What are the management strategies for hypothermia?

Management of Hypothermia

The management of hypothermia should follow a severity-based approach with specific rewarming strategies determined by core temperature measurement, ranging from passive rewarming for mild cases to emergency active core rewarming interventions for severe hypothermia. 1

Classification and Assessment

Hypothermia is classified based on core temperature measurements:

• Cold stress: 35-37°C - Alert, possibly shivering
• Mild hypothermia: 32-35°C - Altered mental status, shivering
• Moderate hypothermia: 28-32°C - Decreased responsiveness, ±shivering
• Severe/profound hypothermia: <28°C - Unresponsive, appears lifeless, slow heart rate and breathing 1

Important: Always use the most reliable temperature measurement method available. Intravascular, esophageal, or bladder thermistor measurements are most accurate, followed by rectal, oral, and tympanic membrane measurements. 1

Management Algorithm

1. Initial Management (All Cases)

• Move patient to warm environment
• Remove wet clothing
• Cover with dry blankets
• Insulate from ground
• Cover head and neck 1

2. Severity-Specific Rewarming Strategies

Cold Stress (35-37°C)

• Passive rewarming only
• Provide blankets for comfort 1

Mild Hypothermia (32-35°C)

• Passive rewarming
• Active external warming (warm blankets, forced air warming systems) 1, 2

Moderate Hypothermia (28-32°C)

• All available passive and active methods
• Active core rewarming:
  • Warm IV fluids (38-42°C)
  • Heated humidified oxygen
  • Target rewarming rate: 0.25-0.5°C per hour 1

Severe/Profound Hypothermia (<28°C)

• Emergency intervention with active core rewarming:
  • Warm IV fluids
  • Heated humidified oxygen
  • Body cavity lavage
  • Extracorporeal blood warming/ECMO for selected cases 1, 2

Recent evidence: A 2025 study found that faster rewarming rates in the early phase (to 33°C) were associated with improved 28-day survival (OR 1.51) and better neurologic outcomes (OR 1.32) 3

Monitoring and Complications Management

• Continuous monitoring of:

  • Core temperature (target 36°C)
  • Cardiac rhythm
  • Blood pressure 1

• Stop rewarming after reaching 37°C to prevent overheating 1

• Monitor for and manage complications:

  • Electrolyte abnormalities
  • Coagulopathy (1°C drop = 10% drop in coagulation function)
  • Cardiac dysfunction
  • Rebound hyperthermia (>38°C) 1

Special Considerations

Cardiac Arrest with Hypothermia

• Continue CPR
• Limit defibrillation attempts until core temperature >30°C
• Consider ECMO for severe cases
• Prolonged resuscitation may be necessary 1

Trauma with Hypothermia

• Hypothermia increases mortality and blood loss
• Consider damage control surgery approach if ongoing bleeding
• Aggressive rewarming is critical 1

Handling Precautions

• Handle patients with moderate to severe hypothermia gently to prevent arrhythmias 1

Common Pitfalls to Avoid

1. Relying solely on clinical presentation: A recent case report (2024) documented a patient with severe hypothermia (25.1°C) who was alert and communicative, demonstrating that clinical presentation can be misleading. Always confirm with core temperature measurement. 4

2. Rewarming too quickly or too slowly: Target appropriate rewarming rates (0.25-0.5°C per hour for moderate-severe cases) to prevent complications. 1

3. Premature termination of resuscitation: The adage "not dead until warm and dead" applies - prolonged resuscitation may be necessary in severe hypothermia. 1

4. Inadequate monitoring: Continuous monitoring of core temperature, cardiac rhythm, and blood pressure is crucial during rewarming. 1

5. Overlooking associated conditions: Hypothermia can develop secondary to toxin exposure, metabolic derangements, infections, and dysfunction of the central nervous and endocrine systems. 2