Key messages

• The diagnosis should be made and an accurate thermometer used to record very low core temperatures.

• Considering the high risk of ventricular fibrillation at 28 °C, hypothermic patients should be moved with caution.

• Any drug administered during hypothermia can reach toxic levels after rewarming, because of the modified pharmacokinetics associated with hypothermia.

• Hypotension, arrhythmias (e.g. atrial flutter or fibrillation, premature ventricular beats), and oliguria disappear with rewarming.

• Once the diagnosis of hypothermia is made, further heat loss must be prevented and rewarming started.

• Passive rewarming takes place via the patient's own heat production and ability to preserve heat loss.

• External active rewarming is achieved by applying a heat source to the body surface.

• Internal active rewarming includes administering warmed humidified air via an endotracheal tube, gastric, peritoneal, and pleural lavage, extracorporeal rewarming, and cardiopulmonary bypass.

• In mild hypothermia, most rewarming can be passive together with hot drinks and warmed humidified oxygen.

• In a moderately hypothermic patient, in coma or respiratory failure, active internal rewarming is recommended using warmed humidified oxygen delivered by mechanical ventilation and gastric lavage. In the presence of cardiovascular instability, peritoneal dialysis or warming by extracorporeal shunt may be required.

• In severe hypothermia with cardiorespiratory arrest, cardiopulmonary bypass is the best method of rewarming.

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