Elsevier

Resuscitation

Volume 84, Issue 5, May 2013, Pages 539-546
Resuscitation

Resuscitation great
Resuscitation of avalanche victims: Evidence-based guidelines of the international commission for mountain emergency medicine (ICAR MEDCOM): Intended for physicians and other advanced life support personnel

https://doi.org/10.1016/j.resuscitation.2012.10.020Get rights and content

Abstract

Background

In North America and Europe ∼150 persons are killed by avalanches every year.

Methods

The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) systematically developed evidence-based guidelines and an algorithm for the management of avalanche victims using a worksheet of 27 Population Intervention Comparator Outcome questions. Classification of recommendations and level of evidence are ranked using the American Heart Association system.

Results and conclusions

If lethal injuries are excluded and the body is not frozen, the rescue strategy is governed by the duration of snow burial and, if not available, by the victim's core-temperature. If burial time ≤35 min (or core-temperature ≥32 °C) rapid extrication and standard ALS is important. If burial time >35 min and core-temperature <32 °C, treatment of hypothermia including gentle extrication, full body insulation, ECG and core-temperature monitoring is recommended, and advanced airway management if appropriate. Unresponsive patients presenting with vital signs should be transported to a hospital capable of active external and minimally invasive rewarming such as forced air rewarming. Patients with cardiac instability or in cardiac arrest (with a patent airway) should be transported to a hospital for extracorporeal membrane oxygenation or cardiopulmonary bypass rewarming. Patients in cardiac arrest should receive uninterrupted CPR; with asystole, CPR may be terminated (or withheld) if a patient is lethally injured or completely frozen, the airway is blocked and duration of burial >35 min, serum potassium >12 mmol L−1, risk to the rescuers is unacceptably high or a valid do-not-resuscitate order exists. Management should include spinal precautions and other trauma care as indicated.

Introduction

In North America and Europe ∼150 persons are killed by avalanches every year,1 with most triggered by skiers, snowboarders and, in the USA and Canada, by snowmobilers.2 Avalanches inflict even higher death tolls in developing countries; for instance avalanches claimed 284 lives in South East Anatolia in 1992, >200 in Kashmir in 1995 and 135 in Kashmir in 2012. The total number of persons in avalanche terrain is unobtainable and mortality in these activity groups can only be roughly estimated. The first recommendations for on-site management and transport of avalanche victims, based on survival analyses,3, 4 case reports5 and case series,6, 7, 8, 9 were proposed in 199610 and 2001.4 The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) established official consensus guidelines including an algorithm in 2002.11 A systematic review of four prognostic factors12 and an International Liaison Committee on Resuscitation (ILCOR) worksheet process were the basis of the recommendations for avalanche resuscitation in the 2010 Resuscitation Guidelines.13, 14 Recommendations for transport and treatment decisions of hypothermic patients including avalanche victims have been recently developed.15 The ICAR MEDCOM sought to systematically develop evidence-based guidelines using a structured worksheet with the mandate to obtain final consensus among the ICAR MEDCOM.

Section snippets

Methods

The objectives, inclusion/exclusion criteria, working group and worksheet of 27 Population Intervention Comparator Outcome (PICO) questions (supplementary data) derived from earlier avalanche resuscitation recommendations4 were developed by the ICAR MEDCOM at a TOPIC meeting. The electronic database of Medline was searched via PubMed with the search terms (avalanche [All Fields]) and (hypothermia [All Fields]) and the database of EMBASE via OVID with (avalanche {Including Related Terms}) and

Findings and recommendations

From a total of 3530 retrieved citations, 96 articles were classified as relevant and were subjected to full review.

Conclusions

The algorithm for the management of avalanche victims is shown in Fig. 2. If lethal injuries are excluded and the body is not frozen, the rescue strategy is governed by the duration of snow burial and, if not available, by the victim's core-temperature. If burial time ≤35 min (or core-temperature ≥32 °C) rapid extrication and standard ALS is important. If burial time >35 min and core-temperature <32 °C, treatment of hypothermia including gentle extrication, full body insulation, ECG and

Conflicts of interest statement

None of the authors have a commercial or industrial conflict of interest. H.B., J.B., B.D., P.P. and K.Z. have published on hypothermia. H.B. receives support as the head of the Institute of Mountain Emergency Medicine, EURAC research.

Acknowledgements

The following ICAR MEDCOM members approved these recommendations at meetings in Longyearbyan (Norway) and Åre (Sweden): Gege Agazzi (Italy); Borislav Aleraj (Croatia); Jeff Boyd (Canada); Bruce Brink (Canada); Douglas Brown (Canada); Hermann Brugger (Italy); Perilif Eduinsson (Sweden); Tore Dahlberg (Norway); John Ellerton (Vice-President, United Kindom); Fidel Elsensohn (President, Austria); Herbert Forster (Germany); Nicole Gantner-Vogt (Principality of Liechtenstein); Andrzod Gorka (Poland);

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.10.020.

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