II. Precautions

  1. ECMO is preferred management for severe Hypothermia (<28 C) or severe cardiac dysrhythmia (e.g. Asystole)
  2. See Hypothermia for related complications (e.g. Rhabdomyolysis)
  3. Anticipate malignant arrhythmia on rewarming (rescue collapse)
    1. Avoid measures that provoke arrhythmias (see below)
    2. Be prepared for recurrent arrhythmia
    3. Continuous monitoring and Defibrillator pads kept in place
    4. Most non-lethal arrhythmias (e.g. Atrial Fibrillation) resolve with rewarming

III. Management: Approach

  1. Hypothermic patient in pulseless arrest
    1. Consider contraindications to Resuscitation below (futile circumstances)
    2. Follow cardiopulmonary arrest algorithm below
    3. Expedite transfer to ECMO center
    4. Initiate rewarming as per protocol below
    5. Consider adjunctive measures (e.g. Intravenous Fluids) as described below
  2. Hypothermic patient with perfusing rhythm
    1. Consider transfer to ECMO center (see indications below)
    2. Initiate rewarming as per protocol below
    3. Consider adjunctive measures (e.g. Intravenous Fluids) as described below
    4. Treat Hypotension with warmed Intravenous Fluids
      1. Hypotension is typically due to Vasoconstriction and cold diuresis
      2. Significant Fluid Replacement (2-5 Liters) may be required to Restore normotension
      3. Vasopressors should only be considered after aggressive rehydration has failed to correct Hypotension

IV. Contraindications: Pulseless, asystolic patients for whom Resuscitation efforts are futile

  1. Cardiac Arrest occurred prior to cooling (based on good history)
  2. Core Temperature >89.6 F (32 C) and still in asystolic rhythm
  3. Patient is so frozen that the chest can not be compressed
  4. Serum Potassium >12 mEq/L and pulseless
  5. Blunt Traumatic pulseless arrest (<1% survival)
  6. Complete submersion Drowning in pulseless adults (Hypoxia precedes cooling)
    1. Case reports of children surviving submersion for >1 hour, core Temperature 66 F (19 C) with CPR, ECMO
    2. Immersion Drowning in water (head above water, not hypoxic) has a better prognosis
  7. Pulseless avalanche victim buried less than 35 minutes or with massive Trauma or airway filled with snow
    1. Body cooling under an avalanche occurs at a rate of 18 F/hour (10 C/hour)
    2. Patients buried for greater than 35 minutes will have a core Temperature <89.6 F (32 C) and may achieve ROSC with rewarming

V. Management: ECMO or Cardiopulmonary Bypass (CPB)

  1. Indications
    1. Hypothermia (core Temperature <32 C or 89.6 F) and cardiac instability (including Cardiac Arrest)
    2. Systolic Blood Pressure <90 mmHg
    3. Ventricular arrhythmia (including Asystole)
    4. Core Temperature <28 C (82.4 F)
  2. Efficacy
    1. Preferred method with best outcomes
    2. Best evidence of any intervention in severe Hypothermia
      1. Pulseless hypothermic patients have 50% survival with ECMO (especially if transport to ECMO Center <6 hours)
      2. Contrast with 10% survival rate in pulseless arrest hypothermic patients treated without ECMO
    3. Raises core Temperature by 1.8 - 3.6 F (1-2 C) per 5 minutes
  3. Modalities
    1. Cardiopulmonary bypass
    2. Arteriovenous or venovenous rewarming
    3. Hemodialysis

VI. Management: Cardiopulmonary Arrest

  1. Start CPR Immediately unless Resuscitation is clearly futile (see contraindications above)
    1. Maintain high quality CPR until adequately perfusing rhythm or Resuscitation efforts halted (after rewarming)
    2. Do not delay CPR while seeking a weak pulse (previously recommendations were to palpate pulse for 45 seconds)
    3. Benefits of perfusion from high quality CPR outweigh the risks of induced arrhythmia
  2. Pulseless dysrhythmia management while hypothermic (<32 C or 89.6 F)
    1. Follow ACLS algorithm but do not persist with unsuccessful interventions until Temperature >32 C or 89.6 F
      1. Resume standard ACLS protocol once core Temperature >32 C or 89.6 F
      2. Hypothermia should no longer be the sole cause of Asystole, once core Temperature is above 32 C or 89.6 F
    2. Asystole
      1. Trial Epinephrine dose every 10 minutes or repeat after core Temperature increase of 5-10 C
      2. Resume standard ACLS protocol with Epinephrine every 3-5 minutes once core Temperature > 32 C or 89.6 F
    3. Ventricular Fibrillation or Pulseless Ventricular Tachycardia
      1. Trial Epinephrine dose every 10 minutes or repeat after core Temperature increase of 5-10 C
      2. Defibrillation trial at presentation, then after core Temperature increase of 5-10 C
      3. Resume standard ACLS protocol for Defibrillation once core Temperature > 32 C or 89.6 F
  3. Rewarming
    1. Transfer to facility with ECMO or cardiopulmonary bypass capabilty (preferred, best outcomes) even if ROSC achieved
    2. See rewarming protocol below
    3. See Rewarming in Hypothermia
  4. Other measures
    1. Advanced Airway
    2. See precautions above

VII. Management: Rewarming in mild to moderate Hypothermia (>28 C) without serious dyrhythmia

  1. See Rewarming in Hypothermia
  2. Remove wet clothing and apply warm blankets
  3. Do not suppress shivering
    1. Shivering is an reflexive, effective method of rewarming
  4. Passive external rewarming
    1. May be all that is needed if core >89.6 F (32 C)
  5. Minimally-invasive active rewarming (see measures and protocols below)
    1. Warmed IV fluids
    2. Warmed, humidified oxygen
  6. Consider Active External Rewarming
    1. Forced air warming systems (e.g. bair hugger) are preferred

VIII. Management: Rewarming in Severe Hypothermia (<28 C) or severe cardiac dysrhythmia (e.g. Asystole)

  1. See Rewarming in Hypothermia
  2. ECMO planned within 6 hours
    1. See Indications above
    2. Avoid other invasive active rewarming methods if ECMO planned
    3. Active External Rewarming
      1. Forced-air warming systems (e.g. Bair Hugger)
    4. Minimally-invasive active rewarming
      1. Warmed IV fluids
      2. Warmed, humidified oxygen
  3. ECMO not available within 6 hours
    1. Consider expert Consultation
    2. See invasive active rewarming methods listed below
    3. Body cavity rewarming (Bladder lavage)
    4. Other methods to consider if available
      1. Peritoneal Dialysis (peritoneal lavage)
      2. Closed thoracic lavage
      3. Open thoracic lavage

IX. Management: Other measures

  1. Empiric antibiotics if Sepsis suspected
    1. Elderly
    2. Neonatal Sepsis
    3. Immunocompromised patients
  2. Empiric therapies in a patient found down
    1. Thiamine if Alcohol Abuse suspected
    2. Dextrose if Glucose testing not immediately available
    3. Do not use empiric Corticosteroids
      1. Only indicated in suspected Adrenal Insufficiency
      2. May be used if refractory to all other measures

X. References

  1. Herbert and Brown in Herbert (2014) EM:Rap 14(1):1-4
  2. Danzl in Marx (2002) Rosen's Emergency Med, p. 1979-96
  3. Danzl in Auerbach (2001) Wilderness Med, p. 135-77
  4. Brown (2012) N Engl J Med 367(2): 1930-8 [PubMed]
  5. McCullough (2004) Am Fam Physician 70:2325-32 [PubMed]

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Ontology: Hypothermia treatment (C0150255)

Definition (NIC) Rewarming and surveillance of a patient whose core body temperature is below 35&#176; C
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 386329003
English Hypothermia measures, Hypothermia Treatment, hypothermia treatments, hypothermia treatment, Hypothermia management, Hypothermia treatment (procedure), Hypothermia treatment
Spanish manejo de la hipotermia, tratamiento antihipotérmico, tratamiento de la hipotermia (procedimiento), tratamiento de la hipotermia