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Path 3 — Medical & first response
Hypothermia
Module 3.310 minStages & recognition5-question check
Module 3.3
Cold, exhausted, and at risk

Hypothermia is the most common medical condition in Mediterranean SAR — and it is routinely underestimated. People assume hypothermia is a winter problem, or that a warm-looking survivor is not hypothermic. Neither is true. Survivors who have spent hours on a overcrowded boat in 24°C air with wet clothing, wind chill, and no shelter can arrive with dangerous core temperature drops regardless of the season.

Understanding the stages of hypothermia, what it looks like, and how to support the medical team's response is important preparation for any crew member going into operational roles.

Medical team leads assessment and treatment
Clinical diagnosis and treatment of hypothermia is the medical team's responsibility. This module prepares non-medical crew to recognise warning signs, support triage, and avoid actions that worsen the condition. Always follow your medical team's direction and your organisation's SOPs.
What you'll cover
  • Why hypothermia is so common in Mediterranean SAR — even in summer
  • The three stages of hypothermia and the signs of each
  • Why "afterdrop" is dangerous and why rough handling causes it
  • What crew should and should not do when receiving hypothermic survivors
  • Specific considerations for infants, children, and the elderly
Estimated time
10 minutes — followed by a knowledge check
Section 1 of 3
The stages of hypothermia

Hypothermia is defined as a core body temperature below 35°C (95°F). It progresses through stages that are clinically distinct. The body fights hard to maintain core temperature — the progression from mild to severe is not linear and can accelerate suddenly.

Presentation matters more than temperature
As a crew member, you are unlikely to have access to a clinical thermometer — and even if you do, core temperature readings are difficult to obtain accurately in a field setting. What matters is how the person presents: their behaviour, responsiveness, whether they are shivering, and whether they can communicate. Use the signs below to assess severity. If in any doubt, treat as moderate and escalate to the medical team.
32–35°C
Mild
Shivering, pale skin, confusion beginning
The body's primary defence is shivering — involuntary muscle contractions that generate heat. The person may appear confused, clumsy, or slow to respond. Skin is pale and cold. Peripheral blood vessels constrict to preserve core heat. This stage is often missed because survivors may appear mildly unwell rather than seriously ill.
28–32°C
Moderate
Shivering stops, muscle rigidity, significant confusion
When shivering stops it may appear the person is improving — they are not. At this stage the person has lost the ability to rewarm from internal mechanisms. Without active external intervention, they will continue to cool. Shivering ceasing means the body has exhausted its capacity to generate heat through that mechanism. Muscle rigidity develops. The person may become paradoxically calm or even make inappropriate decisions (a dangerous effect known as "paradoxical undressing"). Cardiac arrhythmias can begin at this stage.
<28°C
Severe
Loss of consciousness, cardiac risk, may appear dead
At severe hypothermia, the person may be unconscious, have slow or absent pulse, very slow breathing, and dilated pupils. They may appear dead. The heart can develop a dangerous abnormal rhythm. Handling must be extremely gentle — rough movement at this stage can trigger cardiac arrest. Whether resuscitation is attempted is a medical decision, made by the medical team based on available resources and clinical presentation.
Afterdrop
Afterdrop is the phenomenon where core temperature continues to fall after a hypothermic person is removed from cold exposure. Cold blood pooled in the extremities returns to the core as circulation is restored, dropping the core temperature further — sometimes triggering cardiac events in moderate to severe cases. This is why rewarming must be gentle and controlled, and why rough handling or active limb movement is dangerous. The medical team will manage rewarming strategy. Your job is to avoid making it worse.
Section 2 of 3
Hypothermia in the Mediterranean context

The Central Mediterranean is not cold by polar standards. But the conditions on a departure typically create sustained heat loss over many hours — and the cumulative effect is severe.

Why it happens here
A crossing from Libya or Tunisia to Italy or Malta has no fixed duration — crossings can take many hours or several days depending on the vessel, the sea state, and what happens along the way. There is no typical time. People are wet, often from the outset — waves and spray are constant even in moderate conditions. Wind chill over wet clothing dramatically accelerates heat loss. Overcrowding means limited movement, reducing heat generation. Dehydration and lack of food impair the body's ability to thermoregulate. Even in 24°C air with warm water, these compounding factors cause hypothermia — particularly in infants, children, the elderly, pregnant women, and anyone already weakened or malnourished.
Infants and children: highest priority
Infants and young children have a higher surface area-to-mass ratio and minimal subcutaneous fat compared to adults. They lose heat rapidly and cannot shiver effectively. Infants in particular may show very few visible signs of hypothermia beyond stillness and lethargy that could easily be mistaken for normal sleep. Any infant or young child should be prioritised for medical assessment regardless of apparent presentation.
Winter vs summer
Winter Mediterranean crossings present an elevated risk of severe hypothermia — water temperatures of 14–18°C, colder air, more adverse weather, shorter days. Summer crossings are not safe from hypothermia — they carry a different risk profile, not an absent one. Do not assume a calm, warm night means survivors will not arrive hypothermic.
Section 3 of 3
Crew response — do and don't

Most crew members will be involved in the initial stages of receiving survivors — removing them from the water, passing them up from the RHIB, receiving them on deck. These moments matter enormously for hypothermic survivors. Gentle, efficient, warm handling in the first minutes affects outcome.

Do
Handle gently — no rough lifting, no sudden position changes
Remove wet clothing as soon as practicable — cut if necessary
Wrap in blankets or a foil survival bag from head to feet
Move the person to a sheltered, warm environment immediately
Prioritise infants, children, and elderly for immediate medical assessment
Communicate clearly with the medical team — describe what you observed
Offer warm sweet drinks if the person is fully conscious and able to swallow — hot drinks with plenty of sugar support rewarming. Do not give drinks to anyone with impaired consciousness or moderate to severe hypothermia
Don't
Rub or massage the limbs vigorously — promotes afterdrop
Apply direct heat sources (hot water bottles directly on skin)
Give alcohol — it impairs thermoregulation and dilates vessels
Force the person to walk or move to generate heat
Assume shivering means the person is "fine" — it indicates mild hypothermia
Assume absence of shivering means the person is improving
Handle as if fragile
A moderately or severely hypothermic patient whose heart is beating slowly and irregularly is at risk of a dangerous heart rhythm disturbance from rough handling. Treat every survivor you are unsure about as if they are at this risk. Gentle, horizontal transfer. No sudden movements. Alert the medical team before you move them if there is any doubt.
Your organisation's protocol
Every vessel has specific arrangements for survivor reception, warming, and medical handover. Before operations begin, ask your team leader to walk you through the reception flow — where survivors are received, where warming blankets are stored, who leads triage, and how to alert the medical team rapidly. Knowing the route and the system before you need it matters.
Practice — interactive
Identify the stage

Four survivors, each with a different pattern of observations. Read each set of signs and identify the hypothermia stage. After you choose, you'll see whether the recognition was correct and what the crew response should be.

Knowledge check
Before you move on

Five questions on hypothermia recognition and crew response.