Is defibrillation effective in accidental severe hypothermia in adults?

Date First Published:
June 8, 2006
Last Updated:
September 1, 2006
Report by:
Joseph Clift, Medical Student (University of Bristol)
Search checked by:
Lisa Munro-Davies, University of Bristol
Three-Part Question:
In [accidental severe hypothermia (less than or equal to 30 degrees celcius) induced ventricular fibrillation in adults] is [defibrillation] [effective at restoring a sinus rhythm]?
Clinical Scenario:
A 50 year old man is found collapsed in the snow on a very cold winter's night. He is admitted to hospital unconscious with adjuvant cardiopulmonary resuscitation and a low reading rectal thermometer measures his core temperature to be 26 oC. He is in ventricular fibrillation. Should an attempt at defibrillation be made at this temperature or should he be re-warmed first and then defibrillated?
Search Strategy:
Medline 1966 – 06 using Ovid interface.
Search Details:
[AED$ or automated external defibrillat$ or defibrillat$ or VF or ventricular fibrillati$ or CPR or cardiopulmonary resus$ or ALS or advanced life support] and [severe hypothermia or hypothermi$]mp. [mp=title, original title, abstract, name of substance word, subject heading word].

Limited to humans and English language

Cochrane Library Issue 3 2006:

hypothermia [title, abstract or keywords] and defibrillation [title, abstract or Keywords] or ventricular fibrillation [title, abstract or keywords].
Outcome:
Total of 385 papers initially found.

Minimal data set criteria were:
-Accidental induction of hypothermia
-Patient in Ventricular fibrillation
-Core temperature recorded as <30oC
-Adults (> 18 years old)
-Adjuvant cardiopulmonary resuscitation
-Core temperature of defibrillations stated.

This left 17 papers that were relevant
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Intractable ventricular fibrillation associated with profound accidental hypothermia- Successful treatment with partial cardiopulmonary bypass. Towne WD, Geiss WP, Yanes HO et al. 1972 USA. 58 yr old Case Report Successful defibrillation at 34.4 oC. Repeated attempts at external defibrillation unsuccessful.
Profound hypothermia: Value of prolonged cardiopulmonary resuscitation. Schissler P, Parker MA and Scott SJ. 1981 USA. 67 yr old Case Report Successful defibrillation at 30.0 oC. Previous shock at 22.2 oC unsuccessful.
Sustained ventricular fibrillation in deep accidental hypothermia. Nordrehaug JE. 1982 Norway. 33 yr old Case Report Successful defibrillation at 28 oC. Defibrillation attempts at 24, 26 and 27 oC unsuccessful.
Management of profound accidental hypothermia with cardiorespiratory arrest. Althaus U, Aeberhard P, Schupbach P et al. 1982 Switzerland. 40, 42 and 24 yr olds Case Series Successful defibrillation at 26, 36 and 29 oC respectively. Two cases were of successful defibrillation at < 30 oC.
Partial cardiopulmonary bypass for core rewarming in profound accidental hypothermia. Splittgerber FH, Talbert JG, Sweezer WP et al. 1986 USA. Adults less than or equal to 18 yrs. 6 cases Case Series,11 cases ineligible All patients that lived defibrillated at >34 oC. Unsuccessful defibrillations attempted at temperatures lower than 30 oC. Two of the cases died. Further 11 cases analysed from literature, not analysed here as risk of duplication.
Resuscitation of the hypothermic patient. Cohen DJ, Cline JR, Lepinski SM et al. 1988 USA. 32 yr old. Case Report Successful defibrillation at 30 oC. Earlier attempts at defibrillation failed.
Accidental deep hypothermia with cardiopulmonary arrest: extracorporeal blood rewarming in 11 patients. Walpoth BH, Locher T, Leupi P et al. 1990 Switzerland. 4 adults Case Series, 12 cases ineligible Mean temperature of successful defibrillation at 25.6 oC. No exact patient details given
Anesthesiologist-manned helicopters and regional extracorporeal circulation facilities: a unique chance in deep hypothermia. Wisborg T, Husby P, Engedal H, et al. 1991 Norway. 33 yr old Case Report Successful defibrillation at 31 oC. Rewarmed prior to first shock.
Accidental hypothermia with cardiac arrest: recovery following rewarming by cardiopulmonary bypass. Bolgiano E, Sykes L, Barish RA et al. 1992 USA. 22 yr old. Case Report Successful defibrillation at 30 oC. Initial defibrillation at 24 oC unsuccessful. Data on other cases did not meet minimal data set criteria
Severe hypothermia associated with prolonged cardiorespiratory arrest and full recovery. Wolfe CS. 1993 USA. 38 yr old Case Report Successful defibrillation at 24 oC. Initial defibrillation at 23 oC unsuccessful.
Successful resuscitation of a patient with severe accidental hypothermia and prolonged cardiocirculatory arrest using cardiopulmonary bypass. Schwartz AJ and Hensley FA. 1997 Austria. 54 yr old Case conference Case Report Successful defibrillation at 31 oC. Earlier attempts at defibrillation failed.
Back from the dead: extracorporeal rewarming of severe accidental hypothermia in accident and emergency. Ireland AJ, Pathi VL Crawford R et al. 1997 UK. 48 yr old Case Report Successful defibrillation at 24.3 oC. First shock was sufficient.
Cardiopulmonary resuscitation following profound immersion hypothermia. Steedman DJ, Rainer T and Campanella C. 1997 UK. 29 yr old Case Report Successful defibrillation at 37 oC. Initial defibrillations unsuccessful at 28.3, 29.0 and 31 oC.
Successful defibrillation in profound hypothermia (core body temperature 25.6 oC). Thomas R and Cahill CJ. 2000 UK. 82 yr old Case Report Successful defibrillation at 25.6 oC. Patient eventually died.
Dead? Or just cold: profound hypothermic patients with no signs of life. Ko CS, Alex J, Jefferies S et al. 2002 UK. 37 yr old Case Report Successful defibrillation at 37 oC. Previous defibrillation at 30 oC unsuccessful. Core temperature recorded (17 oC) tympanic, therefore accuracy unclear.
European Resuscitation Council Guidelines for Resuscitation 2005. Section 7. Cardiac arrest in special circumstances. Soar J, Deakin CD, Nolan JP et al. 2005 All patients. Guidelines.
Refractory ventricular fibrillation in accidential hypothermia: salvage with cardiopulmonary bypass. Mulpur AK, Mirsadraee S, Hassan TB et al. 2004, UK 20 yr old Case Report Successful defibrillation at 28 oC Previous defibrillation at 25 oC unsuccessful.
One night in a snowbank: a case report of severe hypothermia and cardiac arrest. Moser B, Voelckel W, Gardetto A et al. 2005, Austria 62 year old Case Report Successful defibrillation at 29oC No previous defibrillation attempts.
Author Commentary:
The only published data on this subject is in the form of case reports and a few case series. No higher-level evidence is available. From these there is insufficient data to definitively say whether or not defibrillation is effective in severe hypothermia. 55.6% of cases do however report successful defibrillation at temperatures at or below 30 degrees celcius (15 of 27 cases). This may be due to publication bias and further work would be necessary to be sure.
Bottom Line:
It is reasonable to attempt defibrillation at temperatures below 30 degrees celcius in accidental severe hypothermia. This theraputic strategy is supported by the current European Resuscitation Council guidelines (18).
References:
  1. Towne WD, Geiss WP, Yanes HO et al.. Intractable ventricular fibrillation associated with profound accidental hypothermia- Successful treatment with partial cardiopulmonary bypass.
  2. Schissler P, Parker MA and Scott SJ.. Profound hypothermia: Value of prolonged cardiopulmonary resuscitation.
  3. Nordrehaug JE.. Sustained ventricular fibrillation in deep accidental hypothermia.
  4. Althaus U, Aeberhard P, Schupbach P et al.. Management of profound accidental hypothermia with cardiorespiratory arrest.
  5. Splittgerber FH, Talbert JG, Sweezer WP et al.. Partial cardiopulmonary bypass for core rewarming in profound accidental hypothermia.
  6. Cohen DJ, Cline JR, Lepinski SM et al.. Resuscitation of the hypothermic patient.
  7. Walpoth BH, Locher T, Leupi P et al.. Accidental deep hypothermia with cardiopulmonary arrest: extracorporeal blood rewarming in 11 patients.
  8. Wisborg T, Husby P, Engedal H, et al.. Anesthesiologist-manned helicopters and regional extracorporeal circulation facilities: a unique chance in deep hypothermia.
  9. Bolgiano E, Sykes L, Barish RA et al.. Accidental hypothermia with cardiac arrest: recovery following rewarming by cardiopulmonary bypass.
  10. Wolfe CS.. Severe hypothermia associated with prolonged cardiorespiratory arrest and full recovery.
  11. Schwartz AJ and Hensley FA.. Successful resuscitation of a patient with severe accidental hypothermia and prolonged cardiocirculatory arrest using cardiopulmonary bypass.
  12. Ireland AJ, Pathi VL Crawford R et al.. Back from the dead: extracorporeal rewarming of severe accidental hypothermia in accident and emergency.
  13. Steedman DJ, Rainer T and Campanella C.. Cardiopulmonary resuscitation following profound immersion hypothermia.
  14. Thomas R and Cahill CJ.. Successful defibrillation in profound hypothermia (core body temperature 25.6 oC).
  15. Ko CS, Alex J, Jefferies S et al.. Dead? Or just cold: profound hypothermic patients with no signs of life.
  16. Soar J, Deakin CD, Nolan JP et al.. European Resuscitation Council Guidelines for Resuscitation 2005. Section 7. Cardiac arrest in special circumstances.
  17. Mulpur AK, Mirsadraee S, Hassan TB et al.. Refractory ventricular fibrillation in accidential hypothermia: salvage with cardiopulmonary bypass.
  18. Moser B, Voelckel W, Gardetto A et al.. One night in a snowbank: a case report of severe hypothermia and cardiac arrest.