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. ------------------------------------------------------------ Free Web Email & Filter Enhancements. http://www.freewebemail.com/filtertools/ ------------------------------------------------------------