Successful Extracorporeal Cardiopulmonary Resuscitation in Severe Accidental Hypothermia After Prolonged No-Perfusion and Hypoperfusion with Asystole: A Case Report and Literature Review

Introduction: We report a rare survival case of accidental hypothermia (core temperature 20 °C) with cardiac arrest and an initial rhythm of asystole, in which neurological recovery to the point of verbal communication was achieved after extracorporeal cardiopulmonary resuscitation (ECPR) despite prolonged no-perfusion ( ≥ 30 min) and hypoperfusion times ( ≥ 117 min), reviewing the relevant literature. Case Presentation: A 78-year-old woman developed hypothermia while descending a snowy mountain and called emergency services at 13:53. Rescue was delayed and she was found around 18:00; she was handed over in asystole at 18:30. During ambulance transport, the rhythm changed to ventricular fibrillation (VF) and eight defibrillations were delivered. She arrived at the emergency department at 19:01 in cardiac arrest with VF; bladder temperature was 20 °C, with no evidence of trauma. Arterial blood gas analysis revealed mixed acidosis. Active surface rewarming and high-quality cardiopulmonary resuscitation (CPR) with intubation and mechanical ventilation were initiated. Veno-arterial extracorporeal membrane oxygenation (ECMO) was established 56 min after emergency department (ED) arrival. After rewarming to 35 °C, she was defibrillated to sinus rhythm. Targeted temperature management was continued for 48 h. ECMO was weaned on day 5 (62 h after initiation). Computed tomography (CT) on day 5 showed acute pancreatitis without hypoxic–ischemic brain injury. She was extubated on day 11, discontinued oxygen on day 16, and resumed oral intake on day 17. Brain magnetic resonance imaging (MRI) on day 36 demonstrated hypoxic encephalopathy with residual higher brain dysfunction. She was discharged on day 151 with a Cerebral Performance Category of 3. Conclusion: ECPR may be considered for cardiac arrest due to severe accidental hypothermia, even in patients presenting with asystole and prolonged no-perfusion or hypoperfusion times.