Guideline sources The following summarized guidelines for the evaluation and management of accidental hypothermia are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2020) and the Wilderness Medical Society (WMS 2019). 1 2 Guidelines 1. Diagnostic investigations Field assessment: Classify hypothermia as mild, moderate, severe and profound on the bases of clinical observations, recognizing that: shivering can occur below 32 C, usually with altered mental status patients can have detectable vital signs with core temperatures below 24 C core temperature can overlap between classification categories. B Show 5 more Core temperature measurement: place an esophageal temperature probe, if available, in patients with protected and secured airways. Recognize that esophageal temperature is the preferred method of core temperature measurement. B https://web.pathway.md/diseases/recWvNGvunIameK26 1/4 6/23/23, 1:26 AM Accidental hypothermia Pathway Show 6 more 2. Respiratory support Airway management: Recognize that advantages of advanced airway management outweigh the risk of causing VF. B Place a nasogastric or orogastric tube after the airway is secured to decompress the stomach. B Ventilation: deliver ventilation at the same rate as in normothermic patients in the absence of end-tidal CO monitoring, unless an advanced airway is in place. B Show 5 more 3. Medical management Fluid resuscitation: place intraosseous catheter, if immediate peripheral IV catheter cannot be placed. Use femoral line for the central venous access, if no other option is available. B Show 3 more Vasopressors: do not administer vasoactive drugs until the patient has been rewarmed to 30 C. D Extend dosing intervals twice as long as usual while keeping the usual doses in patients with a core temperature of 30-35 C, to minimize the potential toxic accumulation of medication. D Glucose and insulin: administer glucose for the management of hypoglycemia in patients with hypothermia. A Show 2 more 4. Nonpharmacologic interventions Out-of-hospital management (safety of the rescuer): ensure that the scene is secure and safe to enter and make an evaluation before the decision to rescue or resuscitate a patient. A Out-of-hospital management (patient handling): keep a hypothermic patient horizontal, especially during rescue from water or a crevasse B and limit physical effort by the patient during rescue. Encourage conscious patients to be attentive and focused on survival. B Show 2 more Out-of-hospital management (protection from cold): use insulation and vapor barriers to protect patients from further cooling until they have reached a warm environment, such as the warmed interior of an ambulance. Remove wet clothes, preferably by cutting them off, only when patients have been protected from the cold. B Show 2 more Out-of-hospital management (passive rewarming): encourage shivering in patients with cold- stress or mild hypothermia for rewarming. Ensure adequate insulation of patients with https://web.pathway.md/diseases/recWvNGvunIameK26 2/4 6/23/23, 1:26 AM Accidental hypothermia Pathway hypothermia from the environment to retain the generated heat. A Show 3 more Out-of-hospital management (active rewarming): use active sources of heat. Use rewarming devices in conjunction with vapor barriers and insulation. Use the Heat Pac only outdoors or with proper ventilation carefully monitored to prevent CO accumulation. B Show 11 more Out-of-hospital management (rewarming during transport): use forced air warming during air or ground transport, if available. A Consider continuing other heat sources, if forced air warming is not available. B Show 2 more Out-of-hospital management (non-hypothermic cold-stressed patients): keep cold-stressed patients without hypothermia horizontal. Show 2 more Out-of-hospital management (patients with severe trauma): initiate early and aggressive active rewarming during all phases of out-of-hospital care to prevent hypothermia in severely injured patients. B Transportation: Undertake the following measures when preparing patients for transport: stabilize potential spinal injuries reduce fractures and dislocations to the normal anatomic configuration as much as possible cover open wounds. B Show 6 more 5. Therapeutic procedures Cardiopulmonary resuscitation: attempt CPR unless contraindications exist. Recognize that fixed, dilated pupils, apparent rigor mortis, and dependent lividity are not contraindications to resuscitation in patients with severe hypothermia. A Show 9 more Automated external defibrillation: attempt defibrillation and initiate CPR if shock is advised by an automated external defibrillator. B Show 2 more Transcutaneous pacing: consider performing transcutaneous pacing in patients with hypothermia in the setting of bradycardia with hypotension disproportionate to the core temperature. C 6. Specific circumstances Patients in cardiac arrest: undertake full resuscitative measures, including extracorporeal rewarming when available, in all victims of accidental hypothermia without characteristics suggesting that they are unlikely to survive and without any obviously lethal traumatic injury. B https://web.pathway.md/diseases/recWvNGvunIameK26 3/4 6/23/23, 1:26 AM Accidental hypothermia Pathway Show 3 more References 1. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 2. Dow J, Giesbrecht GG, Danzl DF et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019 Dec;30 4S S47 S69. Open https://web.pathway.md/diseases/recWvNGvunIameK26 4/4