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Recognizing and Treating Hypothermia in the Field: A Guide for EMTs

Introduction

In emergency medicine, time and temperature can both mean life or death. Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce it, causing the core body temperature to fall below 95°F (35°C).

For Emergency Medical Technicians (EMTs), recognizing the early signs of hypothermia and knowing how to intervene in the field are critical to preventing serious complications or death. Whether caused by environmental exposure, trauma, or immersion, hypothermia is a condition every EMT must be prepared to manage effectively.

What Is Hypothermia?

Hypothermia occurs when the body’s heat loss exceeds heat production, leading to a dangerous drop in core temperature. The condition impairs physiological and neurological functions, ultimately affecting the heart, nervous system, and metabolism.

If left untreated, hypothermia can progress to cardiac arrest, respiratory failure, or death. Recognizing the stages of hypothermia and intervening early are essential responsibilities for EMTs in the field.

Recognizing Hypothermia: Signs and Symptoms

Hypothermia presents differently depending on its severity. EMTs should assess not only body temperature but also the environmental factors and patient’s history of exposure.

Mild Hypothermia (95°F–90°F / 35°C–32°C)

  • Shivering (may be vigorous)
  • Cold, pale, or waxy skin
  • Slurred speech or mild confusion
  • Tachycardia and tachypnea
  • Poor coordination or clumsiness

Moderate Hypothermia (89°F–82°F / 31°C–28°C)

  • Shivering slows or stops
  • Muscle stiffness or rigidity
  • Slow, shallow respirations
  • Weak pulse
  • Increasing confusion or lethargy

Severe Hypothermia (<82°F / <28°C)

  • Unconsciousness or coma
  • Very weak or absent pulse
  • Dilated pupils
  • Risk of ventricular fibrillation or asystole

Field Assessment for EMTs

During assessment, EMTs should conduct a primary survey while minimizing movement, as rough handling can precipitate arrhythmias in severely hypothermic patients.

Assessment priorities:

  • Airway and breathing: Ensure a patent airway and provide supplemental oxygen as needed.
  • Circulation: Check for a carotid pulse for 30–60 seconds—bradycardia may be profound but present.
  • Temperature: Use a low-reading thermometer to measure core temperature when available.
  • Environment: Document exposure time, ambient temperature, and whether the patient is wet or dry.

Always consider and rule out other causes such as hypoglycemia, intoxication, or trauma.

Treatment and Management in the Field

1. Prevent Further Heat Loss

  • Move the patient to a warm, dry, sheltered area—such as the ambulance or a heated tent.
  • Remove wet clothing and replace it with dry, insulated materials (blankets, towels, coats).
  • Use heat packs or hot water bottles to warm the neck, axillae, and groin (avoid direct contact with skin).
  • Protect the patient from wind and ground contact.

2. Rewarm the Patient Gradually

  • Mild hypothermia: Use passive rewarming—warm environment, dry blankets, and the patient’s own shivering.
  • Moderate to severe hypothermia: Apply active external rewarming methods:
    • Warmed IV fluids (104°F / 40°C)
    • Humidified warm oxygen if available
    • Avoid rapid or aggressive rewarming, which can cause “afterdrop” (a sudden fall in core temperature as cold blood returns to the heart).

3. Handle Gently

  • Move the patient minimally to avoid precipitating cardiac arrhythmias.
  • Do not perform CPR unless no pulse is detected after a full 60-second check.
  • Defibrillation may be ineffective below 86°F (30°C); continue rewarming and repeat attempts per protocol.

4. Monitor Continuously

  • Use cardiac monitoring if available.
  • Reassess temperature, vital signs, and mental status frequently.
  • Be prepared for hypotension, arrhythmias, and coagulopathy as temperature drops.

5. Transport Promptly

Patients with moderate or severe hypothermia should be transported to a facility capable of active internal rewarming (e.g., warm IV fluids, lavage, extracorporeal warming). Keep the patient horizontal and insulated during movement to prevent afterdrop.

Special Considerations for EMTs

  • Follow the rule: “No one is dead until warm and dead.” Continue resuscitative efforts until the patient’s core temperature reaches at least 90°F (32°C).
  • Treat hypothermia aggressively in trauma patients, as bleeding disorders worsen with cold exposure.
  • Thoroughly document scene conditions, rewarming measures, and temperature trends during transport.

Conclusion

Hypothermia is preventable, recognizable, and treatable—but only when addressed swiftly and correctly. EMTs serve as the crucial first link in the chain of survival for hypothermic patients. Through early recognition, gentle handling, controlled rewarming, and rapid transport, EMTs can make the difference between life and death in the cold.

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References

  1. American Heart Association. (2020). Part 10: Special Circumstances of Resuscitation: Hypothermia. In 2020 American Heart Association Guidelines for CPR and ECC. Circulation, 142(16_suppl_2), S605–S639. https://doi.org/10.1161/CIR.0000000000000917
  2. Centers for Disease Control and Prevention (CDC). (2023). Hypothermia: Emergency Preparedness and Response. U.S. Department of Health and Human Services. https://www.cdc.gov/disasters/winter/staysafe/hypothermia.html
  3. National Association of EMS Physicians (NAEMSP). (2019). NAEMSP position statement: Prehospital management of accidental hypothermia. Prehospital Emergency Care, 23(6), 856–859.
  4. American College of Emergency Physicians (ACEP). (2022). Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Accidental Hypothermia. Annals of Emergency Medicine, 79(5), e67–e80.
  5. National Institute for Occupational Safety and Health (NIOSH). (2023). Cold Stress: Recommendations for Outdoor Workers. https://www.cdc.gov/niosh/topics/coldstress