Hypothermia and frostbite

Last updated: January 21, 2022

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Hypothermia is defined as a core body temperature below 35°C (95°F). It is classified as mild, moderate, or severe based on core temperature. Clinical features range from shivering to progressive bradycardia, coagulopathy, and circulatory collapse. Assessment should begin with determination of the core temperature, followed by ECG. Further tests are mainly used to determine comorbidities or complications (e.g., frostbite). Treatment entails rewarming and supportive care. Mild frostbite is reversible, while severe cases may require amputation. Cardiac arrhythmias are the most common cause of death.


  • The body loses heat through radiation; (most significant means of heat loss), conduction; , convection; , and direct contact with cold surfaces.
  • The hypothalamus attempts to maintain a temperature of approximately 36.5°C (97.7°F) to 37.5°C (99.5°F) by:
  • Hypothermia affects all organ systems
    • General tissue oxygen demand decreases by ∼ 6% per degree Celsius below 35°C.
    • Weakened cellular immune response
    • Cardiovascular effects: depolarization of cardiac cells → ↓ cardiac output and ↓ mean arterial pressure
    • CNS effects: CNS metabolism


  • Definition: core body temperature under 35°C (95°F)
  • Clinical features
    • Mental status changes should be proportional to other clinical signs
    • Determine central core temperature reading with a low-reading temperature probe in the bladder or rectum or an esophageal probe.
Stages of hypothermia Signs and Symptoms

Mild, 32–35°C (90–95°F)


Moderate, 28–32°C (82–90°F)


Severe, < 28°C (82°F)


Avoid rough handling of patients and always warm the trunk BEFORE the extremities; both can lead to peripheral vasodilation in extremity musculature and recirculation of cold, acidemic blood. This afterdrop results in a drop in temperature and arrhythmias! Even positioning for chest x-ray can be dangerous!

Patients with moderate to severe hypothermia may have arrhythmias that are unresponsive to defibrillation; cardiopulmonary resuscitation should be performed until the patient's core body temperature reaches 30–32°C (86–90°F)!


  • Definition: severe localized tissue injury; due to freezing of interstitial and cellular spaces after prolonged exposure to very cold temperatures
  • Clinical features
    • Acute frostbite can occur in isolation or as a complication of hypothermia
      • Areas most frequently affected: face (nose, cheeks, chin), ears, fingers, and toes
      • Cold and paresthesia of affected region
      • Pale; (white or grayish-yellow), blue-red, or blistered hard or waxy skin
  • Diagnostics
  • Treatment
    • Remove wet clothing; avoid walking on frostbitten feet
    • Evaluate for concurrent hypothermia and treat that first!
    • Rewarming
      • Passive: remove wet clothing, cover with blankets, warm room (preferably 28°C (82°F))
      • Active: immerse affected extremity in a warm (preferably 37–39°C) circulating water bath
    • Analgesia and tetanus prophylaxis
    • Manage suspected infections aggressively with antibiotics and sterile dressings

Patients are often affected with both hypothermia and frostbite. Treatment of hypothermia should take priority because it can be acutely life-threatening!


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  7. McIntosh SE, Opacic M, Freer L, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014; 25 (4): p.S43-S54. doi: 10.1016/j.wem.2014.09.001 . | Open in Read by QxMD

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