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Cardiac arrest in accidental hypothermia: Work the patient or don’t start resuscitation?

Follow the mantra “a patient isn’t dead unless they are warm and dead” based on assessment findings and knowing resuscitation contraindications

A wrongful death lawsuit for failing to initiate resuscitative efforts was filed against EMS providers by the family of Jake Anderson in late 2016. According to publicly available news sources, Anderson, 19, was found unconscious with no apparent signs of life in freezing temperatures and declared dead with no interventions or transport to a hospital.

The plaintiff is alleging that the responders failed to perform an assessment, failed to follow their own policy and procedures for hypothermia victims in cardiac arrest and essentially abandoned the patient contributing to his death. We will never be able to say with any certainty that resuscitative efforts would have revived Anderson nor do we know all the facts surrounding the case, but for discussion’s sake, would you have initiated treatment and transport?

From a medical standpoint, the long-held mantra that one isn’t dead until they’re warm and dead was recently supported in the journal Resuscitation by Hilmo and colleagues. In this review, “Nobody is dead until warm and dead": Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas — A retrospective study from northern Norway, Hilmo et al describe their experience successfully resuscitating victims who were down for almost seven hours and one patient who had a core body temperature of 13.7 C (56.6 F). Other interesting results include:

  • Although overall mortality remains high, survivors had surprisingly good neurologic outcomes with favorable overall quality of life.
  • There are no great prehospital predictors of survival, so boldly initiating resuscitation in the absence of contraindications is still warranted.
  • Contraindications to resuscitation include:
    - Avalanche burial >35 minutes with airway packed with snow and initial rhythm of asystole
    - Asphyxiation
    - Hyperkalemia (>12 mmol/L)
    - Hypothermia that occurred after cardiac arrest
    - Obvious mortality such as body decomposition, decapitation, truncal transection, frozen solid chest wall
  • Manner of hypothermia (water, wind/air, snow) had no impact on survival rates.
  • Survival was associated with transport to hospitals with extracorporeal rewarming capabilities

In EMS systems where hospitals with extracorporeal rewarming capabilities are distant, stopping at a smaller hospital en route to check the patient’s serum potassium level is also something to consider.

Extracorporeal life support or ECMO has truly changed the survivability curve in victims of accidental hypothermia. Because determining patient viability in the field is next to impossible in the absence of obvious mortality described above, current science supports the initiation of treatment and transport for patients in cardiac arrest due to accidental hypothermia.

David K. Tan, MD, EMT-T, FAEMS, is associate professor and chief of EMS in the division of emergency medicine at Washington University School of Medicine in St. Louis. He is double board-certified in Emergency Medicine and EMS Medicine by the American Board of Emergency Medicine. Dr. Tan remains very active in EMS at the local, state and national levels as an operational medical director for local police, fire and EMS agencies. He is chairman of the Metropolitan St. Louis Emergency Transport Oversight Commission, vice-chairman of the Missouri State Advisory Council on EMS, and president of the National Association of EMS Physicians. Dr. Tan is a member of the EMS1 Editorial Advisory Board. He also provides medical direction to and the EMS1 Academy.