UMEM Educational Pearls

Clinical pearls for hypothermic cardiac arrest

  • VA-ECMO is rewarming strategy of choice – consider transport/contacting nearest ECMO center whenever possible
    • HOPE score predicts survival probability after ECLS rewarming and may guide ECLS decision making. Predictors include age, sex, mechanism of hypothermia, CPR duration, potassium, and core temperature at admission
  • If access to ECMO center is not available, use external and internal rewarming strategies: removing wet clothes, forced-air heating blankets, warmed IV fluids (38-42C), thoracic and/or peritoneal lavage
  • High-quality continuous CPR is key. Use mechanical CPR when available
  • Lack of consensus with regards to ACLS guidelines. European Resuscitation Council recommends up to 3 attempts at defibrillation and withholding epinephrine while core temp is < 30C. AHA states reasonable to follow standard ACLS algorithms. It has been suggested that administering up to 3 shocks and 3 doses of epinephrine while core temp is <30 C is a reasonable approach, with additional doses guided by clinical response
  • Resuscitate until core temp is at least 32C (warm and dead). Once rewarmed, consider termination of resuscitation with persistent asystole or K >12


Paal P, Gordon L, Strapazzon G et al. Accidental hypothermia–an update. Scand J Trauma Resusc Emerg Med. 2016;24(1). doi:10.1186/s13049-016-0303-7

Pasquier M, Rousson V, Darocha T et al. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: An external validation of the HOPE score. Resuscitation. 2019;139:321-328. doi:10.1016/j.resuscitation.2019.03.017

Misch M, Helman A. Accidental Hypothermia and Cardiac Arrest | CritCases | EM Cases. Emergency Medicine Cases. Published 2019. Accessed January 18, 2022.