Injuries and illness due to cold environment exposure are common in EMS, occurring in urban, rural, and wilderness settings. Urban hypothermia poses a challenge and can both complicate chronic disease and be caused by decompensated chronic disease; a high index of suspicion is necessary to identify multifactorial hypothermia. Out-of-hospital treatment should focus on thermal stabilization and, when possible, rewarming. Other cold-related injuries such as frostbite and nonfreezing cold injuries may present as primary issues or complicate other illness and injuries. Cold-water immersion presents a risk to both responders and patients. Awareness of the cold-water immersion concepts of cold shock, cold incapacitation, hypothermia, and circum-rescue collapse will improve safety and survival for responders and patients.