Hypothermia and Cold Injury: Recognition and Rewarming in the Field

Cold patients die in predictable ways: dysrhythmias, coagulopathy, and rough handling. The EMS priority is passive rewarming, careful movement, and prolonged CPR when needed — because a hypothermic patient is not dead until they are warm and dead.

Staging by core temperature

• Mild (32–35 °C / 90–95 °F): shivering, alert, tachycardic.
• Moderate (28–32 °C / 82–90 °F): shivering stops, confused, bradycardic.
• Severe (< 28 °C / < 82 °F): unresponsive, arrhythmias, may appear dead.

Field management

• Move gently — rough handling can trigger V-fib.
• Remove wet clothing, cover with blankets, apply heat packs to axilla, groin, neck.
• Warm humidified oxygen where available.
• Warmed IV fluids only; no cold saline.

Cardiac arrest in hypothermia

Follow ACLS but expect drugs to be less effective. Limit defibrillation to three attempts if core temp is < 30 °C, then continue CPR and rewarm before further shocks. Prolonged resuscitation is justified — full neurologic recovery has occurred after hours.