Cardiac Arrest in Accidental Hypothermia

Unintentional or accidental hypothermia is a serious and preventable health problem. Severe hypothermia (body temperature <30°C [86°F]) is associated with marked depression of critical body functions, which may make the victim appear clinically dead during the initial assessment. Therefore, lifesaving procedures should be initiated unless the victim is obviously dead (eg, rigor mortis, decomposition, hemisection, decapitation). The victim should be transported as soon as possible to a center where aggressive rewarming during resuscitation is possible.

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Initial Care for Victims of Accidental Hypothermia

When the victim is extremely cold but has maintained a perfusing rhythm, the rescuer should focus on interventions that prevent further loss of heat and begin to rewarm the victim immediately. Additional interventions include the following:

Prevent additional evaporative heat loss by removing wet garments and insulating the victim from further environmental exposures. Passive rewarming is generally adequate for patients with mild hypothermia (temperature >34°C [93.2°F]).

For patients with moderate (30°C to 34°C [86°F to 93.2°F]) hypothermia with a perfusing rhythm, external warming techniques are appropriate.1 Passive rewarming alone will be inadequate for these patients.2

For patients with severe hypothermia (<30°C [86°F]) with a perfusing rhythm, core rewarming is often used, although some have reported successful rewarming with active external warming techniques.3,4 Active external warming techniques include forced air or other efficient surface-warming devices.

Patients with severe hypothermia and cardiac arrest can be rewarmed most rapidly with cardiopulmonary bypass.1,5-10 Alternative effective core rewarming techniques include warm-water lavage of the thoracic cavity8,11-15 and extracorporeal blood warming with partial bypass.16-18

Adjunctive core rewarming techniques include warmed IV or intraosseous (IO) fluids and warm humidified oxygen.19 Heat transfer with these measures is not rapid, and should be considered supplementary to active warming techniques.

Do not delay urgent procedures such as airway management and insertion of vascular catheters. Although these patients may exhibit cardiac irritability, this concern should not delay necessary interventions.

Beyond these critical initial steps, the treatment of severe hypothermia (temperature <30°C [86°F]) in the field remains controversial. Many providers do not have the time or equipment to assess core body temperature or to institute aggressive rewarming techniques, although these methods should be initiated when available.

BLS Modifications

When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect,20,21 and the ECG may even show asystole. If the hypothermic victim has no signs of life, begin CPR without delay. If the victim is not breathing, start rescue breathing immediately.

The temperature at which defibrillation should first be attempted in the severely hypothermic patient and the number of defibrillation attempts that should be made have not been established. There are case reports of refractory ventricular arrhythmias with severe hypothermia; however, in a recent animal model it was found that an animal with a temperature of as low as 30°C had a better response to defibrillation than did normothermic animals in arrest.22,23

If VT or VF is present, defibrillation should be attempted. If VT or VF persists after a single shock, the value of deferring subsequent defibrillations until a target temperature is achieved is uncertain.

It may be reasonable to perform further defibrillation attempts according to the standard BLS algorithm concurrent with rewarming strategies. (Class IIb, LOE C)

To prevent further loss of core heat, remove wet garments and protect the victim from additional environmental exposure. Insofar as possible, this should be done while providing initial BLS therapies. Rewarming should be attempted when feasible.

ACLS Modifications

For unresponsive patients or those in arrest, advanced airway insertion is appropriate as recommended in the standard ACLS guidelines. Advanced airway management enables effective ventilation with warm, humidified oxygen and reduces the likelihood of aspiration in patients in periarrest.

ACLS management of cardiac arrest due to hypothermia focuses on aggressive active core rewarming techniques as the primary therapeutic modality. Conventional wisdom indicates that the hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation; however, the data to support this are essentially theoretical.24 In addition, drug metabolism may be reduced, and there is a theoretical concern that medications could accumulate to toxic levels in the peripheral circulation if given repeatedly to the severely hypothermic victim. For these reasons, previous guidelines suggest withholding IV drugs if the victim’s core body temperature is <30°C (86°F).

In the last decade a number of animal investigations have been performed evaluating both vasopressors and antiarrhythmic medications that could challenge some of this conventional wisdom.25-30 In a meta-analysis of these studies, Wira et al31 found that vasopressor medications (ie, epinephrine or vasopressin) increased rates of return of spontaneous circulation (ROSC) when compared with placebo (62% versus 17%; P<0.0001, n=77). Coronary perfusion pressures were increased in groups that received vasopressors compared with placebo. But groups given antiarrhythmics showed no improvement in ROSC when compared with control groups, although sample sizes were relatively small (n=34 and n=40, respectively).

One small-animal investigation suggested that the application of standard normothermic ACLS algorithms using both drugs (ie, epinephrine and amiodarone) and defibrillation improved ROSC compared with a placebo arm of defibrillation only (91% versus 30%; P<0.01; n=21). Human trials of medication use in accidental hypothermia do not exist, although case reports of survival with use of intra-arrest medication have been reported.9,13,32

Given the lack of human evidence and relatively small number of animal investigations, the recommendation for administration or withholding of medications is not clear.

It may be reasonable to consider administration of a vasopressor during cardiac arrest according to the standard ACLS algorithm concurrent with rewarming strategies. (Class IIb, LOE C)

After ROSC

After ROSC, patients should continue to be warmed to a goal temperature of approximately 32° to 34°C; this can be maintained according to standard postarrest guidelines for mild to moderate hypothermia in patients for whom induced hypothermia is appropriate. For those with contraindications to induced hypothermia, rewarming can continue to normal temperatures.

Because severe hypothermia is frequently preceded by other disorders (eg, drug overdose, alcohol use, or trauma), the clinician must look for and treat these underlying conditions while simultaneously treating hypothermia.

Withholding and Cessation of Resuscitative Efforts

Multiple case reports indicate survival from accidental hypothermia even with prolonged CPR and downtimes.5,17 Thus, patients with severe accidental hypothermia and cardiac arrest may benefit from resuscitation even in cases of prolonged downtime and prolonged CPR. Low serum potassium may indicate hypothermia, and not hypoxemia, as the primary cause of the arrest.33 Patients should not be considered dead before warming has been provided.


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Cardiac Arrest in Accidental Hypothermia