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

Part 12: Cardiac Arrest in Special Situations

“…The core temperature at time of extrication provides a proxy for duration of burial. A case series 450 of buried avalanche victims showed a maximum cooling rate of 8°C per hour, whereas a case report 447 described a maximum cooling rate of 9°C per hour. These…”

“…406,410 -415 Alternative effective core rewarming techniques include warm-water lavage of the thoracic cavity 413,416 -420 and extracorporeal blood warming with partial bypass. [421][422][423] • Adjunctive core rewarming techniques include warmed IV or intraosseous (IO) fluids and warm humidified oxygen. 424 Heat transfer with these measures is not rapid, and should be considered supplementary to active warming techniques.…”

“…Studies of avalanche victims demonstrate a progressive nonlinear reduction in survival as the time of avalanche burial lengthens. 439 -442 The likelihood of survival is minimal when avalanche victims are buried Ͼ35 minutes with an obstructed airway and in cardiac arrest on extrication 440,441,[443][444][445][446][447][448][449] or are buried for any length of time and in cardiac arrest on extrication with an obstructed airway and an initial core temperature of Ͻ32°C. [441][442][443]447,450 It may be difficult to know with any certainty how long an avalanche victim has been buried.…”

Part 8: Advanced Life Support

“…Based on the low incidence of bradycardia that is resistant to atropine these trials may not be pragmatic or possible. 419,420,[422][423][424][425] ; LOE P4 426,427 ) victims who were buried beyond 35 minutes did not survive if they had an obstructed airway (defined as obstructed by avalanche debris or by other means) on uncovering the head. One study (LOE P5) 428 demonstrated that when breathing in simulated air pockets of different volumes, hypoxia and hypercapnia achieved a steady state after 10 minutes.…”

“…432 An avalanche case report described a maximum cooling rate of 9°C/h (LOE P4). 426 Those cooling rates suggested that, at 35 minutes of burial, the core temperature may drop as low as 32°C. Three relevant studies (LOE P3) 423,432,433 and 4 case series or reports (LOE P4) 434,435426,431 recorded ROSC in 22, and survival to hospital discharge in 7 of those 22, buried avalanche victims in cardiac arrest with a core temperature less than 32°C with aggressive rewarming using extracorporeal circulation.…”