Commentary
Managing accidental hypothermia:
progress but still some way to go
Les Gordon,1,2 Peter Paal3
Accidental hypothermia has become much
better understood over the last 25 years.
Not only is it recognised that it signifi-
cantly worsens the prognosis if it occurs
alongside many medical conditions
including major trauma1 2 and elective
surgery,3 but it is also well established that
severe accidental hypothermia (core
temperature <28°C) is eminently surviv-
able if treated correctly, even in the pres-
ence of cardiac arrest.4 In practice,
hypothermia can be divided into two
groups: mild hypothermia (core tempera-
ture 32°−35°C, table 1) and everything
else. In the presence of trauma, mild hypo-
thermia starts at 36°C,5 reflecting its dele-
terious effect on outcome. Mild
hypothermia is very common so prehos-
pital and hospital staff will have experi-
ence managing it. The condition per se is
not lethal and there is a lot of latitude
regarding general management and to
which hospital a patient is taken. By
contrast, severe hypothermia is relatively
rare and very unforgiving. There are
special requirements for managing the
patient with wet clothes, packaging and
the use of heat. Above all, the peri-arrest
and cardiac arrest situations must be
managed differently from the normo-
thermic patient. Moving a patient with
severe hypothermia can easily trigger a
cardiac arrest that is resistant to treatment
until rewarming to >30°C has occurred
(thereby making the rewarming process
more difficult and worsening the ultimate
prognosis), and once an arrest has
occurred, resuscitation should not be
stopped until the patient is warm.
Personnel who rarely encounter patients
with hypothermia cannot be reasonably
expected to remember all the special
requirements and have the appropriate
equipment and skills immediately
1
Department of Anaesthesia, University Hospital
Morecambe Bay Trust, Lancaster, UK
2
Langdale Ambleside Mountain Rescue Team,
Ambleside, UK
3
Department of Anaesthesiology and Intensive Care
Medicine, Barmherzige Bruder Salzburg, Teaching
Hospital, Paracelsus Medical University, Salzburg,
Austria
Correspondence to Dr Les Gordon, Department of
Anaesthesia, University Hospitals Morecambe Bay Trust,
Ashton Road, Lancaster LA1 4RP, UK;
​hlgordon@​btinternet.​com
Gordon L, Paal P. Emerg Med J November 2018 Vol 35 No 11
available unless the important issues have
been thought-through beforehand.
In this issue of the journal, Freeman
and colleagues report the results of a
survey conducted in 2017 on aspects of
hypothermia management by UK Prehos-
pital Search and Rescue providers. The
authors are to be commended for tackling
this important work. The first people to
attend to a patient with hypothermia will
be prehospital healthcare providers or
Search and Rescue personnel depending
on the location, and decisions and actions
taken by them could significantly affect
ultimate patient outcome. It is therefore
essential that these practitioners have a plan
to work from based on best evidence6 and
are appropriately prepared with adequate
knowledge and suitable equipment. The
investigators posed five questions: (1) pack-
aging; (2) use of active warming; (3) specific
requirements for wet casualties; (4) ther-
mometry and (5) availability of a protocol
or standard operating procedure for pack-
aging. No questions were asked about the
management of hypothermic cardiac arrest
or the most appropriate receiving hospital
for patients with hypothermia. Although
the overall response rate was ≈60%, the
results are nevertheless useful. Clearly, there
are not only differences between services
but also differences between organisations
working within the same service and most
importantly, some significant deviation
from published best practice in a way that
would not be expected in the management
of other potentially fatal conditions, for
example, cardiac arrest. One reason for the
wide range of responses may be because the
survey question asked about ‘potentially
cold/hypothermic’ casualties. This descrip-
tion is very broad so it is difficult to assess
the responses because best management
depends on how cold the patient is. Moun-
tain Rescue England and Wales (including
Cave Rescue) has had a severe hypothermia
protocol since 2014 yet surprisingly, only
81% of mountain rescue team respondents
were aware of this. Disappointingly, only
one-third of Ground Ambulance services
have a protocol. Ideally, protocols should
not only describe packaging but should
also include important clinical issues such
as safe handling of a patient who might
have cardiac instability and the manage-
ment of hypothermic arrest. It is pleasing
to see that  >91% of the organisations
Emerg Med J: first published as 10.1136/emermed-2018-207898 on 7 July 2018. Downloaded from http://emj.bmj.com/ on 28 January 2019 by guest. Protected by copyright.
would employ a vapour barrier. This is
considered an effective method of reducing
heat loss, as moving a patient with severe
hypothermia to remove wet clothes can
precipitate a cardiac arrest. Precise opera-
tional practices will be influenced by differ-
ences in work setting, reflecting the ability
to transport equipment into remote areas,
the need for heat and effective insulation
if the patient will remain in a cold envi-
ronment for some time during evacuation
(eg, mountainside or boat compared with
a warm land vehicle or aircraft) and the
speed of transport to hospital. The most
concerning survey results are where prac-
tices known to provide suboptimal care are
used, for example, measuring temperature
by the skin or rectal routes and failure to use
external heat to slow cooling.
Clearly, there is still room for improve-
ment. A recent international survey of
hypothermia management in mountain
rescue also concluded that most teams do
not follow standard guidelines for the treat-
ment of severe hypothermia.7 Although the
Freeman study could not investigate the
reasons underlying the observed divergence
from best practice, it is possible to propose
some factors that might account for the
findings. Accidental hypothermia has been
included in the European Resuscitation
Council section on Cardiac Arrest in Special
Circumstances since 2005, but unlike many
other causes of cardiac arrest, a protocol in
an easy-to-follow format is not provided.
As a result, practitioners have to read the
whole section in the published guideline
themselves and distill the information into a
suitable format for field use. People who are
not used to reading medical publications,
such as some of the organisations surveyed
in the Freeman study, may not feel able to
do this work. Historically, some voluntary
organisations have not had a clear gover-
nance framework because some members
feel that having a structured approach is not
appropriate for their voluntary status, and
they therefore may not employ best-prac-
tice guidelines.
The Freeman study is a wake-up call for
UK prehospital services and also a reminder
for experts that developing guidelines is not
sufficient on its own if the frontline carers
do not use them. Like everything in medi-
cine, achieving the best outcome depends on
practitioners employing the most up-to-date
evidence-based approach. Changing atti-
tudes is never straightforward, but making
a concise version of the protocols avail-
able in an easy-to-follow format is a simple
initiative that could make a difference.
Ideally, resuscitation councils should do
this work because they have the credibility.
   657
 Commentary

Table 1  Staging and treatment of accidental hypothermia in the absence of major trauma (from Brown et al and Paal et al8 9)

Emerg Med J: first published as 10.1136/emermed-2018-207898 on 7 July 2018. Downloaded from http://emj.bmj.com/ on 28 January 2019 by guest. Protected by copyright.
Stage Clinical symptoms Typical core temperature Treatment
Mild (HT I) Conscious, shivering 35°–32°C Warm environment and clothing; warm sweet drinks and active movement (if possible).
Patients with HT I with significant trauma, comorbidities or those suspected of secondary
hypothermia should receive HT II treatment.
Moderate  (HT II) Impaired <32°–28°C Full-body insulation; vapour barrier; active external and minimally invasive rewarming
consciousness* (shivering techniques (warm environment; chemical or electrical heating packs or blankets; forced air;
may have ceased) warm parenteral fluids).
Horizontal position and immobilisation.
Core temperature monitoring (not skin or rectal).
Minimal and cautious movements to avoid arrhythmias.
Severe (HT III) Unconscious*, vital signs <28°C HT II management plus:
present Airway management as required.
Preference to treat in an ECMO/CPB centre, if available, due to the high risk of cardiac arrest.
Consider ECMO/CPB in cases with cardiac instability that is refractory to medical management
and for patients with comorbidities who are unlikely to tolerate the low cardiac output
associated with HT III.
Severe (HT IV) Vital signs absent Cardiac arrest is possible Cardiopulmonary resuscitation and up to three defibrillation attempts and no epinephrine until
below 32°C. Risk increases temperature >30°C.
substantially below 28°C Prevent further heat loss (insulation, warm environment; vapour barrier).
and continues to increase Airway management.
with ongoing cooling. Active external and minimally invasive rewarming (see HT II) during transport is recommended.
Do not apply heat to head.
Transport to ECMO/CPB.
*Consciousness may be impaired by comorbid illness (ie, trauma, central nervous system pathology, toxic ingestion, etc) independent of core temperature.
CPB, cardiopulmonary bypass; ECMO, extracorporeal membrane oxygenation; HT, hypothermia.

A summary of the essential points for acci-
dental hypothermia is shown in table 1
based on recent international reviews.8–11
Versions should also be available for other
groups that could need them, including
control room staff who deploy prehos-
pital teams and hospital staff, especially if
rewarming will have to be undertaken by
non-extracorporeal life support methods.
In the absence of a formal guideline, indi-
vidual organisations have to decide locally
how to manage hypothermia, perhaps
at short notice, with all the potential for
inaccuracy that this approach engenders.
An authoritative evidence-based guideline
supported by education and the availability
of essential equipment is the ideal, as seen
with ALS. Without this approach, a repeat
of this survey done in 5 years’ time will
probably find no improvements.
Correction notice  This article has been corrected
since it was published Online First. In table 1, the
treatment for severe hypothermia has been amended.
Contributors  Both authors have made equal
contributions to the conception of the paper, the
acquisition, analysis and interpretation of appropriate
references, the drafting and revision of the manuscript
and the final approval of the submitted version.
Funding  The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not-for-profit sectors.
Competing interests  None declared.
Patient consent  Not required.
Provenance and peer review  Commissioned;
internally peer reviewed.
© Author(s) (or their employer(s)) 2018. No commercial
re-use. See rights and permissions. Published by BMJ.
To cite Gordon L, Paal P. Emerg Med J
2018;35:657–658.
Received 17 June 2018
Accepted 21 June 2018
Published Online First 7 July 2018
Emerg Med J 2018;35:657–658.
doi:10.1136/emermed-2018-207898
References
1 Wang HE, Callaway CW, Peitzman AB, et al. Admission
hypothermia and outcome after major trauma. Crit
Care Med 2005;33:1296–301.
2 Winkelmann M, Soechtig W, Macke C, et al.
Accidental hypothermia as an independent risk
factor of poor neurological outcome in older multiply
injured patients with severe traumatic brain injury:
a matched pair analysis. Eur J Trauma Emerg Surg
2018.
3 Torossian A, Bräuer A, Höcker J, et al. Preventing
inadvertent perioperative hypothermia. Dtsch Arztebl
Int 2015;112:166–72.
4 Paal P, Brown D. Cardiac arrest from accidental
hypothermia, a rare condition with potentially excellent
neurological outcome, if you treat it right. Resuscitation
2014;85:707–8.
5 Gentilello LM. Advances in the management of
hypothermia. Surg Clin North Am 1995;75:243–56.
6 Gordon L, Ellerton JA, Paal P, et al. Severe accidental
hypothermia. BMJ 2014;348:g1675.
7 Podsiadło P, Darocha T, Kosiński S, et al. Severe
Hypothermia management in Mountain Rescue: a
survey study. High Alt Med Biol 2017;18:411–6.
8 Brown DJ, Brugger H, Boyd J, et al. Accidental
hypothermia. N Engl J Med 2012;367:1930–8.
9 Paal P, Gordon L, Strapazzon G, et al. Accidental
hypothermia – an update. Scand J Trauma Resusc
Emerg Med 2016;24:111.
10 Zafren K. Out-of-hospital evaluation and treatment
of accidental hypothermia. Emerg Med Clin North Am
2017;35:261–79.
11 Haverkamp FJC, Giesbrecht GG, Tan E. The prehospital
management of hypothermia – an up-to-date
overview. Injury 2018;49:149–64.

658 Gordon L, Paal P. Emerg Med J November 2018 Vol 35 No 11