From the Guidelines
For severe hypothermia requiring pressors and continued low body temperature with altered mental status, the next appropriate treatment should focus on aggressive active rewarming while supporting hemodynamics. The treatment approach should prioritize preventing further heat loss and initiating rewarming immediately, as outlined in the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. Key interventions include:
- Preventing additional evaporative heat loss by removing wet garments and insulating the victim from further environmental exposures
- Using external warming techniques, such as forced air or other efficient surface-warming devices, for patients with moderate hypothermia
- Implementing core rewarming techniques, including warm-water lavage of the thoracic cavity, extracorporeal blood warming with partial bypass, or cardiopulmonary bypass, for patients with severe hypothermia
- Administering warmed IV or intraosseous fluids and warm humidified oxygen as adjunctive core rewarming techniques
- Supporting hemodynamics with vasopressors, such as norepinephrine, while continuously monitoring cardiac function and correcting electrolyte abnormalities. It is essential to initiate these interventions promptly, as severe hypothermia has high mortality without prompt intervention to restore normal physiology, and altered mental status and hemodynamic instability indicate a need for aggressive treatment 1.
From the Research
Appropriate Next Treatment for Hypothermia
- The patient's condition requires careful management, as hypothermia can have severe consequences, particularly in older adults, with 80% of associated mortalities occurring in this population 2.
- The relationships between core temperature and vital signs, including heart rate, systolic blood pressure, respiratory rate, and level of consciousness, are generally linear and significantly positive, which can help clinicians make informed decisions about patient care 3.
- In cases of severe hypothermia, patients are at risk of cardiac arrhythmias and cardiac arrest, emphasizing the need for prompt rewarming and supportive care 4.
- The use of vasopressors, such as dopamine and norepinephrine/epinephrine, may be necessary to maintain adequate organ perfusion in patients with hypothermia, but their requirement can persist even after rewarming 5.
- The "dose" of therapeutic hypothermia does not appear to be associated with vasopressor requirement, survival, or neurologic outcome, suggesting that vasopressor or inotropic requirement should not contraindicate therapeutic hypothermia use 6.
Considerations for Treatment
- Preventing further heat loss and initiating rewarming are crucial steps in managing hypothermia 4.
- The level of vasopressor support required may be associated with mortality, with patients requiring additional vasopressors having a higher risk of death due to neurological injury 5.
- The relationships between vital signs and temperature can inform clinical decision-making and guide the management of hypothermic patients 3.