Accidental Hypothermia Clinical

Practice Guideline for British Columbia

Accidental Hypothermia – Evaluation, Triage & Management

Version 1.03: December 9, 2016

Written by: Dr. Doug Brown & BC Accidental Hypothermia Working Group

Scope
The objective of this guideline is to improve the efficiency and effectiveness of the management
of accidental hypothermia in British Columbia. The use of simplified clinical staging, suggested
treatment guidelines as well as triage and transportation algorithms has the potential to
decrease morbidity and mortality of patients with accidental hypothermia in British Columbia. 1,2

Target Population
Adults and children with a core temperature below 35oC presenting to emergency departments,
physicians’ offices, walk-in clinics, nursing stations and pre-hospital care providers.

Applicable Diagnositic Codes: ICD 10 T68

Evaluation and Diagnosis

Patients can be considered to have hypothermia if they have a history of cold exposure (primary
hypothermia) or a disease that predisposes them to hypothermia (secondary hypothermia [see
Appendix F]) AND if their trunk is cold to touch or they have a core temperature measurement
of less than 35oC.1,3,4 (see Appendix G for how to obtain an accurate core temperature)

Accidental hypothermia should be staged using clinical symptoms and core temperature (when
available) as described in table 1.

Version 1.03: December 9, 2016 Page 1 of 15

Table 1: Staging and Treatment of Accidental Hypothermia1,3,4,5,8,9

Stage Clinical Typical Core Treatment

Symptoms Temperature
HT I Conscious, shivering 35 to 32 oC Warm environment and clothing, warm sweet
drinks, and active movement (if possible)
(Mild)
HT I patients with significant trauma, co-morbidities
or those suspected of secondary hypothermia
should receive HT II treatment

HT II* Impaired consciousness** <32 to 28 oC Active external and minimally invasive rewarming
(may or may not be techniques (warm environment; chemical,
(Moderate) shivering) electrical, or forced-air heating packs or blankets;
warm parenteral fluids)
Cardiac & core temperature monitoring
Minimal and cautious movements to avoid
arrhythmias
Full-body insulation, horizontal position and
immobilization

HT III Unconscious**, vital signs <28 oC HT II management plus:

present
(Severe) Airway management as required
Preference to treat in an ECMO/CPB center, if
available, due to the high risk of cardiac arrest
Consider ECMO/CPB in cases with cardiac
instability that is refractory to medical
management
Consider ECMO/CPB for comorbid patients that
are unlikely to tolerate the low cardiac output
associated with HT III

HT IV Vital signs absent cardiac arrest is CPR and up to three doses of epinephrine and
possible below 32o, defibrillation (further dosing guided by clinical
the risk increases response)
substantially below
28oC and continues to Airway management
increase with ongoing Transport to ECMO/CPB***
cooling
Prevent further heat loss (insulation, warm
environment, do not apply heat to head)
Active external and minimally invasive rewarming
(see HT II) during transport is recommended but
controversial, do not apply heat to head
***Transfering a HT IV patient to an ECMO/CPB
center may reduce mortality by 40-90% (NNT ~2),
if ECMO/CPB is not available within six hours of
transport,1,2,7,10,11 consider onsite rewarming with
hot packs or forced air blankets, warm IVF, +/-
warm thoracic lavage, +/- warm bladder lavage +/-
warm peritoneal lavage, do not apply heat to head

*If transport times are similar to an ECMO/CPB centre or an alternative centre, consider
preferential transport to the ECMO/CPB centre for patients with a core temperature <32 oC.

Version 1.03: December 9, 2016 Page 2 of 15

**Consider that consciousness may be impaired by comorbid illness (ie trauma, CNS pathology,
toxic ingestion, etc.) independent of core temperature.

Triage
Isolated stage I & II hypothermia are rarely life threatening unless co-morbidities such as trauma
are present and can usually be managed on site (HT I) or at the closest hospital (HT II) [see
Appendix A]. Secondary hypothermia cases (those caused by medical illness) should be triaged
to hospital.

Patients with stage III and IV hypothermia should ideally be managed in a hospital with extra-
corporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB) [see Appendix A]
unless co-morbid conditions (such as trauma) or prolonged transport time (>6hrs) mandate
transport to a closer hospital (see Appendix B & C).1 Historically BC Ambulance Service (BCAS)
has always transported patients in cardiac arrest to the closest hospital. In the rare cases of
cardiac arrest caused by isolated accidental hypothermia, it is recommended to consider
transporting the patient directly to a hospital with ECMO or CPB capabilities. Note, it is
somewhat rare for a patient to present with cardiac arrest caused by isolated hypothermia and it
can often be difficult to be certain of the cause, therefore it is recommended to contact the
Emergency Physician Online Support (EPOS) phone line for specialist assistance with all stage
III and IV hypothermia patients (EPOS can be accessed by paramedics through BCAS dispatch
and by physicians through the BC Patient Transfer Network [BCPTN], formerly BC Bedline) [see
Appendicies B & C].

Transport & Management

A. HT I (conscious, shivering, core temperature >32oC):
i. Transport: Transport to nearest hospital if injured, consider on-site or hospital
treatment if uninjured. Patients with significant co-morbidities or suspected
secondary hypothermia (caused by a medical condition) should be transported to
hospital.
ii. Management: Provide warm environment and clothing, provide warm sweet drinks,
encourage active movement. HT I patients with traumatic injuries, significant medical
co-morbidities or in whom secondary hypothermia is suspected should be managed
as per HT II.1,3,4,6,8,9

B. HT II (impaired consciousness, may or may not be shivering, core

temperature ~32-28oC) or HT I with trauma
Transport: Transport to nearest hospital. If transport times are similar to an ECMO/CPB centre
or an alternative centre, consider preferential transport to the ECMO/CPB centre for patients
with a core temperature <32oC.

i. Management: 1,3,4,6,8,9
 Active external and minimally invasive rewarming techniques: (see Appendix E)

Version 1.03: December 9, 2016 Page 3 of 15

  warm environment & insulation
 warming blanket placed under the patient
 hot packs, chemical, electrical, or forced-air heating blankets over the
patient
 warm [38-42oC] IV fluids titrated to clinical volume status
 Cardiac & core temperature monitoring
 Minimal and cautious movements to avoid arrhythmias

C. HT III (unconscious, not shivering, vital signs present, core

temperature usually <28oC)
i. Transport: Patients with significant trauma should be transferred to the nearest
appropriate hospital. For all other cases, contact EPOS (access via BCAS dispatch
[paramedics] or BCPTN [MDs & RNs]) to assist with making a transport decision.
Ideally patients with HT III would be cared for in a centre with ECMO/CPB capability
due to the significant risk of cardiac arrest (particularly if the patient has
demonstrated any cardiac instability such as hypotension or ventricular arrhythmia).
In cases with significant co-morbidities or when the transport time to an ECMO/CPB
centre is greater than 6 hours, the EPOS physician may suggest transport to the
nearest appropriate hospital (see Appendix C).
ii. Management:1,3,4,8,9
 HT II management plus: (see Appendix E)
 airway management as required
 warm (38-42oC) IV fluids titrated to clinical volume status (expect
significant volume requirements during rewarming)
 +/- warm (38-42oC) bladder lavage
 Bradycardia, mild hypotension plus or minus atrial fibrillation are common and
usually resolve with rewarming.
 Vasopressors are usually not indicated during early resuscitation due to the
profound vasoconstriction associated with hypothermia and the significant risk of
cardiac arrhythmia. Relative hypotension may be physiologic depending on core
temperature, consider expert consultation prior to starting vasopressors.
 Vasopressors may be indicated later during rewarming if rewarming induced
vasodilation is contributing to significant hypotension.
 In patients with cardiac stability, invasive rewarming strategies (such as body
cavity lavage, endovascular devices and extracorporeal heating systems) are not
recommended due to the increased risk of complications such as hemorrage and
thrombosis.
 If central venous access is required it is important to keep the tip of the catheter
(and guide wire) far from the heart in order to minimise the risk of arrhythmia.
 ECMO or CPB should be considered for patients with cardiac instability who do
not respond to medical management.

Version 1.03: December 9, 2016 Page 4 of 15

 D. HT IV (vital signs absent, core temperature usually <28 oC) [cardiac
arrest is possible below 32o and the risk increases substantially below 28oC]
i. Transport:
 Patients with significant trauma should be transferred to the nearest appropriate
trauma centre or managed as per existing traumatic arrest protocols.
 For patients with a core temperature >32oC and asystole on ECG, hypothermia is
not the cause of cardiac arrest.
 Serum potassium >10-12 mmol/L may be a marker of death before cooling and
the patient is unlikely to benefit from prolonged resuscitation unless the history is
compelling for cooling before cardiac arrest or extremely rapid cooling
simultaneous with cardiac arrest.
 For all other cases, when the history suggests hypothermia prior to cardiac
arrest, contact EPOS (access via BCAS dispatch [paramedics] or BCPTN [MDs
& RNs]) to assist with making a transport decision. Ideally patients with HT IV
would be cared for in a centre with ECMO/CPB capability. In cases with
significant co-morbidities or when the transport time to an ECMO/CPB centre is
greater than 6 hours, the EPOS physician may suggest transport to the nearest
appropriate hospital (see Appendix B). Depending on availability and logistics,
some ECMO providers may elect to dispatch a portable ECMO team in order to
initiate ECMO on site prior to transport.
ii. Management: 1,3,4,8,9
 CPR and up to three doses of epinephrine and defibrillation with further dosing
guided by clinical response (after three defibrillation attempts have been
unsucessful, do not pause CPR to analyze the rythmn until the core temperature
has increased by at least 2-4oC)
 Airway management
 Rewarming with ECMO/ CPB (if available)
 Prevent further heat loss during transport (insulation, warm environment)
 Active external and minimally invasive rewarming (see Appendix E) during
tranport for the patient in cardiac arrest is recommended but controversial
[unlikely to raise the core temperature but may help prevent a further drop in core
temperature, do not apply heat to the head]
 If transport to ECMO/CPB is not available within 6 hours or not recommended,
then continue CPR while rewarming with active external and alternative internal
rewarming including as many of the following as possible:1,2,10,11
 warm environment & insulation
 warming blanket placed under the patient
 hot packs, chemical, electrical, or forced-air hearing blankets over the
patient (avoid applying heat to the head)
 warm (38-42oC) IV fluids titrated to clinical volume status (expect
significant volume requirements during rewarming)
 warm (38-42oC) thoracic and/or peritoneal lavage
 warm (38-42oC) bladder lavage

Version 1.03: December 9, 2016 Page 5 of 15

Abbreviations
BC: British Columbia.

BCAS: British Columbia Ambulance Service.

BCPTN: British Columbia Patient Transfer Network (1-866-233-2337).

BCCH: British Columbia Children’s Hospital.

CPB: Cardiopulmonary Bypass (extracorporeal provision of circulation, oxygenation and

rewarming usually performed in the operating room for a short period of time [<~8 hours]).

CPR: Cardiopulmonary Resuscitation.

ECLS: Extracorporeal Life Support (inclusive term used to describe the use of CPB or ECMO
for the mechanical provision of invasive cardiopulmonary resusciation).

ECMO: Extracorporeal Membrane Oxygenation (extracorporeal provision of circulation,

oxygenation and rewarming commonly performed in the ICU or operating room that can be used
for a prolongued period of time [days]).

EPOS: Emergency Physcian Online Support (provides services to BCPTN and BCAS).

ICU: Intensive Care Unit.

TSBC: Trauma Services of British Columbia.

VIHA: Vancouver Island Health Authority.

BC Accidental Hypothermia Working Group

Brown, Douglas (Co-Chair, Royal Columbian Hospital Emergency Physician)

Evans, David (TSBC Medical Director & Vancouver General Hospital Trauma Surgeon)

Foster, Ryan (Interior Health Critical Care Network, Medical Director)

Gunning, Derek (Royal Columbian Hospital Cardiac Surgeon & ICU)

Isac, George (Regional Critical Care Council & ICU Medical Director, Vancouver General
Hospital)

Jones, Catherine (Co-Chair, TSBC Executive Director)

Kuzak, Nick (Kelowna General Hospital, Emergency Medicine and Anesthesiology)

Lee, Sandra (Guidelines and Protocols of British Columbia Advisory Committee, Medical
Consultant)

Pitfield, Sandy (BCCH ECLS Medical Director & ICU)

Version 1.03: December 9, 2016 Page 6 of 15

Porayko, Lorne (VIHA ICU)

Ring, Todd (Interior Health Authority, Regional Medical Director Emergency Services)

Ryan, John (Prince George Hospital, Emergency Department Head)

Sirounis, Dimetrius (St. Pauls Hospital ICU & Anesthesiology)

Steegstra, Kathy (BCPTN Executive Director)

Thakore, Jaimini (British Columbia Trauma Registry, Manager)

Vu, Erik (BCAS Critical Care Programs)

Wheeler, Steve (BCAS Critical Care Programs, Medical Director)

Yoon, Philip (EPOS Medical Director)

References
1. Brown DJ, Brugger H, Boyd J, Paal P. Accidental hypothermia. N Engl J Med.

2012;367:1930-1938.

2. Paal P, Brown D. Cardiac arrest from accidental hypothermia, a rare condition with

potentially excellent neurological outcome, if you treat it right. Resuscitation. 2014;85:707-708.

3. Brown D, Hypothermia. in: Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 8th Ed. McGraw-Hill New York; 2014.

4. Danzl DF, ed. Accidental Hypothermia. in: Auerbach PS, Ed. Wilderness Medicine. 6th

Ed. Philadelphia, PA: Mosby, 2012:116-42.

5. Durrer B, Brugger H, Syme D. The Medical On-site Treatment of Hypothermia: ICAR-

MEDCOM Recommendation. High Alt Med Biol. 2003;4:99-103.

6. Lundgren P, Henriksson O, Naredi P, Bjornstig U. The effect of active warming in

prehospital trauma care during road and air ambulance transportation-a clinical randomized trial.

Scand J Trauma Resusc Emerg Med. 2011;19:59.

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7. Wanscher M, Agersnap L, Ravn J, et al. Outcome of accidental hypothermia with or

without circulatory arrest: experience from the Danish Præstø Fjord boating

accident. Resuscitation. 2012;83:1078-1084.

8. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for

Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities,

poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac

surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81:1400-1433.

9. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: Cardiac Arrest in Special

Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care. Circulation. 2010;122:S829-61.

10. Boue Y, Lavolaine J, Bouzat P, Matraxia S, Chavanon O, Payen JF. Neurologic recovery

from profound accidental hypothermia after 5 hours of cardiopulmonary resuscitation. Crit Care

Med. 2014;42:e167-70.

11. Lexow K. Severe accidental hypothermia: survival after 6 hours 30 minutes of

cardiopulmonary resuscitation. Arctic Med Res. 1991;50 Suppl 6:112-114.

Version 1.03: December 9, 2016 Page 8 of 15

 Appendix A: Management of Accidental Hypothermia
Patient’s trunk feels cold on examination or core temperature <35oC?

Vital signs present

Yes No

Impaired Consciousness Obvious signs of irreversible death

(see appendix B)
Valid DNR order
Conditions unsafe for rescuer
No Yes
Avalanche burial >35min & airway
packed with snow

No to all Yes to any

Complicating Prehospital cardiac Start CPR, do not delay Consider termination

factors instability transport of CPR
Trauma SBP<90 mmHg(†) Prevent further heat loss
Co-morbidities Ventricular arrhythmias Airway management and up
Suspected Core temperature <28oC to 3 doses of
secondary medication/defibrillation*
hypothermia

No Yes No to all Yes to any

Cardiac arrest from alternate

Transport to cause prior to cooling
nearest appropriate Major trauma
hospital Witnessed normothermic
arrest
Avalanche burial <35min

No to all Yes to any

Contact EPOS** to determine Contact EPOS** to determine Transport to nearest

if transfer to ECMO is if transfer to ECMO is appropriate hospital or
indicated indicated manage as per
see Appendix C Triage Tool see Appendix B Triage Tool supervising MD
for HT III for HT IV

HT I (mild) HT I, HT II or III (mild, mod or severe) HT IV

Warm environment Active external and minimally invasive Do NOT terminate CPR
and clothing rewarming (insulation, hot packs or Transport to ECMO
Warm sweet drinks forced air blankets, warm IVF, allow Prevent further heat loss (insulation, warm
Active movement shivering) environment)
Minimal and cautious movements to Active external and minimally invasive
avoid arrhythmias rewarming during transport is
Airway management if required recommended but controversial
See Appendix E (practical tips) If ECMO not available within 6hrs consider
onsite rewarming with hot packs or
forced air blankets, warm IVF, +/- warm
thoracic lavage, +/- warm bladder lavage
Do not apply external heat to head
* after three defibrillation attempts have been unsuccessful, do not pause CPR to Rewarm to 32oC
analyze the rhythm until the core temperature has increased by at least 2-4oC.

**EPOS: Emergency Physician Online Support: call BC Ambulance Dispatch or the BC Patient Transfer Network and ask to speak with the
EPOS physician. These patients should initially be triaged as LLTO-Red.

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 Appendix B: EPOS Triage Tool for Stage IV Accidental Hypothermia
(Accidental Hypothermia with Absent Vital Signs)
Obvious signs of irreversible death:
Decapitation, decomposition, truncal transection
Body frozen solid (not compressible)
Valid DNR order Consider standard TOR (termination of resuscitation guidelines)
Note: fixed & dilated pupils, areflexia or stiffness Yes to any
that resembles rigor mortis are not reliable
indicators of death in hypothermia.
No to all
Cardiac arrest from alternate cause prior to cooling
Major trauma, hypoxia or medical condition Consider standard TOR
Witnessed normothermic arrest Yes to any
No to all
Drowning:
Submersion (patient goes underwater and has a hypoxic cardiac
Special Circumstances arrest prior to cooling): poor prognosis unless very young with
Drowning, Avalanche or Trauma Yes to any rapid cooling, consider standard TOR
Immersion (patient breathing air during cooling and then has a
hypothermic cardiac arrest): consider transfer to ECMO/CPB
Avalanche:
<35 min burial: hypoxia or trauma likely caused the cardiac arrest,
consider standard TOR
>35 min burial & airway packed with snow: hypoxia likely caused
the cardiac arrest, consider standard TOR
>35min burial & airway patent: hypothermia may have caused the
cardiac arrest, consider transfer to ECMO unless signs of traumatic
arrest
Trauma:
Hypothermia generally increased the mortality in trauma patients,
consider standard TOR for patients with signs of traumatic arrest
Consider tests to exclude need for ECMO/CPB
Core temperature >32°C (see Appendix F) Consider standard TOR
Serum potassium >12mmol L-1 Yes to any

>6hr transport time to ECMO(*) Transport to nearest appropriate hospital***

Yes
No
Contact closest hospital with ECMO/CPB(**) & EPOS HT IV
Emergency Transfer Physician to arrange accepting Do NOT terminate CPR
physician and transport. Also ensure that cardiac Prevent further heat loss (insulation, warm environment, do not
surgery, perfusion, OR, ICU & Emerg are aware. apply heat to head)
Airway management and up to 3 doses of epinephrine/defibrillation
Transport to ECMO, or dispatch portable ECMO & transfer
*Geographic location, vehicle/aircraft availability, If ECMO not available within 6hrs consider onsite rewarming with
weather and road conditions will all impact transport hot packs or forced air blankets, warm IVF, +/- warm thoracic
time. See Appendix D for a map of centers. In lavage, +/- warm bladder lavage, do not apply heat to head
exceptional cases, >6hr transport may be considered. Rewarm to 32oC

**Hospitals with ECMO/CPB:

1. Vancouver General Hospital, ECMO for accidental hypothermia guideline in place, contact ICU doctor on call.
2. BC Children’s Hospital, provincial ECMO center for patient’s <17 y/o, contact PICU doctor on call.
3. Calgary Foothills Hospital, ECMO for accidental hypothermia guideline in place, contact RAAPID South 1-800-661-1700 .
4. Calgary Alberta Children’s Hospital (ACH), contact RAAPID South 1-800-661-1700.
5. Edmonton University of Alberta Hospital, ECMO for accidental hypothermia guideline, contact RAAPID North 1-800-282-9911.
6. Edmonton Stollery Children’s Hospital, provincial ECMO center for patient’s <17 y/o, contact RAAPID North 1-800-282-9911.
7. Kelowna General Hospital, ECMO for accidental hypothermia is provider dependant, contact ICU doctor on call.
8. New Westminster Royal Columbian Hospital, ECMO for accidental hypothermia is provider dependant, contact ICU doctor on call.
9. Vancouver St. Pauls’ Hospital, ECMO for accidental hypothermia guideline in place as part of a formal ECMO-CPR program, contact
emergency physician regarding protocol activation 604-689-4455.
10. Royal Jubilee Hospital, CPB for accidental hypothermia is provider dependant , teleconference cardiac surgeon & ICU on call.
***Interior Health has a high acuity response team (HART), which may be able to provide additional resources to facilities when transport
to ECMO/CPB is not available and/or while awaiting transfer to ECMO/CPB.

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 Appendix C: EPOS Triage Tool for Stage III Accidental Hypothermia
(Unconscious Accidental Hypothermia with Vital Signs)

Prehospital cardiac instability:

Ventricular arrhythmias (afib is OK) No to all
Hypotension out of proportion to hypothermia
Core temperature <28oC
Yes to any

Hypothermia is the likely cause of cardiac

instability (absence of major trauma, medical
condition etc.) No

Yes

<6hr transport time to ECMO/CPB(*) Transport to nearest appropriate hospital***

No
Yes

HT III
Contact closest hospital with ECMO/CPB(**) & EPOS
Active external and minimally invasive rewarming (insulation, hot
Emergency Transfer Physician to arrange accepting
packs or forced air blankets, warm IVF, allow shivering)
physician and transport. Also ensure that cardiac
Minimal and cautious movements to avoid arrhythmias
surgery, perfusion, OR, ICU & Emerg are aware.
Airway management if required

*Geographic location, vehicle/aircraft availability, weather and road conditions will all impact transport time. See Appendix D for a map of
centers. In exceptional cases, >6hr transport may be considered.

**Hospitals with ECMO/CPB:

1. Vancouver General Hospital, ECMO for accidental hypothermia guideline in place, contact ICU doctor on call.
2. BC Children’s Hospital, provincial ECMO center for patient’s <17 y/o, contact PICU doctor on call.
3. Calgary Foothills Hospital, ECMO for accidental hypothermia guideline in place, contact RAAPID South 1-800-661-1700 .
4. Calgary Alberta Children’s Hospital (ACH), contact RAAPID South 1-800-661-1700.
5. Edmonton University of Alberta Hospital, ECMO for accidental hypothermia guideline, contact RAAPID North 1-800-282-9911.
6. Edmonton Stollery Children’s Hospital, provincial ECMO center for patient’s <17 y/o, contact RAAPID North 1-800-282-9911.
7. Kelowna General Hospital, ECMO for accidental hypothermia is provider dependant, contact ICU doctor on call.
8. New Westminster Royal Columbian Hospital, ECMO for accidental hypothermia is provider dependant, contact ICU doctor on call.
9. Vancouver St. Pauls’ Hospital, ECMO for accidental hypothermia guideline in place as part of a formal ECMO-CPR program, contact
emergency physician regarding protocol activation 604-689-4455.
10. Royal Jubilee Hospital, CPB for accidental hypothermia is provider dependant , teleconference cardiac surgeon & ICU on call.
***Interior Health has a high acuity response team (HART), which may be able to provide additional resources to facilities when transport
to ECMO/CPB is not available and/or while awaiting transfer to ECMO/CPB.

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 Appendix D: Provincial ECMO Provider Map

Regional ECMO
Providers

Alberta
Edmonton:
Adults: VGH Adults: U of A
or SPH Peds: Stollery

Calgary:
Adults: Foothills
Peds (All Regions): BC Children’s Peds: ACH
(unless close to Edmonton/Calgary)

Kelowna
Royal General
Royal Columbian
Jubilee

Regional ECMO/CPB Providers:

1. Pediatrics (All Regions):
a) BC Children’s Hospital, provincial ECMO center for patient’s <17 y/o, contact ICU doctor on call (potential exists for BCCH ECMO
team to travel, cannulate locally and transport on ECMO)
b) If close to Edmonton or Calgary, may consider:
• Stollery Children’s Hospital (Edmonton), provincial ECMO center <17 y/o, contact RAAPID North 1-800-282-9911.
• Alberta Children’s Hospital (Calgary), contact RAAPID South 1-800-661-1700 .
2. Vancouver Coastal & Northern Health:
a. Vancouver General Hospital, ECMO for accidental hypothermia guideline in place, contact ICU doctor on call.
b. Vancouver St. Pauls’ Hospital, ECMO for accidental hypothermia guideline in place as part of a formal ECMO-CPR program,
contact emergency physician regarding protocol activation 604-689-4455.
3. Fraser Health Authority:
a) New Westminster Royal Columbian Hospital, ECMO for accidental hypothermia is provider dependent, contact ICU doctor on
call.
4. Interior Health Authority (except for the East Kootenays)
a) Kelowna General Hospital, ECMO for accidental hypothermia is provider dependent, contact ICU doctor on call.
5. Interior Health Authority (East Kootenays: STARS Trauma Hotline 1-888-888-4567)
a) Golden & Cranbrook -> Calgary:
• Calgary Foothills Hospital, ECMO for accidental hypothermia guideline in place, contact RAAPID South 1-
800-661-1700 .
b) Fort St. John, Dawson Creek -> Edmonton:
• University of Alberta Hospital (Edmonton), ECMO for accidental hypothermia guideline in place, contact RAAPID
North 1-800-282-9911.
6. Island Health Authority:
a) Royal Jubilee Hospital, ECMO for accidental hypothermia is provider dependent, teleconference cardiac surgeon & ICU on call.

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 Appendix E: Practical Tips for Rewarming HT II & III (moderate & severe)
(from Tintinalli’s Emergency Medicine 8th Ed.3 with permission)
Hospital Resuscitation Checklist:
 Cardiac monitor & careful handling
 Core temperature monitoring (esophageal, rectal or bladder)
 If cardiac arrest, ventricular dysrhythmia, core temp <28oC or unstable:
• do not stop resuscitation, seek expert consultation (see Apendix B & C)
• potential for good outcome despite prolonged resuscitation, ideally transfer to ECMO center
if indicated
 Minimally invasive rewarming:
 Hypothermia burrito (see below, preference for forced air warming blankets)
 +/- Bladder lavage
(3-way Foley, 40oC saline, 2-4 L/hr by gravity)
[confirm volume in = volume out, will invalidate bladder and rectal temperature measurements]
 IV Fluid Resuscitation: (crystaloid, 38-42oC)
 Titrate fluids to clinical volume status (avoid over-resuscitation)
 10-20 mL/kg (~1L) to start (may be reasonable)
 Additional 10-20 mL/kg per ~3oC core temp increase (may be required)
 Hypothermia is NOT a contraindication to airway management
 Avoid hyperoxia (titrate FiO2 to 92-98%)
 If central venous access is required, keep the tip of the catheter (and guidewire) far from the heart
(femoral, shallow internal jugular or shallow subclavian)
 Avoid vasopressors during early resuscitation (relative hypotension may be physiologic depending on core
temperature, consider expert consultation)

Minimally Invasive Rewarming: (hypothermia burrito)

1 Outer wind & waterproof +/-
reflective tarp (prehospital
5 only)

4 2 Insulation or heating pad*

6
3 Replace wet clothes if
practical, otherwise wrap
patient in plastic
4 Forced air, chemical or
2 3 electrical heating device(s)*
5 Insulating blanket
1
6 Insulate the head**
© Doug Brown

* To avoid burns, keep heating device temperatures

<~40oC.
**If in cardiac arrest, do not apply heat to the head
(allow warm oxygenated blood to rewarm the brain centrally).

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 Appendix F: Causes of Secondary Hypothermia
(from Tintinalli’s Emergency Medicine 8th Ed.3 with permission)

Predominantly Increased Heat Loss

Burns
Iatrogenic (i.e. blood transfusions and other cold infusions, cooling blankets, inadequate
insulation)
Recent birth
Predominantly Impaired Thermogenesis
Impaired shivering (i.e. advanced or very young age, malnutrition, physical exhaustion,
neuromuscular disease)
Multifactorial
Medications & Toxins (i.e. alcohol, anesthetic agents, narcotics, sedatives, vasodilators)
Metabolic & Endocrine disorders (i.e. alcoholic or diabetic ketoacidosis, hypoadrenalism,
hypoglycemia, hypopituitarism, hypothyroid, lactic acidosis, Wernicke’s encephalopathy)
Neurological (i.e. space occupying lesion, stroke, spinal cord injury)
Sepsis (small subset of sepsis cases, more common in the elderly or cachectic patient)
Shock
Trauma

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 Appendix G: Core Temperature Measurement
(from Tintinalli’s Emergency Medicine 8th Ed. 3 with permission)

Make sure that the device being used to measure core temperature is capable of extreme

measurements, and is properly calibrated (thermistor devices are usually preferred). Temperature

measurement at different body sites will yield different readings depending on local perfusion

and environmental conditions. In the intubated patient, the lower third of the esophagus (~24cm

below the larynx in an adult), is the preferred site for core temperature measurement, since it

closely mirrors the cardiac temperature.4 In the absence of an esophageal probe, a rectal probe

inserted to a depth of 15cm or a bladder probe is adequate but realize that these temperatures

often lag behind true core temperature during rewarming and that bladder or peritoneal lavage

may falsely elevate the reading. Oral and infrared tympanic temperature measurements do not

correlate well with core temperature and should not be used. When an accurate core temperature

measurement is not available, management decisions should be made based on clinical staging

(see Table 1 & Appendix A). Ongoing core temperature monitoring should be implemented as

soon as possible for all HT II, III & IV patients.

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