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Vol. 48. Issue 9.
Pages 551-554 (September 2024)
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Vol. 48. Issue 9.
Pages 551-554 (September 2024)
Scientific Letter
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Before and after the first extracorporeal cardiopulmonary resuscitation due to accidental hypothermia in Spain
Antes y después de la primera reanimación cardiopulmonar extracorpórea por hipotermia accidental en España
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Robert Blasco Mariñoa,b, Eduard Argudoc,d,
Corresponding author
eduard.argudo@vallhebron.cat

Corresponding author.
, Iñigo Soteras Martineze,f
a Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d’Hebron, Barcelona, Spain
b Facultad de Medicina, Departamento de Ciencias Médicas. Universidad de Girona, Girona, Spain
c Servicio de Medicina Intensiva, Hospital Universitario Vall d’Hebron, Barcelona, Spain
d Grupo de Investigación en Shock, Disfunción Orgánica y Reanimación (SODIR), Vall d’Hebron Institut de Recerca, Barcelona, Spain
e Sistema d’Emergències Mèdiques (SEM), Spain
f Servicio de Urgencias, Hospital Transfrontarer de la Cerdanya, Girona, Spain
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Table 1. Cases of accidental hypothermia* in the Pyrenees of Catalonia and Andorra from 2000 through 2024.
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Dear Editor:

On November 3, 2019, a 34-year-old woman in cardiac arrest (CA) due to accidental hypothermia was transferred to Hospital Universitario Vall d’Hebron, Barcelona, Catalonia, Spain. The patient was rescued in the Pyrenees with an initial esophageal temperature of 19.4 °C, initial rhythm of asystole, cyanosis in acral parts, and bilateral unresponsive mydriasis. The first venous blood gas revealed: pH levels of 6.8, potassium levels of 4.6, and lactate levels of 10.3. A HOPE score of 88% was calculated, which led to the indication of extracorporeal life support (ECLS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) via ipsilateral right femoro-femoral surgical cannulation. After gradual rewarming at a rate of 3 °C/h, spontaneous circulation was restored after defibrillation once the central temperature exceeded 30 °C. The patient progressed favorably, which eventually led to removing ECMO support 45 h later. The patient was eventually discharged 11 days later with a Cerebral Performance Category of 1.1,2

To date, another case of CA due to accidental hypothermia resuscitated for 3 h had been published in Medicina Intensiva in Spain, but it was an in-hospital CA, and no previous experiences of extracorporeal cardiopulmonary resuscitation (ECPR) had ever been reported in these patients.3

The initially reported case represents the first successful resuscitation in Spain of an out-of-hospital CA patient due to accidental hypothermia and the longest resuscitation published nationally. Nearly 5 years after the accident, the patient is in excellent general condition. To evaluate functionality in activities of daily living, a Barthel test was performed which showed a score of 100/100. Additionally, a multidimensional quality of life test perceived by the person was performed too (the World Health Organization Quality of Life scale abbreviated – WHOQOL-BREF). A psychologist reviewed the test, which revealed a total score of 125/130 (10/10, general area; 34/35, physical; 26/30, psychological; 15/15, social; 40/40, environmental). These data demonstrate that recovery after such a long resuscitation has been complete and reintegration into a normal life in all areas has been successful.

In Catalonia, Spain more than 19,000 rescues have been reported in the natural environment since 2010, with almost 50% being mountain rescues.4 In the past 2 decades, there have been other cases of CA due to accidental hypothermia. With the authorization of the ethics committee of hospital Arnau de Vilanova (CEIC-1308) and the analysis of the reports from the Mountain Intervention Unit of Mossos d’Esquadra and the Mountain Rescue Group of Bombers d'Andorra, all fatal accidents due to accidental hypothermia in the Pyrenees of Catalonia and Andorra from 2000 through 2024 have been compiled (Table 1). A total of 29 cases have been documented so far. Of these, 65.5% involved men, with a median age of 40 years (IQR, 35–48). A total of 48.2% of the cases occurred outside the winter season. The most practiced activity was ski mountaineering, followed by hiking, with most cases occurring in the Ripollés region (51.7%) and Val d’Aran (24.1%). No CPR measures were initiated in 69% of the victims, and only 4 victims (13.8%) were transferred to an ECMO center. Grouping data by number of reported accidents, a total of 17 accidents occurred (6 in winter, 5 in autumn, 4 in summer, and 2 in spring). These data indicate that 64.7% of the accidents occurred in non-winter seasons.

Table 1.

Cases of accidental hypothermia* in the Pyrenees of Catalonia and Andorra from 2000 through 2024.

Victim  Age  Sex  Location  Region  Activity  Season  Accident date  Mechanism  CPR or ECLS attempt  Transfer to an ECMO-capable center  Survivor 
51  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
37  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
35  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
37  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
48  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
28  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
37  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
46  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
38  Balandrau  Ripollès  Ski Mountaineering  Winter  30/12/2000  Accidental  No  No  No 
10  44  Costabona  Ripollès  Ski Mountaineering  Winter  20/1/2001  Avalanche  No  No  No 
11  40  Costabona  Ripollès  Ski Mountaineering  Winter  20/1/2001  Avalanche  No  No  No 
12  44  Fontnegra  Ripollès  Ski Mountaineering  Winter  24/1/2002  Avalanche  No  No  No 
13  37  Urús  Cerdanya  Unknown  Spring  11/4/2004  Accidental  No  No  No 
14  50  Restanca  Val d'Aran  Ski Mountaineering  Winter  15/02/2005  Accidental  No  No  No 
15  60  Aiguestortes  Val d'Aran  Ski Mountaineering  Winter  18/2/2005  Accidental  No  No  No 
16  45  Puigmal  Ripollès  Hiking  Autumn  7/11/2009  Accidental  No  No  No 
17  43  Puigmal  Ripollès  Hiking  Autumn  7/11/2009  Accidental  Yes, CPR  No  No 
18  48  Cavalls de vent  Berguedà  Mountain Race  Autumn  29/9/2012  Accidental  Yes, CPR  No  No 
19  35  Andorra  Andorra  Hiking  Winter  27/12/2012  Accidental  No  No  No 
20  43  Cavalls de vent  Berguedà  Mountain Race  Spring  28/4/2015  Accidental  Yes, CPR  Yes (renal replacement theraphy machine)  No 
21  67  Pica d'estats  Pallars Sobirà  Hiking  Summer  21/08/2015  Accidental  No  No  No 
22  28  Circ de Colomers  Val d'Aran  Hiking  Summer  12/9/2017  Accidental  Yes, CPR  No  No 
23  20  Andorra  Andorra  Hiking  Autumn  29/10/2018  Accidental  Yes, CPR  No  No 
24  34  Fontalba  Ripollès  Hiking  Autumn  4/11/2019  Accidental  Yes, ECLS  Yes (VA-ECMO)  Yes 
25  38  Andorra  Andorra  Hiking  Summer  30/7/2020  Accidental  Yes, CPR  No  No 
26  27  Aiguestortes  Val d'Aran  Hiking  Autumn  25/9/2020  Accidental  No  No  No 
27  27  Aiguestortes  Val d'Aran  Hiking  Autumn  25/9/2020  Accidental  No  No  No 
28  65  Aiguestortes  Val d'Aran  Hiking  Summer  14/9/2022  Accidental  Yes, ECLS  Yes (VA-ECMO)  No 
29  69  Aiguestortes  Val d'Aran  Hiking  Summer  14/9/2022  Accidental  Yes, ECLS  Yes (VA-ECMO)  No 

CPR, cardiopulmonary resuscitation; ECLS, extracorporeal life support; ECMO, extracorporeal membrane oxygenation; F, female; M, male; VA, venoarterial.

*

Cause of death: hypothermia certified in a forensic report.

These results should warn us on the de-seasonalization of accidents due to accidental hypothermia and the need for careful evaluation of each case by personnel trained in hypothermia. Currently, hypothermia remains a poorly recognized entity with many biases in its assessment and management.5 Without the presence of environmental cold or a triggering environment (high mountains, drowning, or snowy terrain), hypothermia can be difficult to suspect. However, hypothermia exists in our environment, both in rural and urban settings, and failing to consider it can lead to underdiagnosis. In turn, the most severe cases could be dismissed for transfer to an ECLS center due to lack of knowledge or protocols.

Some specific cases—like the one initially presented in this article—demonstrate the possibility of surviving an out-of-hospital CA due to accidental hypothermia despite the presence of typical markers of poor prognosis in normothermia (asystole, acidosis, lactate, end-tidal carbon dioxide, CA duration, unresponsive mydriasis). Out of all the cases that were not resuscitated, it is impossible to know if their prognosis would have changed or if CPR should have been initiated. However, same as it happens with very specific conditions for which there care and referral circuits remain available such as stroke, acute myocardial infarction, burns, or acute spinal injury, victims of accidental hypothermia should be taken care of through standardized circuits in centers with resources and experience proportional to the risk of CA.

Therefore, a feasible solution would be to implement a specific rescue chain ranging from prehospital services trained in detection, triage, and initial management to, if necessary, transfer to a reference hospital center capable of managing cases of accidental hypothermia with an altered state of consciousness, hemodynamic instability, or temperature ≤30 °C in adults and ≤32 °C in elderly patients with comorbidities (Fig. 1).6–8 A reference center should be equipped with trained and experienced health care personnel in the management of these cases and, also, with specific treatment protocols and circuits, including ECLS, to shorten transfer times by not having to decide which center to refer to while offering the highest possible quality of care.9,10

Figure 1.

Rescue chain for victims of accidental hypothermia.

ECLS, extracorporeal life support.

(0.29MB).

The approach to this problem can go beyond hospital strategies, providing the first responder with the necessary basics to act and alert. Prevention strategies (providing the victim or responders with the skills needed to resolve the problem when it arises through strategies like informational pamphlets at key points, training courses, information on social networks), prevention campaigns (informational panels, accessible weather information, or preventive advertising campaigns), and intervention strategies (to avoid recurrence of cases, such as improving signals, expanding and securing telephone coverage areas, or improving the traceability of hikers between shelters) can improve the safety of any victim.

Accidental hypothermia is a poorly recognized entity requiring specific management. A total of 86.2% of the victims of all accidents compiled were not transferred to an ECLS-capable center. One out of 3 patients who were put on ECMO survived with excellent functional capacity. The creation of specific circuits associated with reference hypothermia centers should facilitate triage decisions and ensure the proportionality of resources applicable to the risk of CA in any hypothermia victim.

All authors reviewed and approved the final version of the manuscript.

Funding

The authors declare that they have no funding sources to declare.

Authors’ contributions

Robert Blasco was involved in the conceptualization, research, and drafting of the original manuscript, review, and editing.

Eduard Argudo was involved in the conceptualization, drafting, review, and editing of the manuscript.

Iñigo Soteras was involved in the conceptualization, drafting, review, and editing of the manuscript.

Conflicts of interest

None declared. The authors also declare that they have the CEIC approval and the patient’s explicit informed consent for the publication of the case.

Acknowledgments

The authors wish to thank the members of the Mountain Intervention Unit of the Mossos d'Esquadra, Pompiers de la Val d'Aran, and Mountain Rescue Group of Bombers d'Andorra for their diligent acquisition of records.

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Please cite this article as: Blasco Mariño R, Argudo E and Soteras Martinez I. Antes y después de la primera reanimación cardiopulmonar extracorpórea por hipotermia accidental en España, Med Intensiva. 2024. https://doi.org/10.1016/j.medin.2024.05.021

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