Successful treatment of severe accidental hypothermia with cardiac arrest for a long time using cardiopulmonary bypass - report of a case

In the clinical setting, it is often difficult to determine whether hypoxia associated with submersion or severe accidental hypothermia associated with immersion is the cause of cardiac arrest due to drowning. We here report the case of a patient who developed prolonged cardiac arrest because of drowning in the sea, a situation in which one is stumped concerning resuscitation. Using cardiopulmonary bypass (CPB), resuscitation was achieved, and the patient had no neurological deficits.In June 2008, a 57-year-old male was found drifting in the sea at 08:07 a.m. The seawater temperature was 12°C. Emergency medical technicians confirmed his cardiac arrest at the port at 08:28 a.m., and his electrocardiogram showed asystole. He was brought to our emergency department (ED) at 08:51 a.m. A core body temperature of 22.0°C was registered in the rectum, and his pupils were fixed and dilated (Figure 1). Although we continued standard CPR with tracheal intubation and external rewarming using warmed infusions and radiant heat, the patient's temperature remained at 22.8°C 30 min after arrival. In addition, sputum comprising massive bubbles resembling seawater was evident in his endotracheal tube. Because he had been in cardiac arrest for at least 90 min, we were stumped about whether to continue resuscitation or not at that time. However, we found that spontaneous slight gasping breathing without a pulse and chest compressions appeared at 09:24 a.m. We then decided to apply CPB (cannulated from right femoral vessels) for rewarming and circulation because we suspected that the cause of his cardiac arrest was severe accidental hypothermia rather than hypoxia due to drowning. After we started CPB at 09:55 a.m., although his electrocardiogram showed asystole at first, it changed to ventricular fibrillation (VF) of low amplitude as his temperature rose, and its amplitude slowly increased. His condition changed from VF into sinus rhythm without defibrillation at the time point when his