Cold exposure; bradycardia, Osborn J waves
ABCDE
A-B-C; remove wet clothing; active rewarming; continue CPR until warm; handle gently.
Rewarm: warmed humidified air + blankets/heating pads + warm IV fluids → ECLS/VA-ECMO (reasonable, COR 2a — AHA 2025) for hypothermic arrest or core <30 °C with instability — transfer to an ECLS centre
Continue CPR until warm ('not dead until warm and dead'); serum K⁺ >12 mmol/L (or HOPE score <10%) supports termination/futility; while core <30 °C max 3 shocks + 3 adrenaline doses, then defer until >30 °C and space intervals 6–10 min
Order set
- Core temperature
- ECG (Osborn J waves)
- Active rewarming
- Continuous CPR if arrest until warm
- Electrolytes, glucose
Escalate / ICU
- Core temp <30°C / arrhythmia
- Cardiac arrest — continue until rewarmed
- Needs ECMO / active core rewarming
Criteria
AdmitAll significant hypothermia/immersion
ICUCore <30°C, arrhythmia, arrest, ARDS risk
Intubate↓GCS / respiratory failure
DischargeRewarmed, no arrhythmia, oxygenation stable, observed for delayed ARDS
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Core <30°C
- Arrhythmia
- Cardiac arrest
Differentials
- Sepsis
- Endocrine (hypothyroid/adrenal)
- Toxins
Common mistakes
- Iced fluids
- Declaring death before rewarming (unless K⁺ >12 mmol/L / HOPE <10%)
Disposition & follow-up
Rewarm; ICU/ECMO for severe; observe for delayed ARDS.
Discharge package
Medications—
Follow-upObserve for delayed respiratory symptoms
Warning symptomsBreathlessness, cough, fever within 24–48 h
💊 Treatment detail — doses & preparation
Rewarmingdefinitive
DoseRemove wet clothing; passive external + active core (heated IV fluids, forced air); CPR duration extends in hypothermia — 'not dead until warm and dead'
PreparationHeated humidified O₂, warm IV 0.9% saline
MonitorCore temperature probe (oesophageal/rectal); handle gently (VF risk)
📖 ILCOR / WMS Hypothermia; AHA 2025 CPR&ECCReviewed July 2026