Environmental

Hypothermia — elderly female found cold and confused

Intermediate

Elderly · 75yr · female

Patient Information

Dispatch	You are called to a patient (Margaret Hollis, 75YO female) who has been found sitting outside the volunteer tent, cold to touch and confused. Bystanders say she has been there for over an hour.
Patient	Margaret Hollis — 75yr (60kg)
Incident History	Pt was volunteering at the community fair and stepped outside the main marquee approximately 90 minutes ago. Found by another volunteer sitting on a bench, minimally responsive, shivering, and cold to touch. Pt unable to give clear history.
Emergency Contact	David Hollis (Son) — 0412 874 339

Initial Rapid Assessment

Response	Voice
Airway	Patent. Nil airway obstruction. Nil stridor. Pt able to maintain own airway.
Breathing	Spontaneous but shallow and slow. RR reduced. Nil audible wheeze or crackles.
Circulation	Radial pulse weak and bradycardic. Skin cold, pale, and dry to touch peripherally. CRT 4s.
Disability	GCS 11 (E3V3M5). Disoriented to time and place. Responds to voice but confused. Pupils equal and reactive to light.
Exposure	Pt dressed in light cotton clothing appropriate for indoors, not adequate for ambient outdoor temperature. No visible trauma. No rashes. Shivering noted on initial assessment.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	93% (RA)	Mild	10	48	90/60	4s	11	3 3 ++	32.4	4.8 mmol/L	2
10 mins	97% (O2 NRB 10L)	Nil	14	56	98/64	3s	13	3 3 ++	33.1	4.8 mmol/L	1

History Taking

Treatment Response

Diagnosis

This patient is suffering from moderate hypothermia (core temperature 32.4°C) presenting with bradycardia, altered conscious state, reduced respiratory rate, and peripheral shutdown following prolonged cold exposure at a community fair.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not move the patient indoors or to a sheltered warm environment within the first 2 minutes, the patient begins to shiver more violently and GCS drops to 10 — prompt: 'The wind picks up and Margaret becomes increasingly difficult to rouse.')
! (If oxygen is not applied within 3 minutes, SpO2 drops to 90% on room air and respiratory rate decreases to 8 — prompt: 'Margaret's breathing appears to be getting slower and shallower.')
! (If wet or inadequate clothing is not removed and patient is not actively passively re-warmed with blankets, the 10-minute temperature does not improve and remains at 32.4°C — prompt: 'Despite being inside, Margaret still feels very cold to touch.')
! (If BGL is not checked, facilitator prompts: 'You notice Margaret is becoming increasingly drowsy — what other assessment would you perform?')
! (If the trainee attempts to walk the patient or has her stand and mobilise to the FAP, prompt: 'Margaret becomes very unsteady on her feet and nearly falls — what are your concerns about moving her this way?')
! (If the trainee does not consider the beta-blocker (Metoprolol) as a reason why the bradycardia may not resolve easily, facilitator prompts: 'You note the pulse has improved slightly but remains bradycardic at 56 — is there anything in Margaret's history that may be contributing?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm airway patent, breathing present but shallow and slow, pulse weak and bradycardic.
3. Move patient immediately from cold outdoor environment into warm sheltered area (FAP tent or ambulance if available) — avoid sudden or rough movement to reduce risk of triggering ventricular arrhythmia.
4. Position patient recumbent (supine or semi-recumbent in position of comfort) — do NOT walk the patient.
5. Apply oxygen via non-rebreather mask at 10–15 L/min targeting SpO2 94–98% as per Oxygen CPG.
6. Perform Vital Sign Survey — obtain full observations including tympanic temperature, BGL, BP, HR, RR, SpO2, GCS, pupils.
7. Record tympanic temperature (note: may underestimate true core temperature in hypothermia — interpret with clinical context).
8. Perform BGL — result 4.8 mmol/L, no hypoglycaemia treatment required.
9. Remove wet and cold clothing — replace with dry blankets.
10. Apply passive re-warming: wrap patient in blankets, use Ready-Heat blanket if available (do NOT apply directly to skin — place sheet beneath first), utilise vehicle/FAP heater.
11. Do NOT provide warm oral fluids at this time as GCS is 11 and pt cannot safely ingest fluids — reassess once GCS improves to 15.
12. Reassess GCS, temperature, and vital signs at 10 minutes — if GCS improves to 15 and pt can swallow safely, offer warm fluids orally.
13. Monitor continuously for deterioration: watch for reduced RR, dropping GCS, increasing bradycardia, or onset of arrhythmia (without cardiac monitor, rely on pulse palpation and clinical signs).
14. Arrange Priority 1 transport to nearest ED — hypothermia with GCS 11 and bradycardia is time critical.
15. Pre-notify receiving facility of patient's condition, temperature, GCS, and haemodynamic status.
16. Complete IMISTAMBO handover to incoming ambulance crew.
17. Scenario ends on arrival of ambulance and IMISTAMBO handover.
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Hypothermia · Oxygen Delivery · Blood Glucose Monitor · Tympanic Thermometer · Primary Survey · Ready Heat Blanket · Glasgow Coma Scale (GCS)

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Signs/Symptoms	Confusion, weakness, feeling very cold, mild generalised discomfort. Shivering noted initially. Pt reports feeling 'foggy' and unable to remember how long she has been outside.
Allergies	Nil known
Medications	Metoprolol (beta-blocker for hypertension), Atorvastatin. No anticoagulants.
Pertinent History	Known hypertension, managed with Metoprolol. No known cardiac conditions. No history of prior hypothermia episodes. Lives independently at home.
Last Oral Intake	Light breakfast approximately 5 hours prior. Minimal fluid intake during the event.
Events Leading	Pt was volunteering at a community fair ground stall. Left the main heated marquee to take a break and sat on an outdoor bench. Ambient temperature approximately 9°C with a breeze. Was not noticed missing for approximately 90 minutes.
Treatment Prior	Bystander placed a jacket over the patient's shoulders approximately 10 minutes prior to EHS arrival.

Onset	Gradual over approximately 60–90 minutes outdoors in cool ambient temperature.
Pain	Mild generalised discomfort, no specific pain complaint. Reports feeling stiff.
Quality	Diffuse stiffness and weakness. No chest pain or abdominal pain reported.
Radiates	Nil
Severity	2/10