Resuscitation Guidelines for Hypothermic Cardiac Arrest

Core Principles

The American Heart Association recommends that victims of accidental hypothermia should not be considered dead before rewarming has been provided unless there are signs of obvious death, which is a Class 1 recommendation representing the strongest level of guidance 1, 2
Do not stop resuscitation in a hypothermic patient until they have been rewarmed, unless there are obvious signs of death such as rigor mortis or nonsurvivable traumatic injury, as stated by the American Heart Association 1, 2

Continue CPR in hypothermic patients who have a core temperature <30°C (86°F) with cardiac arrest, which is based on guidelines from the American Heart Association 1, 2
Continue CPR in hypothermic patients who have an absence of rigor mortis, as recommended by the American Heart Association 1, 2
Continue CPR in hypothermic patients who have no nonsurvivable traumatic injuries, such as decapitation or massive crush injuries, according to the American Heart Association 1, 2

Defibrillation attempts may be reasonable according to standard BLS algorithms concurrent with rewarming, but success is unlikely until core temperature reaches 30-34°C, as stated by the American Heart Association 1, 2
Epinephrine administration during cardiac arrest according to standard ACLS algorithms concurrent with rewarming may be reasonable, though drug metabolism is significantly reduced below 30°C, as recommended by the American Heart Association 1, 2, 3

Full resuscitative measures, including extracorporeal rewarming when available, are recommended (Class 1) by the American Heart Association 1, 2
Transport to a facility with ECLS capability should be prioritized when feasible, as this may necessitate earlier transport than in normothermic cardiac arrest, according to the American Heart Association 1, 2

Stop resuscitation ONLY when obvious signs of death are present, such as rigor mortis, as recommended by the American Heart Association 1, 2
Stop resuscitation ONLY when nonsurvivable traumatic injury exists, according to the American Heart Association 1, 2
Stop resuscitation ONLY when the patient has been successfully rewarmed to normothermia (≥32-34°C) and remains in refractory cardiac arrest despite appropriate ACLS interventions, as stated by the American Heart Association 1, 2

Victims of accidental hypothermia should not be considered dead before rewarming has been provided unless there are signs of obvious death, according to the American Heart Association 4
Extracorporeal circulation provides the most rapid and effective rewarming for severely hypothermic patients in cardiac arrest, with core rewarming rates that far exceed other methods, as recommended by the American College of Cardiology 5
Patients with severe hypothermia and cardiac arrest can be rewarmed most rapidly with cardiopulmonary bypass, which is the gold standard for this clinical scenario, as stated by the American Heart Association 5

Standard ACLS should be performed concurrently with transport arrangements, as the hypothermic heart may still respond to interventions despite conventional wisdom suggesting otherwise, according to the American Heart Association 6
Defibrillation attempts should continue according to standard BLS algorithms concurrent with rewarming strategies, though success is unlikely until core temperature reaches 30-34°C, as recommended by the American College of Cardiology 4
Passive and external rewarming methods are inadequate for severe hypothermia with cardiac arrest, and active core rewarming is required, as stated by the American Heart Association 5

Hyperkalemia in hypothermia is often a consequence of cellular dysfunction and will typically correct with rewarming, according to the American Heart Association 6
The elevated potassium should not preclude aggressive resuscitation efforts in this context, as recommended by the American College of Cardiology 6

Do not delay transport to an ECMO-capable center while attempting prolonged field resuscitation, as recommended by the American Heart Association 4
Do not rely solely on peripheral warming methods in severe hypothermic arrest—this patient needs extracorporeal rewarming, as stated by the American College of Cardiology 5