Received: 15 August 2018 

|  Revised: 3 September 2018 

|  Accepted: 5 September 2018

DOI: 10.1111/sms.13294

REVIEW ARTICLE

Accidental hypothermia in recreational activities in the

mountains: A narrative review

Emily Procter1   |  Hermann Brugger2  |  Martin Burtscher1,3

1
Department of Sport Science, University of
Innsbruck, Innsbruck, Austria
The popularity of recreational activities in the mountains worldwide has led to an
2
Institute of Mountain Emergency increase in the total number of persons exposed to cold and extreme environments
Medicine, Eurac Research, Bozen/Bolzano, through recreation. There is little conclusive evidence about the risk of hypothermia
Italy for specific activities or populations, nor is it clear which activities are represented in
3
Austrian Society for Alpine and Mountain
the literature. This is a non‐systematic review of accidental hypothermia in different
Medicine, Innsbruck, Austria
recreational activities in the mountains, with a specific focus on outdoor or winter
Correspondence activities that potentially involve cold exposure. Cases of hypothermia have been
Emily Procter, Department of Sport
Science, University of Innsbruck,
reported in the literature in mountaineering, trekking, hiking, skiing, activities per-
Innsbruck, Austria. formed in the backcountry, ultra‐endurance events, and databases from search and
Email: emily.procter@student.uibk.ac.at rescue services that include various types of recreation. Of these activities, hypother-
Funding Information mia as a primary illness occurs most commonly during mountaineering in the highest
This research was funded in part by a
elevation areas in the world and during recreation practiced in more northern or re-
PhD research grant from the University
of Innsbruck (Vice Rector for Research, mote areas. Hypothermia in skiers, snowboarders, and glacier‐based activities is
2015/3/PSY/SPORT‐22) and the most often associated with accidents occurring off‐piste or in the backcountry (cre-
Autonomous Province of Bozen/Bolzano
vasse, avalanche). Organizers of outdoor events also have a role in reducing the inci-
(Abteilung Bildungsförderung, Protocol Nr
404361). dence of hypothermia through medical screening and other preparedness measures.
More complete collection and reporting of data on mild hypothermia and tempera-
ture measurement would improve our understanding of the incidence of hypothermia
in outdoor recreation in future.

KEYWORDS
cold exposure, cooling rate, core body temperature, environmental exposure, hypothermia, outdoor
recreation, sport

1  |   IN TRO D U C T ION are an estimated 35 million mountain tourists in the Western

Human exposure to cold environments was historically asso-
ciated with occupational exposure but has become increas-
ingly recreational in nature. The popularity of recreational
activities in the mountains worldwide has led to an increase
in the total number of persons exposed to cold and extreme
environments through recreation and increasing use of heli-
copter emergency services in some regions.1 Annually, there
United States, 40 million in the Alps and 10 million skiers
and hikers in the Austrian Alps.2 Hiking and trekking rank
among the most popular mountain activities, and downhill
skiing is one of the most popular winter sports worldwide.
Over 2000 downhill ski areas are spread across 67 countries
with an estimated 400 million skier‐days annually.3 Off‐piste
and backcountry winter activities such as ski mountaineering
and snowshoeing have also become increasingly popular. The

The copyright line for this article was changed on 23 November 2018 after original online publication
This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
© 2018 The Authors. Scandinavian Journal of Medicine & Science In Sports Published by John Wiley & Sons Ltd.

|
2464    wileyonlinelibrary.com/journal/sms
 Scand J Med Sci Sports. 2018;28:2464–2472.
Procter et al.
high participation rates in these sports were shown in a recent
in‐field survey in a region in the European Alps.4
Inherent to these outdoor activities is the environmental
exposure, including cold ambient temperatures and altitude.
Maintaining stable body temperature in the face of these en-
vironmental stressors is fundamental for performance and
health.5,6 Accidental hypothermia refers to an involuntary
drop in core body temperature below 35°C and is a poten-
tially fatal condition, particularly in the presence of trauma.7
Severe hypothermia in the absence of other injuries is rare
but the risk for recreationists increases significantly if a per-
son is immobilized due to injury or exhaustion or conscious-
ness is impaired. The potential danger of cold exposure was
emphasized in early reports of hypothermia in hikers.8 Today,
the literature contains various reports of both extraordinary
survival9-11 and unfortunate fatalities12,13 due to hypothermia
during sports and recreation.
However, there is little conclusive evidence about the
risk of hypothermia for specific activities or populations,
nor is it clear which activities are represented in the liter-
ature. The types of injuries sustained during mountain and
wilderness sports were recently presented in a comprehen-
sive review,14 but medical illnesses such as hypothermia
were excluded. We present a non‐systematic review of acci-
dental hypothermia in different recreational activities in the
mountains. This was defined as any active, non‐motorized
athletic pursuit done primarily for leisure purposes in moun-
tain or wilderness areas, with a specific focus on outdoor
or winter activities that potentially involve cold exposure.
We summarize accidental hypothermia in different activi-
ties for which data are available and discuss how advance-
ments in the understanding of cooling rates and temperature
measurement could improve early detection and prevention
of hypothermia in future. This is not intended as a compre-
hensive review of all outdoor activities or organized sport.
Hypothermia due to submersion or immersion in water
during water‐based activities has not been reviewed and can
be found elsewhere.15,16
2  |   D E F IN I T ION O F AC C ID E NTAL
H Y P OT H E R MIA
Accidental hypothermia refers to an involuntary drop in core
body temperature below 35°C. The term accidental is used
to differentiate this condition from induced and therapeutic
hypothermia. Accidental hypothermia may be caused by
exposure (eg, cold air or water) or arise secondary to im-
paired thermoregulation (eg, trauma, alcohol or drug use).
Accidental hypothermia is typically classified into three cate-
gories based on core body temperature: mild (32‐35°C), mod-
erate (28‐32°C) and severe (<28°C).7,17 The gold standard
involves measuring core temperature (eg, in the pulmonary
  
|
   2465
artery or lower third of the esophagus). The advantages and
disadvantages of measuring temperature at different sites in
the body have been reviewed elsewhere.18,19 Less invasive
techniques as well as other systems of staging20 that rely on
clinical signs instead of temperature measurement are often
used in the field because they are more practical, though not
necessarily accurate. Current international recommendations
suggest the use of esophageal or thermistor‐based tympanic
measurement to determine core temperature in hypothermic
patients.17,18,21
3  |   PHYSIOLOGICAL RESPONSE
AND RATE OF COOLING DURING
ACUTE COLD EXPOSURE
Acute cold exposure results in a series of behavioral and
homoeostatic responses to reduce heat flow from the
core to the environment and maintain core body tempera-
ture.22,23 Cutaneous vasoconstriction and thermogenesis
are the most important mechanisms. Peripheral vasocon-
striction reduces peripheral blood flow and thus minimizes
convective heat flow to the environment when a tempera-
ture gradient exists between skin and ambient temperature.
Thermogenesis refers to heat production via involuntary
responses (shivering thermogenesis) or voluntary behavio-
ral responses such as physical activity (non‐shivering ther-
mogenesis). Shivering can increase heat production by 5‐6
times the resting metabolic rate23-26 but is costly in terms
of energy expenditure. Thus, low blood glucose and fatigue
will limit the body’s capacity to produce heat via shivering
thermogenesis.23 Metabolic heat production during volun-
tary physical activity is also considerable because almost
70% of the total energy expenditure of a muscle contraction
is liberated as heat.
Overall thermal balance in a cold environment depends on
ambient temperature, dry or wet conditions, wind, insulation
from clothing, physical activity, and whether these physio-
logical mechanisms remain intact. Severe hypothermia in a
healthy person is unlikely as long as they are responsive and
able to move. It has been shown that walking intensities of
approximately 60% of the individual maximal oxygen con-
sumption are sufficient to offset heat loss in cold ambient
conditions.27-29 However, homeostatic responses in the face
of cold stress will be compromised upon unconsciousness,
immobilization or core temperature <30°C resulting from
injury, intoxication or exhaustion. It is likely that body tem-
perature could drop rapidly if thermoregulation is compro-
mised, though the cooling rate will depend on clothing,30
environmental factors (eg, temperature gradient between the
environment and body, thermal conductance of water or air,
wind, wet conditions) and physiological factors (eg, body
composition, fatigue).
 |
2466       Procter et al.
Case reports from avalanche accidents have reported
cooling rates ranging from <1 to 9.4°C per hour.10,31-33
This discrepancy can be explained in part by differences
in the time of measurement, accuracy of measurement and
other factors specific to each case. For example, these cases
report body temperature at first contact with the victim,
at some point during the rescue or at hospital admission.
These time points will generate different estimates of cool-
ing and may not reflect the rate of cooling during initial
exposure. Some cases have stated colder conditions, poor
insulation from clothing and sweating prior to exposure as
possible reasons for rapid cooling.31 On‐site factors such as
ambient conditions and local cooling of tissues (eg, snow
in the ear canal can influence epitympanic temperature34)
may affect the accuracy of measurements. To differentiate
the degree of cooling during initial exposure, temperature
should be taken immediately upon removing the patient
from the snow.35 Any changes in body temperature there-
after may be reflective of other processes, for example
the afterdrop effect, or due to transport and treatment. To
clarify the rate of cooling directly due to exposure, experi-
mental studies have used continuous temperature measure-
ment during simulated scenarios. Results from simulated
snow burials consistently report a cooling rate of <1°C per
hour,36-40 whereby hypercapnia causes a slight increase in
cooling to ca. 1.2°C per hour.36,37 Insulation of the head
and face does not seem to affect the cooling rate during
simulated burial.40 Cooling due to afterdrop after extrica-
tion from the snow is four times higher than during snow
burial.38
Experimental studies on exercise during cold air expo-
sure generally report that body temperature can be main-
tained during exercise bouts of moderate intensity, but that
the presence of wet and/or windy conditions, low‐intensity,
inactivity or severe fatigue may result in cooling.28,41-43 One
study found that rectal temperature dropped rapidly during
a period of inactivity on a 12‐km self‐paced hike in cold
and wet conditions (‐1°C in 30 minutes).29 In contrast, the
cooling rate seems to be minimal during a short period of
inactivity immediately following exercise in cold conditions
(‐10°C) but no wind or precipitation (‐0.3°C in 10 minutes
based on tympanic temperature).44 Introducing wind of
10 km/h during low‐intensity exercise in cold conditions
(0°C) resulted in decreasing tympanic temperature (infra-
red‐based) unless additional clothing was worn.30 Studies
on the effects of fatigue on thermoregulation have shown
that the body is unable to maintain stable temperature
during prolonged low‐intensity exercise of several hours
in cold conditions (5°C, wet and windy)27,28 or following
multi‐day bouts of prolonged exercise,45,46 though the ab-
solute decrease in rectal temperature is maintained within
approximately 1°C.
4  |  EPIDEMIOLOGY: ESTIMATING
INCIDENCE AND MORTALITY OF
ACCIDENTAL HYPOTHERMIA
Epidemiological data on accidental hypothermia are gener-
ally based on the total number of fatalities or total number
of cases collected in a specified region and period. In some
cases, the numbers are extrapolated to a wider region or pop-
ulation. The following data refer to the general population
and are not specific to sport or recreation. The estimated in-
cidence of accidental hypothermia in the general population
ranges from approximately 1‐5 cases per 100 000 inhabit-
ants per year in European countries47-50 and 5.6 per 1 mil-
lion persons per year in the USA.51 The annual incidence of
fatal cases may be higher in rural compared to urban areas.52
Annual mortality rates from hypothermia range from 0.2 to
1.81 per 100 000 inhabitants.50,53-55 One study of hypother-
mia and other cold‐related morbidity visits to the emergency
department in a period of 10 years (1995‐2004) in the USA
noted that overall mortality was low (2%), thus cautions
against relying on mortality data rather than incidence data.51
However, these values should be considered rough es-
timates because of the many challenges of calculating the
incidence or prevalence of accidental hypothermia. For ex-
ample, there is no way to estimate the total population in
question and as such data are commonly taken from hospital
records, commonly emergency departments at any specified
number of hospitals. Thus, data reflect only those cases re-
quiring hospitalization (or deaths) and do not account for
less severe cases not requiring hospitalization or undiag-
nosed cases of hypothermia. Studies have shown that mild
and moderate hypothermia account for a considerable pro-
portion of all cases of hypothermia.47,48 Secondly, because
data are often collected retrospectively and filtered using
the International Classification of Diseases diagnosis codes,
only those cases for which hypothermia is documented as
such can be retrieved. In addition, it is not always specified
whether hypothermia was the primary injury (eg, from cold
air or water exposure) or developed secondary to another
illness (eg, trauma). Many articles focus exclusively on hy-
pothermia resulting secondary to severe trauma because of
the high incidence and poor prognosis of these cases.56
For these reasons, it is difficult based on existing data to
differentiate cases of hypothermia that are directly due to
cold exposure during recreation. It is possible that a higher
proportion of cases occurring in rural areas is due to expo-
sure during recreation compared to urban areas. However,
data from rural areas show that the activity type is docu-
mented in only a small percentage of all cases.48 Despite
these limitations, the following studies provide some infor-
mation on hypothermia during specific recreational activi-
ties in the mountains.
Procter et al.
4.1  |  Data based on search and
rescue activities
Data from search and rescue services can be a valuable source
of information on accidents during various outdoor sports
and recreation. The incidence of events requiring emer-
gency medical services in US National Parks is 45.9 events
per 1 million visitors, with almost equal percentage due to
traumatic and medical conditions.57 Hypothermia as well as
fatigue/exhaustion are among the most common illnesses re-
ported in some of the most northern US parks.58,59 Data from
mountain rescue teams in Scotland over a two‐year period
(January 1998‐December 1999) showed that 3.5% (2/57) of
fatalities were due to hypothermia and 13.8% (46/333) of all
non‐fatality incidents were persons suffering from cold or
exhaustion without other injuries or illnesses.60 A detailed
review of all search and rescue incidents in a 35‐year period
in Canada (1970‐2005) found that hypothermia was the most
common type of non‐traumatic injury and accounted for
49.4% (153/310) of these injuries.61 Of all persons rescued
by the helicopter rescue services in Austria over a 10‐year
period (1998 to 2008), 10% (9/95) were severely hypother-
mic and 2% (2/95) were moderately hypothermic.62 A re-
cent international survey of 28 mountain rescue teams in ten
countries reported an annual incidence of severe hypother-
mia per rescue team of five cases or fewer.63 Cases of mild
and moderate hypothermia were not reported in this survey.
4.2  | Mountaineering
Data from the highest mountain ranges in the world show that
hypothermia is one of the most common causes of death in
mountaineers, second to trauma and high‐altitude illnesses.
For example, hypothermia was the cause of death in 5.7%
(11/192) of all fatalities that occurred above base camp on
Mt. Everest in the period 1921‐2006,64 15.2% (5/33) of all fa-
talities in the Aconcagua Provincial Park between 2001 and
2012,65 17% (16/96) of all fatalities on Denali between 1903
and 2006,66 4% (2/50) of all fatalities on Mt. Rainier between
1977 and 1997,67 and 10% of all fatalities in Iran between 2006
and 2010.68 Hypothermia was the primary medical condition
in 7.8% (8/102) of all search and rescue events on Denali be-
tween 1990 and 2008.69 In a prospective study of all moun-
taineering accidents admitted to a regional hospital between
2012 and 2013 in Val D’Aosta, Italy, 5.5% (9/202) of victims
were admitted due to hypothermia.70 Most of these cases oc-
curred during trekking or alpine climbing and there was no
difference in frequency during winter or summer months.
4.3  |  Trekking and hiking
Data from the US National Park Service report approximately
279 million recreational visits per year in US National Parks.57
  
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   2467
Of all recreational activities, hiking is the most common activ-
ity requiring search and rescue assistance and resulting in fa-
talities.57,71,72 The specific types of injuries and illnesses were
not specified in these studies. Survey studies of hikers on long‐
distance hiking trails in the US report “hypothermia” in 5%
(13/280) of survey respondents from the Appalachian Trail in
the eastern USA,73 7.5% (6/80) from the Long Trail, Vermont,74
and 7% from the John Muir Trail, California.75 However, these
data are based on retrospective self‐reporting of signs potentially
associated with hypothermia and do not reflect on‐site diagnosis.
4.4  |  Skiing, snowboarding and snowshoeing
It is expected that the incidence of hypothermia in recrea-
tionists in ski resorts is low given the rapid access to first
aid and medical care within resort boundaries. Nevertheless,
one study reported 19 cases of hypothermia (defined as rectal
temperature <36°C) in a ski resort in Australia in the winter
seasons 1983 and 1984.76 These authors also reviewed ski-
ing‐associated deaths in Australia over a 32‐year period and
reported an incidence of hypothermia‐related deaths of 0.18
per million skier‐days.77 It is unknown whether these data
reflect the current situation in ski resorts today.
In comparison to recreation within secured skiing areas,
the incidence of hypothermia in off‐piste or backcountry
recreationists is likely higher. This is in part because of the
risk of prolonged cold exposure associated with crevasse
and avalanches accidents, but also because of the potentially
more challenging rescue procedures from remote terrain.
Hypothermia is the primary illness in 10% of victims of cre-
vasse accidents62,78 and 66% of victims of other accidents
during recreational activities on glaciers.79 In comparison,
hypothermia is the primary cause of death in <1% of buried
avalanches victims,80,81 since it is more likely that a person is
rescued or dies of another cause within the time required until
body temperature drops below 35°C (the most common cause
of death from avalanches is asphyxiation).33,80-82 However, it
is known from case reports of hypothermic avalanche victims
that hypothermia may develop more rapidly than expected in
buried victims and that survival with a good outcome is pos-
sible even after moderate to severe hypothermia.10,31,32
4.5  |  Ultra‐endurance events
Ultramarathons refer to long‐distance events of over 42 km
and can be single‐day or multi‐staged over several days.
Adventure races refer to events of various distances in which
the race course requires completing multiple sporting disci-
plines through rugged wilderness terrain. The length of the
course varies and can be pursued individually or in teams.
Expedition‐length races are the longest events with a mini-
mum of 36 hours and maximum >10 days and may involve
hundreds of kilometers.83
 |
2468       Procter et al.
The unique features of these events, such as the extreme
distances and remoteness, make it difficult for medical care
providers to be adequately prepared for such events.83 Many
authors have observed that the main reason for seeking med-
ical attention during endurance races is for minor injuries/
illnesses such as blisters, musculoskeletal or gastrointestinal
problems.84-88 The overall incidence of injury/illness is es-
timated as 1‐10 per 1000 person‐days of exposure for sin-
gle outdoor activities and one order of magnitude greater for
multistage or competitive events and those with extreme en-
vironments.86 While major trauma or hypothermia are a small
percentage of injuries/illnesses seen during these events, the
potential mortality must be considered.83,89 Cases of hypo-
thermia have been reported in a variety of events. For example,
hypothermia was the main reason for medical consultation in
8% (5/63) of all consultations in the 161‐km Western States
Endurance Run in four years of this event (2010–2013), and
42% of all on‐course consultations in the 2012 race.84 During
the 2003 Primal Quest, an expedition‐length adventure race,
0.5% (2/406) of all injuries/illnesses were due to hypothermia
and both cases required transport to hospital.90 Racing The
Planet® 4 Deserts Series is a 7‐day, 240‐km ultramarathon
running race; over half of the major injuries were classified
as exercise‐associated collapse and an unreported number of
these persons had subsequent hypothermia.85 Retrospective
survey studies of participants of wilderness adventure races
report that up to ca. 20% of survey respondents experienced
signs of hypothermia during races, though these data must be
interpreted with caution because they are based on self‐re-
porting and not on‐site medical diagnosis.91,92
5   |   IM P ROV ING D IAG NOS IS AND
RE P O RT ING OF AC C ID E N TA L
H Y P OTH E R MIA R E QU IR E S CO RE
TE M P ER AT U R E ME A SU R E ME N T
Recent studies have investigated how often core body tem-
perature is measured by emergency medical providers when
attending to cases of accidental hypothermia and whether
esophageal or tympanic measurement is used, as stated by
recommendations.17,18,21 Based on data from hospitals in
Northern Sweden in the period 2000‐2007 temperature was
measured pre‐hospitally in 12.3% of cases (30/244) and the
body site was recorded in 7% of these cases (rectal or epit-
ympanic).48 A survey of 42 pre‐hospital medical service pro-
viders in Norway found that air ambulances and search and
rescue services were better equipped to measure body tem-
perature than ground ambulance services.93 Thermometers
were carried by all fixed wing air ambulance, helicopter air
ambulance and search and rescue services, whereas they were
present in only 12% of the ground ambulance units. The air
ambulances and search and rescue services had temperature
probes suitable for esophageal or tympanic (infrared‐based)
measurement, and the ground ambulances had probes for
rectal and tympanic measurement. Thermistor‐based epitym-
panic probes were not carried by any of the surveyed units. A
survey of emergency rooms in Poland found that body tem-
perature is taken at a peripheral body site in the majority of
hypothermic patients.47 Based on 268 cases of hypothermia
from 42 hospitals, body temperature was taken peripherally
in 57.1% of cases, primarily based on infrared ear thermom-
etry or axilla temperature. Core temperature was measured
in 29.1% of cases, primarily based on esophageal or rectal
temperature and there were no cases in which urinary bladder
or epitympanic (thermistor) probes were used.
6  |   PREVENTION OF
HYPOTHERM IA IN OUTDOOR
RECREATION IN THE M OUNTA I N S
Prevention of hypothermia has first and foremost to do with
adequate preparation.6 Hypothermia can occur even in mod-
erate climates and although there is a peak in colder months
it can occur in any month of the year.48,51 Although prepara-
tion is largely the responsibility of the athlete or recreation-
ist, organizing bodies can also play a role in preparation and
prevention in the case of organized races and outdoor events.
For example, event organizers should assess the potential for
cold injuries, considering not only ambient temperature but
also predicted wind speed, precipitation, altitude and dura-
tion of exposure.94 Where possible, a preparatory medical ex-
amination can be an important tool to screen for preexisting
medical conditions that may increase the risk of cold injury
or conditions worsened by cold exposure.94 It may be impor-
tant to educate participants about precautionary steps that can
reduce the risk of hypothermia, including appropriate cloth-
ing30 and adequate caloric intake and hydration.94-96 Some
authors have suggested better use of weather forecast infor-
mation to provide guidance on the risk of hypothermia.12
Ultra‐endurance events present a particularly challenging
situation for preventing and managing medical conditions
given the race distances, extreme weather conditions and
remoteness of many events.83,86,89,97,98 Strict regulating bod-
ies, such as those in organized sport, do not exist for these
events. There have been efforts, however, to outline general
recommendations for the provision of medical support for
ultra‐endurance events or adventure races in remote environ-
ments.83,89 The authors emphasize that hypothermia, though
not one of the most common illnesses, is potentially life‐
threatening and should be considered for any participant with
a history of exposure to cold water or cold, wet and/or windy
conditions.
A consensus statement by the International Olympic
Committee suggested that prediction modeling to estimate
Procter et al.
core body temperature and exposed skin temperature could
provide the basis for setting ambient air and water tempera-
ture limits for competition in sport.99 This would be a valu-
able tool to assess the potential for hypothermia and other
cold injuries also for outdoor recreation events. Further re-
search is needed on cooling rates in different ambient condi-
tions to enable good prediction modeling.
7  |   L IM ITAT ION S
We reviewed literature that lists hypothermia as a primary ill-
ness but recognize that hypothermia in outdoor recreationists
is most commonly comorbid to other injuries such as trauma.
Thus, the total incidence of hypothermia is higher than the
incidence of primary hypothermia. Water‐based activities
such as boating or swimming were not defined as mountain
recreation for the purpose of this review, though cold water
exposure is a common cause of primary hypothermia. Many
studies do not specify the types of recreational activities in
persons presenting with hypothermia. It is also plausible that
the terms mountaineering, hiking and trekking are used in-
consistently in the literature. We reported the activity type as
it appeared in the individual studies. Finally, hypothermia in
the general population is most commonly due to prolonged
exposure in homeless persons or impaired thermoregulation
from intoxication and this should be considered when inter-
preting incidence and mortality data based on the general
population.
8  |   CO NC LU SION S
This is the first review to summarize data on accidental hy-
pothermia in mountain recreation and serves as a starting
point for further data collection. Cases of hypothermia have
been reported in the literature in mountaineering, trekking,
hiking, skiing, activities performed in the backcountry, ultra‐
endurance events, and databases from search and rescue ser-
vices that include various types of recreation. Existing data
do not allow conclusive statements about the incidence of
accidental hypothermia within these specific recreational
activities. However, the reviewed data suggest that hypo-
thermia as a primary illness accounts for a considerable per-
centage of cases in two main areas: during mountaineering
in the highest elevation areas in the world and during rec-
reation practiced in more northern or remote areas (based
on search and rescue data). Hypothermia in skiers, snow-
boarders, and glacier‐based activities is most often associ-
ated with accidents occurring off‐piste or in the backcountry
(crevasse, avalanche). Hypothermia in hikers on long‐dis-
tance trails is based on self‐reporting and should be inter-
preted with caution. Ultra‐endurance and adventure races
  
|
   2469
are associated with extreme conditions and remoteness, but
the prevalence of hypothermia seems to be low. Adequate
preparation and awareness are paramount in preventing hy-
pothermia. Organizers of outdoor events also have a role in
reducing the incidence through medical screening and other
preparedness measures.
9  |  PERSPECTIVE
In general, the risk of developing accidental hypothermia
during recreational activities in the mountains is low in
healthy, uninjured persons. Poor preparation, unfavorable
environmental conditions, and fatigue may increase the risk
of mild hypothermia, whereas injury leading to immobili-
zation and impaired consciousness will rapidly increase the
risk of moderate and severe hypothermia. Existing data on
hypothermia are likely incomplete and underestimate the
prevalence of mild hypothermia. To increase the robustness
of data in the future it would be important to have more
complete data collection from various regions, inclusion of
cases of mild/moderate hypothermia and improved report-
ing of temperature data. Recent initiatives are working in
this direction, for example, the International Hypothermia
Registry (https://www.hypothermia-registry.org), an on-
line, prospective multi‐center registry, and the Severe
Accidental Hypothermia Center in Cracow, a national net-
work of all pre‐hospital medical services with call to con-
sult services.100
CONFLICT OF INTEREST
The authors declare that they have no competing interests.
ORCID
Emily Procter  http://orcid.org/0000-0001-7363-4862
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How to cite this article: Procter E, Brugger H,
Burtscher M. Accidental hypothermia in recreational
activities in the mountains: A narrative review. Scand
J Med Sci Sports. 2018;28:2464–2472. https://doi.
org/10.1111/sms.13294