 Welcome back to emergency medicine video on hypothermia. But now, a hypothermic patient has arrived. How should we proceed? As with all sick patients in the emergency department, we always start with ABC. Keep in mind that the hypothermic patient needs to be handled gently, as they can easily go into ventricular fibrillation. First, airway. If the patient is non-responsive, or if they're not protecting their airway, we will insert one. It is usually done by intubation. Next, breathing. We should give 100% oxygen. It should also be warmed and humidified. That will decrease further heat loss from the patient. Next, for circulation. We will put the patient on a cardiac monitor. Insert at least two large-bar IVs, and start to give warmed fluids. We would feel for a pulse for at least 30 seconds, since in hypothermic patient the pulse can be faint and very slow. What if the patient has no pulse? We will start CPR. Keep in mind that sometimes this might be difficult if the patient has a frozen chest. We then see whether the patient has a shockable rhythm. If the patient is in ventricular tachycardia or ventricular fibrillation, we should defibrillate. If it persists, we might defer defibrillating more until a higher core temperature is achieved. The evidence up to this point is unclear. We would also give epinephrine. The difference between a hypothermic arrest from all the other cardiac arrests is that CPR and resuscitation should continue until the patient is warmed to at least 30 to 32 degrees Celsius. Next, disability and exposure. We will check their pupils and reflexes. All wet clothing should be removed at this point. How do we establish the diagnosis? First, you need a core body temperature. The usual temperature probe for the tympanic membrane or under the armpit is not accurate for low temperature. So we need a special low reading thermometer. The most accurate probe is an esophageal probe that is inserted in like an NG tube. It will measure core temperature in the esophagus. What about labs? We often start with basic lab work such as CBC, electrolytes, B-ion caratinin, coagulation profile including INR, PTT, and specific cardiac enzymes such as CK and Tramponin. Other blood tests will also be ordered as time goes on. We also would ask for an ECG. An ECG might show a deflection at the end of the Kira's complex, as shown in here and a bit in here. This is called an Osborne J-Wave. It is seen in moderate to severe hypothermic patients. You would also want to do an ECG to see if you can capture any arrhythmias. If the patient only has a frostbite extremity, the affected part should be immersed in warm water. That is about 37 to 39 degrees Celsius. Pain medication should be given since rewarming can be very painful. You might need to consult a plastic surgeon for debridement and other treatment. In Part 3, we would discuss the specific rewarming techniques.