The n e w e ng l a n d j o u r na l of m e dic i n e

Patients trunk feels cold on examination

or core temperature is <35C

Vital signs present

Yes No

Obvious signs of irreversible

Impaired consciousness
death
Valid DNR order
Conditions unsafe for rescuer
Avalanche burial 35 min,
airway packed with snow,
and asystole

No Yes No to all Yes to any

Transport to nearest hospital
if injured; consider on-site or
hospital treatment if uninjured
Prehospital cardiac instability Start CPR, do not delay Consider termination
Systolic blood pressure transport of CPR
<90 mm Hg Prevent further heat loss
Ventricular arrhythmias Provide airway management
Core temperature <28C and up to 3 doses of
epinephrine (at an IV
or IO dose of 1 mg)
No to all Yes to any and defibrillation

HT I Transport to Transport to
Provide warm environment nearest hospital with Cardiac arrest before cooling
and clothing appropriate ECMO or CPB Major trauma
Provide warm sweet drinks hospital Witnessed normothermic
Encourage active move- arrest
ment Avalanche burial <35 min
HT II or III
Minimize movements to No to all Yes to any
prevent arrhythmias
Prevent further heat loss
Use active external and Consider tests to Transport to nearest
minimally invasive confirm need appropriate hospital
rewarming techniques for ECMO or or treat per super-
Provide airway manage- CPB vising doctor
ment as required Core temperature
<32C
Serum potassium
<12 mmol/liter

Yes to all No to any

Transport to hospital with ECMO or CPB;

do not terminate CPR

Prepare for multiorgan failure and need HT IV

for ECMO respiratory support Cardiac Rewarm with ECMO or CPB
No Consider termination
Provide post-arrest management instability If ECMO or CPB not available, provide
ROSC of CPR
Consider therapeutic hypothermia resolved CPR with active external and alter-
3234C for 24 hr native internal rewarming
Rewarm to 32C core temperature

R E SUSCI TAT ION FLUIDS fluids cool rapidly, and cold fluids may aggravate
hypothermia.8,16,28 A considerable volume of flu-
Intravenous fluids should be warmed (38 to 42C id is often required because of the volume loss
[100 to 108F])7,8,16 to prevent further heat loss. with cold diuresis (renal-fluid wasting due to
In a cold prehospital environment, intravenous hypothermia-induced vasoconstriction and di-

1932 n engl j med 367;20 nejm.org november 15, 2012

The New England Journal of Medicine

Copyright 2012 Massachusetts Medical Society. All rights reserved.

Accidental Hypothermia 61