In Response to Cold Card by Giesbrecht

We are impressed by the idea of the Cold Card developed by Dr Giesbrecht.1Giesbrecht GG. "Cold card" to guide responders in the assessment and care of cold-exposed patients.Wilderness Environ Med. 2018; 29: 499-503Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Such a review of the most important issues in a concise form (a checklist) has been used in aviation for many years to improve safety. Because accidental hypothermia is not a very common medical condition, rescue teams have limited experience in this field. Thus, the Cold Card seems to be a useful tool for a brief refreshment of one's knowledge concerning hypothermia. However, some elements of the card should, in our opinion, be reconsidered. In its current form, the Cold Card suggests placing every patient with mild hypothermia in a sitting or lying position for 30 min. The authors of the 2014 Wilderness Medical Society Practice Guidelines highlighted that application of this recommendation should be limited to nonwalking individuals when shelter and rewarming is available.2Zafren K Giesbrecht GG Danzl DF Brugger H Sagalyn EB Walpoth B et al.Hypothermia evidence, afterdrop, and guidelines.Wilderness Environ Med. 2015; 26: 439-441Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Leaving a hypothermic patient sitting or lying down in a cold environment would likely lead to further heat loss. There is no evidence for delaying the evacuation of a healthy, mildly hypothermic individual from a hostile environment. No rescue collapse has been reported in mildly hypothermic individuals without trauma or other comorbidities. Because the availability of intravenous fluid flow warmers in emergency medical services and mountain rescue teams is very limited, the administration of warmed fluids in prehospital settings seems not to be feasible.3Freeman S Deakin CD Nelson MJ Bootland D Managing accidental hypothermia: a UK-wide survey of prehospital and search and rescue providers.Emerg Med J. 2018; 35: 652-656Google Scholar, 4Karlsen AM Thomassen Ø Vikenes BH Brattebø G Equipment to prevent, diagnose, and treat hypothermia: a survey of Norwegian pre-hospital services.Scand J Trauma Resusc Emerg Med. 2013; 21: 63Google Scholar Moreover, some warmers deliver the appropriate fluid temperature at slow flow only.5Lehavi A Yitzhak A Jarassy R Heizler R Katz Y Raz A Comparison of the performance of battery-operated fluid warmers.Emerg Med J. 2018; 35: 564-570Crossref PubMed Scopus (12) Google Scholar Thus, attempts to achieve fast volume replacement may lead to a further drop in body temperature.6Singleton W McLean M Smale M Alkhalifah M Kosahk A Ragina N et al.An analysis of the temperature change in warmed intravenous fluids during administration in cold environments.Air Med J. 2017; 36: 127-130Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar We believe that adding another 2 recommendations to the Cold Card would be beneficial:•The measurement of blood glucose in hypothermic patients with altered mental status should be mandatory.7Zafren K Giesbrecht GG Danzl DF Brugger H Sagalyn EB Walpoth B et al.Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update.Wilderness Environ Med. 2014; 25: S66-S85Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Prolonged shivering may lead to the depletion of glycogen stores and, subsequently, to hypoglycemia.•Early notification of an extracorporeal life support facility is required to prepare staff, equipment, and transportation.8Paal P Gordon L Strapazzon G Brodmann Maeder M Putzer G Walpoth B et al.Accidental hypothermia–an update: the content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).Scand J Trauma Resusc Emerg Med. 2016; 24: 111Crossref PubMed Scopus (143) Google Scholar Because extracorporeal life support is a treatment of choice in hypothermic cardiac arrest, a specific chain of survival must be built into every rescue operation to increase the survival chances of a hypothermic patient.9Truhlář A Deakin CD Soar J Khalifa GE Alfonzo A Bierens JJ et al.European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances.Resuscitation. 2015; 95: 148-201Abstract Full Text Full Text PDF PubMed Scopus (600) Google Scholar Rescue teams should be aware that severe hypothermia is the only reversible cause of cardiac arrest that enables survival without neurological impairment, even after resuscitation lasting several hours. Thus, the statement that "nobody is dead until warm and dead" remains true.