Introduction
On June 23, 2012 in southern France, a group of friends celebrated the end of the school year. The external temperature was 28°C, and the water temperature was 18°C. An 18-year-old woman (weight, 52.5 kg; height, 165 cm; BMI, 19.3 kg/m2) entered the sea at 11:15 pm.
Report
Following is a chronological report of the case:
11:28 pm: The dispatch center of emergency service (SAMU: Service d'Aide Médicale Urgente) received an emergency call from the victim's friends because they could not find her.
11:56 pm: Rescue team searched for the patient on the beach and in the sea.
12:43 am: After a 47-minute search, the victim was found in the sea, floating on her back, 50 meters from the beach. She was unconscious without vital signs, with a Glasgow Coma Scale of three points. Basic life support was provided by the rescue team. Pads of the automated external defibrillator (Lifepak, Medtronic, Minneapolis, Minnesota USA) were connected to the patient and confirmed cardiopulmonary arrest. The electrocardiogram (ECG) was isoelectric (Figure 1.1).
Printout from automated external defibrillator to record prehospital management. Elapsed time is shown in hours and minutes.
Abbreviation: CPR, cardiopulmonary resuscitation
12:46 am: Ventricular fibrillation appeared and defibrillation failed (Figure 1.4).
1:00 am: Return of spontaneous circulation and significant bradycardia (Figures 1.6 and 1.7).
1:21 am: French medical ambulance service (SMUR: Service Mobile d'Urgence et de Réanimation) was on site. The patient was endotracheally intubated and received 5 mg/h of midazolam and 150 μg/h of fentanyl intravenously (IV). Heart rate was approximately 50 bpm with Osborn waves (Figure 1.8).
1:44 am: The ECG demonstrated atrial fibrillation with bradycardia, ventricular extrasystole and Osborn waves (Figure 2).
Electrocardiogram Demonstrating Atrial Fibrillation with Bradycardia, Ventricular Extrasystole and Osborn Waves
2:45 am: The patient was admitted to the intensive care unit (ICU) with an initial central temperature of 28°C, Spo2 = 88% (Fio2 = 100%). The patient received active internal (warm intravenous fluids) and external (Bair Hugger, Arizant Healthcare Inc., Eden Prairie, Minnesota USA) rewarming.
4:15 am: Patient's arterial blood gases showed the following: pH = 7.04; Pco2 = 2.68; kPa, Po2 = 12.75; kPa, Hco3 = 7.8 mmol/L; Pao2/Fio2 = 180; lactate = 12.57 mmol/L; alcohol = 1.37 g/L; Na = 154 mmol/L; Cl = 129 mmol/L; K = 4.3 mmol/L; creatinine = 72 μmol/L; urea = 4.5 mmol/L; GB = 19,400 G/L; PT = 54%; glycemia = 2.38 g/dL; ASAT = 89 UI/L; ALAT = 54 UI/L; and creatinine phosphokinase = 619 UI/L.
Following rewarming, the patient was intentionally kept hypothermic at 34°C for the first 24 hours. Sedation was discontinued on the second day, and was followed by extubation. The patient gradually regained consciousness the following day. After three days of treatment in the ICU, the patient was transferred to an ordinary ward without cerebral dysfunction except for some myoclonus of the right wrist (posthypoxic myoclonus type Lance-Adams syndrome).
Discussion
Several cases with accidental hypothermia and successful resuscitation are documented. The mechanisms leading to hypothermia were, in most reported cases, submersion, immersion, or avalanche accidents. The lowest body temperature documented with successful resuscitation was 13.7°C.Reference Gilbert, Busund, Skagseth, Nilsen and Solbø1 Three hundred eighty-five minutes is the longest time reported until the return of spontaneous circulation and recovery without physical or mental sequelae after hypothermic cardiac arrest.Reference Hagiwara, Yamada and Furukawa2 Different prognostic factors were identified for patients with hypothermia. A fast cooling process without hypoxia or asphyxia offers the best prognosis.Reference Walpoth, Walpoth-Aslan and Mattle3 Submersion time, water temperature, and prompt resuscitation seem to be crucial factors associated with outcome, as well as victim age and the time for the rescue team to arrive on the scene.Reference Claesson, Svensson, Silfverstolpe and Herlitz4 Submersion in cold water and subsequent accidental hypothermia may be beneficial,Reference Claesson, Svensson, Silfverstolpe and Herlitz4 if circulation can be restored. More significant is the serum potassium level in asystolic patients (4.3 mmol/L in this case). A blood pH ≤7 is a poor prognostic sign. A low arterial oxygen pressure provides an early indication that water has been inhaled with the attendant risk of pulmonary edema. The presence of ventricular fibrillation is an adverse sign and responds poorly to defibrillation when the core temperature is below 28°C. The circulation must be supported by chest compression until further attempts can be made when the core temperature has been raised above this level.Reference Szpilman, Bierens, Handley and Orlowski5
Conclusion
To the best of the authors’ knowledge, this is the only case of cardiac arrest with severe hypothermia, then return of spontaneous circulation, documented with an automated external defibrillator recording. The hypothermia occurred during summer heat. After three days, the patient recovered successfully from cardiopulmonary arrest, without important cerebral dysfunction.
