In patients with cardiac arrest from accidental hypothermia patients should be transported during ongoing CPR to a hospital with ability to perform "bypass" rewarming.
Most in-hospital deaths in this group is probably because rewarming does not lead to spontaneous circulation, but data is scarce. However, patients may also die after successful rewarming with return of circulation. We have experienced death several days later from sudden development of cerebral oedema and tamponade. This has led us to question the common practice of rapid rewarming to normothermia and extubation.
Should we expand our ICU treatment by controlling the temperature for 2-3 days, aiming for temperature target 34-35 oC and sedation/controlled ventilation before "waking" up? Should we increase the level of neuromonitoring as a routine in the ICU in such patients?
What are your experiences (if any) and views?
Dear Hans
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Many hypothermic patients have severe infections or other life-threatening illnesses. Patients with "uncomplicated" hypothermia (often due purely to cold exposure) have a fairly low mortality rate; patients with significant associated diseases have a much worse prognosis. ln terms of ultimate outcome, the underlying disease process is far more important than the initial temperature or the rewarming method chosen.
Therefore, evaluation and treatment must include a search for associated diseases as well as management of the hypothermia itself.
If asphyxia or near-drowning precedes the development of hypothermia, the prognosis is very poor. If asphyxia has not occurred, the protective effect of hypothermia may have an important influence on prognosis. Decreased oxygen requirements can protect the brain and other organs against anoxic and ischemic damage. This means that the usual criteria indicating death or irreversibility of disease are not valid in the hypothermic patient, who may even survive prolonged cardiac arrest without neurologic sequelae.
Tintinalli's Emergency Medicine(2011), Section16: Environmental Injuries, Chapter203: Hypothermia, Page 1338.
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