Prevent further heat loss
›Heat loss prevention bundle
›Wet clothing removal
›Dry insulation layers
›Wind barrier
›Warm environment
›Room temperature increase
›Warm blankets and head covering
›Horizontal positioning
›Reduce cardiovascular collapse risk
›Minimize exertion and sudden standing
Rewarming strategies by stage
›Rewarming approach selection
›Passive external rewarming for mild hypothermia
›Insulation and warm environment
›Warm sweet drinks if alert and low aspiration risk
›Caloric support for shivering
›Active external rewarming for moderate hypothermia or failed passive rewarming
›Forced air warming blanket
›Continuous trunk focused warming
›Monitor for hypotension during vasodilation
›Large heat packs to trunk axilla groin
›Avoid direct skin burns
›Avoid small hand foot packs as primary core strategy
›Active internal rewarming for severe hypothermia or instability
›Warmed IV isotonic crystalloid 40-42°C
›Bolus for hypotension with reassessment
›Ongoing warmed maintenance for dehydration and cold diuresis
›Warmed humidified oxygen
›Airway heat exchange support
›Bronchospasm and secretion management
›Lavage options when ECLS unavailable and severe instability
›Peritoneal lavage warmed fluid
›Rewarming rate variable
›Peritonitis risk
›Thoracic lavage warmed fluid
›Invasive procedural risk
›Consider in HT IV when ECMO not available
Cardiac arrest and dysrhythmia management
›Hypothermic cardiac arrest pathway
›High quality CPR with prolonged resuscitation planning
›Prolonged resuscitation potentially indicated until rewarming
›Mechanical CPR consideration for transport to ECLS center
›Defibrillation strategy in severe hypothermia
›If VF or pulseless VT
›Up to 3 shocks
›If persistent VF after 3 shocks and core temperature below 30°C then delay further defibrillation until above 30°C per Resuscitation Council UK 2025 guidance
›Continue CPR and rewarming during delay
›Vasopressor and antiarrhythmic strategy
›If core temperature below 30°C
›Epinephrine 1 mg IV once may be used to facilitate ROSC unless planning ECLS per ERC 2025 guidance
›Repeat dosing deferred until temperature above 30°C
›Drug accumulation concern below 30°C
›If core temperature 30°C or higher and arrest persists
›Standard ACLS medication dosing with extended intervals consideration per local protocol
›Continue aggressive rewarming concurrently
›Bradycardia and atrial fibrillation management
›Rewarming as primary therapy
›Avoid atropine routine use
›Avoid pacing unless persistent hemodynamic compromise after rewarming
›Ventricular ectopy avoidance measures
›Gentle handling
›Correct potassium magnesium and glucose abnormalities
Volume and glucose management
›Fluids and metabolic support
›Warmed isotonic crystalloid resuscitation
›Hypovolemia from cold diuresis
›Vasodilation related relative hypovolemia during rewarming
›Hypoglycemia treatment
›Dextrose IV for glucose below 4 mmol/L
›Recheck glucose every 15-30 minutes until stable
›Electrolyte correction
›Potassium mmol/L correction individualized
›Avoid aggressive replacement during ongoing acidosis shifts
›Serial monitoring during rewarming
›Magnesium mmol/L repletion for ventricular irritability
›Magnesium sulfate IV dosing per local protocol
›Repeat level guided repletion
ECLS and advanced rewarming
›Extracorporeal rewarming decision framework
›Indications for ECMO or cardiopulmonary bypass
›Hypothermic cardiac arrest with potentially reversible cause
›Severe hypothermia with refractory shock and instability
›Failure of conventional rewarming with ongoing instability
›Candidate assessment inputs
›HOPE score estimation when available
›Survival probability informs ECLS activation
›Not solely reliant on potassium
›Contraindications consideration
›Unsurvivable trauma
›Clear irreversible death signs
›Prolonged asphyxia without hypothermia protection context
›Transfer and activation
›Early ECLS center consultation for HT III unstable or HT IV
›Mechanical CPR for transport when feasible