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Case report Prolonged mechanical CPR of a 48-year old male patient in

severe hypothermia conducted in the emergency department -case report
Polish Annals of Medicine

Article in Polish Annals of Medicine · January 2018

DOI: 10.29089/2017.17.00004.

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Izabela Godlewska
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 Pol Ann Med. 2018;25(1):144–
147

Polish Annals of Medicine

journal homepage: httpww

Case report

Prolonged mechanical CPR of a 48-year old male patient in

severe hypothermia conducted in the emergency department –
case report

Izabela Godlewska1,7, Rakesh Jalali1,7, Elżbieta Bandurska-Stankiewicz2,7, Adam Kern3,

Lidia Glinka4,7, Joanna Manta1,7, Leszek Gromadziński5,7, Dariusz Onichimowski6,7
1
Clinical Emergency Department, Regional SPECIALIST HOSPITAL in OLSZTYn, Poland
2
Clinical Department of Endocrinology, Diabetology and Internal DISEASES, Regional SPECIALIST HOSPITAL in OLSZTYN, Poland
3
Cardiology Department, Regional SPECIALIST HOSPITAL in OLSZTYN, Poland
4
Clinical Unit of ANESTHESIOLOGY and INTENSIVE Care, UNIVERSITY HOSPITAL, OLSZTYN, Poland
5
Clinical Department of Cardiology and Internal Medicine, UNIVERSITY HOSpital, OLSZTYN, Poland
6
Clinical department of ANAESTHESIOLOGY and INTENSIVE Care, Regional SpECIALIST HOSPITAL in OLSZTYN, Poland
7
School of Medicine, Collegium Medicum, UNIVERSITY of Warmia and Mazury, OLSZTYN, Poland
article info abstract

Article history I n t r o d u c t io n : Hypothermia is still one of the major problems of modern

Received 1 June 2017 emer- gency medicine. It causes reduction in oxygen consumption by brain
Accepted 22 June 2017 tissue, which has neuro- and cardio protective effect. Most of the time, severe
Available online 2 February 2018 hypothermia leads to prolonged resuscitation resulting in decreased quality of
cardiopulmonary resu- scitation (CPR) due to the rescuers fatigue.
Keywords
Accidental hypothermia Aim: The aim of this paper is to introduce the case of prolonged resuscitation
Sudden cardiac arrest with the use of mechanical device, conducted in hypothermic patient.
Mechanical chest compressions
Gastrointestinal bleeding Case s tudy: We report a case study of 48-year-old male in severe hypother-
Resuscitation mia (19°C) and active gastrointestinal bleeding. We have conducted prolonged
Emergency department CPR for 142 minutes together with noninvasive core warming techniques that
resulted in conversion of pulseless electrical activity to ventricular fibrillation
Doi and achievement of return of spontaneous circulation. Despite proper treatment,
10.29089/2017.17.00004 patient died next day in Intensive Care Unit due to the multi-organ failure.

User license
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4.0 International License.
R es u l ts and d i sc u s s io n : Cardiac arrest in case of severe hypothermia can lead
to survival with good neurologic outcome, however prolonged cardiac arrest results
in hypoxic brain injury and severe neurological dysfunction. It is crucial to initiate
effec- tive chest compressions to maintain minimal cerebral blood flow. Mechanical
devices can be implemented in such situations in order to provide efficient CPR.

C o n c lu s i o n s : Cardiac arrest due to hypothermia can lead to extension of resu-

scitation. To improve survival of patients in situations requiring prolonged resusci-
tation, mechanical devices performing chest compressions should be implemented.
It is possible to successfully warm up hypothermic cardiac arrest patients through
 Pol Ann Med. 2018;25(1):144–
147
noninvasive methods.

CORRESPONDING author: RAKESH Jalali, Clinical Emergency Department of Regional SPECIALIST HOSPITAL in OLSZTYN,
ŻOŁNIERSKA 18, 10-561 OLSZTYN, Poland. Phone: +4889 538 62 99.
E-mail ADDRESS: RAKESH.JALALI@UWM.EDU.PL.
145 Pol Ann Med. 2018;25(1):144–
147
1. IntRoduCtIon immediately. At the same time, core body temperature was
measured and determined at 19°C (at the level of lower one
Identification and treatment of reversible causes of third of the esophagus). Simultaneously basic neurological
sudden cardiac arrest (SCA) are considered to be crucial examination was executed. Patient’s pupils were wide and
interven- tions in the algorithm of advanced life support almost not responding to light. On the Glasgow Coma Scale
(ALS).1 Po- tentially reversible causes are divided in two patient received 3 points. While starting CPR, patient was
groups: 4Hs and 4Ts (Table 1). immediately connected to a monitor which showed heart
rate of 20–30 bpm. In conjunction with the lack of pulse,
table 1. Reversible causes of cardiac arrest. mechanism of cardiac arrest was defined as pulseless elec-
trical activity (PEA). Leading cause of cardiac arrest in
4Hs 4Ts
this case was hypothermia. However, due to the presence
Hypoxia Tension pneumothorax
Hypo- or hyperkalemia and other of acidosis and hypovolemia, this patient manifested 3 of 8
Tamponade
electrolyte disorders reversible causes contributing to SCA.
Hypo- or hyperthermia
Thrombosis (coronary and ALS procedures were implemented immediately after
pulmonary)
Hypovolemia Toxins (poisoning) recognizing cardiac arrest, according to the hypothermia
protocol. In this case, we have promptly introduced both
Hypothermia is still one of the major problems of passive and active core rewarming techniques, such as
modern emergency medicine. It is estimated that about cov- ering patient’s trunk with the thermal blanket,
1500 patients suffer and die from accidental hypothermia infusing warmed fluids and bladder lavage with warm
in United States every year. 2 Poland still lacks exact data saline solu- tion. After intubation patient was
on this entity. Hypothermia causes reduction in oxygen mechanically ventilated with 100% oxygen. Chest
consumption which has neuro- and cardio protective ef- compressions were performed by load distributing band
fect. In all hypothermic patients with no fatal illness nor (LDB) mechanical device. After about 30 minutes of
lethal injury, cardiopulmonary resuscitation (CPR) resuscitation, conversion of the rhythm to VF occurred.
should be implemented and conducted until patient’s Therefore, a single defibrillation was per- formed. After
body is re- warmed. Most of the time, severe delivering shock with the energy of 200 J, no return of
hypothermia leads to pro- longed resuscitation resulting spontaneous circulation (ROSC) was achieved and
in decrease in quality due to the rescuers fatigue. table 2. Venous/Arterial blood test results in time.
Mechanical devices can be introduced to the standard
ALS algorithm while long-lasting CPR, to maintain high 10:35 12:05 1:20 3:45 9:10 5:35
a.m. p.m. p.m. p.m. p.m. a.m.
quality chest compressions.
v a a a v v
pH 7.247 7.258 7.209 7.339 7.162 7.196
2. AIm pCO2, mm Hg 64.9 42.2 53 40.1 61.2 77.2

The aim of this paper is to introduce the case of pO2, mm Hg 38.2 173.7 225.5 294 48.7 41.7
prolonged resuscitation with the use of mechanical BE, mEq/L -0.5 -8.1 -6.8 -4.3 -6.8 -0.8
device, conducted in hypothermic patient. Creatinine, mg/dL 0.8 0.8 0.9 1.1
Urea, mg/dL 56 110 96 76
APTT, s 58.8 73.3 61 40.3
3. CASE StudY
INR 3.62 5.34 4.24 1.81
Patient, 48-year old male, was brought by emergency medi- WBC, 103/mgL 1.82 1.0 2.19 1.09 2.31
cine team (EMT) to emergency department (ED) of the RBC, 106/mcL 4.25 1.33 1.92 2.89 4.69
Regional Specialist Hospital in Olsztyn, Poland. His neigh- Hgb, g/dL 10.6 3.2 5 8.2 13.7
bor found him unconscious in a garden-plot. The outside
Hct, % 34.9 11.3 16.2 25.1 40.6
temperature didn’t exceed 6°C. Patient’s body was chilled
PLT, 103/mcL 22 11 13 15 39
and his clothing was covered in clotted blood. Rescuers
managed to speak with the neighbors, who reported that the K+, mmol/L 2.8 5.4 3.4 2.5 2.95 4.73
day before patient vomited the contents reminding of the
Na , mmol/L
+
141.4 138.4 142.8 145.1 140.0 153.0
coffee grounds. Additionally, patient had history of cerebral
palsy, hypertension, heart failure NYHA IV and alcoholic Cl–, mmol/L 101.1 104.0 107.2 106.8 104.0 108.9
cardiomyopathy. He was admitted to the hospital at 10:38
a.m. in severe condition, with peripheral cyanosis. After Comments: v – venous; a – arterial; pCO2 – partial pressure
opening the airway, there were no signs of normal breath- of CO2, pO2 – partial pressure of O2, BE – base excess,
ing, only agonal gasping. Due to the lack of pulse in the APTT – ac- tivated partial thromboplastin time, INR –
major arteries and the impossibility of detection of blood international nor- malized ratio, WBC – white blood cells,
pressure (BP), cardiac arrest was diagnosed and CPR RBC – red blood cells, Hgb – hemoglobin, Hct – hematocrit,
started PLT – platelet count.
146 Pol Ann Med. 2018;25(1):144–
147
CPR (still performed by the increasing anemia, blood
4. RESultS And neuroprotective effect.
LDB device) was transfusions were initiated Although SCA in case of
continued till 1:00 p.m., (3 units of fresh frozen
dISCuSSIon
severe hypothermia can
when ROSC occurred. At plasma, 4 units of RBC lead to survival with good
Accidental hypothermia is
that time, central body concentrate, 2 units of PLT neurologic outcome,6–9
an unintentional decrease
temperature increased to con- centrate) while prolonged cardiac arrest
of core temperature to
22.6°C. Resuscitation resuscitation was still results in hypoxic brain
35°C or below which is
lasted for 142 minutes. ongoing. We have also injury and severe
most of the time caused
Results of blood tests administered proton pump neurological dysfunction.10
by environmental
pointed to the presence of inhibitors (esomeprazole a It is crucial to initiate
exposure.3 There are some
acidosis with pH of 7.247. total of 7 ampoules, 40 mg effective chest
condi- tions and diseases
Hemoglobin levels each in continuous compressions to main- tain
predisposing to excessive
maintain- ing 10.6 g/dL at infusion), antibiot- ics minimal cerebral blood
drop in body temperature,
10:40 a.m., decreased to (metronidazole 500 mg, flow. One way of
such as injury, alcohol or
3.2 g/dL in less than 4 ceftriaxone 1.0 g) and potentially improving the
drug abuse, elderly or
hours. Coagulation fentanyl 100 mcg. quality of chest
very young age and
parameters were also At 7.15 p.m. patient has compression is with
lowered mental status.1
highly elevated. All these been transferred to automat- ic mechanical
We presume that in this
disorders combined with intensive care unit of this devices, which can apply
case gastrointestinal
history of coffee-ground same hospital with the BP compression more
bleeding led to patient’s
vomiting, pointed to the of 130/74, heart rate of 93 consistently than manual
collapse in garden-plot
features of active upper bpm and core body massage. Also, the
while the outside
gastroin- testinal bleeding temperature of 29.5°C. engineering of such
temperature was low.
(Table 2). Despite of the further devices may target
Influence of both ambient
temperature and uncon- additional physiological
sciousness resulted in mecha- nisms to improve
severe hypothermia. circulatory output.
According to the Swiss Nowadays there are two
system,3 hypothermia is types of mechanical
classi- devices used worldwide:
fied in five stages: LDB (Au- toPulse) and
(1) mild hypothermia active chest
(patient is conscious, decompression piston
his body is shiv- ering: device (LU- CAS). So far
35°C–32°C) there are no clear
(2) moderate hypothermia evidences on the
(patients’ consciousness advantage from the routine
is im- paired, there is no use of these mechanical
shivering: 32°C–28°C) devices.1 However, ERC
(3) severe hypothermia guidelines 2015 emphasize
(patient is unconscious: the key role of mechanical
28°C–24°C) chest compression in
(4) profound hypothermia selected patients (e.g.
(apparent death: 24°C– when manual chest
13.7°C)
treatment conducted in compressions are
(5) death due to
Figure 1. Patient’s chest intensive care unit impractical or compromise
hypothermia (less than
X-ray performed at 1:20 (pharmacotherapy, provider safety).
13.7°C). Temperature
p.m. Presence of the fluid transfusions of 12 units of Randomized controlled
of 13.7°C is the lowest
within the right pleural PLT concen- trate and 4 trials in the field of emer-
recorded tempera-
cavity. Heart is shifted to units of RBC concentrate) gency medicine, especially
ture in hypothermic
the left side and its size is multiple organ failure was in the subject of
patient who was
magnified. progressing and at the time resuscitation, are
successfully resusci-
of re-arrest, CPR has not controversial and difficult
tated.4
been undertaken. Patient to conduct,11 which makes
Gastroenterologist Low core temperature
was declared dead at 9:45 re- search on mechanical
performed emergency causes decrease in basic
am of the next day. chest compressions
gastroscopy, which revealed metabo- lism and
challenging.
duodenal ulcer with a neurologic function,5
The implementation of
diameter of approxi- mately which in terms of cardiac
mechanical chest
30 mm (Forrest IIb). Due to arrest can have
compression device in case
147 Pol Ann Med. 2018;25(1):144–
147
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