Hypothermia in children: Management
- Howard M Corneli, MD
Howard M Corneli, MD
- Professor of Pediatrics
- University of Utah School of Medicine
- Section Editor
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This article discusses the treatment of unintentional hypothermia in children. The clinical manifestation of hypothermia in children, neonatal hypothermia, and frostbite are discussed separately. (See "Hypothermia in children: Clinical manifestations and diagnosis" and "Short-term complications of the preterm infant", section on 'Hypothermia' and "Frostbite".)
DEFINITION OF HYPOTHERMIA
Hypothermia is defined as a core body temperature below 35°C (95°F). The stage of hypothermia, defined by core temperature, has a major impact on both recognition and treatment. The most commonly used definitions found in the literature are as follows [1-4]:
●Mild – Core temperature 32 to 35°C (90 to 95°F)
●Moderate – Core temperature 28 to 32°C (82 to 90°F)
●Severe – Core temperature below 28°C (82°F)
- Giesbrecht GG. Cold stress, near drowning and accidental hypothermia: a review. Aviat Space Environ Med 2000; 71:733.
- Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311.
- Brown DJ, Brugger H, Boyd J, Paal P. Accidental hypothermia. N Engl J Med 2012; 367:1930.
- 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.
- Durrer B, Brugger H, Syme D, International Commission for Mountain Emergency Medicine. The medical on-site treatment of hypothermia: ICAR-MEDCOM recommendation. High Alt Med Biol 2003; 4:99.
- Zafren K, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med 2014; 25:S66.
- Boyd J, Brugger H, Shuster M. Prognostic factors in avalanche resuscitation: a systematic review. Resuscitation 2010; 81:645.
- 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; 43:e521.
- Hughes A, Riou P, Day C. Full neurological recovery from profound (18.0 degrees C) acute accidental hypothermia: successful resuscitation using active invasive rewarming techniques. Emerg Med J 2007; 24:511.
- Monika BM, Martin D, Balthasar E, et al. The Bernese Hypothermia Algorithm: a consensus paper on in-hospital decision-making and treatment of patients in hypothermic cardiac arrest at an alpine level 1 trauma centre. Injury 2011; 42:539.
- Walpoth BH, Walpoth-Aslan BN, Mattle HP, et al. Outcome of survivors of accidental deep hypothermia and circulatory arrest treated with extracorporeal blood warming. N Engl J Med 1997; 337:1500.
- Silfvast T, Pettilä V. Outcome from severe accidental hypothermia in Southern Finland--a 10-year review. Resuscitation 2003; 59:285.
- Wollenek G, Honarwar N, Golej J, Marx M. Cold water submersion and cardiac arrest in treatment of severe hypothermia with cardiopulmonary bypass. Resuscitation 2002; 52:255.
- Eich C, Bräuer A, Kettler D. Recovery of a hypothermic drowned child after resuscitation with cardiopulmonary bypass followed by prolonged extracorporeal membrane oxygenation. Resuscitation 2005; 67:145.
- Corneli HM. Accidental hypothermia. J Pediatr 1992; 120:671.
- Bolte RG, Black PG, Bowers RS, et al. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA 1988; 260:377.
- Fisher JD, Schaefer C, Reeves JJ. Successful resuscitation from cardiopulmonary arrest due to profound hypothermia using noninvasive techniques. Pediatr Emerg Care 2011; 27:215.
- Gentilello LM, Cobean RA, Offner PJ, et al. Continuous arteriovenous rewarming: rapid reversal of hypothermia in critically ill patients. J Trauma 1992; 32:316.
- Hultzer MV, Xu X, Marrao C, et al. Pre-hospital torso-warming modalities for severe hypothermia: a comparative study using a human model. CJEM 2005; 7:378.
- Lundgren JP, Henriksson O, Pretorius T, et al. Field torso-warming modalities: a comparative study using a human model. Prehosp Emerg Care 2009; 13:371.
- Harnett RM, O'Brien EM, Sias FR, Pruitt JR. Initial treatment of profound accidental hypothermia. Aviat Space Environ Med 1980; 51:680.
- Scaife ER, Connors RC, Morris SE, et al. An established extracorporeal membrane oxygenation protocol promotes survival in extreme hypothermia. J Pediatr Surg 2007; 42:2012.
- Danzl DF, Pozos RS. Accidental hypothermia. N Engl J Med 1994; 331:1756.
- Gill BS, Cox CS Jr. Thermodynamic and logistic considerations for treatment of hypothermia. Mil Med 2008; 173:743.
- Feldman KW, Morray JP, Schaller RT. Thermal injury caused by hot pack application in hypothermic children. Am J Emerg Med 1985; 3:38.
- Truell KD, Bakerman PR, Teodori MF, Maze A. Third-degree burns due to intraoperative use of a Bair Hugger warming device. Ann Thorac Surg 2000; 69:1933.
- Koller R, Schnider TW, Neidhart P. Deep accidental hypothermia and cardiac arrest--rewarming with forced air. Acta Anaesthesiol Scand 1997; 41:1359.
- Steele MT, Nelson MJ, Sessler DI, et al. Forced air speeds rewarming in accidental hypothermia. Ann Emerg Med 1996; 27:479.
- Kornberger E, Schwarz B, Lindner KH, Mair P. Forced air surface rewarming in patients with severe accidental hypothermia. Resuscitation 1999; 41:105.
- Danzl DF, Pozos RS, Auerbach PS, et al. Multicenter hypothermia survey. Ann Emerg Med 1987; 16:1042.
- 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.
- Graham CA, McNaughton GW, Wyatt JP. The electrocardiogram in hypothermia. Wilderness Environ Med 2001; 12:232.
- Gilbert M, Busund R, Skagseth A, et al. Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest. Lancet 2000; 355:375.
- Hall KN, Syverud SA. Closed thoracic cavity lavage in the treatment of severe hypothermia in human beings. Ann Emerg Med 1990; 19:204.
- Lexow K. Severe accidental hypothermia: survival after 6 hours 30 minutes of cardiopulmonary resuscitation. Arctic Med Res 1991; 50 Suppl 6:112.
- Quan L, Wentz KR, Gore EJ, Copass MK. Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics 1990; 86:586.
- Orlowski JP. Drowning, near-drowning, and ice-water drowning. JAMA 1988; 260:390.
- Brugger H, Paal P, Boyd J. Prehospital resuscitation of the buried avalanche victim. High Alt Med Biol 2011; 12:199.
- Hauty MG, Esrig BC, Hill JG, Long WB. Prognostic factors in severe accidental hypothermia: experience from the Mt. Hood tragedy. J Trauma 1987; 27:1107.
- Schaller MD, Fischer AP, Perret CH. Hyperkalemia. A prognostic factor during acute severe hypothermia. JAMA 1990; 264:1842.
- Mair P, Kornberger E, Furtwaengler W, et al. Prognostic markers in patients with severe accidental hypothermia and cardiocirculatory arrest. Resuscitation 1994; 27:47.
- Dobson JA, Burgess JJ. Resuscitation of severe hypothermia by extracorporeal rewarming in a child. J Trauma 1996; 40:483.
- Kjaergaard B, Bach P. Warming of patients with accidental hypothermia using warm water pleural lavage. Resuscitation 2006; 68:203.
- Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest--report of a case and review of the literature. Resuscitation 2005; 66:99.
- Brunette DD, Sterner S, Robinson EP, Ruiz E. Comparison of gastric lavage and thoracic cavity lavage in the treatment of severe hypothermia in dogs. Ann Emerg Med 1987; 16:1222.
- Otto RJ, Metzler MH. Rewarming from experimental hypothermia: comparison of heated aerosol inhalation, peritoneal lavage, and pleural lavage. Crit Care Med 1988; 16:869.
- Winegard C. Successful treatment of severe hypothermia and prolonged cardiac arrest with closed thoracic cavity lavage. J Emerg Med 1997; 15:629.
- de Caen A. Management of profound hypothermia in children without the use of extracorporeal life support therapy. Lancet 2002; 360:1394.
- Coskun KO, Popov AF, Schmitto JD, et al. Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients. Artif Organs 2010; 34:1026.
- Althaus U, Aeberhard P, Schüpbach P, et al. Management of profound accidental hypothermia with cardiorespiratory arrest. Ann Surg 1982; 195:492.
- DelRossi AJ, Cernaianu AC, Vertrees RA, et al. Heparinless extracorporeal bypass for treatment of hypothermia. J Trauma 1990; 30:79.
- Bräuer A, Wrigge H, Kersten J, et al. Severe accidental hypothermia: rewarming strategy using a veno-venous bypass system and a convective air warmer. Intensive Care Med 1999; 25:520.
- Laniewicz M, Lyn-Kew K, Silbergleit R. Rapid endovascular warming for profound hypothermia. Ann Emerg Med 2008; 51:160.
- Fox JB, Thomas F, Clemmer TP, Grossman M. A retrospective analysis of air-evacuated hypothermia patients. Aviat Space Environ Med 1988; 59:1070.
- DEFINITION OF HYPOTHERMIA
- INITIAL MANAGEMENT
- Decision to resuscitate and rewarm
- Core temperature measurement
- Prehospital rescue and triage
- - Prehospital declaration of death
- Prehospital patient care and transport
- Initial hospital care
- Rewarming techniques
- - Passive rewarming
- - Active external rewarming
- - Active internal rewarming
- TREATMENT OF MILD HYPOTHERMIA
- TREATMENT OF MODERATE OR SEVERE HYPOTHERMIA
- Supportive care
- - Airway and breathing
- - Chest compressions
- - Vascular access and intravenous fluid therapy
- - Glucose homeostasis
- Perfusing bradycardic rhythms
- Nonperfusing cardiac rhythms
- - Ventricular arrhythmias with hypothermia
- - Asystole or pulseless electrical activity
- - Duration of resuscitation
- Choosing rewarming methods
- - Moderate hypothermia with intact circulation
- - Severe hypothermia with intact circulation
- - Severe hypothermia with absent circulation
- - Failure to rewarm
- Post-resuscitation care
- PREDICTION OF NEUROLOGIC OUTCOME
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS