# Care of Trauma Patient with Accidental Hypothermia Practice Guidelines #### **Purpose:** The purpose of this practice guideline is to provide guidance and standardize the approach to the management of trauma patients with accidental hypothermia. **Definition:** Hypothermia is defined as the involuntary drop of core temperature below 36°C (95°F). Symptoms vary based on severity of hypothermia (see section A. Clinical Signs). **A. ****Clinical Signs**

*Hypothermia *	* Body temperature*	* Clinical features*
Mild	32.2°C to 36°C (90°F to 96.8°F)
			Hypertension
			Shivering
			Tachycardia
			Tachypnea
			Vasoconstriction

			Apathy
			Ataxia
			Cold diuresis—kidneys lose concentrating ability
			Hypovolemia
			Impaired judgment
Moderate	28°C (82.4°F) to 32.2°C (90°F)	Atrial dysrhythmias
		Decreased heart rate
		Decreased level of consciousness
		Decreased respiratory rate
		Dilated pupils
		Diminished gag reflex
		Extinction on shivering
		Hyporeflexia
		Hypotension
		J wave
Severe	< 28°C (82.4°F)
		Coma
		Decreased or no activity on electroencephalography
		Nonreactive pupils
		Oliguria
		Pulmonary edema
		Ventricular dysrhythmias/asystole

** ** **B. ****General Principles** 1. Room temperature should be maintained at approximately 85ºC (29.4ºF). Use of overhead heating lamps should be considered in the trauma bay. 2. Rewarming of the trunk should be undertaken BEFORE the extremities to minimize hypotension and acidemia due to arterial vasodilation and core temperature drop. 3. Initiate or maintain CPR if required – Palpate pulse for full minute – An initial attempt at defibrillation can be made but if unsuccessful, further attempts at defibrillation and antiarrhythmic intravenous medications should be held until the patient is warmed to above 30°C. 4. Gingerly handle patients to reduce risk of inducing malignant dysrhythmia. **C. ****Re-Warming** 1. Mild Hypothermia 32.2°C to 36°C (90°F to 96.8°F) 1. - Room temperature should be maintained at approximately 85ºC (29.4ºF). - - Remove all wet clothing. - Obtain rectal temperature. If temperature will not register, insert a temperature sensing foley catheter or rectal probe thermometer. - Rewarm patient using passive and active external rewarming: - - Heated blankets in neck, groin, axilla, torso - Bair Hugger - RT to place on warmed, humidified O2. - Infuse Warm intravenous (IV) Fluids: - - Warmed isotonic crystalloids or - Place IV fluids on rapid infuser to utilize warming mechanism. Adjust flow rate so fluids are not delivered at rapid rate unless there is an indication for rapid fluid resuscitation. 2. Moderate to Severe Hypothermia 28°C to 32.2°C (82.4°F - 90°F) to < 28°C (<82.4°F) 1. - Obtain temperature using either temperature sensing foley, esophageal temperature sensing probe or rectal temperature sensing probe (if utilizing gastric and/or bladder lavage, use the rectal temperature sensing probe). - Employ all interventions listed under mild hypothermia. - Consider use of Artic Sun device. - Consider use of body bag to maintain the warm air around the patient. - Per MD order, assist with active internal rewarming via: - - Gastric lavage - Bladder lavage - Peritoneal lavage - Thoracic lavage - Continuous Veno-Venous Hemodialysis (CVVHD) – Consider consulting nephrology for initiation of CVVHD. - Extracorporeal Membrane Oxygenation (ECMO) – Consider consulting ECMO team and Cardiothoracic Surgery for initiation of ECMO. **D. ****Rate of Rewarming** 1. Slow rewarming - increases temperature by approximately 0.3-1.2°C/h. 1. 1. Warmed IV solutions. 2. Heated, humidified oxygen by mask/endotracheal tube. 3. Warmed blankets and/or Bair Hugger 2. Moderate rewarming – increases temperature by approximately 3°C/h. 1. 1. Artic sun 2. Warmed gastric lavage 3. Warmed bladder lavage 4. Warmed peritoneal lavage 3. Rapid rewarming – increases temperature by approximately 6°C – 19°C/h. 1. 1. Warmed thoracic lavage 2. CVVHD 3. ECMO E. **Traumatic hypothermic cardiac arrest** 1. Continuation of resuscitation in traumatic hypothermic cardiac arrest will be at the discretion of the trauma surgeon and/or emergency medicine physician in accordance with previously established guidelines for traumatic cardiac arrest resuscitation *(Reference 1,2,7).* **References:** 1. American College of Surgeons. (2018). *Advanced trauma life support: Student course manual*. 2. Burlew, C., Moore, E., Moore, F., Coimbra, R., McIntyre Jr., R., Davis, J, Sperry, J., & Biffl, W. (2012). Western Trauma Association critical decisions in trauma: Resuscitative thoracotomy. *Journal of Trauma and Acute Care Surgery, 73*(6),1359-1363. 3. Duong H, Patel G. Hypothermia. \[Updated 2021 Jan 27\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK545239/](https://www.ncbi.nlm.nih.gov/books/NBK545239/) 4. Essentials of Emergency Medicine, Chapter 6, Temperature Related Disorders, 2006 5. Paal, P., Brugger, H., & Strapazzon, G. (2018). Accidental hypothermia. In Romanovsky, A. (Ed), *Thermoregulation: From basic neuroscience to clinical neurology* (pp.547-561). Elsevier Science Inc. [https://doi.org/10.1016/B978-0-444-64074-1.00033-1](https://doi.org/10.1016/B978-0-444-64074-1.00033-1) 6. Paal, P., Gordon, L., Strapazzon, G., Brodman Maeder, M., Putzer, Walporth, B., Wansher, M., Brown, D., Holzer, M., Broessner., & Brugger, H. (2016). Accidental hypothermia-an update. *Scandinavia Journal of Trauma, Resuscitation and Emergency Medicine, 24*, 111. doi: 10.1186/s13049-016-0303- 7. Seamon, M., Haut, E., Van Arendonk, K., Barbosa, R., Chiu, W., Dente, C., Fox, N., Jawa, R., Khwaja, K., Lee, J., Magnotti, L., Mayglothling, J., McDonald, A., Rowell, S., To, K., Falck-Ytter, Y., & Rhee, P. (2015). An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. *Journal of Trauma and Acute Care Surgery, 79*(1), 159-173. 8. StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available fro 9. Zafren, K., & Giesbrecht, G. (2014, July). State of Alaska: Cold injuries guidelines. [http://dhss.alaska.gov/dph/emergency/documents/ems/documents/alaska%20dhss%20ems%20cold%](http://dhss.alaska.gov/dph/emergency/documents/ems/documents/alaska%20dhss%20ems%20cold%25)20injuries%20guidelines%20june%202014.pdf **Author(s)** Developed by: Trauma Program Coordinator Reviewed by: Trauma Operations Committee and Trauma Performance Improvement and Patient Safety (PIPS) Committee **Last Updated** February, 2022