Cardiac Arrest in Hypothermia-Reply

In Reply.—  We agree with Dr White that sinus bradycardia in patients with core temperatures of less than 26 °C can be associated with a grave prognosis, since such patients are at high risk of having ventricular fibrillation develop. We included sinus bradycardia in our discussion to warn physicians to avoid therapeutic measures (intubation, overventilation, excessive bicarbonate replacement, and pacing wire placment) that might precipitate this hemodynamically less favorable rhythm. As discussed by Wickstrom et al,¹ monkey experiments suggest that any physical stimulus can trigger the onset of ventricular fibrillation in the cold heart. Hypothermic patients should be handled gently. Rewarming, of course, must be instituted. External rewarming has been associated with conversion to fibrillation.^2,3 In view of the high risk of this arrhythmia in patients with bradycardia and core temperatures below 26 °C, perhaps aggressive core rewarming by peritoneal dialysis should be instituted in hope of preventing