Core Temp <32 degrees leads to impaired shivering and confers increased risk for malignant ventricular dysrhythmias. Core Temp <28 degrees substantially increases risk of cardiac arrest. 

 

If in cardiac arrest:

• VA ECMO. Rewarming rate ~6 degrees per hour.
• Cardio Pulmonary Bypass. Rewarming Rate ~9 degrees per hour.
• Consider transfer to center with ECMO or CPB capabilities
• Consider up to 3 defibrillation attempts for shockable rhythm
• Consider with holding epi until core temp >30 degrees and doubling interval between doses (q6-10 minutes) until core temp >35 (European Resuscitation Council recs – note this differs from AHA guidelines/recommendations)

 

If perfusing rhythm:

• Institute active external rewarming (warm environment, forced-air heating blankets, arctic sun, warm parenteral fluids). Rewarming Rate ~ 0.1-3.4 degrees per hour.
• Consider minimally invasive rewarming with TTM cooling/rewarming catheter (Alsius/Zoll) via femoral vessel. Rewarming Rate ~3.5 degrees per hour.
• Hemodialysis or CRRT can be considered if intravascular rewarming device unavailable. Rewarming rate 2-4 degrees per hour.
• Avoid IJ or SC central lines, rewarming catheters, and HD catheters -- myocardial irritation with wire/catheter may precipitate ventricular dysrhythmia.

 

Consider addition of more invasive rewarming techniques in those with hemodynamic/cadiac instability or without access to VA ECMO/CPB:

• Thoracic lavage. Rewarming rate ~ 3 degrees per hour
• Peritoneal lavage. Rewarming rate ~ 1-3 degrees per hour  
•  

Consider stopping resuscitation efforts if/when:

• K >12- suggests hypoxia before cooling, no reported survivors. Some recommend K of 10 as cutoff in adults.
• Rewarmed to 32 degrees and no signs of life.

References

 

Douglas J. A. Brown, Hermann Brugger, Jeff Boyd, Peter Paal. (2012). Accidental Hypothermia. New England Journal of Medicine. https://doi.org/10.1056/NEJMra1114208