Don’t Freeze Up: Essential Pharmacy Pearls for Hypothermic Cardiac Arrest

The phrase “you’re not dead until you’re warm and dead” is frequently referenced in clinical practice, yet its practical application requires deeper understanding of the physiologic and pharmacologic changes that occur during severe hypothermia (core body temperature <30°C). While hypothermic cardiac arrest still follows advanced cardiac life support (ACLS) principles, it is important for emergency medicine pharmacists to understand and apply these key considerations to optimize the resuscitative management of hypothermic patients. Hypothermia alters pharmacokinetics and pharmacodynamics, promotes drug accumulation to often toxic levels, and necessitates modified dosing and defibrillation strategies at low core body temperatures. This presentation will review the pathophysiology of hypothermia and its impact on cardiac arrest physiology, including altered receptor sensitivity, reduced metabolism, and mechanisms underlying neuroprotection. Additionally, it will highlight medication-specific modifications to ACLS pharmacotherapy, including temperature thresholds for drug administration, interval adjustments, risks of drug accumulation, and considerations for vasoactive support after return of spontaneous circulation. Lastly, it will discuss early consideration of extracorporeal life support, including pharmacist-driven considerations surrounding anticoagulation and hypothermia-associated coagulopathy. Knowledge of hypothermia specific resuscitation principles enables emergency medicine pharmacists to support safer, more effective care and promote best practices during hypothermic cardiac arrest.