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Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022
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Image of ice rescue from the US Coast Guard [public domain].
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Hypothermia, defined as a core body temperature below 35°C,[1] may arise accidentally and in a variety of conditions, from wilderness outings to inner cities and aquatic environments. It usually occurs because of exposure to or an inability to protect oneself from a cold environment. Hypothermia-related hospitalizations and deaths have increased in frequency.[2]
Primary hypothermia occurs in a person with intact thermoregulation and the ability to generate heat but who is exposed to severe cold, which eventually overwhelms the body's heat-generating abilities. The speed at which hypothermia develops depends on many factors, including body size, age, presence of insulation (eg, clothing, body fat), and local conditions (eg, precipitation, wind speed).[1] While any cold environment may precipitate hypothermia, immersion in cold water rapidly reduces body temperature and may cause hypothermia in minutes. Hypothermia can be exacerbated by impaired thermoregulation due to medications, alcohol or illicit drugs, injury, or comorbid conditions. Small children and elderly persons are at the greatest risk, which is compounded in older adults by chronic diseases, medications that alter or delay the body's response to cold, and lack of physiologic reserve.[3]
Secondary hypothermia results from impaired thermoregulation in patients with an acute medical condition (eg, sepsis, hypothyroidism, adrenal insufficiency, salicylate overdose). Therapeutic hypothermia, or medically induced hypothermia, has been studied as a medical intervention in various settings (eg, post-cardiac arrest patients with return of spontaneous circulation [ROSC], neonatal hypoxic-ischemic injury, cardiac and aortic surgery).
Image of thermoregulation during strenuous activities from Betts JG, Young KA, Wise JA, et al. OpenStax. [Creative Commons Attribution License 4.0 license (CC by 4.0).]
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Heat loss occurs via the following mechanisms:
Evaporation: Vaporization of body water
Radiation: Radiation of infrared heat away from the body
Convection: Transfer of heat to currents of air or water
Conduction: Direct transfer of heat to an adjacent surface or object
Under dry conditions, most heat loss (~50-60%) occurs via radiation.[4] Convective heat loss to cold air and conductive heat loss in water are the most common mechanisms of accidental hypothermia.
Under normal physiologic conditions, the hypothalamus controls heat regulation both through conservation (vasoconstriction and stimulation of behavioral responses) and through production (elevation of the metabolic rate and activation of skeletal muscle to induce shivering).
Image from Flickr | Taco Witte (background) [Creative Commons Attribution License 2.0 Generic (CC by 2.0)] / Dreamstime (figure).
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Physiology
Central nervous system metabolism decreases linearly with temperature. The consequence of this decrease is that at temperatures below 33°C, cerebral metabolism is markedly reduced. Therefore, patients with hypothermia may initially manifest confusion, which can progress to delirium and coma. The decrease in cerebral metabolism associated with moderate-to-severe hypothermia may be neuroprotective in some cases, and many case reports exist of patients with severe hypothermia or hypothermic cardiac arrest who make a complete or near-complete neurologic recovery.[5]
Of note, pupils will not react to light if core body temperature is below 28°C. Thus, pupillary reaction cannot be relied on for assessment of neurologic function in hypothermia.[3]
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Initially, the body's response to immersion in a cold environment involves vasoconstriction in peripheral tissues, such as the extremities, shunting blood flow to the core. As a result, the kidneys experience a sudden increase in circulating volume. Simultaneously, hypothermia also impairs renal concentration of urine. These factors contribute to an early diuresis of dilute urine in hypothermic patients, which may in turn contribute to dehydration and electrolyte abnormalities.
Another important physiologic effect of hypothermia is that it causes a shift in the oxyhemoglobin disassociation curve to the left, reducing oxygen release to the tissues. Despite reduced oxygen demand by tissues with lowered metabolic rates, overall tissue oxygen content may be inadequate as a result.
Image of medical students participating in a hypothermia hands-on training from US Department of Defense | Petty Officer 1st Class Adam Eggers [public domain].
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Mild hypothermia is commonly defined as a core temperature between 32°C and 35°C. In this stage, the hypothalamus attempts to reestablish thermal homeostasis by stimulating the metabolic rate and shivering, leading to tachycardia, tachypnea, and increased cardiac output. The physiologic effects of mild hypothermia are typically minimal—the body still maintains the ability to produce and retain heat via shivering and vasoconstriction—although they may be influenced by the presence of comorbid conditions such as traumatic injury, medications, intoxication, or diabetes. Confusion or ataxia may be present. Vasoconstriction in the extremities raises the central circulating volume and thereby increases renal filtration and diuresis.[4]
In moderate hypothermia (core temperature: 28°C-32°C), shivering ceases and body metabolic processes slow, resulting in reduced heat production. Patients in this stage require active rewarming because they are not actively producing adequate heat to independently rewarm. Clinical conditions in moderate hypothermia are typically more severe than in mild hypothermia, with increasing mental status depression and decreasing pulse and respiratory rate. Cardiac arrhythmias (eg, atrial fibrillation [AF]) as well as loss of reflexes and muscle tone may be noted.[4]
Persons with severe hypothermia (core temperature: <28°C) are at risk for dysrhythmias (eg, ventricular fibrillation [VF], pulseless electrical activity [PEA], asystole). Coma or severely depressed mental state is usually present.[4]
Top table courtesy of Medscape. Data in bottom table from Durrer et al.[6]
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Clinical Scoring Systems for Hypothermia
Multiple clinical grading systems have been used to assess hypothermia severity and predict outcomes. The Swiss Hypothermia Staging System developed by the International Commission for Mountain Emergency Medicine is one such system in common use. It is shown in the bottom table.[6] The Swiss System describes stages based on measured core body temperature and associated clinical signs, including the presence or absence of shivering. However, differing responses to cold among patients, as well as differing clinical and comorbid conditions, introduce a significant degree of variability into the clinical findings associated with any particular hypothermic temperature. As such, considerable overlap between patient stages has been noted, and clinical findings do not necessarily correlate with each clinical stage/temperature.[6] Furthermore, there is a wide degree of temperature measurement imprecision and variability, particularly in the measurement of extremely low body temperatures.
The Revised Swiss System (RSS), which stages hypothermia based on cardiac arrest risk, is replacing the Swiss System. The RSS utilizes the AVPU (Alert, Verbal, Painful, Unconscious) consciousness scale, as well as the presence or absence of vital signs, to predict which patients are at elevated risk for cardiac arrest and thus require more aggressive rewarming measures such as extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB).[7]
Image from Mine T, Sato I, Kishima H, Miyake H. J Med Case Rep. 2012;6:429. [Open access.] PMID: 23272675, PMCID: PMC3760449.
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Diagnosis and Laboratory Studies
The diagnosis of hypothermia must be based on accurate core temperature readings. Many thermometers in common use are unable to correctly read temperatures below 34°C; an appropriately calibrated low temperature thermometer must be used. Also, assessment of the core body temperature requires invasive temperature monitoring. Most oral or surface body temperature thermometers, including those reading temporal artery temperature and tympanic membrane temperature, will not provide low temperature reading with any degree of accuracy. Invasive temperature probes represent the closest measure of core body temperature. A variety of probes have been utilized, including rectal, bladder, and distal esophageal. Given its proximity to the heart, the distal esophageal probe is thought to provide the best overall core body temperature estimate.[3,4]
Hypothermia impairs the function of potassium channels and thus causes a slowing of impulse conduction in cardiac myocytes and a prolongation of electrocardiographic (ECG) intervals, including the PR, QRS, and QT. A sequence of characteristic ECG changes is noted with progressive hypothermia. Osborne J waves (sudden positive deflections after the QRS waves, at the J points [leads V4-V6 of segment A above, arrows]) are often noted, with the amplitude of the Osborne wave proportional to the degree of hypothermia. (Segment B shows the same leads in the same patient after warming.) Note that Osborne waves are not specific to hypothermia and may be seen in other medical conditions.[3,4]
Cardiac pacemaker cells also experience impaired function with decreasing core temperature, initially leading to bradycardia. In this setting, bradycardia will not respond to the usual pharmacologic interventions (eg, atropine), and rewarming is required to restore normal electrophysiologic function. As hypothermia advances further, sinus bradycardia may lead to AF, possibly with a slow ventricular response, eventually to VF and, ultimately, to asystole.
ECG depicting hyperkalemia (8.2 mmol/L) from Wikimedia Commons | Drs Michael-Joseph F Agbayani and Eddieson Gonzales (Manila, Philippines).
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Hypothermia may cause significant laboratory abnormalities. Hypothermic patients commonly manifest a metabolic acidosis (often from lactic acidosis).[3] Furthermore, hypothermia typically causes an increase in hematocrit; thus, low hematocrit in hypothermic patients may indicate the presence of another injury or condition such as hemorrhage or anemia. A decline in serum potassium level has been noted in hypothermic patients, but many patients may manifest hyperkalemia in the presence of comorbid conditions such as renal failure, rhabdomyolysis, or crush injuries, as may occur in avalanche victims.[8,9] Coagulation times are typically elevated from hypothermic inhibition of normal coagulation pathways, and hypothermic patients may show clinical evidence of coagulopathy, which improves with warming and is not an indication for blood product transfusion.[9]
Pancreatitis is common in hypothermic patients and may contribute to hypoinsulinemia and hyperglycemia.[10]
Arterial blood gas (ABG) values change with hypothermia as well: Hydrogen ion concentration, arterial carbon dioxide tension (PaCO2), and arterial oxygen tension (PaO2) all decline. ABG analyzers warm blood to 37°C for comparison with normal values (also calibrated at 37°C). ABG analysis of warmed blood from hypothermic patients will show higher PaO2 and PaCO2 and a lower pH than what is actually present in the patient's blood. The best approach to employing ABG analysis in hypothermic patients is to use uncorrected values, recognizing the effects of hypothermia on the sample as well as on the acid-base and gas partial pressures in the patient's bloodstream.[9]
For any hypothermic patient, it is important to be aware of comorbid or concomitant conditions, such as sepsis, intoxication, or metabolic/endocrine derangements (eg, diabetes/diabetic ketoacidosis, adrenal insufficiency, or hypothyroidism), and to direct diagnostic testing accordingly.
Image of navy personnel undergoing wet-clothing hypothermia Basic Underwater Demolition/Seal (BUD/S) training from US Navy, Naval Health Research Center [public domain].
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Clinical Management
The management of mild hypothermia in patients who are conscious and alert, with intact shivering, is straightforward and involves removing the patient from the cold environment, removing wet clothing, and providing insulation in the form of warmed blankets or heat-reflective barrier blankets. In neurologically intact patients who meet the criteria for mild hypothermia, a hot, sweet, nonalcoholic drink can be provided. While this will not warm the patient's core temperature, the carbohydrates will fuel shivering.
Although removal of wet clothes is desirable, it should not be performed in a cold or windy environment. If the patient is still in the environment that caused hypothermia, they should be wrapped in a sealed vapor barrier, and an external heat source (eg, forced-hot-air blankets, chemical heat packs, warm water bottles) should be applied. To minimize the risk of burns, do not apply heat sources directly to the skin.[3] Warmed intravenous (IV) fluids may be considered.
Images of warming blankets for localized rewarming from Costanzo S, Cusumano A, Giaconia C, Mazzacane S. Biomed Res Int. 2014;2014:136407. [Open access.] PMID: 25485278, PMCID: PMC4251640.
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Patients with mild-to-moderate hypothermia who cannot generate their own heat (ie, those who are not shivering and may have deranged vasoregulation) require active rewarming, which involves actively returning heat to the patient instead of simply preventing further heat loss. This may be accomplished via different approaches, including IV infusion of warmed (40°C-42°C) fluids and the use of forced-hot-air blankets (eg, Bair-Hugger). Although most hypothermic patients are hypovolemic (possibly secondary to cold diuresis) and require significant fluid replacement, generally the volume of warmed IV fluids is insignificant to produce substantial changes in core body temperature. Inhalation rewarming with warmed, humidified air delivered via a ventilator may prevent further heat loss; however, it is unlikely to significantly increase core body temperature.
Pleural lavage of warmed fluids is effective in elevating core body temperature in moderate hypothermia. Warmed IV fluids are introduced into the thoracic cavity via thoracostomy tubes and then removed and again replaced with warmed fluids. Gastrointestinal (GI), bladder, or peritoneal lavage with warmed (40°C) fluids may have a limited effect on core body temperature, but these measures risk fluid and electrolyte derangements.
Endovascular rewarming probes are increasingly used in active rewarming of hypothermic patients. Endovascular probes are linked to a core temperature monitor (usually an esophageal temperature probe) and coordinate rewarming in response to the core body temperature.[11]
Adequate oxygenation is critical for preventing cardiac arrest; thus, supplemental oxygen should be provided. Pulse oximetry is likely to be inaccurate or difficult to obtain in hypothermic patients owing to peripheral vasoconstriction.[9]
Image from Wikimedia Commons | Blausen Medical Communications, Inc. [Creative Commons Attribution 3.0 Unported License.]
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Patients with severe hypothermia should be kept immobile, and unnecessary invasive procedures or maneuvers should be limited; movement at core temperatures lower than 30°C can incite dysrhythmias or cardiac arrest.[4,9] Hemodialysis, CPB (shown), or ECMO is appropriate for these patients and has been shown to be effective.[6] Patients with moderate-to-severe hypothermia and respiratory distress (as in near drowning) or severely depressed mental status (either from hypothermia or related injury or intoxication) may require endotracheal intubation.
In the process of rewarming, the following effects may be noted and should be taken into account:
Afterdrop phenomenon: As the periphery is warmed (via forced-hot-air blankets or other methods that unselectively rewarm the core and the periphery simultaneously), cold blood is returned to the core, contributing to a potential initial decrease in core body temperature; accordingly, in moderate-to-severe hypothermia, rewarming efforts should emphasize core rewarming over peripheral rewarming.[6]
Volume depletion: Peripheral vasodilation from peripheral rewarming as well as relative volume depletion from renal cold diuresis may lead to initial hypovolemia and possibly shock. During rewarming, hypothermic patients may require volume support in the form of boluses of crystalloid to support perfusion.
Rewarming acidosis: This effect, analogous to the afterdrop phenomenon, occurs as lactic acid is returned to the core from the periphery during peripheral rewarming.
Image of military medical personnel connecting a patient to an ECMO system from US Air Force | Staff Sgt Kevin Iinuma [public domain].
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Patients with cardiovascular instability should undergo rapid core rewarming. A fall in core body temperature to below 32°C places the patient at risk for cardiac arrest. The risk significantly increases at temperatures below 28°C.[4,9] Resuscitation efforts should focus on high-quality cardiopulmonary resuscitation (CPR) and the provision of rapid rewarming. It is unclear to what degree resuscitative medications (such as atropine and epinephrine) and therapies (such as defibrillation) are effective at severely hypothermic core body temperatures. However, some recent data suggest that there may be some benefit and that defibrillation in particular may be attempted even with body temperatures below 30°C.[12]
Patients in cardiac arrest because of hypothermia should be considered candidates for extracorporeal life support (ECLS). ECLS is effective because it provides continuous oxygenation and hemodynamic support while also enabling rewarming.[9] Patients who present to care with a core body temperature lower than 28°C, dysrhythmia, or hypotension should be transported to an ECLS-capable center.[6]
Admission x-ray and computed tomography (CT) scan showing suspected aspiration of a large amount of water in an adult found in 12°C seawater with a core temperature of 22°C (rectal) from Sawamoto K, Tanno K, Takeyama Y, Asai Y. Int J Emerg Med. 2012;5(1):9. [Open access.] PMID: 22300441; PMCID: PMC3287102.
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
The observation that patients with very low core temperatures, even in the severe hypothermia range, have been resuscitated with good neurologic outcomes has led to the saying, "They're not dead until they're warm and dead." That is, hypothermic, asystolic patients should be rewarmed before being pronounced dead. This is true, of course, only when it may be assumed that asystole occurred as a result of hypothermia, and not another associated or unrelated condition, such as trauma or asphyxia. Consider resuscitation until rewarming achieves a core temperature of 32°C-35°C.[4] Patients who have been effectively rewarmed and who have received appropriate and quality resuscitative interventions at this point may be assumed to be irretrievable.
In cases where cardiac arrest is deemed to be secondary to hypothermia and not to some other cause (eg, trauma), several markers may assist in resuscitation decision-making for severely hypothermic patients in asystole. ROSC is considered unlikely when the serum potassium level exceeds 12 mmol/L.[13]
Other factors associated with poor outcomes in hypothermia include evidence of intravascular coagulation with deficient fibrinogen levels, as well as extreme lactic acidosis (>20 mmol/L). Cardiac arrest owing to another process (eg, asphyxia or trauma, such as in an avalanche burial or drowning) is also associated with poor outcomes. Cardiac arrest in a patient whose core temperature is not in the severe hypothermia range suggests that the arrest may be due to another cause.[5]
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Hypothermia in Children
Accidental hypothermia can also occur in children, and it is managed similarly to adults. Children are at an increased risk of hypothermia due to having a greater body surface area-to-mass ratio than adults, as well as having a higher metabolic rate. Infants are at even more heightened risk because of their limited fat stores and their inability to shiver or move out of a cold environment.[14] However, although the pediatric population is at higher risk for hypothermia, they may also have an increased ability to tolerate and recover from this condition.
Rapid rewarming is indicated in mild hypothermia, and advanced cardiovascular life support (ACLS) protocol is indicated in cardiac arrest. Pediatric patients in cardiac arrest secondary to hypothermia warrant expert consultation prior to cessation of resuscitative efforts, and they likely should be transferred to an ECLS center, if available.[14]
Image from Wikimedia Commons | ScifoRobert. [Creative Commons Attribution-Share Alike 4.0 International License.]
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
A homeless patient is brought into a New York City emergency department (ED) in January after being found unconscious outside of a public library. The patient is unresponsive and pulseless, with an initial cardiac rhythm of asystole. CPR is in progress, and an advanced airway was placed correctly in the field. The patient's core temperature is 28°C. Finger-stick blood glucose level is normal. Intranasal naloxone administered in the field produced no response.
What are the first steps in resuscitating this patient?
Check for fixed and dilated pupils, areflexia, and stiffness. If present, terminate resuscitation efforts.
Attempt to rewarm the patient to a target temperature of 36°C with hot packs, forced-hot-air blankets, and warm IV fluids.
Continue ACLS protocol, prevent further heat loss, and attempt to transfer the patient to an ECLS center.
Check the patient's potassium level. If it exceeds 10 mmol/L, stop resuscitation efforts.
Image from US Navy | Journalist 2nd Class J Maurer via Flickr [public domain].
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Answer: C. Continue ACLS protocol, prevent further heat loss, and attempt to transfer the patient to an ECLS center.
The use of vasopressors in cardiac arrest in hypothermia is controversial, but most sources agree with following ACLS protocol for at least three cycles to evaluate for clinical response. If available within 6 hours, transfer to an ECLS center is likely appropriate.
A. Pupillary response, areflexia, and stiffness are not reliable indicators of death in hypothermia and should not be used as criteria to terminate resuscitation. B. Rewarming the patient is an important part of the resuscitation of a hypothermic patient, but the target temperature is 32°C. D. A serum potassium level above 10 mmol/L may indicate a poor prognosis, but it is not above the 12 mmol/L cutoff currently accepted to justify termination of resuscitation. Furthermore, checking a potassium level is not likely to be the best next step in the management of this patient.
Joseph U Becker, MD | February 2, 2022 | Contributor Information
A 38-year-old man is brought to the ED, having been rescued from a mountaintop after becoming lost during a ski trip. His core temperature is 31°C.
Which of the following is the most appropriate next step in management?
Avoid perturbing the patient with intubation, CPR, or IV lines to avoid precipitating VF.
Administer warmed fluids, provide the patient with blankets, and resuscitate as usual.
Administer warmed fluids, provide active rewarming with forced-hot-air rewarming blankets, and provide resuscitation while attempting to limit unnecessary manipulation of the patient.
Do not resuscitate; a patient with a temperature in this range is not salvageable.
Image of an ECMO treatment unit from Trudzinski FC, Schlotthauer U, Kamp A, et al. Euro Surveill. 2016;21(46):30398. [Open access.] PMID: 27918254; PMCID: PMC5144944. A: ECMO system; B: thermoregulatory device.
Hypothermia: The Cold Facts
Joseph U Becker, MD | February 2, 2022 | Contributor Information
Answer: C. Administer warmed fluids, provide active rewarming with forced-hot-air rewarming blankets, and provide resuscitation while attempting to limit unnecessary manipulation of the patient.
Given the clinical scenario, as well as the 31°C core temperature, this patient's own ability to produce heat has likely been overwhelmed; passive warming measures (eg, simply providing blankets or removing wet clothing) probably will not be effective. Thus, active methods (eg, warmed fluids or forced-hot-air blankets) or even more invasive measures (eg, ECMO or hemodialysis) should be considered. Patients in this temperature range, with or without vital signs, should be resuscitated.
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Contributor Information
Author
Joseph U Becker, MD
Associate Professor, Department of Emergency Medicine
Stanford University School of Medicine
Palo Alto, CA
Disclosure: Joseph U Becker, MD, has disclosed no relevant financial relationships.
Reviewer
Nicole Cimino-Fiallos, MD, FAAEM, FACEP
Emergency Medicine Specialist
US Acute Care Solutions;
Assistant Medical Director
Emergency Department
Meritus Medical Center
Hagerstown, MD
Disclosure: Nicole Cimino-Fiallos, MD, FAAEM, FACEP, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
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References
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QuickStats: Death rates* attributed to excessive cold or hypothermia† among persons aged
≥ 15 years, by urbanization level§ and age group - National Vital Statistics System, 2015-2017. MMWR Morb Mortal Wkly Rep. 2019 Feb 22;68(7):187. PMID: 30789882
Paal P, Gordon L, Strapazzon G, et al. Accidental hypothermia-an update: The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med. 2016 Sep 15;24(1):111. PMID: 27633781
Dow J, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society clinical practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2019 update. Wilderness Environ Med. 2019 Dec;30(4S):S47-S69. PMID: 31740369
Debaty G, Moustapha I, Bouzat P, et al. Outcome after severe accidental hypothermia in the French Alps: a 10-year review. Resuscitation. 2015 Aug;93:118-23. PMID: 26095302
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Musi ME, Sheets A, Zafren K, et al. Clinical staging of accidental hypothermia: The Revised Swiss System: Recommendation of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Resuscitation. 2021 May;162:182-187. PMID: 33675869
Soeholm H, Kirkegaard H. Serum potassium changes during therapeutic hypothermia after out-of-hospital cardiac arrest-should it be treated? Ther Hypothermia Temp Manag. 2012 Mar;2(1):30-6. PMID: 24717135
Inoue H, Uemura S, Harada K, et al. Risk factors for acute pancreatitis in patients with accidental hypothermia. Am J Emerg Med. 2019 Feb;37(2):189-193. PMID: 29764735
Laniewicz M, Lyn-Kew K, Silbergleit R. Rapid endovascular warming for profound hypothermia. Ann Emerg Med. 2008 Feb;51(2):160-163. PMID: 17681640
Mair P, Gasteiger L, Mair B, Stroehle M, Walpoth B. Successful defibrillation of four hypothermic patients with witnessed cardiac arrest. High Alt Med Biol. 2019 Mar;20(1):71-77. PMID: 30801202
Romlin BS, Winberg H, Janson M, et al. Excellent outcome with extracorporeal membrane oxygenation after accidental profound hypothermia (13.8°C) and drowning. Crit Care Med. 2015 Nov;43(11):e521-e525. PMID: 26317568
Mehrotra S, Misir A. Special traumatized populations: accidental hypothermia in children. Curr Pediatr Rev. 2018;14(1):28-33. PMID: 29651952
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