Hypothermic cardiac arrest far away from the center providing rewarming with extracorporeal circulation

In the Northern hemisphere, most victims of accidental hypothermic cardiac arrest have a history of drowning or entombment by avalanches. Consequently, asphyxia and cardiac arrest develop before the body temperature has fallen to a sufficiently low level for oxygen demand to meet the supply. However, some patients have the advantage that they can breathe while being cooled until the heart stops [1-5].An alcohol-intoxicated man, 41 years of age, fell into a river on the coast of North Norway after leaving a party between 3 and 4 o'clock a.m. on 30 December. Approximately 1 h later, passers by spotted him shouting for help and pulled him out of the water. One of them undressed and attempted to warm him by skin-to-skin contact at the prevailing air temperature of -2°C. The patient lost consciousness and stopped breathing as the paramedics lifted him into the ambulance at 04.45 a.m. One of them started cardiopulmonary resuscitation (CPR) and continued it during the drive to the local hospital. Upon arrival at 05.01 a.m., his electro-cardiogram (ECG) was isoelectric, rectal temperature was 27.5°C, and arterial blood gases displayed pH 7.00, PaCO2 10.60 kPa, PaO2 3.60 kPa, HCO3 -18.5 mmol/l, and BE -11.3 mmol/l. He had no visible injuries except for a wound in the occipital region. He was endotracheally intubated and received 90 mmol of trimetamol (Tribonat？, Fresenius Kabi AS, Oslo, Norway) intravenously (IV). Following two IV injections of 1 mg epinephrine (Adrenalin？, Nycomed Pharma AS, Asker, Norway), his ECG shifted to ventricular fibrillation (VF), but attempts at defibrillation failed. At 6.00 o'clock, the physician in charge contacted the ambulance dispatch center of the University Hospital of North Norway (UNN) in Troms？ (latitude: 69°, 40' North). The anesthesiologist on duty for the helicopter and the thoracic surgical team decided to fly the 260 km (140 NM) to the local hospital and bring the patient to UNN for rewarming by means of extracorporeal circulation.