Elsevier

Resuscitation

Volume 83, Issue 9, September 2012, Pages 1078-1084
Resuscitation

Clinical paper
Outcome of accidental hypothermia with or without circulatory arrest: Experience from the Danish Præstø Fjord boating accident

https://doi.org/10.1016/j.resuscitation.2012.05.009Get rights and content

Abstract

Background

Resuscitation guidelines for the treatment of accidental hypothermia are based primarily on isolated cases. Mortality rates are high despite aggressive treatment aimed at restoring spontaneous circulation and normothermia.

Methods

The present report is based on a boating accident where 15 healthy subjects (median age 16 (range 15–45) years) were immersed in 2 °C salt water. Seven victims were recovered in circulatory arrest with a median temperature of 18.4 °C (range 15.5–20.2 °C). They were all rewarmed with extracorporeal membrane oxygenation (ECMO) and were subsequently evaluated with advanced neuroradiological and functional testing. The remaining 7 had established spontaneous circulation without the use of ECMO. One victim drowned in the accident.

Results

The victims that survived the accident without circulatory arrest were predominantly females with a higher body mass index. Victims with circulatory arrest pH on arrival was a median of 6.61 (range 6.43–6.94), with ECMO being established a median of 226 (178–241) min after the accident. Magnetic resonance spectroscopy showed neuronal dysfunction in five. In five victims initial normal white matter spectra progressed to show evidence of abnormal axonal membranes. Based on the seven-level Functional Independence Measure test functional outcome was good in six circulatory arrest victims and in all without circulatory arrest. Mild to moderate cognitive dysfunction was seen in six and severe dysfunction in one circulatory arrest victim.

Conclusion

Seven patients with profound accidental hypothermic circulatory arrest were successfully resuscitated using a management approach that included extracorporeal rewarming, followed by successive periods of therapeutic hypothermia and sedated normothermia and intensive neurorehabilitation. Seven other hypothermic victims (core temperature as low as 23 °C) that did not suffer circulatory arrest also survived the accident.

Section snippets

Methods

The study is based on 13 healthy (7 boys, 6 girls aged 15–17 years) students at a continuation high school, and two adult teachers (a 33 year old female that survived the accident and a 44 year old male who drowned). Victims and/or victim's parents provided informed consent to publication of this report.

The accident occurred February 11, 2011 on a 20 km2 fjord with a depth of 2–5 m. On the day of the accident the air temperature was 4 °C, the wind speed was 7 m/s, the water temperature was 2 °C, and

Results

Among the seven victims with circulatory arrest the first recorded temperature was a median of 18.4 °C (15.5–20.2 °C). All victims were pulseless with dilated pupils unresponsive to light (Table 1). Arterial blood gases analysed according to the Alpha-Stat principle demonstrated severe metabolic acidosis in all with a median pH of 6.61 (6.43–6.94), and lactate concentration a median of 21.0 mmol/l (9.4–24.0 mmol/l) (Table 1 and Fig. 2A). Six victims were weaned from ECMO when return of spontaneous

Discussion

The present analysis of a boating accident involving 13 teenagers and 2 adults provides a unique insight into the development of accidental profound hypothermia and 6-month outcomes. As opposed to previously reported individual case reports/case series, this report is able to describe an entire population, minimizing publication bias. In the group with circulatory arrest a regimen of extracorporeal rewarming followed by therapeutic hypothermia and normothermia with sedation and supportive

Conflict of interest statement

No conflict of interest exists for any of the authors.

Acknowledgements

We are indebted to the emergency physicians, paramedics, search and rescue teams and volunteers taking part in the rescue action on February 11, 2011, as well as the emergency staff at the primary care centres involved in the rescue and referral of victims to the tertiary centres. All provided an extraordinary effort that is the direct cause of the exceptionally high survival rate.

Contributors: Michael Wanscher contributed for the drafting of manuscript, participation in the collection of data;

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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.05.009.

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