X-Message-Number: 21347 From: Randy <> Subject: cold water drowning and revival citation Date: Tue, 04 Mar 2003 22:29:00 -0600 References: <> In case anyone is interested in finding source for the cold water revival phenomenon, here is a writeup of a case in the British medical journal Lancet: from: http://www.thelancet.com/search/search.isa excerpts below: Resuscitation from accidental hypothermia of 13 7 C with circulatory arrest Mads Gilbert, Rolf Busund, Arne Skagseth, Paul ge Nilsen, Jan P Solb In a victim of very deep accidental hypothermia, 9 h of resuscitation and stabilisation led to good physical and mental recovery. This potential outcome should be borne in mind for all such victims. Mortality from deep accidental hypothermia with circulatory arrest remains high, despite improved prehospital survival, rewarming techniques in hospital, and new types of heart and lung assistance.1,2 The lowest temperature reported in a survivor of accidental hypothermia is 14 4 C in a child.3 Long-term survival of up to 33% with minimum cerebral impairment after accidental deep hypothermia (core temperature <28 C) with circulatory arrest has been reported in young healthy adults.4 Our hospital uptake area in Norway is sparsely populated and subarctic. In several cases of accidental deep hypothermia we have used continuous prehospital cardiopulmonary resuscitation (CPR), air-ambulance evacuation, and rewarming with emergency cardiopulmonary bypass. No adult patient has yet survived to discharge, despite initial re-establishment of a perfusing cardiac rhythm and normalised organ function. Death has been due to progressive uncontrollable systemic oedema with pulmonary insufficiency and fatal brain swelling. On May 20, 1999, at 1820 h, an experienced female off-piste skier aged 29 years fell while skiing down a waterfall gully. She and her two companions were junior registrars at the local hospital, trained in CPR, and equipped for extreme conditions. The woman became wedged between rocks and overlying thick ice, and the space was continuously flooded by icy water. Her skis prevented her from sliding and served as a grip by which her two companions tried to extract her. 7 min later, her friends called the emergency medical dispatch centre at Narvik Hospital by mobile telephone. The woman struggled under the ice for 40 min. At 1900 h she had stopped moving. At 1939 h rescue teams arrived. They cut a hole in the ice downstream and removed her from the water, at which time she was clinically dead. Basic CPR was started immediately. An air ambulance arrived at 1956 h, bringing a rescuer and an anaesthesiologist who performed oral endotracheal intubation, ventilated her with 100% oxygen, and winched her into the helicopter. CPR and positive-pressure manual ventilation bag-to-tube was continued during the 1 h flight to Troms University Hospital. They arrived at 2110 h. The patient was immediately taken to the operating room. She had no spontaneous respiration or circulation, her pupils were widely dilated and unresponsive to light. Electrocardiography was isoelectric. Separate electronic pharyngeal and rectal temperature probes measured initial temperature as 14 4 C. An arterial blood sample showed normal serum potassium and oxygenation, moderate hypercarbia, and severe metabolic acidosis (table). Foamy pink fluids streamed from the endotracheal tube. A team of cardiac surgeons, anaesthesiologists, perfusionists, and specialised nurses continued CPR with 100 120 external chest compressions and 15 20 ventilations per min, while the patient was prepared for cardiopulmonary bypass by femoral access, using a fully heparin-coated system. Systolic arterial blood pressure was around 75 mm Hg measured at a femoral-artery catheter during CPR. Full cardiopulmonary bypass bloodflow was reached at 2150 h. Rectal temperature decreased to 13 7 C at 2152 h. Mean arterial pressure was kept at 50 mm Hg; cardiopulmonary bypass flow started at 0 5 L/min and increased to 3 5 L/min as the venous return improved. ..... Home Search Journal Simple Results Text Volume 355, Number 9201 29 January 2000 Research letters Resuscitation from accidental hypothermia of 13 7 C with circulatory arrest Mads Gilbert, Rolf Busund, Arne Skagseth, Paul ge Nilsen, Jan P Solb In a victim of very deep accidental hypothermia, 9 h of resuscitation and stabilisation led to good physical and mental recovery. This potential outcome should be borne in mind for all such victims. Mortality from deep accidental hypothermia with circulatory arrest remains high, despite improved prehospital survival, rewarming techniques in hospital, and new types of heart and lung assistance.1,2 The lowest temperature reported in a survivor of accidental hypothermia is 14 4 C in a child.3 Long-term survival of up to 33% with minimum cerebral impairment after accidental deep hypothermia (core temperature <28 C) with circulatory arrest has been reported in young healthy adults.4 Our hospital uptake area in Norway is sparsely populated and subarctic. In several cases of accidental deep hypothermia we have used continuous prehospital cardiopulmonary resuscitation (CPR), air-ambulance evacuation, and rewarming with emergency cardiopulmonary bypass. No adult patient has yet survived to discharge, despite initial re-establishment of a perfusing cardiac rhythm and normalised organ function. Death has been due to progressive uncontrollable systemic oedema with pulmonary insufficiency and fatal brain swelling. On May 20, 1999, at 1820 h, an experienced female off-piste skier aged 29 years fell while skiing down a waterfall gully. She and her two companions were junior registrars at the local hospital, trained in CPR, and equipped for extreme conditions. The woman became wedged between rocks and overlying thick ice, and the space was continuously flooded by icy water. Her skis prevented her from sliding and served as a grip by which her two companions tried to extract her. 7 min later, her friends called the emergency medical dispatch centre at Narvik Hospital by mobile telephone. The woman struggled under the ice for 40 min. At 1900 h she had stopped moving. At 1939 h rescue teams arrived. They cut a hole in the ice downstream and removed her from the water, at which time she was clinically dead. Basic CPR was started immediately. An air ambulance arrived at 1956 h, bringing a rescuer and an anaesthesiologist who performed oral endotracheal intubation, ventilated her with 100% oxygen, and winched her into the helicopter. CPR and positive-pressure manual ventilation bag-to-tube was continued during the 1 h flight to Troms University Hospital. They arrived at 2110 h. The patient was immediately taken to the operating room. She had no spontaneous respiration or circulation, her pupils were widely dilated and unresponsive to light. Electrocardiography was isoelectric. Separate electronic pharyngeal and rectal temperature probes measured initial temperature as 14 4 C. An arterial blood sample showed normal serum potassium and oxygenation, moderate hypercarbia, and severe metabolic acidosis (table). Foamy pink fluids streamed from the endotracheal tube. A team of cardiac surgeons, anaesthesiologists, perfusionists, and specialised nurses continued CPR with 100 120 external chest compressions and 15 20 ventilations per min, while the patient was prepared for cardiopulmonary bypass by femoral access, using a fully heparin-coated system. Systolic arterial blood pressure was around 75 mm Hg measured at a femoral-artery catheter during CPR. Full cardiopulmonary bypass bloodflow was reached at 2150 h. Rectal temperature decreased to 13 7 C at 2152 h. Mean arterial pressure was kept at 50 mm Hg; cardiopulmonary bypass flow started at 0 5 L/min and increased to 3 5 L/min as the venous return improved. -------------------------------------------------------------------------------- On admission After 5 min On CPB with Just before Just after Worst values First values on First values in to operating on CPB cardiac perfusing CPB stopped CPB stopped without CPB connection intensive care room rhythm to ECMO Time 2120 h 2155 h 2215 h 0028 h 0049 h 0322 h 0445 h 0600 h pH 6 65 6 54 6 64 7 14 7 10 7 00 7 30 7 29 PaCO2 (kPa) 7 7 11 4 8 7 4 6 6 7 12 0 4 5 4 5 PaO2 (kPa) 64 8 11 0 10 2 26 5 6 0 7 06 70 1 73 0 Base deficit 27 27 27 15 14 8 8 8 Haemoglobin (g/L) 15 7 13 1 12 2 7 4 9 6 8 1 10 2 9 3 Glucose (mmol/L) . . . . 30 9 . . . . . . 15 3 . . Potassium (mmol/L) 4 3 8 2 6 7 4 2 4 0 3 4 3 6 3 1 Pharyngeal temperature ( C) 14 4 18 2 25 0 37 6 37 4 . . . . . . Rectal temperature ( C) 14 4 13 7 14 2 36 0 36 4 . . . . . . CPB=cardiopulmonary bypass; ECMO=extracorporeal membrane oxygenator; PaCO2=partial pressure of carbon dioxide; PaO2=partial pressure of oxygen. Blood chemistry values during CPR and rewarming -------------------------------------------------------------------------------- A maximum temperature gradient of 10 C was maintained between the woman's venous blood and the heat exchanger of the cardiopulmonary-bypass machine. At 2200 h, ventricular fibrillation started, which converted spontaneously to a pulse-generating cardiac rhythm after 15 min. Rectal tempurature remained at 14 2 C, whereas pharyngeal and oesophageal temperature had increased to 25 0 C and 31 5 C, respectively. We performed chest drainage followed by a median sternotomy because of bleeding from a lesion in the left subclavian artery caused by previous cannulation of the subclavian vein. The lesion was sutured directly. We disconnected the patient from cardiopulmonary bypass after 179 min. At 170 min, the patient's rectal temperature had reached 36 0 C. Because of increasing cardiorespiratory insufficiency, we placed new cannulas in the patient's femoral vein and artery and she was connected to an extracorporeal membrane oxygenator (ECMO). She was transferred to the intensive-care unit after 9 h of resuscitation, rewarming, and stabilisation, and remained there for 28 days. ECMO was needed for 5 days, during which time several organ dysfunctions developed that required, in addition to ECMO, haemodiafiltration and respiratory support. Transitory haemorrhagic diathesis, atrophic gastritis, ischaemic colitis, and polyneuropathy also occurred. After intravenous sedation was stopped, the patient was mentally alert with adequate responses and spontaneously moved three of four extremities. After an unsuccessful extubation on day 11, she was tracheotomised and remained on a ventilator for 35 days, partly because of critical illness polyneuropathy. She was transferred to her local hospital by air ambulance on day 28 and moved to a rehabilitation unit on day 60. At follow-up, 5 months after the accident, she had residual partial pareses of the upper and lower extremities that was improving. Her mental function was excellent and she was gradually returning to work. She had also resumed hiking and skiing. Victims of very deep accidental hypothermia with circulatory arrest should be seen as potentially resuscitable with a prospect of full recovery. Reliable prognostic markers are unclear after cold-water immersion.5 An optimum mechanism of cooling (whole-body cooling with subsequent circulatory arrest instead of warm hypoxic arrest followed by cooling), rapid prehospital response, continuous CPR, and rapid extracorporeal blood rewarming may improve outlook. We thank the first responders, Marie L Falkenberg and Torvind O N sheim; the staff at Narvik Emergency Medical Dispatch Centre (AMK) and Narvik Rescue Centre (police); St le Mikalsen, Anita Kjelstrup, Gunnar Farstad, Jon Sennevik, Nils Elby, Ingebrigt Kjelstad, the crew of Sea King rescue and the air ambulance; the staff at Troms Emergency Medical Dispatch Centre (AMK); and the staff in the operating room, intensive-care unit, departments of anaesthesia, surgery, neurology, biomedicine, and social services. 1 Kornberger E, Mair P. Important aspects in the treatment of severe accidental hypothermia: the Innsbruck experience. J Neurosurg Anesth 1996; 8: 83 87. [PubMed] 2 Bjertnaes L, Vaage J, Almdahl SM, et al. Extracorporeal membrane oxygenation (ECMO) as lung or heart assist. Acta Anaesth Scand 1996; 40: 293 301. [PubMed] 3 Lloyd EL. Accidental hypothermia. Resuscitation 1996; 32: 111 24. [PubMed] Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=21347