II. Approach

  1. See Hypothermia Management for protocol on using these rewarming techniques

III. Management: Passive Rewarming

  1. Indications
    1. Mild Hypothermia
    2. Relies on intact energy and Thermoregulation
  2. Technique
    1. Move the patient to warm, dry environment
    2. Remove wet clothing
    3. Apply warm blankets

IV. Management: Active External Rewarming

  1. Indication
    1. Mild Hypothermia
    2. Relies on intact circulation
    3. Rewarm core first (as below) in serious cases
      1. Otherwise risk of adverse effects as below
  2. Technique
    1. Apply hot water bottles or heating pads to trunk
    2. Forced-air warming systems (e.g. Bair Hugger)
      1. Preferred option in active external warming
      2. Least likey to cause adverse effects below
    3. Arteriovenous anastomosis reheating
      1. Hands immersed in 113 F (45 C) water or
      2. Device encloses Forearm in heated air at -40 mmHg
  3. Adverse effects
    1. General
      1. Patient may appear to worsen before improving
      2. Do not stop rewarming prematurely
      3. Rewarm core first in serious cases
      4. Least adverse effects with forced air rewarming
    2. Core Temperature afterdrop
      1. Results from cold peripheral blood return
    3. Rewarming acidosis
      1. Redistribution of pooled peripheral Lactic Acid
    4. Peripheral vasodilation (Rewarming shock)
      1. Venous peripheral pooling

V. Management: Minimally Invasive Active Core Rewarming

  1. Airway rewarming
    1. Humidified oxygen at 104-113 F (40-45 C)
    2. Increases core temp by 1.8-4.5 F (1.0-2.5 C)/hour
  2. Intravenous Fluids
    1. Warmed saline to 38 C (100.4 F)
      1. Previously fluids were recommended to be heated to 43 C (109 F)
    2. Heat in blood warmer or calibrated microwave

VI. Management: Invasive Active Core Rewarming - Extracorporeal blood warming (ECMO)

  1. See Hypothermia Management
  2. Indications (Preferred method with best outcomes)
    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)
  3. 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
  4. Modalities
    1. Cardiopulmonary bypass
    2. Arteriovenous or venovenous rewarming
    3. Hemodialysis

VII. Management: Invasive Active Core Rewarming - non-ECMO methods (second line)

  1. Body cavity rewarming
    1. Indicated if extracorporeal warming not available within 6 hours
    2. Raises core temp by 1.8 - 2.7 F (1-1.5 C)/hour
    3. Modalities
      1. Bladder lavage (preferred)
      2. Other methods with risk or difficult administration (Gastric Lavage, Colonic lavage)
  2. Closed thoracic lavage
    1. Consider in hypothermic, pulseless arrest (Hypothermia stage 4) if extracorporeal warming not available within 6 hours
    2. Raises core temp by 5.4 F (3 C)/hour
    3. Heated Normal Saline
    4. Administered via Chest Tubes
      1. In: Midaxillary Thoracostomy tube
      2. Out: Midclavicular Thoracostomy tube

VIII. Management: Invasive Active Core Rewarming - non-ECMO methods (rarely used)

  1. Peritoneal Dialysis (peritoneal lavage)
    1. Consider in hypothermic, pulseless arrest if extracorporeal warming not available within 6 hours
    2. Raises core temp by 1.8 - 5.4 F (1-3 C)/hour
    3. Technique
      1. Instill fluid 104-113 F (40 C to 45 C)
      2. Fluid administered at 6-10 liters/hours
      3. Fluid options
        1. Normal Saline
        2. Lactated Ringers
        3. Dialysate solution
  2. Open thoracic lavage
    1. Consider in hypothermic, pulseless arrest if extracorporeal warming not available within 6 hours
    2. Direct lavage after thoracotomy
    3. Increases core temp by 14.4 F (8 C)

IX. References

  1. Danzl in Marx (2002) Rosen's Emergency Med, p. 1979-96
  2. Danzl in Auerbach (2001) Wilderness Med, p. 135-77
  3. McCullough (2004) Am Fam Physician 70:2325-32 [PubMed]

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