Hypothermia - Frostbite - Frostnip

Management of Pediatric Hypothermia and Peripheral Cold Injuries in the Emergency Department

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.

*NEW* Quick Search this issue!

  About This Issue

Infants, children, and adolescents are at higher risk for primary cold injuries due to a combination of physiologic and cognitive factors. This issue describes the workup and management of hypothermia, frostbite, and frostnip in pediatric patients. It provides guidance for prompt diagnosis, management strategies for stabilization, and recommendations for transfer when necessary. You will learn:

•  Why pediatric patients are more susceptible to cold injuries
•  How to determine the severity of hypothermia, based on the patient’s core body temperature and associated clinical findings
•  What types of thermometers are appropriate for use in patients with hypothermia, as well as temperature measurement strategies
•  When CPR should be initiated, and when it is appropriate to stop resuscitation efforts
•  When diagnostic studies are warranted, and which studies should be ordered for patients at different stages of hypothermia
•  Types of rewarming techniques, including passive and active rewarming methods
•  How to manage patients with mild, moderate, or severe hypothermia, as well as those with frostnip or frostbite
•  Indications and evidence for the use of extracorporeal membrane oxygenation

  Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
    1. Hypothermia
    2. Peripheral Cold Injuries
      1. Frostnip
      2. Frostbite
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Vital Signs
      2. Other Physical Examination Findings
      3. Peripheral Cold Injuries
  9. Diagnostic Studies
    1. Laboratory Studies
    2. Other Studies
  10. Treatment
    1. Hypothermia
      1. Mild Hypothermia (Hypothermia Stage I)
      2. Moderate Hypothermia (Hypothermia Stages II and III)
        • Hypothermia Stage II
        • Hypothermia Stage III
      3. Severe Hypothermia (Hypothermia Stage IV)
        • Airway Management
        • Circulatory Support
        • Irrigation for Rewarming
        • Extracorporeal Membrane Oxygenation
    2. Peripheral Cold Injuries
  11. Special Circumstances
    1. Afterdrop
    2. Hypothermia in the Wilderness Setting
    3. Hypothermia After Trauma
    4. Therapeutic Hypothermia in Children
  12. Controversies and Cutting Edge
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in Management of Pediatric Patients With Cold Injuries
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway for the Management of a Pediatric Patient With Hypothermia
  19. Tables and Figures
    1. Table 1. Mechanisms of Heat Loss
    2. Table 2. Differential Diagnosis for Hypothermia
    3. Table 3. Staging of Hypothermia
    4. Table 4. Electrocardiogram Findings In Hypothermia
    5. Table 5. Rewarming Techniques
    6. Table 6. Indications and Contraindications for Extracorporeal Membrane Oxygenation
    7. Figure 1. Possible Electrocardiogram Changes for Patients With Hypothermia
  20. References



Hypothermia occurs when the core body temperature falls below 35ºC (95ºF) due to primary exposure (eg, environmental exposure) or secondary to other pathologies. Infants, children, and adolescents are at higher risk for primary cold injuries due to a combination of physiologic and cognitive factors, but quick rewarming and appropriate disposition can result in survival and improved neurological outcomes. Treatment for cold injuries is guided by severity and can include passive or active measures. This issue reviews the stages of hypothermia and offers recommendations for emergent management of pediatric patients with hypothermia; guidance is also provided for the identification and management of frostnip and frostbite.


Case Presentations

An EMS call comes in to your ED: “7-year-old girl drowning in a frozen lake. ETA now.” EMS personnel then rush into the trauma bay with CPR in progress. The paramedic reports that the girl had wandered away from her family, who found her 90 minutes later on the bank of a nearly frozen lake. The girl had no pulses on EMS arrival, so they started CPR and brought her straight to the ED. On examination, she is in wet clothing, has no signs of trauma, is pulseless, and has an initial rectal temperature of 23.8ºC (74.8ºF). As you prepare for intubation and continue CPR, you try to control your racing mind and prioritize. What are the best ways to rewarm this patient? What lab tests should you be ordering? Does she need ECMO?

A 17-year-old boy comes into your ED complaining of numbness and hardening of his fingers. He is a previously healthy foreign exchange student who is staying with a host family. The symptoms started yesterday after he went snow skiing for the first time. He says he wore gloves, but he was having a hard time holding the ski poles, so he took them off midway through the day. On examination, the fingertips on both of his hands are firm to the touch, have a dark discoloration, and are without sensation. The firmness and discoloration extend only to the distal interphalangeal joint in most of the fingers, but to the proximal interphalangeal joint in the middle finger of his left hand. The thumb on his right hand has a sizeable blister. As you step out of the room, you shake your head at the idea of skiing without gloves and contemplate the next steps. How do you classify the severity of his cold injuries? Does his thumb need debridement? Should you consult a hand surgeon and/or the burn center? What is the long-term prognosis for his injuries?



Pediatric cold injuries can be generalized, as with hypothermia, or they can be localized, as with peripheral injuries. Pediatric patients are at higher risk for cold injury due to their smaller ratio of body mass to body surface area.1 An understanding of the pathophysiology of cold exposure is necessary to identify the treatment goals for an injury. The appropriate management will vary greatly, depending on the severity of the exposure.

This issue of Pediatric Emergency Medicine Practice describes the workup and emergent management of primary hypothermia in pediatric patients. It provides guidance for prompt diagnosis and management strategies for stabilization, and recommendations for transfer to a pediatric referral center when necessary.


Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms hypothermia, extracorporeal membrane oxygenation, cold injury, and pediatrics. The search identified 16 review articles and 38 clinical trials; of the clinical trials, 31 pertained to prevention of hypothermia and induced hypothermia in neonates and preterm infants. There is a dearth of literature on the treatment of severe hypothermia in the pediatric patient. Many recommendations are extrapolated from case series and animal studies.


Risk Management Pitfalls in Management of Pediatric Patients With Cold Injuries

6. “I obtained an initial temperature but did not continuously monitor it.”

Continuous temperature monitoring will indicate whether the interventions are working or more aggressive therapy is needed. Having an appropriate probe for monitoring core body temperature is imperative; the temperature measurement method may need to be changed, based on the rewarming method being used.

7. “I was 2 boluses in before I remembered to give heated IV fluids.”

Do not forget to prewarm isotonic fluids before administering a bolus. Cold IV fluids can cancel the benefits of other rewarming therapies. If there is time, prewarm the fluids so that they are ready on the patient’s arrival.

10. “I didn’t think getting the patient to an ECMO center would make a difference.”

If you identify a patient who needs ECMO and it is not available at your center, transfer the patient as early as possible. Contacting the ECMO center yourself can help facilitate the transfer and prepare the accepting hospital’s ECMO team. As a hospital system, performing in situ simulation for a critically ill patient in need of ECMO will help prepare for the infrequent times it occurs. For high-acuity, low-frequency emergencies like this, simulation can identify process and management issues in your hospital.


Tables and Figures

Table 1. Mechanisms of Heat Loss
Table 2. Differential Diagnosis for Hypothermia



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. 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 is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. Madhok M, Kant S. Postgraduate Textbook of Pediatrics. 2nd ed. New Delhi, India: Jaypee Brothers Medical Publishers Ltd.; 2018. (Textbook)
  2. Kliegman R, Stanton B, St. Geme JW, et al. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016. (Textbook)
  3. Ludwig S, Fleisher G. Textbook of Pediatric Emergency Medicine. Baltimore, MD: Williams & Wilkins; 1983. (Textbook)
  4. Gilsanz V, Hu HH, Kajimura S. Relevance of brown adipose tissue in infancy and adolescence. Pediatr Res. 2013;73(1):3-9. (Review)
  5. Brown DJ, Brugger H, Boyd J, et al. Accidental hypothermia. N Engl J Med. 2012;367(20):1930-1938. (Review)
  6. Corneli HM. Accidental hypothermia. Pediatr Emerg Care. 2012;28(5):475-480. (Review)
  7. Bruen KJ, Ballard JR, Morris SE, et al. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg. 2007;142(6):546-551. (Retrospective review; 32 patients)
  8. Nygaard RM, Whitley AB, Fey RM, et al. The Hennepin Score: quantification of frostbite management efficacy. J Burn Care Res. 2016;37(4):e317-e322. (Review)
  9. Handford C, Buxton P, Russell K, et al. Frostbite: a practical approach to hospital management. Extrem Physiol Med. 2014;3:7. (Review)
  10. Murphy JV, Banwell PE, Roberts AH, et al. Frostbite: pathogenesis and treatment. J Trauma. 2000;48(1):171-178. (Review)
  11. Baumgartner EA, Belson M, Rubin C, et al. Hypothermia and other cold-related morbidity emergency department visits: United States, 1995-2004. Wilderness Environ Med. 2008;19(4):233-237. (Review)
  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: 2014 update. Wilderness Environ Med. 2014;25(4 Suppl):S66-S85. (Review)
  13. Strapazzon G, Procter E, Paal P, et al. Pre-hospital core temperature measurement in accidental and therapeutic hypothermia. High Alt Med Biol. 2014;15(2):104-111. (Review)
  14. Darocha T, Kosinski S, Jarosz A, et al. The chain of survival in hypothermic circulatory arrest: encouraging preliminary results when using early identification, risk stratification and extracorporeal rewarming. Scand J Trauma Resusc Emerg Med. 2016;24:85. (Prospective observational case series; 10 patients)
  15. Shin J, Kim J, Song K, et al. Core temperature measurement in therapeutic hypothermia according to different phases: comparison of bladder, rectal, and tympanic versus pulmonary artery methods. Resuscitation. 2013;84(6):810-817. (Review)
  16. Lefrant JY, Muller L, de La Coussaye JE, et al. Temperature measurement in intensive care patients: comparison of urinary bladder, oesophageal, rectal, axillary, and inguinal methods versus pulmonary artery core method. Intensive Care Med. 2003;29(3):414-418. (Prospective cohort; 42 patients)
  17. Darocha T, Kosinski S, Jarosz A, et al. Extracorporeal rewarming from accidental hypothermia of patient with suspected trauma. Medicine (Baltimore). 2015;94(27):e1086. (Case report; 1 patient)
  18. Tomaszewski W. Changement electrocardiographiques observes chez un homme mort de froid. Arch Mal Coeur Vaiss. 1938;31:525-528. (Review)
  19. Gillen JP, Vogel MF, Holterman RK, et al. Ventricular fibrillation during orotracheal intubation of hypothermic dogs. Ann Emerg Med. 1986;15(4):412-416. (Animal study; 11 subjects)
  20. Corssen G, Allarde R, Brosch F, et al. Ketamine as the sole anesthetic in open-heart surgery. A preliminary report. Anesth Analg. 1970;49(6):1025-1031. (Preliminary study; 14 patients)
  21. Danzl DF, Pozos RS, Auerbach PS, et al. Multicenter hypothermia survey. Ann Emerg Med. 1987;16(9):1042-1055. (Survey)
  22. Ujhelyi MR, Sims JJ, Dubin SA, et al. Defibrillation energy requirements and electrical heterogeneity during total body hypothermia. Crit Care Med. 2001;29(5):1006-1011. (Randomized animal study; 15 domestic farm swine)
  23. 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)
  24. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council guidelines for resuscitation 2010 section 1. Executive summary. Resuscitation. 2010;81(10):1219-1276. (Review)
  25. Sheak KR, Wiebe DJ, Leary M, et al. Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest. Resuscitation. 2015;89:149-154. (Multicenter cohort study; 583 patients)
  26. Yagi T, Nagao K, Kawamorita T, et al. Detection of ROSC in patients with cardiac arrest during chest compression using NIRS: a pilot study. Adv Exp Med Biol. 2016;876:151-157. (Pilot observational study; 19 patients)
  27. Fleisher G, Ludwig S, Henretig F, et al. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. (Textbook)
  28. Coskun KO, Popov AF, Schmitto JD, et al. Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients. Artif Organs. 2010;34(11):1026-1030. (Case series; 13 patients)
  29. Weems MF, Friedlich PS, Nelson LP, et al. The role of extracorporeal membrane oxygenation simulation training at extracorporeal life support organization centers in the United States. Simul Healthc. 2017;12(4):233-239. (Cross-sectional survey)
  30. Scaife ER, Connors RC, Morris SE, et al. An established extracorporeal membrane oxygenation protocol promotes survival in extreme hypothermia. J Pediatr Surg. 2007;42(12):2012-2016. (Retrospective review; 4 patients)
  31. Hughes A, Riou P, Day C. Full neurological recovery from profound (18.0 degrees C) acute accidental hypothermia: successful resuscitation using active invasive rewarming techniques. Emerg Med J. 2007;24(7):511-512. (Case report; 1 patient)
  32. Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma. 2005;59(6):1350-1354. (Safety study; 19 patients)
  33. Brown D, Ellerton J, Paal P, et al. Hypothermia evidence, afterdrop, and practical experience. Wilderness Environ Med. 2015;26(3):437-439. (Review)
  34. Martin RS, Kilgo PD, Miller PR, et al. Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank. Shock. 2005;24(2):114-118. (Observational review)
  35. Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med. 2017;376(4):318-329. (Randomized controlled trial; 329 patients)
  36. Romlin BS, Winberg H, Janson M, et al. Excellent outcome with extracorporeal membrane oxygenation after accidental profound hypothermia (13.8 degrees C) and drowning. Crit Care Med. 2015;43(11):e521-e525. (Case report; 1 patient)
  37. Skarda D, Barnhart D, Scaife E, et al. Extracorporeal cardiopulmonary resuscitation (EC-CPR) for hypothermic arrest in children: is meaningful survival a reasonable expectation? J Pediatr Surg. 2012;47(12):2239-2243. (Retrospective review; 9 patients)
  38. Walpoth BH, Walpoth-Aslan BN, Mattle HP, et al. Outcome of survivors of accidental deep hypothermia and circulatory arrest treated with extracorporeal blood warming. N Engl J Med. 1997;337(21):1500-1505. (Retrospective cohort; 42 patients)
  39. American Academy of Pediatrics. Extreme temperatures: heat and cold. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/children-and-disasters/pages/extreme-temperatures-heat-and-cold.aspx. Accessed December 15, 2018. (Parental handout)
  40. Federal Emergency Management Agency. Winter storms/extreme cold. Available at: https://www.ready.gov/kids/know-the-facts/winter-storms-extreme-cold. Accessed December 15, 2018. (Website)
  41. Duff J, Walker K, Edward KL, et al. Effect of a thermal care bundle on the prevention, detection and treatment of perioperative inadvertent hypothermia. J Clin Nurs. 2018;27(5-6):1239-1249. (Implementation study; 729 patients)
  42. Pasquier M1, Zurron N, Weith B, et al. Deep accidental hypothermia with core temperature below 24°C presenting with vital signs. High Alt Med Biol. 2014;15(1):58-63. (Case report)
  43. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346(8):549-556. (Multicenter trial)
Publication Information

Ashish Shah, MD; Manu Madhok, MD

Peer Reviewed By

Theodore E. Macnow, MD; Hiromi Yoshida, MD,MBA

Publication Date

January 1, 2019

Pub Med ID: N/A

Get Permission

Content you might be interested in
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.