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The Case of Anna Bagenholm

In 1999, Anna Bagenholm survived a cardiac arrest after a prolonged down-time and a temperature of just 13.7c. The circumstances of her survival continue to make international news and to inform and inspire research about target temperature management. There have been very few documented cases of survival from such extreme hypothermia, especially with minimal neurological impact. Consider the statistics on neurological impact from ordinary cardiac arrests, with less down-time, and Anna’s case becomes even more extraordinary. But does her survival mean we should target hypothermia in cardiac arrest patients? Should we target hypothermia in ROSC? Let’s have a look at the case and the research that has followed:

The case

Situation: 29 Year Old Female (Anna Bagenholm) is submerged head-first in a hole in the ice in a mostly frozen stream for 80 minutes.

Background: She has no medical history. She has slid down an icy slope while skiing with colleagues.

Assessment: She was conscious for the first 40 minutes, but has been unconscious for 40 mins since. After recovery, she is in cardiac arrest. Her ECG shows asystole. During the resuscitation attempt, the following is also learned:

  • Temp: 13.7
  • Pupils: dilated

She is warmed and the resuscitation team are watching an echo of her heart, which begins to move. ROSC was not gained until 4 ½ hours after she fell, and she spent 35 days on life support.

Questions: What would your expectations be of her ROSC management? What would your expectations of her survival and neurological impact be?

Recommendation — today:

  • Maintain a target temperature at a constant value between 32°C and 36°C for at least 24 h. 
  • Avoid fever (> 37.7°C) for at least 72 h after ROSC in patients who remain in coma. 
  • Do not use pre-hospital intravenous cold fluids to initiate hypothermia. 

(Resuscitation Council, 2021)

Decision/Outcome: Not only does Anna survive, her long-term neurological impact is minimal. Have a look at the video:

More Questions:

  • What target temperature does your Trust follow for ROSC management? Do you think it should be lower, or higher, having seen Anna’s case?
  • Do you think it’s possible to replicate the results of Anna’s treatment? What makes her situation so different to a cardiac arrest patient who has been treated with target temperature management?

The Research

Have a look at the results of some recent studies into target temperature management, below:

YearIn or out of hospital studyPresenting rhythmTargetsOutcome  
2002OHCAShockable33 and 37Positive for survival and neurological impact
2010OHCAShockableCooled IV fluids (No target temperature listed)No difference
2013OHCABoth shockable and non-shockable, but presumed cardiac cause33 and 36No difference
2014OHCABoth shockable and non-shockable2L of normal saline at 4 degrees, vs standard careNo difference
2018OHCAShockable32, 33, 34No difference
2019OHCA and IHCANon-shockable33 vs 37.5Improved survival and good neurological outcome (CPC = 1 or 2)
2021OHCAPresumed cardiac cause33 vs 37.5No difference
Adapted from: Rasmussen and Girotra, 2021.

Final discussion point:

Why can’t controlled studies replicate the kind of outcome that Anna had? Share your thoughts below, or on our Facebook or Twitter pages.


References (excluding videos and direct links above):

Rasmussen, T. P. and Girotra, S. 2021. A Contemporary Update on Targeted Temperature Management, Available at: https://www.acc.org/latest-in-cardiology/articles/2021/11/09/13/16/a-contemporary-update-on-targeted-temperature-management (Accessed 15/05/2022).

Resuscitation Council, 2021. Post-Resuscitation Care Guidelines, Available at: https://www.resus.org.uk/library/2021-resuscitation-guidelines/post-resuscitation-care-guidelines (Accessed 15/05/2022).

Author

  • Louise Sopher is a Paramedic, Resuscitation Practitioner, and Resuscitation Council ALS Instructor based in Hertfordshire. She has been a registered Paramedic for over 5 years. She is the founder of Article 999.

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