Rewarming of children and adolescents with accidental hypothermia

T: temperature; C: Centigrade; F: Fahrenheit; IV: intravenous; ECR: extracorporeal rewarming; ECMO: extracorporeal membrane oxygenation.
* If used, rectal temperatures should be taken deep in the rectum (not in cold stool) but may still show time lags. Preferred central sites include the esophagus, nasopharynx, central vein, or bladder. In critical or unstable patients, measurement at two or more separate central sites is recommended.
¶ Aggressive volume expansion is vital during rewarming of moderate to severe hypothermia. Give an initial bolus of 20 mL/kg of heated (40 to 44°C [104 to 111°F]) IV normal saline using high-capacity warmers and tubing. Repeated boluses should be given according to hemodynamic status.
Δ Peripheral pulses can be difficult to detect in patients with severe hypothermia. Rapid bedside cardiac ultrasound may help distinguish cardiac contractions with a perfusing rhythm from pulseless electrical activity. However, standard chest compressions should be provided if there is any uncertainty about core temperature or a perfusing rhythm.
◊ Inadequate rewarming may suggest sepsis, occult trauma or child abuse, toxins, metabolic disease, and other causes. Refer to UpToDate content on hypothermia in children and adolescents for more detail.
§ Pulseless hypothermic patients may be refractory to conventional Pediatric Advanced Life Support until rewarming has occurred. Resuscitative efforts should continue until the child's core temperature is 34 to 35°C (93 to 95°F). Because of the neuroprotective effects of hypothermia, complete recovery of patients with severe hypothermia and cardiac arrest has been well documented even after prolonged resuscitation.
¥ For pleural cavity lavage, two large chest tubes are placed in the left thorax for inflow and outflow. Sufficient quantities of heated saline must be available for continuous lavage. When placing chest tubes, avoid contacting the heart to prevent triggering of ventricular arrhythmias.