Recent stories... followed by facts

Charles Brault EMT-P


The cold that nearly killed her also helped to save her
'She's had an incredible recovery'
Anne Marie Owens, with files from Chris Purdy
National Post; The Edmonton Journal

Larry Wong, The Edmonton JournalDoctors at Edmonton's University Hospital 
expect an almost complete recovery for this girl, whose body temperature 
dropped by 21 degrees.

An Edmonton toddler who was clinically dead when brought to hospital has 
pulled through with a good chance of a complete recovery, with little 
likelihood of brain damage and minimal harm from frostbite.
Despite being so frozen paramedics had difficulty opening her mouth, the 
girl is at risk only of losing some toes to frostbite, medical staff said 
yesterday.
The girl wandered outside in the middle of the night in -24 C weather 
wearing only a diaper. Her mother awoke at 3 a.m. Saturday and found the 
toddler curled up and frozen in the middle of the backyard.
By yesterday, however, the child was conscious and breathing without a 
ventilator.
"We call her 'Miracle,'" said Dr. Allan De Caen, of the pediatric intensive 
care unit at University Hospital. "We've got a young lady that just over 24 
hours ago had her heart stop for two hours and the concern was whether she 
would survive, period. She's had an incredible recovery."
The name of the girl, who had her first birthday last week, has not been 
released.
Her 26-year-old single mother is distraught and has remained by her 
daughter's bedside.
Police have said no charges will be laid.
She crawled out of her mother's bed sometime early on Saturday morning and 
went outside into the snowy backyard, where her tiny footprints show she 
walked around before lying down in the snow.
The back door of the house where the girl, her older sister and her mother 
were staying had been left open.
When paramedics and police arrived at the house, they described the child 
as "frozen solid," with no sign of a pulse.
Her body temperature had dropped down to 16 C, less than half of the normal 
37 C.
It is not known how long the child remained outside.
Babies and younger children lose bodily heat more readily because they have 
a higher surface-to-body weight ratio, and are at greater risk of 
developing hypothermia. In this case, however, the extreme cold temperature 
and the child's age may be partly responsible for her amazing recovery.
"She was, in effect, cryopreserved," said Steve Buick, spokesman for 
Alberta's Capital Health authority. "The child herself, being so small, was 
frozen quite profoundly. The cold preserved her body and her brain ... It 
was a double-edged sword."
Scientists have noted a hibernation reflex that occurs in these kinds of 
cases where human beings survive several hours of immersion in cold water 
or exposure to cold temperatures because of a reflex similar to what occurs 
in hibernating mammals.
In Saskatchewan, a two-year-old girl survived the lowest recorded body 
temperature, 14 C, after being accidentally locked out of her house for six 
hours at -40 C in 1994.



Frozen toddler hears from winter survivor

Saturday, March 3, 2001
Shaunavon, Sask. -- A Saskatchewan girl who nearly froze to death seven 
years ago has a message of hope for an Edmonton toddler who went through a 
similar ordeal. Karlee Kosolofski says she wants to tell 13-month-old Erika 
Nordby that "everything will be all right."
Erika continues to make a rapid recovery in an Edmonton hospital after her 
heart stopped for about two hours last weekend when she wandered into her 
back yard in frigid temperatures.
Karlee was 2½ when she wandered out of her home and was found six hours later.
CP




Karlee's coldest night
The Erika Nordby story bears an eerie resemblance to the
case of a tiny Regina girl, who almost froze to death
seven years ago when she wandered out
into a frigid night. Now nine, her
recovery has been a long, slow climb.
KIM HONEY

Saturday, March 3, 2001
Little Karlee Kosolofski was just getting used to having both her parents 
home all day when her dad, Robert, returned to his job at the Dairy 
Producers Co-op in Regina. He had been off work for a couple of months 
because of a shoulder injury; his wife, Karrie, was a stay-at-home mom. The 
2½-year-old was living in Roleau, Sask., with her parents and siblings 
Kimberley, 7, and Keith, 5, on Feb. 23, 1994, the day her life changed forever.
That night, the alarm her father set to wake him for his early-morning 
shift at the dairy also woke Karlee. Robert put her into bed with her mom, 
Karrie, before he left at about 2:30 a.m. When he drove into the alley 
behind the two-storey house, he noticed the light was still on in the 
garage; he decided to leave it until he got home from his shift that 
afternoon. Then he headed off into a very bad snowstorm.
Sometime after he left, Karlee woke up, clambered out of her parents' bed, 
and went into her room. From there, she had a clear view of the back yard 
and the single-car garage built on the back corner of the 100-foot by 
100-foot lot. Later, Karlee told him she had seen the light, thought he was 
out there, and gone to find him.
The little girl, who weighed less than 30 pounds, pulled on her red parka 
and pink Sorel winter boots and went out the back door into the snow 
swirling in the yard. It was -22 Celsius, but with the windchill, it was 
more like -40. In those conditions, flesh freezes in one minute. 
Afterwards, Karlee remembered "being tired and going to sleep," her mother 
says. As she passed out from acute hypothermia in the snow on the back 
step, the boot on her left foot dropped off, exposing her skin to the 
elements. That leg later had to be amputated.
Her mother, Karrie, woke up about 8 a.m. and went downstairs to find her 
son watching television. When she asked him where his little sister was, he 
said he thought Karlee was still sleeping. As Karrie walked by the back 
door, she caught a glimpse of red through the window. When she took a 
closer look, the full horror of what she was seeing registered: Her 
youngest daughter, little Karlee, was lying motionless in the snow in her 
jacket, boots and cotton nightgown.
Karrie carried her inside, tried to administer CPR, called the neighbour to 
come and get Keith (Kimberley was at her aunt's) and called a nurse who 
lived in Roleau. When she called Robert next at work, she told him Karlee 
had gone outside and that she had frozen. Robert didn't understand. "I 
initially thought it was just frostbite or whatever. At one point she told 
me, 'No. She's frozen. She's not breathing.' "
Robert called 911, jumped into the car and raced home. He beat the 
ambulance, which had got lost in the snowstorm.
The sight of his little girl lying motionless on her back on his weight 
bench in the living room was almost too much to bear. Karrie had tried to 
perform CPR, but the toddler's chest was so frozen she couldn't compress 
it. The foot that the boot had fallen off looked chalky white, Robert 
remembers.
"For all intents and purposes, she was [clinically dead]. She didn't have a 
heartbeat and her pupils were fixed and dilated," he says. "We still hoped 
[she could be revived], but it wasn't a lot of hope."
Karlee's body temperature, normally 36 degrees Celsius, had dropped to 14, 
and the doctors estimated she had been outside for close to six hours.
In a case eerily reminiscent of Karlee's, just a week ago one-year-old 
Erika Nordby was found -- wearing a jeans and a shirt -- frozen facedown 
outside an Edmonton house, almost seven years to the day after Karlee's 
accident. When a friend tried to tell Karrie about Erika, Karrie was 
certain they had mixed up the details of Karlee's case.
"I thought that's what they were hearing about and they had just confused 
it," she says. "It really did bring back a lot of it."
The memories come flooding back this time of year anyway, Karrie says. It's 
like any anniversary of an important event in a life: As the date draws 
near, the mind's eye returns again and again to the circumstances of the day.
Like Karlee, Erika had no heartbeat, but her body temperature hadn't 
dropped as low: It was 16 degrees. In Wisconsin, two-year-old Les Hynek 
suffered a similar case of severe hypothermia this week after he slipped 
outside wearing only a diaper, pajamas and a sweatshirt. He remains in 
critical condition.
But when the ambulance rushed Karlee to Plains Hospital in Regina seven 
years ago, doctors had few case histories to draw upon when they were 
deciding how to treat the baby. They decided to try slowly warming her 
blood using a heart-lung bypass machine. It worked; after three hours, her 
heart started beating again.
By the time Karrie and Robert were allowed to see her in the Intensive Care 
Unit about 5 p.m., Karlee had been sedated to numb the pain of frostbite. 
Her eyes were swollen shut, the skin on her legs had been cut open so it 
wouldn't split from the swelling, and she couldn't talk because she was on 
a respirator. But Karlee knew her parents were there, and when Karrie asked 
her a few questions, her daughter moved her head to indicate yes or no.
Doctors proclaimed Karlee nothing short of a miracle, the same word used in 
the past few days to describe Erika's case. The one-year-old was revived 
after spending several hours outside in -17 degree weather with a windchill 
that made it feel like -29. Her mouth was frozen shut and her legs were 
like solid blocks of ice, but her heart restarted on its own after doctors 
used a special blanket to slowly warm her body.
In the wake of Erika's ordeal, Karrie and Robert have been inundated with 
requests from reporters to tell their story again. About a year-and-a-half 
ago the couple separated: Karrie moved three-and-a-half-hours west to 
Shaunavon, Sask., not far from her mother's farmhouse. The kids live with 
Karrie, but she shares custody with Robert. They go back to Roleau to visit 
their father on long weekends.
It's a bittersweet time because, as Robert says, "it brings back a lot of 
memories, good and bad."
There was the outpouring of support -- letters, gifts, and encouraging 
words -- from doctors, neighbours and strangers. There was the day they 
realized Karlee had survived the accident with no noticeable brain damage 
and the day, when she was three, that tests showed she was functioning on a 
mental level a half year to a year beyond her age.
Some of the darkest days came in the wake of the accident. Particularly 
painful were media reports that said Karlee had been locked out of the 
house, and the horrified response from people who believed it.
"Locked out sounds terrible. Karlee was never locked out; the door was 
never locked. That's something that has been a misconception," Karrie says.
Even if Karlee had had the strength to open the back door, she was too 
short to reach the knob, her mother says. Regardless, hypothermia would 
have slowed her mental faculties to the point where she wouldn't have been 
able to formulate the idea to knock on the door or open it.
Karrie said one of the hardest lessons to learn in life is that there are 
some things you just can't control.
"Accidents happen and they're exactly that. That blame sometimes just 
doesn't happen. There is no one to blame."
As for Erika's mother, Karrie "really feels for her." Although she knows 
everyone reacts differently to the stress of a sick child, it really brings 
back those first moments when she and Robert didn't know if Karlee would 
live or die.
"It's hard to describe. It's almost a feeling of numbness . . . When you're 
really excited or really upset, things almost don't seem real," she says. 
"It's an emotional struggle you go through, wondering whether she is going 
to actually make it or not make it."
When Karlee's heart started beating, Karrie said she and Robert were still 
worried because there were so many other possible complications. They 
feared pneumonia in her weakened state; they weren't sure if her 
intellectual development had been affected; they didn't know if she'd lose 
some toes, a leg, or two legs.
Once it was clear Karlee had no intellectual impairment, Karrie said the 
knowledge that her baby's brain had escaped unscathed outweighed any 
worries about how she would cope with an artificial limb.
It's been a long, slow climb, just the same. Karlee has been treated at the 
Shriner's Hospital in Montreal where she has undergone several operations 
over the past seven years to repair damage to her right leg. One of the two 
bones in her thigh was growing at a slower rate than the other, so it was 
broken and metal pins were inserted to hold it apart while new bone grew in 
the space.
Most recently she underwent a skin expansion, where doctors inserted a 
balloon under some healthy tissue on her right leg and inflated it with 
water, which stretched the skin and allowed doctors to use it to replace 
some damaged skin. For over a year Karlee used a wheelchair, but after the 
balloon was removed last year and her leg healed, it marked the end of her 
surgeries.
"They're over," says Karlee, now 9. "The only time I go to Montreal is for 
a couple of checkups."
Karrie says her daughter is learning to walk -- again. It's a task that she 
has had to tackle many times over the past seven years.
"She takes it all so well; she's a wonderful patient," says her mom. "Not 
just from a mother's point of view. Her doctor is very happy with her."
As for Karlee, she says she has gone through so many operations she's used 
to it. "I sort of know how it feels now, and I'm not so scared."
To brother Keith, 12, and sister Kimberley, 14, she's the typical little 
sister: a bit of a pest. Her favourite subject is math; her mom says she 
would rather do sums than go out for recess. Karrie thinks this is a good 
thing, since her youngest daughter wants to be a veterinarian. Karlee helps 
look after the family's two cats and two dogs and, in her bedroom, a 
menagerie of stuffed animals are displayed, in rotation, because there 
isn't enough room for all of them.
She loves swimming, which she does weekly at the local hotel pool.
"You can never get me in the bathtub but, for some reason, when there's 
swimming pool, you can never get me out," she says.


Acta Anaesthesiol Scand 1997 Nov;41(10):1359-64
Deep accidental hypothermia and cardiac arrest--rewarming with forced air.

Koller R, Schnider TW, Neidhart P

Department of Anaesthesia and Intensive Care, University of Berne, Switzerland.

BACKGROUND: During the last two cold winters we have treated 5 severely 
hypothermic patients (temperature below 30 degrees C) with active external 
rewarming rather than with extracorporal circulation and heat exchanger. 
PATIENTS: Two patients were found in cardiac arrest, and 3 victims of 
mountain accidents suffered deep hypothermia without arrest. In one of 
them, ventricular fibrillation (VF) was converted successfully to a sinus 
rhythm at a core temperature of 25.9 degrees C. Both arrested patients 
developed an adequate hemodynamic state during resuscitation although they 
were at very low temperature. All the patients were warmed with a 
convective cover inflated with warm air of about 38 degrees C (Bair 
Hugger). The core temperature increased by approximately 1 degree C/h in 
all patients. During rewarming we observed neither an initial drop of the 
core temperature (afterdrop) nor cardiac arrhythmias. The outcome of all 5 
patients was good without neurological sequelae. CONCLUSION: We conclude 
that external rewarming with forced air is a feasible alternative to 
cardiopulmonary bypass in severely hypothermic patients with electrical 
activity. This method can be used even in patients with VF because 
defibrillation can be successfully performed in deep hypothermia. Although 
after-drop during external rewarming is feared, we did not observe this 
phenomenon. Rewarming with forced air is inexpensive, easy to perform and 
direct access to the patient is possible at any time. It does not require 
heparinisation and can be used in hospitals where they do not have 
cardiopulmonary bypass facilities. Thus, this method is particularly useful 
in situations when the hypothermic patient cannot be transferred to a major 
medical center.

Comment in:
·       Acta Anaesthesiol Scand. 1998 Sep;42(8):1018-20

: Lijec Vjesn 1995 Jun;117 Suppl 2:89-90
[Accidental hypothermia with cardiorespiratory arrest. Case report].

[Article in Serbo-Croatian (Roman)]

Nincevic N, Mlinaric J

Sluzba za anesteziju i intenzivno lijecenje Opce bolnice Zadar.

A case of an effective cardiopulmonary resuscitation in a 71-year-old woman 
following drowning in a cold water and cardiopulmonary arrest for at least 
20 minutes is presented. Intubation, ventilation with 100% oxygen, external 
cardiac massage and administration of adrenaline, 1 mg intravenously, were 
implemented. Ventricular fibrillation, which occurred after adrenaline 
therapy, responded to electrical defibrillation with 200 J and converted 
into a sinus rhythm. Metabolic acidosis was corrected by intravenous sodium 
bicarbonate administration. The patient became gradually conscious, and she 
was weaned from mechanical respiration after 12 hours. Subsequently, the 
patient was extubated. There were no neurological deficits.
Rev Esp Anestesiol Reanim 1994 Mar-Apr;41(2):109-12
[Severe accidental hypothermia: rewarming by total cardiopulmonary bypass].

[Article in Spanish]

Cortes J, Galvan C, Sierra J, Franco A, Carceller J, Cid M

Servicio de Anestesiologia y Reanimacion, Hospital General de Galicia, 
Santiago de Compostela, La Coruna.

We present a case of a 20-year-old male with a history of habitual drug use 
who suffered extreme hypothermia (26 degrees C) after several hours' 
accidental exposure to low ambient temperature. The patient presented in 
deep coma with recurring ventricular fibrillation that yielded to 
electrical defibrillation once a central temperature of 27.4 degrees C was 
reached through internal rewarming with intravenous liquids and gastric 
lavage with warm water. Because this method was slow, we decided to 
continue rewarming with extracorporeal circulation through cannulation of 
the femoral vein and artery. The patient recovered consciousness after 
three hours, with no neurological secuelae. Emergency room staff have 
available the means for recognizing hypothermia and a protocol for its 
management. Extracorporeal circulation is an effective method for internal 
rewarming and must be used when the patient requires cardiopulmonary 
resuscitation or presents signs of severe hemodynamic instability.





Can J Surg 1992 Apr;35(2):184-7
Cardiopulmonary bypass for resuscitation of patients with accidental 
hypothermia and cardiac arrest.

Baumgartner FJ, Janusz MT, Jamieson WR, Winkler T, Burr LH, Vestrup JA

Department of Surgery, University of British Columbia, Vancouver.

Hypothermic patients have been successfully rewarmed by a number of 
methods. However, when cardiac arrest occurs, as it frequently does at core 
temperatures of less than 27 degrees C, prolonged cardiopulmonary 
resuscitation (CPR) is required, because defibrillation can rarely be 
achieved until the patient has been rewarmed to 30 degrees to 34 degrees C. 
Five cases of accidental hypothermia with cardiac arrest treated with 
cardiopulmonary bypass are discussed. The first patient died as a result of 
inadequate low-flow cardiopulmonary bypass by the femorofemoral route. The 
second patient had prolonged CPR by closed-chest cardiac massage and warm 
peritoneal lavage followed by transthoracic cardiopulmonary bypass. This 
patient regained consciousness but was found to be paraplegic and died from 
bowel infarction related to peritoneal rewarming without adequate 
perfusion. In the last three patients, high-flow cardiopulmonary bypass was 
rapidly achieved using a no. 28 French chest tube for femoral venous 
cannulation, and they recovered completely. In cases of accidental 
hypothermia with cardiac arrest, rapid institution of full cardiopulmonary 
bypass provides excellent circulatory support and rapid rewarming. This 
avoids the complications of prolonged inadequate circulation that occur 
when closed-chest cardiac massage and external rewarming are used.





Schweiz Med Wochenschr 1992 Feb 1;122(5):161-4
[Severe accidental hypothermia with cardiopulmonary arrest: prolonged 
resuscitation without extracorporeal circulation].

[Article in German]

Roggero E, Stricker H, Biegger P

Ospedale distrettuale, La Carita, Locarno.

We describe a case of severe hypothermia in a 32-year-old patient who fell 
into a crevasse. Three hours later he was rescued and flown to a district 
hospital. On arrival he was apparently dead, with cadaveric skin, dilated 
and fixed pupils, pulseless and in respiratory arrest. His rectal 
temperature was 26 degrees C. On the ECG monitor there was first 
ventricular fibrillation, then, after several unsuccessful attempts at 
defibrillation, the heart became asystolic. Cardiopulmonary resuscitation 
was begun with orotracheal intubation and external cardiac compression, 
which eventually lasted 4 hours and continuously required a team of 6 
persons. Only at a temperature of 32.5 degrees C could the patient be 
defibrillated with success. In the absence of extracorporeal circulation 
(ECC) the victim was rewarmed by warm-air breathing and by instillation of 
warm saline in peritoneum, stomach and bladder. In this way the rewarming 
velocity was 1.8 degrees C/hour. The postacute course was characterized by 
severe rhabdomyolysis (CK of 100,000 U/L) with non-oliguric renal failure, 
which necessitated several sessions of hemodialysis. Four months later the 
asymptomatic patient returned to work. Our case shows that a severely 
hypothermic patient can successfully be treated in a primary hospital not 
equipped with an ECC, provided that there is a sufficiently large team. 
Further, uninterrupted external cardiac compression guarantees efficient 
circulation even over several hours. Electric defibrillation in a 
hypothermic patient is ineffective unless normal body temperature has been 
reached. Lastly, every effort to continue resuscitation must be made in the 
still hypothermic patient whose absence of clinical response may obscure 
the real possibility of complete recovery.





Ann Fr Anesth Reanim 1987;6(3):217-8
[Accidental deep hypothermia and circulatory arrest. Treatment with 
extracorporeal circulation].

[Article in French]

Feiss P, Mora C, Devalois B, Gobeaux R, Christides C

A 27-year old female was discovered at 4 a.m. lying in a wet field, the 
ambient temperature being of 4 degrees C. Her rectal temperature had fallen 
to 19 degrees C. She was comatose and failed to respond to noxious stimuli. 
Her pupils were dilated and fixed. Her respiratory rate was reduced to 
three to four breaths per min. Her blood pressure was not measurable and 
neither femoral or carotid pulse could be detected. The heart was in sinus 
rhythm with a rate of 40 b X min-1. During her transfer to hospital, she 
was ventilated with oxygen, a tidal volume of 300 ml and a rate of 10 b X 
min-1. On arrival in the emergency room, a short period of ventricular 
fibrillation preceded cardiac arrest. Cardiac massage and sodium 
bicarbonate infusion were continued during the transfer of the patient to 
the operating theatre. A femoro-femoral cardiopulmonary bypass was started 
with a bloodless priming, 3 mg X kg-1 heparin and a flow of 3,000 to 3,500 
ml X min-1. Mean arterial pressure was maintained between 65 and 85 mmHg; 
cardiac massage was discontinued during the bypass. Within 50 min, 
ventricular fibrillation appeared, rectal temperature had increased to 33 
degrees C. Electrical defibrillation (300 J) was successful. 
Cardiopulmonary bypass was stopped after 63 min. The postoperative course 
was uneventful, apart from transient pulmonary oedema. At the time of 
discharge, a week later, no loss of intellect or change in behaviour could 
be perceived.(ABSTRACT TRUNCATED AT 250 WORDS)





Am Surg 1986 Aug;52(8):407-12
Partial cardiopulmonary bypass for core rewarming in profound accidental 
hypothermia.

Splittgerber FH, Talbert JG, Sweezer WP, Wilson RF

Six cases of treatment of severe accidental hypothermia using 
cardiopulmonary bypass for core rewarming are reported and eleven cases 
from the literature are analyzed. Thirteen patients survived. Overall 
survival was more likely in patients who had vital signs initially. Initial 
mean core temperatures in the new cases was 22.8 C. Surface and 
conventional core rewarming methods resulted in an average temperature 
increase of 2.4 C per hr. Electrical defibrillation was generally without 
success until the core temperature had been raised to above 30 C. Between 
one and six hours after admission, partial femoral-femoral cardiopulmonary 
bypass (CPB) for core rewarming was started, causing a mean temperature 
increase of 9.5 C per hr. Four patients required a thoracotomy. Two 
patients had a massively dilated heart with contusions, and could not be 
weaned off bypass. None of the four long-term survivors had a demonstrable 
central nervous system (CNS) deficit. All patients developed temporary 
pulmonary problems; two developed wound infections. The average hospital 
stay was 21 days. CPB for core rewarming allows circulatory support while 
avoiding myocardial damage from prolonged external cardiac massage; rapidly 
increases the myocardial temperature and counteracts myocardial temperature 
gradients so that DC electroversion is successful; avoids "rewarming 
shock"; and improves microcirculatory flow. A prospective randomized trial 
to compare rapid surface rewarming and CPB rewarming is suggested. 
Immediate CPB for rewarming is recommended for patients in ventricular 
fibrillation with core temperatures below 30 C. Prolonged external cardiac 
massage (ECM) should not be used. The value of surface rewarming and 
non-CPB core rewarming methods remains undefined.










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