Surviving two hours of ventricular fibrillation in accidental hypothermia

Cardiac arrest as a consequence of deep accidental hypothermia is associated with high mortality. Standardized prehospital management as well as rewarming with extracorporeal circulation (ECC) are important factors to improve survival. The objective of this case report is to illustrate the importance of effective cardiopulmonary resuscitation (CPR) and ECC in a cardiac arrest following deep accidental hypothermia.

A 42-year-old man was found unresponsive to external stimuli and pulseless at an outdoor temperature of 1°C. CPR was started at the scene by laypersons, and the emergency medical services (EMS) arrived 5 minutes after the emergency call. Resuscitation according to International Liaison Committee on Resuscitation (ILCOR) guidelines was initiated by EMS. The first recorded rhythm was ventricular fibrillation (VF), which persisted, despite repeated defibrillation. The patient showed signs of severe hypothermia and, during ongoing CPR, was transported to hospital where on arrival the patient's rectal temperature was measured at 22°C. Resuscitation measures were continued and warming was started at the emergency room. Due to persistent VF and deep hypothermia, the patient was transferred to a cardiothoracic surgical unit for rewarming with ECC. At commencement of ECC, CPR had been going for approximately 130 minutes and a total of 38 defibrillations had been made. During this time interval the patients was pulseless. At a core temperature of 30°C, one defibrillation restored sinus rhythm and subsequently stable circulation was achieved. The patient received a further 24 hours of hypothermia treatment at 32-34°C. He was discharged to rehabilitation facilities after 3 weeks of hospital care. Three months after the cardiac arrest the patient was fully recovered, was back to work, and had resumed normal activities.

We demonstrate a case of cardiac arrest due to deep accidental hypothermia that stresses the importance of effective CPR and early-stage consideration of the use of ECC for safe and effective rewarming.