Accidental Hypothermia — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Core temperature grade
   Core temperature grade? (Accidental hypothermia = core temp <35°C. Grades: mild 32–35°C (shivering, thermoregulation preserved), moderate 28–32°C (impaired consciousness, shivering may cease), severe <28°C (coma, vital signs present), profound <24°C. ECG: bradycardia, Osborn/J waves (~32°C, raise VF risk), prolonged intervals. Handle gently to prevent VF; monitor, find and correct hypoglycemia, beware coagulopathy (labs may read falsely normal once blood is warmed); find coexisting causes (alcohol, hypoglycemia, sedatives, sepsis, hypothyroidism).)
   • Severe <28°C / unstable / arrest → Severe/arrest → core rewarming/ECMO
   • Moderate 28–32°C → Moderate · active external rewarming
   • Mild 32–35°C (shivering) → Mild · passive external rewarming
2. [End] Mild · passive external rewarming
   Mild 32–35°C (shivering, thermoregulation present): passive external rewarming — remove wet/cold clothing, blankets/warming blankets, warm environment + warm oral fluids; monitor, correct hypoglycemia.
3. [End] Moderate · active external rewarming
   Moderate 28–32°C: active external rewarming (forced warm air, heating pads on the trunk not the limbs, to prevent afterdrop/increased metabolic demand) + active internal (warm humidified oxygen 40–45°C, warm IV fluids); continuous monitoring, gentle handling, correct hypoglycemia.
4. [End] Severe/arrest → core rewarming/ECMO
   Severe <28°C / hemodynamically unstable / arrest: active internal/core rewarming — warm humidified oxygen, warm IV fluids, body-cavity lavage; ECMO/cardiopulmonary bypass is the gold standard for severe disease with instability/arrest (improves neurologically intact survival). For arrest, use modified ACLS: very gentle handling, continuous CPR, do not declare death before rewarming to ≥32°C ('not dead until warm and dead'); defibrillation/drugs may be ineffective at very low temperatures.

Source guidelines & references

• Accidental hypothermia grading and rewarming (Merck Manual; REBEL EM; WMS)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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