Case reportFull recovery of an avalanche victim with profound hypothermia and prolonged cardiac arrest treated by extracorporeal re-warming☆
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.
References (41)
- et al.
Field management of avalanche victims
Resuscitation
(2001) - et al.
Hypoxia and Hypercapnia during respiration into an artificial air pocket in snow: implications for avalanche survival
Resuscitation
(2003) - et al.
On-site triage of avalanche victims with asystole by the emergency doctor
Resuscitation
(1996) - et al.
One night in a snow bank: a case report of severe hypothermia and cardiac arrest
Resuscitation
(2005) - et al.
Neuromuscular blockade significantly decreases systemic oxygen consumption during hypothermic cardiopulmonary bypass
J Cardiothorac Vasc Anesth
(1991) - et al.
Accidental hypothermia treated by extracorporeal blood-warming
Lancet
(1967) - Winterberichte 1990–2005. Davos, Switzerland: Eidgenössisches Institut für Schnee- und Lawinenforschung...
- et al.
Der Lawinennotfall, eine aktuelle Übersicht
Der Anästhesist
(2006) - et al.
Avalanche survival chances
Nature
(1994) - et al.
Pattern and severity of injury in avalanche victims
High Alt Med Biol
(2007)
On-site treatment of avalanche victims, ICAR MEDCOM recommendation
High Alt Med Biol
Accidental hypothermia
Tests and assessment
The Halstead-Reitan neuropsychological test battery
Management of profound accidental hypothermia with cardiorespiratory arrest
Ann Surg
Differentialdiagnose des Herzkreislaufstillstands hypothermer Lawinenopfer: retrospektive Analyse von 32 Lawinenunfällen
Schweiz Rundsch Med
Hypercapnia increases core temperature cooling rate during snow burial
J Appl Physiol
Effects of carbon dioxide inhalation on physiological responses to cold
Aviat Space Environ Med
Hypercapnia lowers the shivering threshold and increases core cooling rate in humans
Aviat Space Environ Med
Eucapnic hypoxia lowers human cold thermoregulatory response thresholds and accelerates core cooling
J Appl Physiol
Cited by (108)
Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update
2023, Wilderness and Environmental MedicineSurvival probability in avalanche victims with long burial (≥60 min): A retrospective study
2021, ResuscitationCitation Excerpt :Although the terms “rigor mortis” or “fixed dilated pupils” were mentioned in one patient, they should not be considered as reliable signs of death in accidental hypothermia.21 Although survival probability for avalanche victims in CA is low, full recovery after resuscitation and ECLS rewarming has been observed in victims with long burial and severe hypothermia.19,17,22–25 In our study, none of the survivors sustained CA.
Witnessed Cardiac Arrest in a Hypothermic Avalanche Victim Completely Buried for 2 Hours
2021, Wilderness and Environmental MedicineWilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update
2019, Wilderness and Environmental MedicineCitation Excerpt :These patients will need close monitoring to ensure they do not become hypothermic. Hypothermic patients have survived with normal neurologic function even after cardiac arrest.23,76–78 Many of the usual indicators of death, such as fixed, dilated pupils and apparent rigor mortis, are unreliable in hypothermic patients.76,77
- ☆
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.
- 1
Tel.: +39 0474 917111; fax: +39 0474 917000.
- 2
Tel.: +39 0474 581111; fax: +39 0474 581000.
- 3
Tel.: +43 512 504 22400; fax: +43 512 504 22450.
- 4
Tel.: +44 43 1 3202463.