Cold water rescue introduces physiological, environmental, and cognitive factors that reduce the reliability of standard triage systems. Hypothermia, immersion effects, and time distortion challenge symptom-based prioritisation, increasing the risk of under- or over-triage in maritime and austere SAR operations. This presentation explores the design of rapid, context-specific decision tools—such as checklists, modifiers, and digital prompts—to support triage in extreme conditions. Key discussion points include hypothermia as a context modifier, cognitive load under time pressure, characteristics of effective rapid decision aids, and potential integration into training, simulation, and digital support systems. Adapting triage to cold water operations requires moving from universal algorithms to context-aware tools, enabling safer and more consistent prioritisation decisions.