Monday, 4 March 2013

Part 1. Avalanche Resuscitation Guideline Update

Avalanche Resuscitation Guideline Says Cardiac Arrest Survival Relatively High

Reuters/New York Times

"The core message is that rescuers as well as paramedics and emergency physicians should be aware of the special circumstances in an avalanche accident," Dr. Hermann Brugger from ICAR, Bozen/Bolzano, Italy told Reuters Health. "They should consider that even patients in cardiac arrest do have a good chance of survival if they are found with a patent airway which may indicate that they were able to breathe during burial."

The Commission reviewed 96 articles in establishing the guideline. The review showed that the overall survival rate of avalanche involvements is 77% and depends on the grade and duration of burial and the pathological processes of asphyxia, trauma, and hypothermia. Grade of burial is the strongest single factor for survival.

Throughout the guidelines, the authors emphasize prompt location and extrication of buried victims.

"First of all, physicians should make sure that conditions at the site of the avalanche are safe (we lost too many rescuers' lives in the line of duty due to secondary avalanches)," Dr. Brugger said. "Secondly, the physician should try to gather some information about the circumstances of the accident, the number of missed persons and the time when the avalanche was released to assess the duration of burial. If the buried victims are localised, the extrication from the snow masses should be done as carefully as possible and great attention to the patency of the airway should be paid."

CPR should be initiated in virtually all unresponsive cases, and ventilation should be combined with chest compression.

"If the airway of a patient who was buried more than 35 minutes is free, the physician should not give up hope, even in the absence of vital signs," Dr. Brugger said. "Especially if the cardiac arrest occurs during the rescue procedure or transport, that has been frequently reported, they should be treated optimistically and transported under continuous cardiopulmonary resuscitation to a centre for extracorporeal rewarming. The longest successful cardiopulmonary resuscitation of a hypothermic patient reported in literature was six and a half hours and the neurological outcome of those survivors is amazingly excellent."

When trauma is evident, the guidelines recommend adequate spinal stabilisation throughout extrication, on-scene management, and transport.

Hypothermia is common in avalanche victims. The guidelines recommend resuscitation for cardiac arrest victims with core temperatures below 32 degrees Celsius and a patent or unknown airway but suggest withholding resuscitation for those in asystolic cardiac arrest, core temperature below 32 degrees Celsius, and an obstructed airway.

Rewarming and oxygen therapy are also advised for hypothermic victims.

Dr. Brugger and colleagues will be establishing an international registry for collecting data on out-of hospital and in-hospital avalanche victims. "We know very little about the pathophysiological factors determining survival and about the cooling rates during and after burial," he said. "So, monitoring the core temperature and analysing clinical data would help us to better understand why some of the victims are able to survive while others do not."

I thought I would share this excellent summary from Reuters/New York Times. The second part on trauma I feel I can take a bit of credit  for as I have pushed this consistently through the years and with ICAR. There may be some folk with red faces reading this in the guidelines as I was given a hard time for really pushing this back in the day.

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