Mark et al. International Journal of Emergency Medicine 2012, 5:7 http://www.intjem.com/content/5/1/7 and at 09.18 a.m., he was connected to a cardiopulmon- ary bypass (CPB) using a fully heparin-coated system with access via the right femoral vein and artery. After 30 min on CPB, 5 h 3 min after cardiac arrest, his eso- phageal temperature had increased to 33°C, and the VF was electro-converted into a nodal rhythm, which resulted in asynchronous ventricular contractions, as assessed by transesophageal echocardiography. After 2 h 21 min on CPB, his rectal temperature had risen further to 36.5°C paralleled by gradually improving cardiac function. He was weaned off CPB at 11.37 a.m., 6 h 52 min after cardiac arrest, maintaining a mean systemic arterial pressure of 55 mmHg supported by infusions of norepinephrine (Noradrenalin®, NAF, Oslo, Norway) 130 ng/kg/min, pitressin (Glypressin®, Ferring legemi- dler, Oslo, Norway) 120 ng/kg/min, and milrinon (Coro- trop®, Sanofi-Aventis Norge, Oslo, Norway) 120 ng/kg/ min. At 12.30 a.m., he was transferred to the ICU. Then, his serum myoglobin was 17,000 μg/l, ASAT 1,242 U/l, ALAT 214 U/l, creatinine 195 μmol/l, CK- MB 61 μg/l, thrombocyte count 50 × 109/l, fibrinogen 1.0 g/l, D-dimer 10.7 μg/l FEU, and antithrombin III 27%, and the ethanol gel test was positive. Concomi- tantly, arterial oxygen saturation (SaO2) reached a nadir of 73%. He was subjected to airway recruitment, and the SaO2 level rose to 90%. Postoperatively, his condition was complicated with pneumonia requiring antibiotics and continuation of pressure-controlled mechanical ventilation (Servo I, MAQUET GmbH & Co., Rastatt, Germany). Moreover, renal failure as assessed by hourly diuresis of below 20 ml/h; serum urea and creatinine levels of 11.3 mmol/l and 195 μmol/l, respectively, indicated the need for veno-venous hemofiltration (Prismaflex system, Gambro, Lund, Sweden). The coagulation dysfunction normalized after transfusion of freshly frozen plasma and thrombo- cyte concentrates, and the patient’s liver function regressed during the first week. He was weaned off mechanical ventilation and extubated on 3 January, and was transferred to the local hospital 12 days later. In a letter 3 years after the accident he wrote that he has quit smoking and abusing alcohol, and works as a logis- tic consultant. He has no neurological sequelae and enjoys life with his family. He wanted us to emphasize in the case report that the accident became an incentive for him to change to a healthier lifestyle. Discussion We are not aware of previous reports of successful resuscitation after hypothermic cardiac arrest of a com- parably long duration. A PubMed search revealed the case of an alcohol-intoxicated man who was found out- doors with cardiac arrest and a rectal temperature of 23.2°C. Subjected to surface rewarming combined with Page 2 of 3 intraperitoneal lavage and intravenously infused warm fluids at the local hospital, he resumed spontaneous cir- culation with sinus rhythm at a rectal temperature of 28°C 6 h after CPR was started. However, neurological examination before discharge revealed “slow cerebra- tion” and peripheral neurological dysfunction in both arms [3]. Walpoth and co-workers surveyed the outcomes of victims of accidental hypothermic cardiac arrest varying between 30 min and 4 h who were successfully rewarmed with extracorporeal circulation [4]. Recently, colleagues at our hospital reported the case of a female off-piste skier who fell and was trapped head down between rocks and overlying ice, and sprinkled with gla- cial water in her face until cardiac arrest. With a body temperature reaching a nadir of 13.7°C and cardiac arrest for almost 3 h, she was successfully resuscitated on CPB followed by a period of extracorporeal mem- brane oxygenation because of severe respiratory failure. She had no sequelae 2 years later [5]. Regarding our patient, a well-equipped ambulance dis- patch center and its staff of specialized nurses and flight coordinators, supervised by the anesthesiologist on duty for the helicopter, played an important role by coordinat- ing the total pre- and intra-hospital resources. Because of other similar actions during the last few years, the center, which is an integral part of our Department of Emer- gency Medical Services, has obtained experience in coor- dinating the transfer of patients with cardiac arrest with rotor or fixed-wing aircraft over long distances [5]. Our university hospital is the only center for cardiovascular surgery in the area providing rewarming with extracor- poreal circulation. The next center is located in Trond- heim, approximately 600 km to the south. Although the dispatch center could have chosen to use a correspond- ingly staffed and equipped ambulance plane, flying at double speed, the helicopter was preferred because it could provide “door-to-door” transfer. Arriving at the local hospital under ongoing CPR, the rectal temperature of the patient already had fallen by 10° C, which corresponds to a 60-70% decrease in cerebral metabolic rate, based on a 6-7% reduction per degree fall in body temperature [7]. Presumably, his alcohol intoxi- cation helped him avoid most of the shivering and the resulting increase in oxygen consumption that normally occurs during exposure to cold water. In anesthetized dogs cooled from 37 to 25°C core temperature, investiga- tors noticed that cardiac output fell spontaneously by 65% [8]. Although performed by experienced specialists according to the guidelines [6], we have no evidence of the efficacy of the cardiac compressions. However, by extrapolating from the results of the latter investigators, we assume that a cardiac output of 30-40% of normal should be sufficient to balance the oxygen demand at a