Submersion, accidental hypothermia and cardiac arrest, mechanical chest compressions as a bridge to final treatment: a case report
© Friberg and Rundgren; licensee BioMed Central Ltd. 2009
Received: 13 October 2008
Accepted: 20 February 2009
Published: 20 February 2009
Three young men were trapped in a car at the bottom of a canal at two meters depth, after losing control of their vehicle. They were brought up by rescue divers and found in cardiac arrest. One of three patients had return of spontaneous circulation (ROSC), at 47 min after the accident. This sole survivor had the longest submersion time of the three and he received continued mechanical chest compressions during transportation to the hospital. His temperature at admission was 26.9°C, he was rewarmed to 33°C and kept there for 24 h, followed by continued rewarming to normothermia. On day three, he woke up from coma and was discharged from the intensive care unit after one week. At follow-up six months later, he had a complete cerebral recovery but still had myoclonic twitches in the lower extremities. A mechanical device facilitates chest compressions during transportation and may be beneficial as a bridge to final treatment in the hospital. We recommend that comatose patients after submersion, accidental hypothermia and cardiac arrest are treated with mild hypothermia for 12–24 h.
Submersion with cardiac arrest is a great challenge to our prehospital rescue teams. First, rescue divers must bring the victims to the surface, followed by cardiopulmonary resuscitation (CPR) and transportation to a hospital. Submersion time, water temperature and prompt resuscitation seem to be crucial factors for outcome, and so do age and time for the rescue team to arrive on scene [1, 2]. Submersion in cold water and subsequent accidental hypothermia may be beneficial [3, 4], if circulation can be restored. There are no randomized, controlled trials (RCT) evaluating care of submersion patients since, luckily, the victims are few. We report a case of successful resuscitation after using mechanical chest compressions in a patient with cardiac arrest due to hypothermia caused by submersion.
A cold Saturday night in mid March, the driver of a car lost control and the car went over the barrier and through the ice into a canal. The accident occurred in a densely populated area in southern Sweden and was observed by several people. Rescue divers and ambulance staff were immediately notified and were on the scene 11 min later. Within another 10 min, three young men, trapped in the backseat of the car at a depth of two meters, had been rescued; all three were pulseless with asystolic cardiac arrest. CPR was immediately initiated in all three, one was transported to the local hospital with ongoing manual chest compressions but never had return of spontaneous circulation (ROSC), and was eventually declared dead. Two patients were transported to Lund University Hospital with ongoing CPR (patient 1 and 2), a 15 min drive away.
Patient characteristics (all time measures in min).
Rescue team on scene
Time to CPR
Time to ROSC
Outcome 6 months
Initial pH (α-stat)
In this report, three formerly healthy young men were rescued with pulseless asystole and severe accidental hypothermia after submersion in cold water; one regained spontaneous circulation and eventually recovered fully. All three were treated by the same prehospital team and the only survivor was the last one to be brought up by the rescue divers. The two patients who were taken to our hospital both had initial mask ventilation, both were intubated with approximately 10 min interval, followed by controlled ventilation. One had initially manual (patient 1) and the other continued mechanical (patient 2) chest compressions.
Why only patient 2 regained circulation can only be speculated on; one reason may be that his airway was secured at an earlier time than patient 1. The potential benefit of younger age in cases of accidental hypothermia and submersion has been addressed , but age did not differ between the survivor and the non-survivors in this report. Another reason may be that early and uninterrupted mechanical chest compressions in our survivor made a difference. There are experimental studies and case reports supporting a beneficial effect of mechanical chest compressions [9, 10], but there are no RCTs supporting its use [11–13]. However, it has been shown that "hands-off time" is shorter and compression quality is improved when a mechanical device is used during transportation [14, 15]. On arrival in the ER, both patients had a severe combined acidosis, a marker of a bad outcome . Once ROSC was established in our survivor and a CT-scan had excluded major trauma, controlled rewarming to 33°C and therapeutic hypothermia for 24 h was performed, using a femoral catheter and an external temperature control device. The use of CPB in assisting circulation and for controlled rewarming has been recognized as the method of choice in this situation [17, 18], and was also considered in our patient(s). Due to a limited 24 h access to CPB capacity, even in a university hospital, an intravenous catheter and an external temperature control device may be used as an alternative method for controlled rewarming in patients with ROSC. In our patient, rewarming was stopped at 33°C and the temperature kept stable for 24 h, which is in compliance with existing guidelines, stating that therapeutic hypothermia may be considered for patients with initial non-shockable rhythms . A similar case with accidental hypothermia (without submersion), cardiac arrest and prolonged resuscitation including mechanical chest compressions during transportation, was recently highlighted .
Submersion victims with accidental hypothermia and cardiac arrest should be treated according to existing CPR guidelines. A mechanical chest compression device facilitates chest compressions during transportation and may be beneficial as a bridge to final treatment in the hospital. Accidental hypothermia must be corrected, if possible in a hospital with CPB capacity. We recommend that rewarming should be stopped at 33°C in comatose patients, followed by 12–24 h treatment before continued rewarming to normothermia.
Written informed consent was obtained from the surviving patient for publication of this case report, and from next of kin of the two casualties. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Region Skane (HF) and Lund University Hospital (HF, MR), Sweden
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