Successful treatment of severe accidental hypothermia with cardiac arrest for a long time using cardiopulmonary bypass - report of a case
© Sawamoto et al; licensee Springer. 2012
Received: 16 July 2011
Accepted: 2 February 2012
Published: 2 February 2012
Accidental hypothermia is defined as an unintentional decrease in body temperature to below 35°C, and cases in which temperatures drop below 28°C are considered severe and have a high mortality rate. This study presents the case of a 57-year-old man discovered drifting at sea who was admitted to our hospital suffering from cardiac arrest. Upon admittance, an electrocardiogram indicated asystole, and the patient's temperature was 22°C. Thirty minutes of standard CPR and external rewarming were ineffective in raising his temperature. However, although he had been in cardiac arrest for nearly 2 h, it was decided to continue resuscitation, and a cardiopulmonary bypass (CPB) was initiated. CPB was successful in gradually rewarming the patient and restoring spontaneous circulation. After approximately 1 month of rehabilitation, the patient was subsequently discharged, displaying no neurological deficits. The successful recovery in this case suggests that CPB can be considered a useful way to treat severe hypothermia, particularly in those suffering from cardiac arrest.
In the clinical setting, it is often difficult to determine whether hypoxia associated with submersion or severe accidental hypothermia associated with immersion is the cause of cardiac arrest due to drowning. We here report the case of a patient who developed prolonged cardiac arrest because of drowning in the sea, a situation in which one is stumped concerning resuscitation. Using cardiopulmonary bypass (CPB), resuscitation was achieved, and the patient had no neurological deficits.
Accidental hypothermia is defined as an unintentional decrease in body temperature below 35°C . Severe accidental hypothermia (core temperature below 28°C) is still associated with a high mortality rate ranging from 30-80% [2, 3]. Major causes of severe accidental hypothermia are drowning (submersion or immersion), being caught in an avalanche, and exposure to cold air. Submersion is associated with hypoxia because of sinking until being completely covered with water. Immersion is associated with accidental hypothermia because of sinking until being covered with water except for the face. As has been well described, since 'a hypothermic patient is not dead until warm and dead,' resuscitation should be continued in the hospital until the patient has been rewarmed to 33-35°C [3–5]. It is common knowledge that low temperature increases the ischemic tolerance of the brain. Several authors have described remarkable neurologically intact recovery after prolonged cold-water immersion [3, 4, 6]. However if asphyxiation precedes cardiac arrest, even in the hypothermic patient, the chances of survival seem to be less, because hypothermia cannot render its cerebral protective effect [1–6]. Therefore, in such cases, active treatment cannot have a sufficiently positive outcome.
There is no consensus on reliable prognostic indicators to determine the efficacy of active rewarming for hypothermic cardiac arrest patients . Therefore, most emergency physicians continue efforts to resuscitate for some time, as previously indicated. Recently, it has been reported that active internal rewarming using CPB is useful for resuscitation in cases where severe accidental hypothermia develops into cardiac arrest . However, it is generally difficult for all emergency departments to use CPB because of limitations in the availability of CPB or lack of manpower. It can be speculated that in many cases resuscitation is discontinued without waiting for rewarming to occur.
Laboratory data on admission
Arterial blood gases
395 × 104
13.8 × 104
It is recommended that severe hypothermic patients be treated by active internal rewarming methods. These include an extracorporeal circulation device such as CPB, continuous renal replacement therapy (CRRT) and body cavity lavage . CPB can rewarm patients the fastest and has the potential to support unstable hemodynamics, which may include the complex syndrome of rewarming shock.
In conclusion, this case represents successful recovery from severe hypothermic cardiac arrest with a good neurological outcome. For severe hypothermia, particularly in cardiac arrest patients, CPB is an extremely useful treatment device. The diagnostic criteria and management for the resuscitation of hypothermic cardiac arrest patients are still unclear, because we need to accumulate such cases.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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