Intended for healthcare professionals

Endgames Case report

The management of accidental hypothermia

BMJ 2009; 338 doi: (Published 10 June 2009) Cite this as: BMJ 2009;338:b2085
  1. W G Headdon, senior house officer, gastroenterology12,
  2. P M Wilson, fourth year medical student1,
  3. Harry R Dalton, consultant gastroenterologist and honorary senior lecturer12
  1. 1Peninsula College of Medicine and Dentistry, Plymouth, Devon
  2. 2Royal Cornwall Hospital, Truro, Cornwall
  1. H R Dalton harry.dalton{at}

    Case history

    A 24 year old male surfer presented to the emergency department unconscious. Lifeguards had spotted him drifting out to sea on his surfboard. Upon return to the beach he was confused, unable to walk in a straight line, and shivering violently. He subsequently collapsed and paramedics were called. On arrival at the emergency department, the patient’s Glasgow coma score was 3, and he appeared cyanotic with a regular pattern of breathing at a rate of eight breaths per minute. His pulse was irregular at 36 beats per minute and his blood pressure was unrecordable. His rectal temperature was 27.8°C. As his airway was suctioned in preparation for orotracheal intubation, the patient’s cardiac rhythm changed to ventricular fibrillation. After a pulse check and precordial thump, defibrillation was performed at 150 joules and basic life support was commenced. Two further shocks were given at appropriate intervals and 1 mg of intravenous adrenaline (epinephrine) was administered.


    • 1 What is the most appropriate next resuscitation step?

    • 2 How should this patient’s low temperature be managed?

    • 3 At what point should resuscitation be stopped if unsuccessful?


    Short answers

    • 1 Basic life support should continue until core temperature is greater than 30°C. Cardioactive drugs and further defibrillation should be withheld until this temperature is reached.

    • 2 Invasive rewarming methods should be used, such as airway warming; warm bladder, pleural, peritoneal, or nasogastric lavage; and, if available, partial cardiopulmonary bypass.

    • 3 Resuscitation should continue until core temperature is more than 30°C or be discontinued if the patient has obvious lethal injuries.

    Long answers

    1 Steps for resuscitation

    This patient is hypothermic. Hypothermia is defined as a core temperature of less than 36°C.1 The drop in temperature can be rapid or slow, with the …

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