›Warmed IV normal saline if IV access obtained
›Target fluid temperature 40 to 42°C
›Avoid large volumes in patients with cardiac risk
›Cold diuresis — expect volume depletion
›Cold suppresses ADH, causing diuresis
›Typical deficit 1 to 2 litres
›Avoid Lactated Ringer in severe hepatic dysfunction
›Impaired lactate metabolism
Nutritional and oral support
›Oral rewarming support
›Warmed, high-calorie oral fluids if alert and intact swallow
›Hot beverages (tea, soup, sweetened drinks)
›No evidence that warm fluids alone rewarm core significantly
›Caloric support sustains shivering
›Caloric intake priority
›Shivering increases metabolic rate 5 to 6 times baseline
›High-carbohydrate foods support glycogen replenishment
›Avoid alcohol
›Vasodilation worsens heat loss
Pharmacological management
›Drug management principles
›No specific pharmacological treatment indicated for mild hypothermia itself
›Rewarming-focused management is primary therapy
›Hypoglycaemia correction
›If glucose < 3.5 mmol/l — oral glucose if alert
›IV dextrose 50 mL D50W if unable to take orally
›Avoid QT-prolonging drugs
›Hypothermia itself prolongs QT interval
›Additive risk of torsades de pointes
›Drug clearance reduced during hypothermia
›Narrow therapeutic index drugs require dose adjustment
›Pharmacokinetics normalize with rewarming
Treatment of secondary causes
›Myxedema coma treatment
›Levothyroxine 300 to 500 mcg IV loading dose
›Maintenance 50 to 100 mcg IV daily
›Hydrocortisone 100 mg IV every 8 hours
›Give before or concurrent with thyroid hormone
›Prevents precipitation of adrenal crisis
›Warmed IV fluids and active external rewarming concurrent
›Adrenal crisis treatment
›Hydrocortisone 100 mg IV bolus
›Then 200 mg per 24 hours by continuous infusion or 50 mg every 6 hours
›Normal saline 1 to 2 litres IV rapid infusion for hypotension
›Dextrose-containing saline if hypoglycaemic
›Sepsis with hypothermia treatment
›Broad-spectrum antibiotics within 1 hour of recognition
›Piperacillin-tazobactam 4.5 g IV every 6 hours, or equivalent
›Fluid resuscitation 30 mL/kg IV crystalloid for hypotension
›Norepinephrine 0.1 to 0.3 mcg/kg per minute if refractory hypotension
›Titrate to MAP > 65 mmHg
Cardiac arrhythmia management
›Arrhythmia management principles
›Atrial fibrillation in hypothermia
›Typically self-terminates with rewarming
›Avoid antiarrhythmic drugs unless AF persists post-rewarming
›Ventricular arrhythmia
›Rare in mild hypothermia (more common below 30°C)
›If VF develops — CPR and defibrillation per ALS guidelines
›AHA 2025 Guidelines: defibrillation attempt reasonable in hypothermic VF
›Avoid medications that prolong QT during hypothermia
›Amiodarone, sotalol, haloperidol, ondansetron — use with caution