What is the best course of treatment for hypothermia?

Treatment of Hypothermia

Immediately move the patient to a warm environment, remove all wet clothing, and initiate aggressive rewarming using a tiered approach based on core body temperature: passive warming for mild hypothermia (32-35°C), active external rewarming for moderate hypothermia (28-32°C), and active internal rewarming including extracorporeal support for severe hypothermia (<28°C). 1, 2

Initial Stabilization and Assessment

• Remove wet clothing immediately as this is the single most important first step to prevent further heat loss 1, 3
• Move to a warm environment and shield from wind using plastic or foil layers in addition to dry insulating layers 1
• Obtain core temperature using esophageal, bladder, or rectal probe—tympanic and axillary measurements are unreliable and should not guide treatment 2
• Insulate from cold surfaces and cover head and neck to minimize ongoing heat loss 1, 3

Critical pitfall: Clinical presentation can be misleading—a patient may appear alert with mild symptoms despite severe hypothermia (core temperature <28°C), so always base treatment decisions on measured core temperature, not clinical appearance alone 4

Tiered Rewarming Protocol

Mild Hypothermia (32-35°C)

• Apply passive rewarming with at least two warm blankets 1, 2
• Increase environmental temperature to reduce heat loss 1
• Provide high-calorie warm fluids if patient is alert and able to swallow 2, 5
• Monitor core temperature every 15 minutes 1

Passive rewarming alone may be insufficient—one study showed passive techniques actually caused temperature decrease during transport, while active rewarming increased core temperature by 0.74°C 1

Moderate Hypothermia (28-32°C)

• Continue all mild hypothermia measures 2, 5
• Apply forced-air warming blankets (e.g., Bair Hugger) which increase temperature by 0.8°C and reduce pain and anxiety 1, 3
• Administer warmed intravenous fluids to increase core temperature 1, 3
• Provide humidified, warmed oxygen via ventilation 1, 3
• Use heating pads and radiant heaters as additional external warming sources 1
• Monitor core temperature every 5 minutes 1, 3

Severe Hypothermia (<28°C)

• Continue all moderate hypothermia measures 2, 5
• Activate emergency response system for potential extracorporeal life support 1, 2
• Implement active internal rewarming including peritoneal lavage, extracorporeal membrane oxygenation (ECMO), or cardiopulmonary bypass 1
• Handle patient extremely gently to avoid triggering ventricular fibrillation 1, 3
• Monitor continuously for cardiac arrhythmias, coagulopathy, and hypotension 3, 2

Important consideration: External rewarming can still be effective even in severe hypothermia—one study successfully warmed 15 patients with temperatures below 30°C to above 35°C using forced-air warmers alone 1

Rewarming Targets and Monitoring

• Target minimum core temperature of 36°C before considering the patient stable or transferring between units 1, 3, 2
• Stop rewarming at 37°C—temperatures above this threshold are associated with increased mortality and poor outcomes 1, 2
• Use combination warming techniques simultaneously if hypothermia is inadequately controlled with single modality 1

Special Considerations for Trauma Patients

Hypothermia in trauma is an independent predictor of mortality, with temperatures below 34°C associated with >80% mortality risk in patients requiring massive transfusion 1, 2

• Begin warming in prehospital phase with blankets and removal of wet clothing 1
• Implement aggressive rewarming on hospital arrival if injuries require damage control therapy 1
• Target normothermia (36-37°C) to optimize coagulation, as each 1°C drop reduces coagulation factor function by 10% 1, 2
• Recognize that coagulopathy completely resolves with aggressive warming 1, 2

Critical Pitfalls to Avoid

• Do not place heating devices directly on skin—always use insulation between heat source and skin to prevent burns 1
• Do not delay definitive care for active rewarming in the field 1
• Do not use pressure immobilization as this is contraindicated 1
• Do not rely on clinical presentation alone—always confirm severity with core temperature measurement 4