Elsevier

Resuscitation

Volume 76, Issue 3, March 2008, Pages 474-480
Resuscitation

Case report
Full recovery of an avalanche victim with profound hypothermia and prolonged cardiac arrest treated by extracorporeal re-warming

https://doi.org/10.1016/j.resuscitation.2007.09.004Get rights and content

Summary

Survival of hypothermic avalanche victims with cardiac arrest is rare. This report describes full recovery of a 29-year-old backcountry skier completely buried for 100 min at 3.0 m (9.8 ft) depth. On extrication he was unconscious, but breathing spontaneously into an air pocket; core body temperature measured 22.0 °C (71.6 °F). He was intubated and ventilated on site. Ventricular fibrillation commenced during helicopter transportation, whereby chest compression was lacking for 15 min. At the nearest hospital continuous cardiopulmonary resuscitation was initiated, but defibrillation failed. Tympanic core body temperature measurement confirmed life-threatening hypothermia of 21.7 °C (71.1 °F) and serum K+ was 4.3 mmol/l, necessitating transferral to a hospital with cardiopulmonary bypass facilities. Defibrillation finally succeeded following re-warming, by femoral veno-arterial bypass, to 34.5 °C (94.1 °F). Total duration of cardiac arrest was 150 min. The patient developed pulmonary oedema, treated by extracorporeal membrane oxygenation, but progressed well and was discharged from hospital on day 17, fit to resume professional and social activities. Follow-up cerebral magnetic resonance imaging 2 years after avalanche burial demonstrated only minimal changes attributable to unrelated, prior cranial trauma. Extensive neurological and psychological investigations gave excellent results. This report confirms previous literature that an air pocket with patent airways is essential for survival of a completely buried avalanche victim after 35 min and endorses the recommended management strategies of the International Commission for Mountain Emergency Medicine ICAR MEDCOM. In particular, all hypothermic victims extricated with an air pocket and free airways must be treated optimistically, even despite prolonged cardiac arrest. This remarkable case documents the fastest drop in core temperature ever recorded during snow burial, namely 9.0 °C (16.2 °F)/h, and the second-lowest reversible core temperature in avalanche literature.

Introduction

On average 140 persons, mostly skiers and snowboarders, die every year in North America and Europe due to avalanches (approximately 35 in North America, 100 in the European Alps and 5 in other parts of Europe).1, 2 If caught in an avalanche, the chance of survival depends on: (a) depth of burial; (b) duration of burial; (c) presence of an air pocket and clear airways; and (d) severity of mechanical injuries.3, 4 Death is attributable primarily to asphyxiation, whereas hypothermia (which in conjunction with hypoxia and hypercapnia constitutes the triple H syndrome5) and fatal injuries are of lesser importance.6 In 2001 the International Commission for Mountain Emergency Medicine ICAR MEDCOM proposed an algorithm (Figure 1) for the pre-hospital management of persons buried in an avalanche or pronouncement of death on site.7 Here we present a unique case of survival of an avalanche victim (W.M.) with profound hypothermia and cardiac arrest and discuss the relevant pathophysiology, on-site treatment, re-warming strategies and complications. Extensive follow-up assessment 2 years after the accident is reported. W.M. gave his written consent to publication.

Section snippets

The avalanche accident

On February 19th 2005 four backcountry skiers climbed a mountain of the Eastern Alps in Northern Italy. A slab avalanche was triggered at 9.35 a.m., at an altitude of 2050 m (6726 ft), completely burying W.M., a fit, healthy 29-year-old male and the 62-year-old group leader. The uninjured companions called the emergency dispatch centre by mobile phone for help, whereupon three helicopters were activated immediately to transport two emergency physicians, rescue teams and avalanche dogs with their

Discussion

The lowest reversible core temperature recorded in avalanche literature was reported by Althaus et al. in 1982 in Switzerland,11 where a 42-year-old man was extricated in asystole after being buried for 5 h, recovering fully after re-warming with cardiopulmonary bypass (CPB) from a rectal temperature of 19.0 °C (66.2 °F). The present case documents the second-lowest core temperature survived in an avalanche accident to date and, moreover, the fastest rate of cooling during snow burial ever

Conclusions

This report demonstrates that an avalanche victim can survive without sequelae after being deeply buried for 100 min, breathing into a small, closed air pocket, despite core cooling at an unprecedented high rate, confirming the guidelines of ICAR MEDCOM7 and findings of previous literature3, 4, 5 that an air pocket with patent airways is essential for survival of a completely buried avalanche victim after 35 min. Establishment of the presence or absence of an air pocket and clear airways is the

Conflict of interest statement

The authors are not involved in any financial interest and did not get any grants. This implies commercial affiliation as well as consultancy, stock, or equity interests, and patent-licensing arrangements that could be considered a conflict of interest.

Acknowledgments

The authors wish to thank the Mountain Rescue Service provided by the South Tyrolean Alpine Association and the Helicopter Emergency Medical Service of the Province of Bolzano, Italy for supplying the data on the avalanche rescue operation, as well as Dr. Martin Karner, Department of Radiology at the General Hospital Bruneck, for assistance with MRI.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2007.09.004.

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