<p> Diagnosis:  Hypothermia ICD-diagnosis for T.68 for ICD-10 (1997-)  Frostbite ICD-diagnosis for T.33.0-T35.7 for ICD-10 (1997-)  Drowning ICD-diagnosis for T.75.1 for ICD-10 (1997-)</p><p> give diagnosis:______</p><p>Person-number:______Name:______</p><p>Address:______</p><p>Hospital:______</p><p>Accident site information</p><p>Date (year/month/day):______Time:______</p><p>Found  outdoors, shere:______ indoors, where (ex. room with open window)______How long was the person incapacitated before they were found?______Outdoor temp: air:______oC if indoors:______oC water:______oC</p><p>Wind: ______m/s precipitation: ______mm Type (ex. rain, snow, wet snow):______</p><p>Clothing:______Hat:______Gloves:______Shoes:______Life vest:______</p><p>Status at accident site Core body temperature:______oC Temp taken (where?):  oral  rectal  axillary  ear  other:______</p><p>For frostbite: Localization: Area:</p><p>Previous medical condition:______Alcohol intoxication:  yes  no describe:______Drug intox:  yes  no describe:______</p><p>Level of consciousness (GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity:  shivering  stiff Speech:  distinct  slurring  no speech Coordination and balance:  normal  defective, desc describe:______TRANSPORT</p><p>Date (year/month/day):______time:______</p><p>Temperature i vehicle during transport, Time for transport Sled ______oC ______hours, minutes Ambulance ______oC ______hours, minutes Helicopter ______oC ______hours, minutes Airplane ______oC ______hours, minutes Other ______oC ______hours, minutes</p><p>Body core temperature when transport started: ______oC where measured: ______ended: ______oC where measured? ______</p><p>Status during transport</p><p>For Frostbite: Localization: Area?:</p><p>Level of consciousness GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity:  shivering  stiff Speech:  distinct  slurring  no speech Coordination and balance:  normal  defective, Describe: ______Hospital/ward</p><p>Hospital:______Ward:______</p><p>A) Status at arrival When? Date:______Time:______Core body temperature: oral: ______oC esophageal: : ______oC axillary: ______oC ear: ______oC rectal: : ______oC other/where: ______oC</p><p>Level of consciousness (GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity:  shivering  stiff Speech:  distinct  slurring  no speech Coordination and balance:  normal  defective, Describe: ______</p><p>Size of cold injury: Describe depth:______Describe area/size:______</p><p>Other injuries/describe? ______B) Laboratory results at admission EKG ______platelets ______Hb, leucocytes ______PT ______hematocrit ______aPTT ______sodium ______B-glucose ______potassium ______Krea ______Amylase ______</p><p>O2Hb Sat% ______Ethanol ______pO2 ______pCO2 ______other ______pH ______</p><p>C) X-ray findings Chest x-ray ______Skeletal ______CT ______Other ______</p><p>D) Rewarming Hypothermia/drowning Core body temerature at start: ______oC measured by: ______At finish: ______oC measured by:______</p><p>*Rewarming method  passive, describe ______rewarming time:______ active, describe ______rewarming time: ______Cold injury/frostbite: Method, describe ______rewarming time: ______Flushing after ______min Teknetium scintiagraphy:  yes  no findings:______ Heart, describe (ex. arythmias, VF):______ Respiratory, describe (ex secretions, pulmonary edema)______ Neurological, describe (ex. seizures, deficits): ______ Bleeding, describe:______ Other, describe:______ Operations, describe:______</p><p>E) Rewarmings end Core body temperature, where :______oC Status when rewarming completed: Level of consciousness (GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity:  shivering  stiff Speech:  distinct  slurring  no speech Coordination and balance:  normal  defective, Describe: ______Extent of cold injury/frostbite: Describe depth:______Desctrbe extent/area:______</p><p>Teknetium scintiagraphy:  yes  no findings:______ Heart, describe (ex. arythmias, VF):______ Respiratory, describe (ex secretions, pulmonary edema)______ Neurological, describe (ex. seizures, deficits): ______ Bleeding, describe:______ Other, describe:______ Operations/amputation, describe:______</p><p>F) Discharged from hospital When (year/month/day):______Season:______General status including: level of consciousness, neurological deficit, extent of cold injury/frostbite:______Follow up/return visit</p><p>When? How long after injury (year/month/day):______</p><p>General status including: level of consciousness, neurological deficit, extent of cold injury/frostbite______</p><p>Cold sensitivity, describe:______Impaired balance, describe:______Impaired walk, describe:______Quality of life:______Other:______</p>