception of transport to the operating room for cardiopulmonary bypass). Patients who must be transported prior to rewarming will need ongoing cardiac monitoring and, ideally, should be transported in the company of the treating physician.
  5. “I put warm blankets on him and started IV fluids. I don’t know why his temperature hasn’t improved.”
    If passive external rewarming fails in mild hypothermia, turn to more aggressive rewarming measures, but also begin to investigate reasons why the patient is not rewarming as expected. Underlying infection is a common cause of slowed or failed rewarming, and individuals who fail to rewarm should be treated empirically with antibiotics.45
  6. “His pupils were fixed and dilated, so I thought he would have a bad outcome.”
    Fixed and dilated pupils can be seen at temperatures below 27°C and are expected by the time a patient reaches a core temperature of 22°C.14 While alternate causes of decreased cerebral perfusion should be considered, it is possible that this finding is due solely to hypothermia, and is not necessarily indicative of a poor neurologic outcome.
  7. “I didn’t think he needed fluids because his heart rate was normal.”
    “Normal“ vital signs in a hypothermic patient are, typically, not normal. In a moderately hypothermic patient, bradycardia is expected. The presence of a normal heart rate should be perceived as relative tachycardia, and an etiology should be sought and the patient treated. Hypovolemia is often present in hypothermic individuals and should be treated with warm IV fluids.
  8. “I didn’t see any evidence of hyperkalemia on his ECG.”
    Typical ECG changes seen with hyperkalemia are blunted in hypothermia. Acute renal failure and rhabdomyolysis are common in hypothermic patients and can lead to severe hyperkalemia. Despite a nondiagnostic ECG, keep a high index of suspicion for hyperkalemia both on presentation and during their ED course, as potassium levels can fluctuate rapidly during rewarming.
  9. “Just after I examined the patient’s extremities for frostbite, he had a ventricular fibrillation arrest.”
    Extreme care should be taken when moving and examining a patient with moderate or severe hypothermia. Movement of a patient’s extremities may increase the return of cold blood to central circulation, causing a further drop in temperature and placing a patient at further risk for hemodynamic instability and cardiac arrest. While this should not prevent you from completing necessary tasks (eg, intubation), the treatment team should try to minimize any extraneous movement or jostling until a patient is rewarmed.
  10. “The patient was in asystole and didn’t respond to multiple rounds of epinephrine, so we called the code.”
    The adage, “a patient is not dead until he is warm and dead” still holds true. Resuscitation of a hypothermic cardiac arrest patient should be continued until the patient is adequately rewarmed, as individuals with extremely low core temperatures who are given prolonged CPR can have good neurologic outcomes. Ventricular fibrillation may be refractory to defibrillation until a patient is sufficiently rewarmed. If a patient remains pulseless at 32°C, resuscitation efforts may then be terminated.

Tables And Figures

Table 1. Risk Factors For Thermoinstability And Secondary Hypothermia


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study are included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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  3. Vassal T, Benoit-Gonin B, Carrat F, et al. Severe accidental hypothermia treated in an ICU: prognosis and outcome. Chest. 2001;120(6):1998-2003. (Retrospective review; 47 patients)
  4. No author listed. Number of hypothermia-related deaths, by sex--National Vital Statistics System, United States, 1999- 2011. MMWR Morb Mortal Wkly Rep. 2013;61(51 & 52):1050. (Retrospective review)
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  8. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council guidelines for resuscitation 2010, section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81(10):1400-1433. (Guidelines; consensus paper)
  9. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S829-S861. (Guidelines; consensus paper)
  10. Zafren K, Giesbrecht GG. State of Alaska cold injuries guidelines. Juneau, AK: Department of Health and Social Services, Division of Public Health; 2014:5-17. (Guidelines)
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  12. * Zafren K, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia. Wilderness Environ Med. 2014;25(4):425-445. (Guidelines)
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Publication Information

Megan L. Rischall, MD; Andrea Rowland-Fisher, MD

Publication Date

January 1, 2016

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