ICAR MEDCOM 2013 MINUTES, BOL,CROATIA · Fidel gave a report of the Mountain Rescue training in Kathmandu in May 2013. New papers published, submitted or in press No papers submitted

ICAR MEDCOM 2013 MINUTES BOLCROATIA

Thursday October 17 2013

WelcomePresident Fidel Elsensohn welcomed the members of the Commission

Attending see appendix

Apologies Nicole Gantner-Vogt Kazue Oshiro Herbert Forster Guumlnther Sumann Theohearis Sinifakoulis Peter Mair Rick de Decker Arthur Morgan Tore Dahlberg

Introductions Introductions of new and old members

Minutes of the last meetingThe minutes from the Spring meeting were approved without changes

Internet platformFidel mentioned the internet platform and encouraged all members to registerhttpwwwstage4usicar

Financial Report and Bank AccountOur balance is euro 853196 No change since last meeting

Presidentrsquos report

Fidel and Hermann were in Taiwan in November 2012 at the World Congress Mountain Medicine representing ICAR MEDCOM and promoting the World Congress of Mountain Medicine that will take place in Bolzano in May 2014

Jose Ramon Morandeira passed away suddenly this year He introduced mountain medicine in Spain He was a professor at Zaragoza He was an expert in treating frostbite He sponsored many research expeditions We had a moment of silence for our friend who is no longer with us

International Commissionfor Mountain Emergency MedicineICAR MEDCOM

Founding of the Bulgarian Mountain Medicine Society in SofiaLectures from Hermann Peter and Fidel

Spring meeting in Bad Toumllz (see minutes)

Meetings of the Executive Board The new proposes for proposed to the Bylawswill be presented at the Assembly of Delegates

Next yearrsquos meeting is in South Lake Tahoe 6-10 October 2014The 2015 meeting will be in Ireland

Elections of officers All officers were elected for another termFidel Elsensohn - PresidentJohn Ellerton ndash Vice President and President-ElectKen Zafren ndash Vice President

Report of Nepalese Mountain Rescue ProjectFidel gave a report of the Mountain Rescue training in Kathmandu in May 2013

New papers published submitted or in pressNo papers submitted at this time

Diploma in Mountain MedicineJohn Ellerton discussed the new regulations of the ICAR MEDCOM UIAAMEDCOM ISMM This will be a topic at the ISMM meeting in Bolzano in May 2015There are currently about 25 courses worldwide The process of evaluating courses will need to be changed to accommodate this large number The syllabus will need to be updatedThere was a discussion about methods to ensure that others can verify whether someone holds a diplomaThere was a discussion about assessment of coursesCurrently certification is for life There was a discussion about whether individuals should be required to renew their diplomasThe final topic regarded charging the courses in order to support the administrative committee

Papers in preparation

Modular First Aid Kit for Alpinists Mountain Guides and Alpinist Physicians (title has been modified) Reisten O Soteras I WigetThe paper will be revised and the revised version will be presented at the Spring meeting

Analgesia in the mountains and remote areas Ellerton J Paal P et al

Evidence-based recommendations for canyoning rescue Soteras I Strapazzon G

Avalanche triage form Blancher M Kotkman A

Alpine trauma registry Strapazzon G

German data collection Muumlller N

Short communications

Ladislav Kotrusz Medical Training in Slovak Mountain RescueThe level of medical education is excellent but the organization plans to improve the training for medical care in mountain rescue

Giancelso Agazzi Avalanche rescue 1909The Laghi Gemelli (Twin Lakes) Pass avalanche of December 7 1909 buried a group of 7 mountaineers killing one victim The depth of the snow that slid was 2 meters A compact layer above slid on a poorly compacted deep layer The group sat out a blizzard for 2 days at the hut before attempting to cross the pass Six of the eight were on foot while 2 were on skis One turned around due to cold feet They were accompanied by a mountain guide at the hut The guide refused to lead the group over the pass because of dangerous snow conditions

The rescuers were notified by telegram the next day The rescuers including 2 doctors were hampered by a storm Some of the rescuers suffered frostbite It took two days to evacuate two of the injured victims One victim reported complete burial with an air pocket The body of the dead victim was found on December 26

Volker Lischke Medical simulation training in helicopter-assisted mountain rescue operationsVarious personnel must work together randomly assorted In order to improve performance a training center was established The goal was to promote skill level behavior which is much faster than rule-level behavior The training facilityin Bad Toumllz Germany includes a maneuverable helicopter simulator and a cable car on cables Volker described the results of the initial training involving rescuers including doctors from all over Germany

Alex Kottman Avalanche Victim Resuscitation Checklist (flowchart)

Further discussion The modified checklist was accepted

Manuel Genswein Survival chance optimized procedures in rescue and how to minimize injuries during evacuationManuel presented an algorithm designed to conserve resources by concentrating efforts on avalanche victims with higher chance of survival Many patients have little hope of survival Once rescuers have identified a patient with little chance of survival if resources are limited only a short course of CPR is provided If unsuccessful rescuers then shift efforts to victims with higher survival chances including victims who are still buried A second flowchart prioritizes evacuation of multiple victims depending on the expected survival benefit of transport to medical care A third flowchart ldquoPriorities and elementary procedures in basic level companion rescuerdquo presents a flowchart for companion rescue including the need to call or go for help prioritizing rescue attempts and resuscitation of multiple victims

Jeff Boyd Avalanche triageJeff presented a case of 17 school children buried of whom 7 were rescued by 2 mountain guides who happened to be on a slope above the valley where the avalanche ran One of the rescued victims dug out and saved 3 other victims Two deeply buried victims were found by organized rescuers with obstructed airways The esophageal temperatures of the these two dead victims were both above 32degC This led to the development of Canadian AvSAR ndash Rescue triage

In a multiple casualty incident (MCI) resources are overwhelmed Priority ndashmodified ndash survival probabilities ndash ldquogreatest good for the greatest numberrdquo Modified ndash rather than ldquoreverserdquo ndash triage Jeff presented the algorithm from the paper by Bogle et al in Wilderness and Environmental Medicine the AvSORT algorithm Patients with severe injuries who are not breathing would be managed expectantly

A working group are planning to extend the avalanche check list to a triage algorithm Hermann Brugger proposed a joint effort among several groups to develop a triage algorithm Manuel Genswein proposed applying simulation techniques Hermann pointed out that simulations are not a high level of evidence There is limited data The Swiss database may be useful We may be able to produce a joint paper with the avalanche commission

Joint preconference in Lake TahoeFidel announced a joint conference of the Medical Commission and the Avalanche Commission to discuss mass casualty incidents The main theme of the conference in Lake Tahoe is mass casualty incidents

Mountain Rescue Book ndash Iztok Tomazin

Iztok presented his book which will be a compendium of stories of mountain rescue doctors It will be published in English and German and will include photos Members of the commission are encouraged to submit chapters to Iztok

FORTHCOMING EVENTS

2014 ICAR MedCom Spring meeting in BozenBolzano Italy in conjunction with the X ISMM World Congress of Mountain Medicine Our session will be on Thursday May 29 to finish papers and to plan the preconference for Lake Tahoe The next few days will include the mountain rescue sessions

2014 October 5-10 ICAR General Assembly Lake Tahoe Nevada USA

2015 May dates to be determined Spring meeting Ticino Switzerland (Oliver Reisten and Gregoire Zen-Ruffinen)

2015 ICAR General Assembly Ireland

2016 ICAR MedCom Spring meeting Cape Town South Africa

CLOSINGFidel closed the meeting

MINUTES TAKEN BEI KEN ZAFREN

Michael Swangard Canada Igor Zulian Croatia Volker Lischke Germany Joe OGorman Ireland Marko Petrovic Serbia Kotrusz Ladislav Slovaki Kyfouidou Sofia Greece Krassen Demizev Bulgaria Erik Sandstrom Sweden Marie Nordgren Sweden Perolof Edvinsson Sweden Moskal Wozciech Poland Ashish Lohani Nepal Marija Mijuskovic Montenegro Borislav Aleraj Croatia Richard Price New Zealand Alex Kottmann Switzerland Marc Blancher France Oliver Reisten Switzerland Inigo Soteras Spain Peter Miskovic Croatia Jaroslav Edlman Czech Republic David Hillebrandt UIAA Medcom Mario Milani Italy Greg Zen Ruffinen Switzerland Fidel Elsensohn (President) Austria Ken Zafren (Vice President) USA John Ellerton (Vice President) England and Wales Peter Paal Austria Jeff Boyd Canada Dave Watson Canada Bruce Brink Canada

Johannes Schiffer Germany Natalie Muller Germany Iztok Tomazin Slovenia Oslashyvind

Thomassen Norway Hermann Brugger Italy Sven Christjar Skiaa Norway Mario Milani Italy Lana Donlagic Croatia

ANylirfCtsbrttv

WILDERNESS amp ENVIRONMENTAL MEDICINE 21 28ndash34 (2010)

ONCEPTS

riaging Multiple Victims in an Avalanche Settinghe Avalanche Survival Optimizing Rescue Triagelgorithmic Approach

ee B Bogle MD Jeff J Boyd MBBS UIAGM Kyle A McLaughlin CCFP (EM)

rom the University of Calgary Calgary AB Canada (LB Bogle) Mineral Springs Hospital Banff AB Canada (JJ Boyd) and theepartment of Emergency Medicine University of Calgary Calgary AB Canada (KA McLaughlin)

As winter backcountry activity increases so does exposure to avalanche danger A complicatedsituation arises when multiple victims are caught in an avalanche and where medical and other rescuedemands overwhelm resources in the field These mass casualty incidents carry a high risk of morbidityand mortality and there is no recommended approach to patient care specific to this setting other thanbasic first aid principles The literature is limited with regard to triaging systems applicable to avalancheincidents In conjunction with the development of an electronic avalanche rescue training module by theCanadian Avalanche Association we have designed the Avalanche Survival Optimizing Rescue Triagealgorithm to address the triaging of multiple avalanche victims to optimize survival and dispositiondecisions

Key words mass casualty incident triage avalanche mountain rescue AvSORT

vimodos

tttsivs

ntroduction

valanche fatalities have been increasing over time inorth America with a 10-season average of 41 deathsear between 1998ndash1999 and 2007ndash20081 This corre-ates with the increase in backcountry skiing snowboard-ng and snowmobiling23 Injuries are diverse and mayange from asphyxia to traumatic injuries (eg spinalractures) and to exposure injuries (eg hypothermia)4

urrently it is common for extricated avalanche victimso be treated according to standard first aid principlesuch as evaluating and treating the ABCs (airwayreathing and circulation) Additionally an avalancheesuscitation algorithm has been developed5 Whereashese can help guide the management of individual pa-ients they are not designed as triage tools for multipleictimsMass casualty incident is a term that may be used in

ircumstances when multiple victims place an excessiveemand on finite resources6 Mass casualties in an ava-anche incident not uncommonly overwhelm first re-ponders due to limited manpower in remote settings andhe time necessary to locate dig out and extricate buried

Corresponding author Lee B Bogle MD University of Calgary

aalgary AB Canada (e-mail elboglegmailcom)

ictims7ndash10 In such incidents triage needs to rapidlydentify those that will benefit from limited resources anday only allow simple lifesaving interventions such as

pening an airway or stopping major bleeding911 Tra-itional cardiopulmonary resuscitation may not be anptimal use of resources12 notably while other potentialurvivors remain buried

The hospital disposition of extricated victims shoulde determined wherever possible with those minimallynjured being sent to the nearest health care facility andhose more severely injured ideally being transported toesignated trauma centers1314

Avalanche rescues entail unique factors that necessi-ate a distinct triage system Our goal was to develop ariage tool to guide first-response avalanche rescuers inhe management of avalanche incidents when initial re-ources are overwhelmed by mass casualties By follow-ng a simple algorithmic approach to victim assessmentictims may receive simple lifesaving measures and betratified for evacuation to the most appropriate facility

oncept development

he existing mass casualty triage systems Simple Tri-

ge and Rapid Treatment (START) Care-Flight and

TlutuejlA

iwtgpmreaptvtdurmbwicssbitna

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

Avalanche Survival Optimizing Rescue Triage 29

riage Sieve were evaluated for applicability to ava-anche rescue815ndash17 A literature search was performedsing PubMed EMBASE and Google Scholar usinghe search term ldquoavalancherdquo Broad Internet searchessing Google and hand-searching augmented the lit-rature search This project was undertaken in con-unction with the development of an electronic ava-anche rescue training module by the Canadianvalanche Association1018

Triage literally means ldquoto sortrdquo19 A mass casualtyncident is typified by rescuers and resources being over-helmed and the general principle of a mass casualty

riage system is to prioritize victims to promote thereatest survival benefit for the greatest number6 Therompt identification of severely injured persons thatay benefit from simple interventions given the limited

esources is particularly essential Several triage systemsxist for mass casualty incidents START Care-Flightnd Triage Sieve use an algorithmic approach to stratifyatients based on readily observed characteristics such ashe ability to walk respiration status the ability of aictim to obey a command and capillary refill Based onhese factors patients are assigned to immediate urgentelayed or unsalvageable categories When the individ-al criteria of these triage systems were analyzed in aetrospective study it was found that a reduction in theotor component of the Glasgow Coma Score (GCS)

elow 6 or a systolic blood pressure less than 80 mm Hgere the most sensitive predictors of severe injury11 An

nability to obey a simple command reflects a motoromponent of the GCS score of less than 620 The ab-ence of a radial pulse is considered indicative of aystolic blood pressure of less than 80 mm Hg20 and haseen proposed as an alternative for slowed capillary refilln mass casualty incidents17 Whereas these triage sys-ems are useful in the general prehospital setting they areot designed for the specific and austere environment ofvalanche rescue

Overtriage for hospital disposition is the situationhere patients with relatively minor injuries are as-

igned to higher-level trauma centers incorrectly andrate of up to 50 is acceptable in a mass casualty

etting to prevent missing any serious injuries13 Un-ertriage is the situation where those who are seriouslynjured are not appropriately triaged to the severity ofheir injuries and are thus sent to the nearest hospitalnstead of a trauma center Undertriage rates of up to are acceptable13

An avalanche resuscitation algorithm derived fromriginal research and adopted by consensus amongxpert rescue physicians of the Medical Commissionf the International Commission for Alpine Rescue

ICAR MedCom) has been developed521 (Figure 1) i

owever it is designed for organized rescue teamshich in Europe usually include specialist physiciansith advanced life support (ALS) equipment and that

espond rapidly due to the widespread cellular phoneoverage and short helicopter flight times22 This rapidnd skilled response although ideal rarely applies torst responders in North America who may have very

imited equipment may lack ALS training and may beverwhelmed by mass casualties The ICAR MedComlgorithm focuses on the management of individualictims and is not a triage toolIn developing our proposed mass casualty algorithm

everal factors were taken into account The algorithmould need to promptly identify survivable and nonsur-ivable injuries under the resource-strained circum-tances then divide the potential survivors into thoseequiring immediate urgent or delayed treatment whenesources allow

The avalanche literature describes asphyxia as theause of death in the majority of fatalities as well as apectrum of lethal and nonlethal mechanical trauma thatay range in incidence from 5 to 32423ndash25 (Table)sphyxia is due to avalanche debris obstructing the

irway from mechanical chest compression and re-reathing expired air resulting in hypercapnia and hyp-xia2627 The presence of an ldquoair pocket defined as anypace surrounding the mouth and the nose no matterow small with a patent airwayrdquo is necessary for pro-onged survival from burial528 Rescue diggers shouldlways search for this air pocket In victims buried foronger than 35 minutes the absence of an air pocketoretells death29

he AvSORT algorithm

aking into account the above factors we propose theollowing Avalanche Survival Optimizing Rescue Tri-ge (AvSORT) algorithm for mass casualties whenesources are overwhelmed (Figure 2) We have re-ained general management concepts from existentass casualty triage systems but have incorporated

ey elements specific to avalanche rescue The inclu-ion of a step to determine ldquoobvious fatal traumardquo iseemed necessary due to the mechanical injury thatan occur during an avalanche Though it relies on theudgment of the first responder as to what is obviouslyatal it could allow rescuers to reallocate preciousime to victims who could be saved After 35 minutesf burial the presence of an air pocket is a criticaleterminant of survival and its absence would desig-ate a victim as expectant When burial time is lesshan 35 minutes or the time is unknown and the airway

s obstructed by impacted material such as snow or by

Fgf ith

30 Bogle Boyd and McLaughlin

ccluding posture then the airway should be clearedepositioned and opened before the breathing is reas-

A S S E S S M E NT OF THE E XTRIC

Conscious

Breathing

Obvious fatal injuries

Start CPR intubate

Checkburial time andorcore temperature

Asytole

Air pocketand free airway

Hypotheadminchangtrans

with i

intubate ventilate humidified oxygen

transport to hospit hypothermia exper unit with cardiopul

Pronouncepatient dead

Hypothe rm ia I pa tie nt a le rt sh ive ring (coreHypothe rm ia II pa tie nt drow sy non-sh ive rinHypothe rm ia II I pa tie nt unconscious (core teHypothe rm ia IV pa tie nt not bre a th ing (core

Hypothermia III

35 min an

igure 1 Algorithm for on-site management of avalanche victims Suidelines Transport to nearest hospital for serum potassium measuracilities is not logistically possible Source Reprinted from Ref 18 w

essed t

The ability to obey simple commands the presence ofradial pulse and heart rate are also incorporated as

E D P A TIE NT

Continue resuscitationfollow standard ACLSprotocol

le 35 min andor ge 32deg C

lt 32deg C

ricular fibrillation

ia I-IIer hot sweet drinkslothing if practicable

t to nearest hospitalnsive care unit

ithe orary bypass

s or uncertain

Hypothermia IVcontinue resuscitaionVF apply 3 DC shockstransport to unit with

cardiopulmonary bypass

m pe ra ture a bout 35-32deg C [95-896deg F])core te m pe ra ture a bout 32-28deg C [896-824deg F])

e ra ture a bout 28-24deg C [824-752deg F])pe ra ture lt 24deg C [lt 752deg F])

ng of hypothermia according to Swiss Society of Mountain Medicinent if hospitalization in a specialist unit with cardiopulmonary bypasspermission

rmiste c

pornte

al wiencmon

teg (m p

tagieme

riage factors as in other mass casualty triage algo-

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

ithms121516 Capillary refill will be unreliable with coldxposure and was avoided30 If there is doubt at anyecision step such as total burial time or obvious fatalnjury the decision must be made in a conservativeanner to proceed with additional evaluation of the

ictim The AvSORT algorithm is designed to assignany patients to the ldquoimmediaterdquo hospital disposition

ategory in order to overtriage victims by the appropriate013 Patients in the immediate category should receiveriority first aid and transport out of the field and shouldemand more initial attention than those in the urgentategory who subsequently receive priority for treatmentnd transport over delayed category patients Patients inhe expectant category should only be reassessed after allther victims are attended When manpower is increasedhen further treatment of expectant victims may be con-idered Formal pronouncement of death and notificationf legal authorities should be performed according torocedures established in the particular jurisdictionVery importantly the proposed triage algorithm does not

epend on medical equipment and is designed to be simpleo use in a stressful situation It might be printed as a quickeference card to be placed in first responders rescue kits

The 2008ndash2009 season was marred by an above-averagevalanche fatality rate in North America with 54 deaths1

wenty-three of the 40 fatal incidents involved multiplendividuals being caught injured andor buried The num-er of individuals caught in these fatal avalanches rangedrom 1 to 11 individuals Research has shown that in 26f avalanche incidents where complete burials occurredhere were 4 or more complete burials in the party7

The best chance for survival is for companion rescueither by members of the same party or nearby parties as

able Pattern and severity of injury in 105 avalanche victimsa

Type of injury Occurrence (n)b

sphyxia - fatal 33ervical spine fracture withdislocation - fatal

ypothermia - fatal 1xtremity trauma 20hest trauma 18pine fracture 7erebral trauma 2bdominal trauma 1elvic fracture 1inor or no injury 21

a Source Reprinted with permission4b The occurrence of these injuries distributed among the 105 victims

n this study

he initial survival rate of 92 at 15 minutes of burial time c

lummets to only 30 at 35 minutes29 Recovery timesnclude location of the victim best with an avalanche trans-eiver in addition to shoveling heavy consolidated ava-anche debris down to the victim and subsequent extricationrom the burial hole Deeper burials are associated withonger and more difficult extraction Victims buried deeperhan 200 cm have a probability of survival of only 10ompared with 80 for those buried less than 50 cm24

The inevitable delay for organized rescue provided bytrained rescue team that is off-site is believed respon-

ible for the limited increase in survival despite improve-ents in rescue and medical care29

The AvSORT algorithm is designed to improve ava-anche victimsrsquo outcomes in a mass casualty incident byffering only the simple lifesaving interventions of open-ng airways and stopping external bleeding to alreadyeverely hypoxic or injured victims but allowing firstesponders to recover other victims who may have betterhances of survival Rescuers will also have started toriage for evacuation to appropriate facilities when trans-ort becomes available Using simple criteria will reduceonfusion and allow direction in the potentially chaoticircumstance of a large avalanche rescue especially withespect to the final destination of seriously injured vic-ims The importance of appropriate evacuation decisionss demonstrated by the finding that direct transport ofore severely injured patients to an accredited trauma

enter has been shown to reduce morbidity and mortal-ty1431 In some circumstances due to transportationimitations individuals may be transported to the nearestealth care facility for stabilization and initial treatmentntil further transport can be arrangedMass casualty avalanche incidents not uncommonly

verwhelm first responders that are limited to a few indi-iduals and that have to manage a large number of victimsorcing rescuers to focus on victim recovery efforts withimited initial resuscitation opportunities7827 As there maye no way of knowing the injury status of buried individ-als rescuers must assume that some may be buried withinor injuries but are in danger of death from asphyxiation

nd need prompt extraction Thus it would be for thereater benefit of the whole to extract potential survivorshat risk asphyxia while buried rather than engage in pro-racted resuscitation on probable nonsurvivors This as-umption is based on the critical element of time of burialeflected in the well-established survival curve29 Rescuersay be forced to make tactical triage decisions incorporat-

ng such factors as relative burial depths measured byransceiver signal strengths as well as probing that mayverride initial extensive resuscitative measures Addition-lly rescuers need to ensure their own safety and the riskf being buried in subsequent avalanches may preclude

omprehensive resuscitation3233

Walking

Breathing

Able to follow simple commands (eg lsquoSqueeze my handrsquo or lsquowiggle your feetrsquo)

GREENDelayedtreatment ampevacuation after YELLOW

Send to closest hospital

YELLOWUrgent treat amp evacuate after RED victims

Send to closest hospital for additional evaluation

REDImmediate treatment highest priority

Send to Trauma Center

Palpable radial pulse (Check underside of wrist on the thumb side of the forearm for 10 s)

Heart rategt 120 bpm

Clear ampreposition airway to open it Breathing

BLACKExpectant assumed deceased

No further treatment unless resourcesand time permit

Yes check for and stop major external bleeds

No or unsure

Airpocket present

Buried gt 35 min

Buried lt 35 min or unknown

igure 2 The Avalanche Survival Optimizing Rescue Triage (AvSORT) algorithm for the management of multiple burials in an avalanche toe used as an initial triage tool when needs exceed resources Further treatment within the scope of rescuer ability with standard first aid principles

ay be warranted upon extraction and evaluation of all victims

WamutiitwtsgcAams

imitations

hile our algorithm is designed for the initial man-gement of mass casualty avalanche incidents whenanpower is overwhelmed it is not designed for sit-

ations where resources allow for standard resuscita-ion and treatment of all extracted individuals such asn the ICAR MedCom ALS algorithm Each avalanchencident is unique in the mix of numbers of buriedypes of injuries and abilities of first responders asell as dynamic changes in any layered response

herefore no one static system will handle all evolvingituations appropriately We propose the AvSORT al-orithm to help guide rescuers to triage victims effi-iently thereby optimizing survival We anticipate thevSORT algorithm will be used in conjunction with

ppropriate avalanche training equipment and com-on sense to adequately manage avalanche risk and

afely execute a rescueOur proposed AvSORT algorithm is based on estab-

ished concepts in avalanche and mass casualty triageedicine but has not been subjected to formal case-based

tudy for this specific incident type Further prospectiveesearch into the performance of this algorithm is neededo validate its efficacy in the field

cknowledgments

e wish to thank Ken Wylie and the Canadian Ava-anche Association for their input and advice in thisroject

eferences

1 Avalancheorg Avalanche accidents database Availableat httpavalancheorgaccidentsphp Accessed May 132009

2 Page C Atkins D Shockley L Yaron M Avalanche deathsin the United States a 45-year analysis Wilderness Envi-ron Med 199910145ndash151

3 Van Tilburg C In-area and backcountry snowboardingmedical and safety aspects Wilderness Environ Med200011102ndash108

4 Hohlrieder M Brugger H Schubert HM Palvic M Eller-ton J Mair P Pattern and severity of injury in avalanchevictims High Alt Med Biol 2007856ndash61

5 Brugger H Durrer B Adler-Kastner L Falk M TschirkyF Field management of avalanche victims Resuscitation2001517ndash15

6 Sasser S Field triage in disasters Prehosp Emerg Care200610322ndash323

7 Genswein M Thorvaldsdottir S Zweifel B Remote re-verse triage in avalanche rescue Proceedings of the Inter-national Snow Science Workshop September 21-27 2008

Whistler BC Canada Avalanche-Researchcom Olympic

Valley CA 2008 Available at httpavalanche-researchcomsitedynamic_libraryaspflv8issw_sep22_2008_1340libraryflvamplogID148 Accessed April 14 2009

8 Stethem C Piche M Winter 2003 in Southern BC ndashperspective recognition management Proceedings of theInternational Snow Science Workshop September 19ndash242004 Jackson Hole WY International Snow ScienceWorkshop American Avalanche Institute Wilson WY2004 Available at wwwavalancheorgissw2004issw_previous2006proceedingsdatapapers117pdf AccessedAugust 18 2009

9 Penniman D Baumann F The SME avalanche tragedy ofJanuary 20 2003 a summary of the data Proceedings ofthe International Snow Science Workshop September19ndash24 2004 Jackson Hole WY 2004

0 Boyd J Wylie K Avalanche triage Avalanche Canada(Revelstoke) Canadian Avalanche Association 20088364ndash67

1 Garner A Lee A Harrison K Schultz C Comparativeanalysis of multiple-casualty incident triage algorithmsAnn Emerg Med 200138541ndash548

2 Waeckerle JF Disaster planning and response N EnglJ Med 1991324815ndash821

3 Kennedy K Aghababian RV Gans L Lewis CP Triagetechniques and applications in decision making AnnEmerg Med 199628136ndash144

4 Sampalis JS Denis R Frechette P Brown R Fleiszer DMulder D Direct transport to tertiary trauma centers versustransfer from lower level facilities impact on mortality andmorbidity among patients with major trauma J Trauma199743288ndash295

5 Arnold T Cleary V Groth S Hook R Jones D Super GSTART Newport Beach CA Newport Beach Fire andMarine Department 1994

6 Hodgetts TJ Porter C eds Major Incident Medical Man-agement and Support The Practical Approach 2nd edLondon UK BMJ Publishing Group 2002

7 Benson M Koenig KL Schultz CH Disaster triageSTART then SAVEmdasha new method of dynamic triage forvictims of a catastrophic earthquake Prehosp DisasterMed 199611117ndash124

8 Tomm I eTraining for Mountain Operations AvalancheCanada (Revelstoke) Canadian Avalanche Association20078014ndash16

9 MacKersie RC Field triage and the fragile supply oflsquooptimal resourcesrsquo for the care of the injured patientPrehosp Emerg Care 200610347ndash350

0 American College of Surgeons Committee on TraumaAdvanced Trauma Life Support for Doctors StudentCourse Manual 8th ed Chicago IL American College ofSurgeons 2002

1 Brugger H Durrer B On-site treatment of avalanchevictims ICAR-MEDCOM-recommendation High Alt MedBiol 20024421ndash424

2 Berghold F Death in an avalanchemdashemergency medicine

gleanings of the avalanche catastrophe on 28 March 2000

in the ldquoHohe Tauernrdquo [in German] Der Notarzt 200117182ndash185

3 Johnson SM Johnson AC Barton R Avalanche traumaand closed head injury adding insult to injury WildernessEnviron Med 200112244ndash247

4 Jamieson B Geldsetzer T Trends and patterns in ava-lanche accidents In Avalanche Accidents in Canada Vol-ume 4 1984-1996 Revelstoke BC Canada Canadian Av-alanche Association 19967ndash20

5 Grossman MD Saffle JR Thomas F Tremper B Ava-lanche trauma J Trauma 1989291705ndash1709

6 McIntosh SE Grissom CK Olivares CR Kim HS Trem-ber B Cause of death in avalanche fatalities WildernessEnviron Med 200718293ndash297

7 Stalsberg H Albretsen C Gilbert M et al Mechanism ofdeath in avalanche victims Virchows Arch A Pathol AnatHistopathol 1989414415ndash422

8 Brugger H Sumann G Meister R et al Hypoxia andhypercapnia during respiration into an artificial air pocketin snow implications for avalanche survival Resuscita-

tion 20035881ndash88

9 Falk M Brugger H Adler-Kastner L Avalanche survivalchances Nature 199436821

0 Anderson B Kelly AM Kerr D Clooney M Jolley DImpact of patient and environmental factors on capil-lary refill time in adults Am J Emerg Med 20082662ndash 65

1 MacKenzie E Rivara F Jurkovich GJ et al A nationalevaluation of the effect of trauma-center care on mortalityN Engl J Med 2006354366ndash378

2 Kristensen K Genswein M Atkins D Risk and avalancherescue Proceedings of the International Snow ScienceWorkshop September 21ndash27 2008 Whistler BC CanadaAvalanche-Researchcom Olympic Valley CA 2008Available at httpavalanche-researchcomsitedynamic_libraryaspflv8issw_sep26_2008_1655libraryflvamplogID195 Accessed April 14 2009

3 Hohlrieder M Thaler S Wuertl W et al Rescue missionsfor totally buried avalanche victims conclusions fromtwelve years of experience High Alt Med Biol 20089

229ndash233

wwwelseviercomlocateajem

American Journal of Emergency Medicine (2013) 31 384ndash389

Brief Report

LUCAS compared to manual cardiopulmonary resuscitationis more effective during helicopter rescuemdasha prospectiverandomized cross-over manikin study

Gabriel Putzer MDa Patrick Braun MDa Andrea ZimmermannaFlorian Pedross PhDb Giacomo Strapazzon MDc Hermann Brugger MDc Peter Paal MDa

aDepartment of Anesthesiology and Critical Care Medicine Innsbruck Medical University Anichstraszlige 356020 Innsbruck AustriabDepartment of Medical Statistics Informatics and Health Economics Innsbruck Medical University Schoumlpfstraszlige 41 16020 Innsbruck AustriacInstitute of Mountain Emergency Medicine EURAC research Viale Druso 1 39100 Bolzano Italy

Received 19 May 2012 revised 8 July 2012 accepted 8 July 2012

AbstractObjective High-quality chest-compressions are of paramount importance for survival and goodneurological outcome after cardiac arrest However even healthcare professionals have difficultyperforming effective chest-compressions and quality may be further reduced during transport Wecompared a mechanical chest-compression device (Lund University Cardiac Assist System [LUCAS]Jolife Lund Sweden) and manual chest-compressions in a simulated cardiopulmonary resuscitationscenario during helicopter rescueMethods Twenty-five advanced life supportndashcertified paramedics were enrolled for this prospectiverandomized crossover study A modified Resusci Anne manikin was employed Thirty minutes oftraining was allotted to both LUCAS and manual cardiopulmonary resuscitation (CPR) Thereafterevery candidate performed the same scenario twice once with LUCAS and once with manual CPRThe primary outcome measure was the percentage of correct chest-compressions relative to totalchest-compressionsResults LUCAS compared to manual chest-compressions were more frequently correct (99 vs 59P b 001) and were more often performed correctly regarding depth (99 vs 79 P b 001) pressurepoint (100 vs 79 P b 001) and pressure release (100 vs 97 P = 001) Hands-off time wasshorter in the LUCAS than in the manual group (46 vs 130 seconds P b 001) Time until firstdefibrillation was longer in the LUCAS group (112 vs 49 seconds P b 001)Conclusions During this simulated cardiac arrest scenario in helicopter rescue LUCAS compared tomanual chest-compressions increased CPR quality and reduced hands-off time but prolonged the timeinterval to the first defibrillation Further clinical trials are warranted to confirm potential benefits ofLUCAS CPR in helicopter rescuecopy 2013 Elsevier Inc All rights reserved

Conflict of interest statement None of the authors has a conflict of interest Corresponding author Tel + 43 512 504 82617E-mail address gabrielputzerukiat (G Putzer)

0735-6757$ ndash see front matter copy 2013 Elsevier Inc All rights reservedhttpdxdoiorg101016jajem201207018

385LUCAS compared to manual cardiopulmonary resuscitation

1 Introduction

11 Background

After cardiac arrest high-quality chest-compressions areof paramount importance for survival and good neurologicaloutcome Unfortunately even healthcare professionals havedifficulty performing effective cardiopulmonary resuscita-tion (CPR) Chest-compressions often are too shallowhands-off time is too long [1] and CPR performancedeteriorates over time [2] During helicopter transport chest-compression effectiveness may be further reduced due tomovements of the vehicle confined space and prevailingsafety regulations [3] Such limiting factors could be thecause of low survival rates reported in helicopter transportedcardiac arrest patients [4]

12 Importance

Mechanical chest-compression devices deliver uninter-rupted chest-compressions of a predefined depth and rateThus chest-compression devices may play an important rolein maintaining good quality CPR in specific circumstanceswhere CPR is difficult to perform for example helicoptertransport or when CPR has to be performed over a longperiod for example during hypothermic cardiac arrest [56]However data supporting this assumption are limited [7]We hypothesized that the Lund University Cardiac AssistSystem (LUCAS Jolife Lund Sweden) could improvechest-compression quality during helicopter transport com-pared to manual CPR LUCAS is an electrically poweredpiston device providing 4 to 5 cm deep chest-compressionsand active decompressions back to the neutral position with afrequency of 100 minminus 1 and a duty cycle of 50

13 Goal of this investigation

The primary outcome measure was the percentage ofcorrect chest-compressions relative to total chest-compres-sions with LUCAS compared to manual CPR [89]Secondary outcome measures were compression depthpressure point complete pressure release and compressionrate as well as hands-off time and time untilfirst defibrillation

2 Methods

21 Study design and setting

The ethics committee of the Ludwig Maximilian Univer-sity Munich Germany waived the requirement for acommittee approval of this manikin study and authorizedcommencement of the study This prospective randomizedcross-over manikin study was conducted at the simulation

centre of the BavarianMountain Rescue Service in Bad ToelzGermany in February 2011 (wwwbergwacht-bayernde)

22 Participants

Twenty-five healthy advanced life support (ALS)ndashcertified paramedics with no previous experience usingLUCAS were enrolled (Supplemental Figure 1) Allcandidates signed informed consent and participated volun-tarily Before starting the test the candidates were instructedby ALS-certified instructors on LUCAS and conventionalmanual CPR according to the American Heart Association(AHA) 2010 guidelines [10] for 30 minutes respectivelyEach candidate performed the identical scenario in arandomized order (wwwrandomizerorg) once withLUCAS and once with manual chest-compressions

23 Intervention

Immediately after the training a standardized simulatedcardiac arrest scenario was presented to the candidates ldquoYouare part of a helicopter crew called to a hypothermic cardiacarrest patient Neither pulse nor breathing is detectable andbystander CPR is being performed Core body temperature is28degC (824degF) Please take care of this patientrdquo

A modified Resusci Anne manikin (Laerdal StavangerNorway) was employed For better CPR error analysis thescenario was divided into three parts before during andafter helicopter flight The before flight part started with ashort emergency assessment performed by an emergencyphysician (BP) In the manual group the candidatesperformed manual chest-compressions in rotation with thephysician every 2 minutes In the LUCAS group candidatesperformed manual chest-compressions until LUCAS place-ment At this point mechanical chest-compressions com-menced until termination of the test Candidates were notcorrected during placement or conduction of LUCAS ormanual chest-compressions After applying the defibrilla-tion pads on the manikin the electrocardiogram showedventricular fibrillation Three defibrillations at intervals of2 minutes were given without reversing ventricularfibrillation The manikin was intubated ventilated with abag-valve device (Ambu Bad Nauheim Germany) andafter the third defibrillation fastened on a stretcher andtransported to the helicopter to conclude the before flightpart (~ 6 minutes)

The during flight part consisted of a simulated eightminute flight (average transport time of medical helicoptersin the Eastern European Alps) The manikin was loaded intothe helicopter (BK117dummy MBB Ottobrunn Germany)and connected to an Oxylog ventilator (Draumlger LuumlbeckGermany) In the manual group the candidates continuedchest-compressions while kneeling beside the manikin`schest and the physician was positioned behind the headAfter landing the manikin was loaded on a trolley

386 G Putzer et al

In the after flight part CPR continued on the manikinwhich was placed on a trolley for the simulated two minutetransport to the trauma department Manual chest-compres-sions were delivered in a straddling position [11]

24 Outcome measures

The primary outcome measure was the percentage ofcorrect chest-compressions relative to total chest-compres-sions The percentage and not the absolute number ofcorrect chest-compressions was used to rule out the influenceof too high or low compression rates Secondary outcomemeasures were depth pressure point complete pressurerelease and rate of chest-compressions hands-off time andtime to first defibrillation

The LUCAS default setting for chest-compressionsdepth was 38 to 51 mm in alignment with the 2005 AHAguidelines [12] Because the candidates were alreadytrained according to 2010 guidelines we considered allcompressions with a depth of 40 to 60 mm as correct tocombine the LUCAS default setting with the 2010 AHAguidelines [10] The pressure point was counted as correctwhen performed in the lower half of the sternum andpressure release was correct when complete release betweenchest-compressions was recorded by the Laerdal SkillReporting System (Laerdal Stavanger Norway) Correctpressure rate was defined as 100 to 120 chest-compressionsper minute Data were analyzed with Microsoft Excel(Microsoft Redmond WA) and SPSS (Version 18 IBMArmonk NY)

25 Statistical analysis

In a pilot LUCAS vs manual CPR study the mean ofcorrect chest-compressions was 80 vs 60 and SD was15 Based on these data and considering α= 01 and β=90 15 participants were necessary to allow for significantresults To allow for possible dropouts 25 participants wereincluded in this study The outcome measure values arepresented as mean plusmn SD and 95 confidence interval (95CI) The Kolmogorov-Smirnov test was used to test fornormality Student t test was used for paired samples withnormal distribution and Wilcoxon test for samples withnon-normal distribution All reported P values were 2 sidedand a type I error level of 5 was considered The statisticalpower varies between 90 and 99 depending on thegroup comparisons

3 Results

Two candidates were excluded from the analysis becauseof incomplete data recording during the scenario due to wiredislocation between the manikin and the data-recordinglaptop The remaining 23 candidates (6 female) had a mean

age of 29 plusmn 11 years mean height of 178 plusmn 10 cm and meanweight of 75 plusmn 14 kg

31 Primary outcome

LUCAS compared to manual chest-compressions weremore frequently correct both before (97 vs 61 P b001) during (100 vs 41 P b 001) and after flight(100 vs 76 P b 001) as well as in the overall scenario(99 vs 59 P b 001 Table 1 and Fig 1A)

32 Secondary outcome

LUCAS compared to manual chest-compressions weremore often performed correctly regarding depth (99 vs79 P b 001) pressure point (100 vs 79 P b 001) andpressure release (100 vs 97 P = 001 Table 1 andFig 1B-D) In the LUCAS compared to the manual groupmean compression rate was less (100 vs113minminus 1 P b001) hands-off time was shorter (46 vs 130 seconds P b001) and time to first defibrillation was longer (112 vs 49seconds P b 001) The mean compression depth did notdiffer between groups (49 vs 47 mm P b 309 Table 2)

The before flight part in the LUCAS compared with themanual group lasted on average 393 (95 CI 383-403) vs350 seconds (95 CI 336-364) the during flight part 491(95 CI 484-499) vs 488 seconds (95 CI 482-493) theafter flight part 169 (95 CI 165-172) vs 170 seconds(95 CI 166-175) and the overall scenario 1053 (95 CI1039-1067) vs 1008 seconds (95 CI 990-1025)

4 Discussion

In this study of simulated CPR during helicopter rescueLUCAS chest-compressions were more often correct thanmanual chest-compressions Also total hands-off-time wasshorter in the LUCAS group whereas time to firstdefibrillation was longer

While LUCAS delivered uninterrupted high-qualitychest-compressions the quality of manual chest-compres-sions was consistently inferior throughout the scenario(Table 1) This was most pronounced during the helicopterflight with only 41 of correct manual chest-compressions(Fig 1A) most likely because of the confined space and theunfavorable position of the candidates in the helicopter Thiscontrasts with a prior manikin study reporting that manualchest-compressions were equally effective during helicopterflight as on the ground with ~ 77 correct chest-compres-sions by assessing chest-compressions depth and pressurepoint [3] Similarly another manikin study found acomparable chest-compressions depth during helicopterflight when compared to CPR at the scene However themedian chest-compressions depth was only 33 mm duringflight and 37 mm at the scene [13] These two studies are

Table 1 Absolute numbers of chest compression variables in both groups presented as mean valueplusmnstandard deviation and 95 CIBefore denotes performance before flight during during flight after after flight and overall the overall scenario

LUCAS group 95 CI Manual group 95 CI

Total chest compressionsBefore 588 plusmn 38 572-605 508 plusmn 58 483-533During 814 plusmn 29 801-826 909 plusmn 44 890-928After 279 plusmn 16 272-286 242 plusmn 20 234-251Overall 1681 plusmn 53 1658-1704 1659 plusmn 94 1618-1700Correct chest compressionsBefore 567 plusmn 34 553-582 309 plusmn 136 250-367During 814 plusmn 29 801-826 369 plusmn 233 268-470After 279 plusmn 16 272-286 186 plusmn 74 154-218Overall 1660 plusmn 45 1640-1679 864 plusmn 381 699-1028Correct depth of chest compressionsBefore 579 plusmn 37 563-595 389 plusmn 124 335-442During 814 plusmn 29 801-826 705 plusmn 224 608-802After 279 plusmn 16 272-286 203 plusmn 68 173-233Overall 1671 plusmn 52 1649-1694 1296 plusmn 380 1132-1460Correct pressure point of chest compressionsBefore 583 plusmn 36 567-599 426 plusmn 88 389-464During 814 plusmn 29 801-826 539 plusmn 200 453-625After 279 plusmn 16 272-286 228 plusmn 49 207-249Overall 1675 plusmn 50 1654-1697 1194 plusmn 260 1081-1306Correct pressure release of chest compressionsBefore 581 plusmn 38 565-597 476 plusmn 90 437-515During 814 plusmn 29 801-826 894 plusmn 75 862-927After 279 plusmn 16 272-286 238 plusmn 23 228-248Overall 1673 plusmn 50 1652-1695 1608 plusmn 166 1536-1680

lacking a mechanical CPR group Our study clearly showsthat LUCAS can improve CPR during a transport scenarioHowever a recent manikin study showed that LUCAS chest-compressions are less efficient than manual chest-compres-sions [14] According to this study 57 of the participantsdid not apply the mandatory stabilization strap of LUCASwhich resulted in sliding of LUCAS on the chest duringCPR Contrary to our study the participants did not trainwith LUCAS directly before the study This may be thereason for the poor CPR quality with LUCAS andemphasizes the imperative of regular training to applyLUCAS efficiently

The hands-off time in our study was remarkably short inboth study groups In the manual group it accounted for only13 of the total scenario time In real life hands-off times ofup to ~ 50 have been reported as a result of multiple tasksduring CPR [115] In the LUCAS group the hands-off timeaccounted for only 4 of the total scenario time and wasonly registered before initiation of mechanical CPR andduring rhythm analysis

Chest-compression quality and shorter hands-off timedirectly influence survival during CPR [9] This isparticularly important for hypothermic cardiac arrest pa-tients as prolonged CPR may be required before return ofspontaneous circulation [516] Despite prolonged CPRoutcome may be good and improved by high-quality CPR

as provided by a mechanical chest-compression deviceTherefore recently published expert-based guidelines of theUniversity Hospital Berne Switzerland recommend theinitiation of mechanical chest-compressions for all hypo-thermic cardiac arrest patients immediately after helicopterlanding until return of spontaneous circulation [17]

Time to the first defibrillation was prolonged in theLUCAS group due to time required for installation of thedevice before the first rhythm analysis The time delay untilfirst defibrillation may negatively affect clinical outcome[18] However a recently published cluster-randomized trialfound no difference in survival or neurological outcomewhether an early or delayed (ie 2 minutes) defibrillation wasperformed [19] Moreover longer periods to check for pulseand respirations as well as a maximum of three defibrillationsare recommended below a core body temperature of 30degCTherefore a short delay until first defibrillation in hypother-mic cardiac arrest seems to be of lesser importance tonormothermic cardiac arrest provided that the time until firstdefibrillation is bridged with high-quality manual CPR

5 Limitations

Firstly CPR was simulated on a manikin and transportand flight were performed in a simulator Thus this setting

Fig 1 Graphs display chest compression variables for the LUCAS and the manual group before during and after flight and for theoverall scenario Outliers and extreme values are shown as circles () or as asterisks () respectively A Correct chest compressions() B Correct chest compression depth () C Correct chest compression pressure point () D Correct chest compressionpressure ()

388 G Putzer et al

does not necessarily reflect a real CPR scenario Secondlyimprovements in CPR depicted by this study may not resultin improved patient outcomes Although there have beenstudies demonstrating that mechanical chest-compressionsmay improve clinical parameters such as blood pressure [20]coronary perfusion pressure [21] cortical cerebral bloodflow [22] and end-tidal CO2 [23] no high-quality study hasbeen published yet which shows improved outcome inhumans [2425] Thirdly it was not possible to blind thecandidates to the intent of the study But they were blinded tothe adequacy of chest-compressions

Table 2 Secondary outcome measure variables of both groups prese

LUCAS Group

Hands-off time (s) 46 plusmn 5Time to first defibrillation (s) 112 plusmn 12Mean compression rate (1minminus 1) 100 plusmn 05Mean compression depth (mm) 49 plusmn 2

6 Conclusions

During this simulated cardiac arrest scenario in helicopterrescue LUCAS compared to manual chest-compressionsincreased CPR quality and reduced hands-off time butprolonged the time interval to the first defibrillation Furtherclinical trials are warranted to confirm potential benefits ofLUCAS-CPR in helicopter rescue

Supplementary data to this article can be found online athttpdxdoiorg101016jajem201207018

nted as mean valueplusmnstandard deviation and 95 CI

95 CI Manual Group 95 CI

43-48 130 plusmn 15 123-136107-118 49 plusmn 6 47-52100-100 113 plusmn 6 110-11648-50 47 plusmn 6 45-50

Acknowledgments

We thank all candidates who participated in our study theBergwacht Bayern Physio-Control and Roraco (ViennaAustria) for providing the simulation centre LUCAS and aResusci-Anne Manikin respectively We are indebted to InaBeeretz Philipp Mahlknecht and Gerhard Staggl for theirlogistical and technical help as well as to Emily Procter forreviewing the manuscript

References

[1] Wik L Kramer-Johansen J Myklebust H et al Quality ofcardiopulmonary resuscitation during out-of-hospital cardiac arrestJAMA 2005293(3)299-304

[2] Hightower D Thomas SH Stone CK et al Decay in quality of closed-chest compressions over time Ann Emerg Med 199526(3)300-3

[3] Thomas SH Stone CK Bryan-Berge D The ability to perform closedchest compressions in helicopters Am J Emerg Med 199412(3)296-8

[4] Stone CK Thomas SH Kassler GP Survival from cardiac arrestduring air medical transport Air Med J 199615(1)29-31

[5] Gilbert M Busund R Skagseth A et al Resuscitation from accidentalhypothermia of 137 degrees C with circulatory arrest Lancet2000355(9201)375-6

[6] Putzer G Tiefenthaler W Mair P Paal P Near-infrared spectroscopyduring cardiopulmonary resuscitation of a hypothermic polytrauma-tised cardiac arrest patient Resuscitation 201283(1)e1-2

[7] Holmstrom P Boyd J Sorsa M Kuisma M A case of hypothermiccardiac arrest treated with an external chest compression device(LUCAS) during transport to re-warming Resuscitation 200567(1)139-41

[8] Christenson J Andrusiek D Everson-Stewart S et al Chestcompression fraction determines survival in patients with out-of-hospital ventricular fibrillation Circulation 2009120(13)1241-7

[9] Edelson DP Abella BS Kramer-Johansen J et al Effects ofcompression depth and pre-shock pauses predict defibrillation failureduring cardiac arrest Resuscitation 200671(2)137-45

[10] Berg RA Hemphill R Abella BS et al Part 5 adult basic life support2010 American Heart Association Guidelines for CardiopulmonaryResuscitation and Emergency Cardiovascular Care Circulation2010122(18 Suppl 3)S685-705

[11] Lei Z Qing H Yaxiong Z The efficacy of straddling external chestcompression on a moving stretcher Resuscitation 201081(11)1562-5

[12] Anonymous Part 4 Adult Basic Life Support 2005 American HeartAssociation Guidelines for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care Circulation 2005112V-19-IV-34

[13] Havel C Schreiber W Riedmuller E et al Quality of closed chestcompression in ambulance vehicles flying helicopters and at thescene Resuscitation 200773(2)264-70

[14] Blomberg H Gedeborg R Berglund L et al Poor chest compressionquality with mechanical compressions in simulated cardiopulmonaryresuscitation a randomized cross-over manikin study Resuscitation201182(10)1332-7

[15] Krarup NH Terkelsen CJ Johnsen SP et al Quality of cardiopulmo-nary resuscitation in out-of-hospital cardiac arrest is hampered byinterruptions in chest compressionsndasha nationwide prospective feasi-bility study Resuscitation 201182(3)263-9

[16] Lexow K Severe accidental hypothermia survival after 6 hours 30minutes of cardiopulmonary resuscitation Arctic Med Res199150(Suppl 6)112-4

[17] Monika BM Martin D Balthasar E et al The Bernese HypothermiaAlgorithm a consensus paper on in-hospital decision-making andtreatment of patients in hypothermic cardiac arrest at an alpine level 1trauma centre Injury 201142(5)539-43

[18] Perkins GD Brace SJ Smythe M et al Out-of-hospital cardiac arrestrecent advances in resuscitation and effects on outcome Heart 2011

[19] Stiell IG Nichol G Leroux BG et al Early versus later rhythmanalysis in patients with out-of-hospital cardiac arrest N Engl J Med2011365(9)787-97

[20] Duchateau FX Gueye P Curac S et al Effect of the AutoPulseautomated band chest compression device on hemodynamics in out-of-hospital cardiac arrest resuscitation Intensive Care Med 201036(7)1256-60

[21] Liao Q Sjoberg T Paskevicius A et al Manual versus mechanicalcardiopulmonary resuscitation An experimental study in pigs BMCCardiovasc Disord 20101053

[22] Rubertsson S Karlsten R Increased cortical cerebral blood flow withLUCAS a new device for mechanical chest compressions compared tostandard external compressions during experimental cardiopulmonaryresuscitation Resuscitation 200565(3)357-63

[23] Axelsson C Karlsson T Axelsson AB Herlitz J Mechanical activecompression-decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbondioxide (P(ET)CO2) during CPR in out-of-hospital cardiac arrest(OHCA) Resuscitation 200980(10)1099-103

[24] Lerner EB Persse D Souders CM et al Design of the CirculationImproving Resuscitation Care (CIRC) Trial a new state of the artdesign for out-of-hospital cardiac arrest research Resuscitation201182(3)294-9

[25] Perkins GD Woollard M Cooke MW et al Prehospital randomisedassessment of a mechanical compression device in cardiac arrest(PaRAMeDIC) trial protocol Scand J Trauma Resusc Emerg Med20101858

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

Letters to the Editor 273

valanche Triage Are Two Birds in the Bushetter Than One in the Hand

o the Editorn a previous issue of Wilderness and Environmentaledicine Bogle Boyd and McLaughlin discuss a pro-

osed triage algorithm for use in avalanche incidents inhich the number of victims exceeds the capacity of the

escuers to give optimum treatment to each victim1 Theylaim that this algorithm which they call ldquoAvSORTrdquoill help rescuers ldquorapidly identify those that will benefit

rom limited resourcesrdquoWhile a triage algorithm for multiple casualty ava-

anche incidents might be useful the proposed algorithmas potential problems The main difficulty is the as-umption that someone who is still buried might have aetter chance of suvival than someone who is extricatedithout obviously lethal injuries This assumption is

ontrary to the common wisdom that a bird in the hands worth two in the bush

The authors quote statistics showing that there haveeen many fatalities in avalanches with multiple victimsut they have not analyzed past avalanche incidents toee what effects their proposed algorithm might have hadf it had been applied in actual incidents Instead theyave modified existing trauma triage algorithms in a dataacuum While they claim that the AvSORT avalancheould produce desirable percentages of overtriage andndertriage they present no evidence in support of thisssertion They also present no evidence that their algo-ithm would result in an increased number of survivors

The authors are not specific about the conditions underhich their proposed algorithm should be used What is theefinition of a ldquomass casualty incidentrdquo For example doeshis term apply in the case of 2 avalanche victims and 2ninjured rescuers The algorithm also does not define howrst responders should determine when they are ldquoover-helmedrdquo nor does it give criteria for determining if the

rea is ldquoremoterdquo Is an area remote if the response time forescue is 2 hours Arrested hypothermic patients have beenuccessfully rewarmed after 4 hours of cardiopulmonaryesuscitation (CPR) even in Europe2

It is important that the proposed algorithm not be useds a reason to deviate from established resuscitationuidelines except under the most extenuating circum-tances Apneic severely hypothermic avalanche victimsave been successfully resuscitated2 It is critical toecognize that victims buried for more than 35 minutesho have a patent airway have a chance of survival Theuiding principle should be not to give up It would beragic if a rescuer did not try to resuscitate such a patientue to feeling ldquooverwhelmedrdquo The proposed algorithm

hould be modified so that victims buried longer than 35 e

inutes who have a patent airway but are not breathingot be triaged to the ldquoexpectantrdquo category They shouldeceive CPR and be transferred to a hospital capable oferforming cardiopulmonary bypassBecause the authors are advocating a triage guideline

hey have not specified all the specifics of treatment inhe various triage categories For this rescuers will needo follow another algorithm such as the Internationalommission for Mountain Emergency Medicine (ICAREDCOM) avalanche resuscitation guidelines3 The au-

hors present these guidelines but state that they ldquorarelyrdquopply to first responders in North America It is true thathe ICAR MEDCOM guidelines cannot be fully appliedithout the use of cardiac monitoring but they are pre-ominantly based on clinical criteria that do not requirepecial equipment The authors note that if the number ofescuers is adequate to search for buried victims as wells treat extricated victims standard treatment guidelinespply In this case there is no need for a triage algorithm

Although the proposed algorithm makes use of theuration of burial to determine treatment it does not useuration as a prognostic factor for buried victims Ava-anche survival probability of buried victims is 91 at 18inutes but drops precipitously to 34 after 35 minutes

s victims without an air pocket die from asphyxiation4

urvival then decreases gradually to a mere 7 at 130inutes as victims with a ldquoclosedrdquo air pocket succumb to

low asphyxia and hypothermia It makes less sense toivert resources from treating extricated victims with ahance of survival to searching for buried victims afterbout 2 hours than it does at 35 minutes Unfortunatelyhe reality of avalanche incidents even in Europe is thatncreased rescue capabilities have not increased survivalhis is because the best chance for an avalanche victim

o survive is to be extricated rapidly by other members ofhe party who were not buried

Another problem with the proposed algorithm is theesignation of destination hospital While the Europeanlps are dotted with hospitals only a 15-minute helicop-

er flight from almost any point and referral centersapable of intensive care within 30 minutes the situationn North America is that even the closest hospital may ben hour or more away by helicopter and ldquotrauma centersrdquore often beyond the range of helicopter transport at alln the case of apneic hypothermic patients the mostppropriate destination hospital may not be a traumaenter but should be a center capable of performingardiopulmonary bypass

A recent case report5 illustrates the major potentialitfall of the proposed triage algorithm In this caseeport 2 skiers were completely buried in an avalanchen the Italian Alps Uninjured companions activated an

mergency response by cell phone Amazingly the first

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

tatcombewft(cTssldquoupcrlscimtommt

274 Letters to the Editor

ictim was breathing when extricated from a depth ofm (98 ft) after 100 minutes However he was uncon-

cious and severely hypothermic with an epitympanicore temperature of 22degC (716degF) The second skier wasound a few minutes later in asystole without an airocket He was declared dead by the emergency physi-ians on site according to the ICAR avalanche guide-ines

The first patient was intubated and transported to theearest hospital by helicopter During transport he wentnto ventricular fibrillation He continued to be venti-ated but chest compressions were not administered for5 minutes Initial attempts at defibrillation at the desti-ation hospital were unsuccessful because of hypother-ia He was subsequently transferred to a referral hos-

ital where he could be placed on cardiopulmonaryypass He was successfully resuscitated and rewarmede eventually made a complete neurologic recoveryHad there been few rescuers rather than the many who

ctually responded and had the AvSORT algorithm beenpplied the first victim would have been triaged to theimmediate treatmentrdquo category and transferred to arauma center However if ventricular fibrillation hadtarted before he was placed in the helicopter and theecond victim had not yet been found the first victimould have been triaged or retriaged into the category of

expectantrdquo management and would have received nourther treatment The result would have been a fatalutcome rather than the complete recovery he actuallyxperienced

Until the authors of the AvSORT algorithm can pro-uce convincing data to show that their proposed triageethod would increase survival in multi-casualty ava-

anche incidents rescuers should resuscitate potentiallyive victims who have already been found and not divertecessary medical resources to further searching

Ken Zafren MDAlaska Mountain Rescue Group International

Commission for Mountain Emergency Medicine (ICARMEDCOM) Alaska Native Medical Center

Anchorage AK Stanford University Medical CenterStanford CA USA

eferences

Bogle LB Boyd J McLaughlin KA Triaging multiplevictims in an avalanche setting the Avalanche SurvivalOptimizing Rescue Triage (AvSORT) algorithmic ap-proach Wilderness Environ Med 20102128ndash34

Althaus U Aeberhard P Schuumlpbach P Nachbur BH Muumlhle-mann W Management of profound accidental hypothermia

with cardiorespiratory arrest Ann Surg 1982195492ndash495 o

Brugger H Durrer B On-site treatment of avalanche victimsICAR-MEDCOM-recommendation High Alt Med Biol20023421ndash425

Falk M Brugger H Adler-Kastner L Avalanche survivalchances Nature 199436821

Oberhammer R Beikircher W Houmlrmann C et al Fullrecovery of an avalanche victim with profound hypothermiaand prolonged cardiac arrest treated by extracorporeal re-warming Resuscitation 200876474ndash480

n Reply to Avalanche Triage

o the Editorn reply to the letter by Dr Ken Zafren we take thispportunity to resolve any confusion with the use of thevalanche Survival Optimizing Rescue Triage (Av-ORT) algorithm1

On February 1 2003 in backcountry Canada 2 moun-ain guides watch with horror as an avalanche engulfsnd buries a school group of 17 participants belowhem2-4 They immediately realize their priority for res-ue is to uncover as many victims as possible prior to thenset of asphyxia They ldquocannot save everybodyrdquo4 butust focus on ldquothe greatest good for the greatest num-

errdquo5-11 They decide as 2 rescuers they will only dignough to allow resumption of breathing to clear air-ays and to hand responsive victims their own shovels

or self-extrication before moving on They recognizehat to stop and attempt cardiopulmonary resuscitationCPR) on any one asphyxiated victim will seriouslyompromise the survival of other victims still buriedhe first victim recovered in the first 5 minutes is thechool teacher who calls on his satellite phone for out-ide organized rescue As the avalanche debris sets uplike concreterdquo4 victims who are not buried too deep arencovered while deep burials are passed over due to theressure of time One victim goes on after fully extri-ating himself to locate and uncover 3 of his classmatesesulting in their survival The first rescue helicopterands after 55 minutes and of the 17 buried victims 10urvive The rational action of the 2 mountain guides isredited with the survival of the majority of these victimsn this mass casualty avalanche incident34 The develop-ent of our proposed AvSORT algorithm is a result of

his and other similar incidents that we cite in the text ofur article This algorithm is designed for the ldquoinitialanagement of mass casualty avalanche incidents whenanpower is overwhelmedrdquo1 We must re-emphasize

hisBy comparison Dr Zafren cites an incident in which 3

elicopters with 15 rescuers 2 emergency physiciansnd 2 dog handlers are on scene for 2 buried victims 1

f whom survives12 This would never be considered a

13 13 13 13 13 13 13 AVALANCHE13 VICTIM13 RESUSCITATION13 CHECKLIST13 13 13 13 13 13 13 13 13 13 13 13 copy13 ICAR13 MEDCOM13 Ko4mann13 A13 Blancher13 M13 Spichiger13 T13 Boyd13 J13 Brugger13 H13

Time13 of13 avalanche13 13 ____13 13 ____13

ECG13 Asystole13

Airway13 FIRST13 AID13

Obvious13 lethal13 trauma13 or13

body13 totally13 frozen13

BLS13 Provider13 ALS13 Provider13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

le35 min13 gt35 min13Burial13 Time13

YES13 NO13NO13 YES13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

___13 mmolL-shy‐113

gt12 mmolL-113

STOP13 ge3213 Core13 Temp13 13 ____13 13 __degC13

lt3213 CirculaFon13 Stable13

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

(If13 unknown13 use13 13 core13 temp)13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

APPROPRIATE13 MEDICAL13 FACILITY13

ECLS13

CPR13 13

Core13 Temp13 ge28degC13 and13

ALS13 ALS13

STOP13

le12mmolL-113

ALS13 ALS13 Provider13 Name13

YES13NO13 Long13 transport13 or13 mulFple13 casualFes13

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

13 uncovering13 the13 face13

If13 du

n13 of13 burial13 is13 un

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

rmistor-shy‐based13 sensor)13 tem

perature13

R13 can13 be

13 with

held13 if13 unaccep

table13 level13 of13 risk13 for13 the13 rescue

r13 total13

body13 frozen

13 or13 ob

s13 lethal13 trauma13 (decapita

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

13 cardiac13 instability13 (ven

tricular13

arrhythm

ias13 systolic13 blood

13 pressure13 lt90m

mHg)13 or13 core13 te

rature13

lt28degC13 shou

ld13 be13 transported13 towards13 hospital13 w

ith13 ECLS13 rewarming13

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

ing13 crush13 injuries13 and

13 con

n13 of13 th

e13 use13 of13

larizing13 paralyNcs)13 in13 an13 adult13 w

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

factors13 consistent13 with

13 non

-shy‐survival13 term

on13 of13 resuscitaNo

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

ALS13 =13 Advanced13 Life13 Sup

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

BypassExtracorporeal13 M

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

IM13 RESUSCITATION13 CHECKLIST13 13 13 13 13 13 13 13 13 13 13

13 copy13 ICAR13 MED

COM13 Ko4

n13 A13 B

lancher13 M

13 Spichiger13 T13 B

oyd13 J13 Brug

ger13 H

Copyright (c) Society of Critical Care Medicine and Lippincott Williams amp Wilkins Unauthorized reproduction of this article is prohibited

Critical Care Medicine wwwccmjournalorg 1

Objective To describe the successful neurologic recovery from profound accidental hypothermia with cardiac arrest despite the longest reported duration of cardiopulmonary resuscitationDesign Case reportSetting MountainPatient A 57-year-old woman experienced profound accidental hypothermia (169degC) in a mountainous region of Grenoble She was unconscious and had extreme bradycardia (6 beatsmin) at presentation A cardiac arrest occurred at the mobilization that was not responsive to electrical shocks or epinephrineIntervention Cardiopulmonary resuscitation was continued for 307 minutes after rescue until venoarterial extracorporeal mem-brane oxygenation blood flow had been established at the emer-gency department Measurements and Main Results At a 3-month follow-up the patient showed good physical and mental recoveryConclusion With no evidence of trauma or asphyxia profound accidental hypothermia with cardiac arrest represents a specific condition for which successful neurologic recovery is feasible

despite prolonged cardiopulmonary resuscitation (Crit Care Med 2013 4200ndash00)Key Words accidental hypothermia cardiac arrest extracorporeal rewarming mountain

Long-term survival rates of up to 60 with minimal neurologic impairment after profound accidental hypo-thermia with cardiac arrest have been reported in young

healthy adults (1 2) This is essentially due to improved pre-hospital life support and effective rewarming techniques in hospital (3) We report the case of a severe hypothermic vic-tim who received cardiopulmonary resuscitation (CPR) for 5 hours until full extracorporeal blood flow was established The patient showed good physical and mental recovery at a 3-month follow-up Written informed consent was obtained from our patient

CASE PRESENTATIONA 57-year-old woman (59 kg 165 m) and her friend were found lost during a snowstorm on December 16 2011 in the French Alps at 2000 m altitude An emergency call was made at 443 pm Because of continuing snowfall access to the vic-tims was very difficult and only five members of the rescue team arrived on site at 835 pm The first victim was conscious She was transferred to the nearest hospital and discharged a few hours later with no medical injury The second victim fell unconscious around 25 minutes before the arrival of the recov-ery team according to the first victim Carotid pulse rate was 6 beatsmin and she had no perceptible breathing movements A cardiac arrest occurred when the victim was mobilized and CPR began immediately (840 pm) An automated external defibrillator was put on the victimrsquos chest and a ventricular fibrillation rhythm was identified at first Despite three elec-trical shocks successively delivered the subsequent cardiac rhythm was asystole Epinephrine at an intraosseous dose of 1 mg had no clinical response Full-body insulation was pro-vided but body temperature was not measured Although the

Copyright copy 2013 by the Society of Critical Care Medicine and Lippincott Williams amp Wilkins

DOI 101097CCM0b013e3182a643bc

1Pole Anestheacutesie-Reacuteanimation Hocircpital Michallon Grenoble France2Grenoble Institut des Neurosciences Universiteacute Joseph Fourier Greno-ble France

3INSERM U836 Grenoble France4Service UrgencesndashSMUR Centre Hospitalier Albertville Moutiers Moutiers France

5Service de Chirurgie Cardiaque Hocircpital Michallon Grenoble France

This work was performed at Hocircpital Michallon and Universiteacute Joseph Fou-rier Grenoble France

Dr Payenrsquos institution received grant support from Hutchinson Tech and Novonordisk Dr Payen consults for Baxter Dr Payen lectured for Abbott GE Healthcare and Integra Lifescience Dr Payenrsquos institution consulted for Biocodex SA Dr Payenrsquos institution lectured for Laboratoire franccedilais du Fractionnement et des Biotechnologies The remaining authors have disclosed that they do not have any potential conflicts of interest

For information regarding this article E-mail jfpayenujf-grenoblefr

Neurologic Recovery From Profound Accidental Hypothermia After 5 Hours of Cardiopulmonary Resuscitation

Yvonnick Boue MD123 Julien Lavolaine MD1 Pierre Bouzat MD PhD123 Sophie Matraxia MD4

Olivier Chavanon MD PhD5 Jean-Franccedilois Payen MD PhD123

Boue et al

2 wwwccmjournalorg March2013bullVolume42bullNumber3

decision was made to immediately evacuate under CPR it was impossible to both move and resuscitate in these adverse environmental conditions and deep snow Manual ventilation was technically impossible as well An alternating sequence with 1 minute of manual 100-chest compressions and 1-min-ute walking to reach the road was therefore undertaken for 25 minutes with a distance of 11 km and a 122-m difference in height Once on the road (1030 pm) advanced life support was provided including endotracheal intubation and mechanical ventilation with 100 oxygen along with the continuation of manual chest compressions Initial end-tidal Co

2 ranged

between 12 and 19 mm Hg The victim was then transported by road ambulance for admission to the emergency department of the regional level I trauma center at 110 am A mechanical chest-compression device (Lucas Jolife AB Physio-Control Lund Sweden) was in use only during the last hour of the transportation

On arrival the rectal temperature was 169degC according to a properly calibrated low-temperature reading thermom-eter The patient was thus classified as hypothermia stage IV according to the Swiss staging system (4) (Table 1) No sign of trauma was found using extended-focused assessment with sonography for trauma (CX 50 Philips Healthcare Eindhoven The Netherlands) or with anterior-posterior radiographs of the chest and the pelvis On arrival the level of serum potas-sium was 58 mmolL and other biological variables from venous samples were pH 725 Pao

2 48 mm Hg Paco

2 38 mm

Hg serum sodium 140 mmolL lactate 57 mmolL creatine kinase 4576 IUL and activated partial thromboplastin ratio 15 Based on these findings an extracorporeal heating system using surgically exposed femoral access sites and venoarterial extracorporeal membrane oxygenation (ECMO) was consid-ered CPR was continued until full extracorporeal blood flow was established at 147 am that is 307 minutes after rescue Arterial blood gases were Pao

2 (69 mm Hg) Paco

2 (26 mm

Hg) and pH (735) A spontaneous cardiac activity with sinus rhythm was detected at 308 am when body temperature had risen to 338degC The patient was then transferred to an ICU and kept in mild hypothermia (35degC) for the next 24 hours

In the ICU ECMO operated at a blood flow of 4 Lmin with 04 inhaled oxygen fraction and 12 mghr norepineph-rine to maintain mean arterial blood pressure at 70ndash80 mm

Hg Under volume-controlled mechanical ventilation initial biological measurements were arterial Pao

2 (74 mm Hg) and

Paco2 (33 mm Hg) arterial pH (721) and serum lactate (231

mmolL) Extracorporeal life support was required for 3 days due to severe cardiac dysfunction During the 55 days of her ICU stay acute kidney failure developed in the patient due to massive rhabdomyolysis which was treated by hemodiafiltra-tion Three weeks after the insult she had a severe epistaxis in relation with arterial hypertension which was treated by transcatheter arterial embolization of internal maxillary arter-ies and a pulmonary embolism treated by heparin infusion A first neurologic assessment of the patient after cessation of IV sedation on day 14 showed mental alertness with full motor responses to command of all extremities The findings from electroencephalography were normal At day 42 brain MRI revealed the integrity of brain parenchyma and no evidence of brain anoxo-ischemic lesions (Fig 1) The patient was trans-ferred from the ICU to a neurologic rehabilitation unit with no organ failure and she left hospital 1 month later Mild cogni-tive impairment with an impairment of short-term memory and an alteration in executive functions such as planning and flexibility was attested 3 months after the insult by a mini-mental state score of 24 of 30 (normal cognition if ge 25 of 30) and a bedside score of 11 of 18 according to the frontal assess-ment battery (5 6)

DISCUSSIONSurvival with no or minor neurologic impairment after pro-found accidental hypothermia and cardiac arrest is possible even when a number of hours of CPR is required before the initiation of extracorporeal rewarming such as can occur in nonasphyxiated victims of mountain accidents (7ndash12) Accord-ing to a recent review (3) our case with a CPR duration of 5 hours in accidental hypothermia should represent the longest reported duration of CPR leading to good neurologic recovery

The key issue in the resuscitation of hypothermic cardiac arrest is deciding whether the victim is eligible for initial CPR until extracorporeal rewarming Patients with nonasphyxiated profound accidental hypothermia are known to have better prognosis than drowned patients with secondary hypothermia (13) As such guidelines for avalanche resuscitation and ter-mination of CPR in mountain rescue have been recently pub-lished (14 15) In the absence of causes of death such as trauma or asphyxia patients with accidental hypothermia showing no vital signs should be considered for CPR On the other hand asystole on electrocardiogram normothermic cardiac arrest and unwitnessed loss of vital signs are all criteria to terminate CPR (15) Our case presented with none of these latter criteria Furthermore the presence of an extreme bradycardia at pre-sentation even transient might be considered as a vital sign in a patient with profound accidental hypothermia In cases of hypothermic cardiac arrest the prehospital duration of CPR cannot be considered in the decision about whether or not to undertake extracorporeal rewarming

In our case a nonconventional CPR sequence for 25 min-utes was imposed due to the geographical situation and adverse

TAblE 1 Staging of Accidental Hypothermia (4)

Stage Clinical SymptomsCore

Temperature (degC)

HT I Conscious with shivering 35ndash32

HT II Impaired consciousness with no shivering

32ndash28

HT III Unconsciousness vital signs present

28ndash24

HT IV No vital signs lt 24

HT = hypothermia

Online Case Report

environmental conditions Whether the alternating 1-minute chest compressions and 1-minute walk sequence was effective at providing vital blood flow to the brain in this case of deep hypothermia and protecting the patientrsquos brain is conjectural In experimental models of prolonged cardiac arrest the inter-ruption of circulation during the initial CPR facilitated cardiac function and neurologic recovery (16) In addition hypother-mia is believed to slow cerebral metabolism rate which is one of the several mechanisms underlying protective effects of hypothermia (17) MRI evaluation of our patient can attest that whatever the mechanism of protection involved in this case there was no evidence of brain anoxo-ischemic lesions

Our patient had normal serum potassium at admission despite a prolonged and precarious resuscitation It is recom-mended to consider CPR as futile whenever the serum potas-sium level is higher than 12 mmolL (3) Conversely a low potassium level on arrival is not a guarantee of survival (1 13) The measurement of serum potassium should be viewed as additional piece of information wherever doubt exists at initial presentation Another point is the high rewarming rate

of the patient (9degChr) until spontaneous defibrillation at 33degC body temperature (2) The rewarming rate after profound accidental hypothermia was reported around 5degChr (13) These rates of rewarming are mark-edly higher than therapeu-tic hypothermia reversal in postcardiac arrest patients (lt 1degChr) (17) In acciden-tal hypothermia cardiopul-monary bypass allows high rewarming rates that theo-retically might protect the heart from myocardial dam-ages due to persistent ven-tricular fibrillation Once spontaneous cardiac activity is obtained the rewarming rate should be slowed down Neurologic outcome was improved in patients weaning off coronary artery bypass at 33degC compared with patients actively rewarmed until 37degC (18) Collectively these find-ings favor controlling the rewarming rate and keeping the patient in mild therapeu-tic hypothermia following the rewarming phase after accidental hypothermia (3) as was done in our case

CONClUSIONIn conclusion this case report shows that a good neurologic recovery can be obtained following prolonged CPR in pro-found accidental hypothermia This strongly indicates that hypothermic cardiac arrest should not be considered as an irreversible condition in mountain accident victims providing no evidence of trauma or asphyxia

REFERENCES 1Silfvast T Pettilauml V Outcome from severe accidental hypother-

mia in Southern FinlandmdashA 10-year review Resuscitation 2003 59285ndash290

2 Walpoth BH Walpoth-Aslan BN Mattle HP et al Outcome of survivors of accidental deep hypothermia and circulatory arrest treated with extracorporeal blood warming N Engl J Med 1997 3371500ndash1505

3 Brown DJ Brugger H Boyd J et al Accidental hypothermia N Engl J Med 2012 3671930ndash1938

4 Durrer B Brugger H Syme D International Commission for Mountain Emergency Medicine The medical on-site treatment of hypother-mia ICAR-MEDCOM recommendation High Alt Med Biol 2003 499ndash103

Figure 1 T2-weighted MRI sequence showing integrity of brain parenchyma and basal ganglia

Boue et al

5 Folstein MF Folstein SE McHugh PR ldquoMini-mental staterdquo A practical method for grading the cognitive state of patients for the clinician J Psychiatr Res 1975 12189ndash198

6 Dubois B Slachevsky A Litvan I et al The FAB A frontal assessment battery at bedside Neurology 2000 551621ndash1626

7 Hughes A Riou P Day C Full neurological recovery from profound (180 degrees C) acute accidental hypothermia Successful resus-citation using active invasive rewarming techniques Emerg Med J 2007 24511ndash512

8 Gilbert M Busund R Skagseth A et al Resuscitation from accidental hypothermia of 137 degrees C with circulatory arrest Lancet 2000 355375ndash376

9 Husby P Andersen KS Owen-Falkenberg A et al Accidental hypo-thermia with cardiac arrest Complete recovery after prolonged resus-citation and rewarming by extracorporeal circulation Intensive Care Med 1990 1669ndash72

10 Lexow K Severe accidental hypothermia Survival after 6 hours 30 minutes of cardiopulmonary resuscitation Arctic Med Res 1991 50(Suppl 6)112ndash114

11 Oberhammer R Beikircher W Houmlrmann C et al Full recovery of an avalanche victim with profound hypothermia and prolonged cardiac arrest treated by extracorporeal re-warming Resuscitation 2008 76474ndash480

12 Mark E Jacobsen O Kjerstad A et al Hypothermic cardiac arrest far away from the center providing rewarming with extracorporeal circula-tion Int J Emerg Med 2012 57

13 Farstad M Andersen KS Koller ME et al Rewarming from accidental hypothermia by extracorporeal circulation A retrospective study Eur J Cardiothorac Surg 2001 2058ndash64

14 Brugger H Durrer B Elsensohn F et al 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 Resuscitation 2013 84539ndash546

15 Paal P Milani M Brown D et al Termination of cardiopulmonary resus-citation in mountain rescue High Alt Med Biol 2012 13200ndash208

16 Segal N Matsuura T Caldwell E et al Ischemic postconditioning at the initiation of cardiopulmonary resuscitation facilitates functional cardiac and cerebral recovery after prolonged untreated ventricular fibrillation Resuscitation 2012 831397ndash1403

17 Polderman KH Mechanisms of action physiological effects and complications of hypothermia Crit Care Med 2009 37S186ndashS202

18 Sahu B Chauhan S Kiran U et al Neurocognitive function in patients undergoing coronary artery bypass graft surgery with cardiopulmo-nary bypass The effect of two different rewarming strategies J Cardiothorac Vasc Anesth 2009 2314ndash21

KAEHRR

Resuscitation 84 (2013) 539ndash 546

Contents lists available at SciVerse ScienceDirect

Resuscitation

jo u rn al hom epage wwwelsev ier com locate resusc i ta t ion

esuscitation great

esuscitation of avalanche victims Evidence-based guidelines of thenternational commission for mountain emergency medicine (ICAR MEDCOM)ntended for physicians and other advanced life support personnel

ermann Bruggeralowast Bruno Durrerb Fidel Elsensohnc Peter Paald Giacomo Strapazzonaveline Winterbergere Ken Zafrenf Jeff Boydg

International Commission for Mountain Emergency Medicine ICAR MEDCOM Institute of Mountain Emergency Medicine EURAC Research Drususallee 1 I-39100 BozenBolzanotalyInternational Commission for Mountain Emergency Medicine ICAR MEDCOM Air Glaciers CH-3822 Lauterbrunnen SwitzerlandInternational Commission for Mountain Emergency Medicine ICAR MEDCOM Austrian Mountain Rescue Service Schloesslestrasse 36 A-6832 Roethis AustriaInternational Commission for Mountain Emergency Medicine ICAR MEDCOM Department of Anaesthesiology and Critical Care Medicine Innsbruck Medical University Anichstrasse5 A-6020 Innsbruck AustriaInternational Commission for Mountain Emergency Medicine ICAR MEDCOM Swiss Air Rescue Service REGA Englerweg 10 CH-3860 Meiringen SwitzerlandInternational Commission for Mountain Emergency Medicine ICAR MEDCOM Division of Emergency Medicine Stanford University Medical Center California 10181 Curvi Stnchorage AK 99507 USAInternational Commission for Mountain Emergency Medicine ICAR MEDCOM Department of Emergency Medicine Mineral Springs Hospital Box 400 Bow Avenue Banff AB T1LA5 Canada

r t i c l e i n f o

rticle historyeceived 2 September 2012eceived in revised form 14 October 2012ccepted 23 October 2012

eywordsvalanchextracorporeal circulationypothermiaesuscitationewarming

a b s t r a c t

Background In North America and Europe sim150 persons are killed by avalanches every yearMethods The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) systemat-ically developed evidence-based guidelines and an algorithm for the management of avalanche victimsusing a worksheet of 27 Population Intervention Comparator Outcome questions Classification of rec-ommendations and level of evidence are ranked using the American Heart Association systemResults and conclusions If lethal injuries are excluded and the body is not frozen the rescue strategy isgoverned by the duration of snow burial and if not available by the victimrsquos core-temperature If burialtime le35 min (or core-temperature ge32 C) rapid extrication and standard ALS is important If burial timegt35 min and core-temperature lt32 C treatment of hypothermia including gentle extrication full bodyinsulation ECG and core-temperature monitoring is recommended and advanced airway management ifappropriate Unresponsive patients presenting with vital signs should be transported to a hospital capableof 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 extracorporealmembrane oxygenation or cardiopulmonary bypass rewarming Patients in cardiac arrest should receiveuninterrupted CPR with asystole CPR may be terminated (or withheld) if a patient is lethally injured orcompletely frozen the airway is blocked and duration of burial gt35 min serum potassium gt12 mmol Lminus1risk to the rescuers is unacceptably high or a valid do-not-resuscitate order exists Management shouldinclude spinal precautions and other trauma care as indicated

A Spanish translated version of the abstract of this article appears as Appendixn the final online version at httpdxdoiorg101016jresuscitation201210020lowast Corresponding author at Institute of Mountain Emergency Medicine EURACesearch Drususallee 1 BozenBolzano Italy Tel +39 0471 055541

ax +39 0471 055549E-mail addresses hermannbruggereuracedu (H Brugger) bdcaremedch

B Durrer) fidelelsensohnaonat (F Elsensohn) peterpaalukiat (P Paal)iacomostrapazzoneuracedu (G Strapazzon) evelinewinterbluewinchE Winterberger) zafrenalaskacom (K Zafren) zmtndoctelusnet (J Boyd)

300-9572$ ndash see front matter copy 2012 Elsevier Ireland Ltd All rights reservedttpdxdoiorg101016jresuscitation201210020

1 Introduction

In North America and Europe sim150 persons are killed byavalanches every year1 with most triggered by skiers snowboard-ers and in the USA and Canada by snowmobilers2 Avalanchesinflict even higher death tolls in developing countries for instanceavalanches claimed 284 lives in South East Anatolia in 1992 gt200

in Kashmir in 1995 and 135 in Kashmir in 2012 The total number ofpersons in avalanche terrain is unobtainable and mortality in theseactivity groups can only be roughly estimated The first recommen-dations for on-site management and transport of avalanche victims

5 scitati

bwfosLwitiMlc

acaIl[E(oacAaftEcies

40 H Brugger et al Resu

ased on survival analyses34 case reports5 and case series6ndash9

ere proposed in 199610 and 20014 The International Commissionor Mountain Emergency Medicine (ICAR MEDCOM) establishedfficial consensus guidelines including an algorithm in 200211 Aystematic review of four prognostic factors12 and an Internationaliaison Committee on Resuscitation (ILCOR) worksheet processere the basis of the recommendations for avalanche resuscitation

n the 2010 Resuscitation Guidelines1314 Recommendations forransport and treatment decisions of hypothermic patients includ-ng avalanche victims have been recently developed15 The ICAR

EDCOM sought to systematically develop evidence-based guide-ines using a structured worksheet with the mandate to obtain finalonsensus among the ICAR MEDCOM

Methods

The objectives inclusionexclusion criteria working groupnd worksheet of 27 Population Intervention Comparator Out-ome (PICO) questions (supplementary data) derived from earliervalanche resuscitation recommendations4 were developed by theCAR MEDCOM at a TOPIC meeting The electronic database of Med-ine was searched via PubMed with the search terms (avalancheAll Fields]) and (hypothermia [All Fields]) and the database ofMBASE via OVID with (avalanche Including Related Terms) andhypothermia Including Related Terms) The Cochrane Databasef Systematic Reviews was searched with the terms (avalanche)nd (accidental hypothermia) Additional hand searching of arti-les reference texts and reference lists was also performedll articles relevant to clinical management of victims of snowvalanches and related accidental hypothermia were extracted forurther review These were evaluated for quality and relevance tohe PICO questions and recommendations were developed at a SCI-NCE meeting The recommendations were further examined andonsensus was reached at a MANUSCRIPT meeting in Aringre Swedenn October 2011 Classification of recommendations and level ofvidence are ranked using the American Heart Association (AHA)ystem (Table 1)

Findings and recommendations

From a total of 3530 retrieved citations 96 articles were classi-ed as relevant and were subjected to full review

urvival probability

The overall survival rate of avalanche victims is 7714531886)4 Survival depends on the grade and duration of burialnd the pathological processes of asphyxia trauma and hypother-ia

rade of burial

Analysis of a Swiss sample showed that 39 (7351886) of

ictims involved in an avalanche were completely buried with sur-ival in complete burials (ie burial of the head and chest1) of 476350735) versus 958 (11031151) in partial burials4 Grade ofurial is the strongest single factor for survival

1 In Europe the term completely buried refers to burial of at least the head and chestn North America the term completely buried is reserved for when the individual isotally buried beneath the snow surface and partially buriedndashcritical for when thendividual is partially buried with at least the head under the snow surface and withreathing impaired5758 The term critical burial will be used hereafter to identifyurials that impair breathing and therefore risk asphyxia

on 84 (2013) 539ndash 546

Duration of burial

Biostatistical survival analysis of critically buried victims1 inSwitzerland and Canada shows a progressive non-linear reductionin survival as duration of burial increases and distinct phases3416

In Switzerland survival probability remains above 80 until 18 minafter burial (ldquosurvival phaserdquo) and plummets thereafter to 32(ldquoasphyxia phaserdquo) whereas the Canadian survival curve shows anearlier and steeper decline from 77 at 10 min to 7 at 35 minwhich reflects a greater mortality from trauma and an earlier onsetof asphyxia due to denser snow in some regions of Canada1617

(Fig 1) Supportively hypoxia has been shown to be correlatedto snow density in an experimental study18 Another identifiabledecrease in survival occurs at 90 min due to hypothermia combinedwith hypoxia and hypercapnia4 The duration of burial is thereforean indication of pathology and should dictate treatment strategy

31 Asphyxia

Asphyxia was found to be the most common cause of death inthree case series that relied on autopsy full forensic external exam-ination andor pre-mortem clinical findings161920 Asphyxia mayoccur in combination with trauma and hypothermia16

311 ExpediencySurvival decreases rapidly in the ldquoasphyxia phaserdquo ie in the

first 35 min3417

Recommendations Companions should locate and extricateburied victims expeditiously (Class 1 LOE B)

Organized rescue should be mobilized early (Class I LOE B)

312 Duration of burial and airway patencyA systematic review12 confirmed that a patent airway was

essential for survival for gt35 min of critical burial with four ofthe analyzed retrospective studies describing survival to hospi-tal discharge in victims buried gt60 min who were found withpatent airways No survivors were reported in any of the 14 case-control and case series for victims with an obstructed airway andgt35 min of burial A prospective randomized crossover experi-mental study found that when breathing into a simulated air pocketsubjects achieved a steady state of survivable hypoxia for at least20 min in 39 (1128) of uninterrupted tests18 Other prospectiveexperimental studies have indicated that redirecting gas exchangeaway from an air pocket such as might occur in avalanche debriswith large blocks or an opening to environmental air improvesoxygenation21ndash23

Recommendation If burial gt35 min airway patency should bedetermined upon exposure of the face (Class I LOE A)

The ancillary presence of an air pocket should be determined bydigging from the side of the victim in order to not harm the victimor destroy the air pocket (Class I LOE C)

313 ResuscitationResuscitation guidelines recommend standard CPR in hypox-

aemic cardiopulmonary arrest1314 Ventilation should be com-bined with chest compressions as compression-only CPR isinappropriate for avalanche burial

Recommendations Factors and decisions are integrated in a man-agement algorithm (Fig 2) (Class IIa LOE C)

For victims buried lt35 min found in cardiac arrest presumeasphyxia and initiate standard CPR with ventilations as soon as thehead and chest are free regardless of airway patency (Class I LOE B)

For victims buried gt35 min found in non-asystolic cardiac arrestwith a patent airway but who are not hypothermic (ge32 C) pre-sume asphyxia and initiate standard CPR with ventilations as soonas the head and chest are free (Class IIa LOE B)

H Brugger et al Resuscitation 84 (2013) 539ndash 546 541

Table 1Classification of recommendations and level of evidence according to the ACCFAHA task force on practice guidelinesa

Size of treatment effect

LEVEL (Quality) of evidence (LOE)CLASS I CLASS IIa CLASS IIb CLASS IIIBenefit raquogt Risk Benefit raquo Risk Benefit ge Risk No Benefit or HarmProcedureTreatment shouldbe performedadministered

It is reasonable to performprocedureadministertreatment

ProcedureTreatment may beconsidered

ProcedureTreatment of nobenefit or harmful

LEVEL A Recommendation thatprocedure or treatment isusefuleffective

Recommendation in favor oftreatment or procedure beingusefuleffective

Recommendationrsquosusefulnessefficacy less wellestablished

Recommendation thatprocedure or treatment is notusefuleffective and may beharmful

Data derived from multiplerandomized clinical trialsor meta-analyses

Sufficient evidence frommultiple randomized trials ormeta-analyses

Some conflicting evidencefrom multiple randomizedtrials or meta-analyses

Greater conflicting evidencefrom multiple randomizedtrials or meta-analyses

LEVEL B Recommendation thatprocedure or treatment isusefuleffective

Data derived from a singlerandomized trial ornonrandomized studies

Evidence from singlerandomized trial ornonrandomized studies

Some conflicting evidencefrom single randomized trial ornonrandomized studies

Greater conflicting evidencefrom single randomized trial ornonrandomized studies

LEVEL C Recommendation thatprocedure or treatment isusefuleffective

Only consensus opinion ofexperts case studies or

Only expert opinion case orstandard of care

Only diverging expert opinioncase studies or standard of

standard of care care

a Manual for ACCAHA Guideline Writing Committees (Accessed 01 September 2

For victims buried gt35 min found in asystolic cardiac arrest withn obstructed airway resuscitation may be initiated but can beerminated if not successful (Class I LOE A)

14 Advanced airwayAdvanced airway management (eg endotracheal intubation

nd supraglottic airway devices) performed by experienced per-

onnel enables effective ventilation reduces the likelihood ofspiration for avalanche victims in periarrest14 and may improveurvival24 In prehospital settings with long transport timesndotracheal intubation is associated with improved survival25

Fig 1 Comparison of survival curves in Canada (black n = 30xtracted from Haegeli et al16 with permission from CMAJ

care care

t httpcircahajournalsorgsitemanualindexxhtml)

However complications are unacceptably frequent when per-formed by inexperienced providers2526 Supraglottic devices maybe more efficient and safer than endotracheal intubation or bag-mask ventilation for less experienced rescuers

Recommendations For unresponsive victims advanced airwaymanagement should be performed if the rescuer is competent inthis skill and if airway management succeeds within a reasonable

time (Class I LOE A)

For rescuers not experienced in advanced airway managementventilation is most effective with mouth-to-mask or bag-masktechniques (Class I LOE A)

1) and Switzerland (grey n = 946) from 1980 to 2005

542 H Brugger et al Resuscitati

Fig 2 Management of the buried avalanche victim In all cases gentle extricationand spinal precautions Where appropriate core temperature and ECG monitoringoxygen insulation heat packs on trunk 09 NaCl andor 5 glucose only if an intra-venous or intraosseous line can be established within a few minutes specific traumacare as indicated 0Clinicians may consider withholding resuscitation at the scene ifit increases risk to the rescue team or if the victim is lethally injured or completelyfrozen 1If duration of burial is unknown core temperature may substitute 2Initiatestandard ALS including ventilations and chest compressions as indicated Resusci-tation may be terminated in normothermic patients if ALS is not successful after20 min Transport victims with concern of respiratory (eg pulmonary oedema) orother-system injury to the most appropriate medical centre 3Hospital capable ofadvanced external or core rewarming Patients who present with cardiac instability(ventricular arrhythmias systolic blood pressure lt90 mm Hg) or core-temperaturelt28 C should be transported towards ECC rewarming Defibrillation beyond threeattempts may be delayed until core-temperature gt30 C If direct transport to ECCrewarming is practical the nearest ED can be bypassed If K+ at hospital admis-sion exceeds 12 mmol Lminus1 consider stopping resuscitation (after excluding crushinjuries and consideration of the use of depolarizing paralytics) in an adult withK+ 8ndash12 mmol Lminus1 and other factors consistent with non-survival termination ofresuscitation should be considered ALS Advanced Life Support ED EmergencyDepartment ICU Intensive Care Unit ECC extracorporeal circulation

on 84 (2013) 539ndash 546

For a potential survivor with a failed airway hospital transfershould be hastened with early alert of appropriate support (Class ILOE C)

315 TransportPost-resuscitation care including therapeutic hypothermia is

integral to improving survival2526 Mechanical chest compressiondevices improve rescuer safety and reduce manual energy expendi-ture and may improve outcome during transport26 Delayed onsetof pulmonary oedema has been reported in avalanche victims withvital signs after short burials27

Recommendations If resuscitation is successful or termination-of-CPR criteria are not met (see Termination of CPR) victims shouldbe transported to the nearest hospital preferably one with inten-sive care services (Class IIa LOE C)

Mechanical chest compression devices and therapeutichypothermia may be considered for prolonged transports (ClassIIb LOE B)

If victims present with signs or concern of respiratory or othersystem injury they should be transported to the nearest emergencydepartment for advanced assessment and observation (Class I LOEC)

32 Trauma

Trauma was the principal cause of death in 235 (48204) offatalities in western Canada16 55 (236) in Austria19 and 54(356) in Utah20 However in the Canadian sample major traumaie injury severity score (ISS) gt15 was additionally found in 130(1292) of autopsied ldquoasphyxiardquo fatalities Chest trauma repre-sented 458 (1124) of single-system injuries 521 (2548) werefound on the surface or not critically buried16 In the Austrian sam-ple 86 (9105) of fatality cases had an ISS score gt13 althoughonly 55 (236) were ascribed to trauma the two trauma fatal-ities were fracture-dislocations of the cervical spine19 Similarlyin the Utah sample trauma was associated with asphyxia in 89(556) of fatalities in addition to the 54 (356) ascribed to traumaalone autopsies found head abdominal and limb injuries to becommon20 Differing rates are dependent on topographical factors(eg open versus forested terrain)16

321 On-site managementCurrent resuscitation guidelines emphasize spinal stabiliza-

tion chest decompression for tension pneumothorax haemorrhagecontrol prompt evacuation to definitive care and considerationof permissive hypotension in the resuscitation of shock1314

Tourniquets are life-saving in exsanguinating limb injuries28 Intraumatic cardiac arrest survival is approximately 56 and pro-longed CPR gt16 min is associated with a poor outcome13 In severehead trauma outcomes are improved with early intubation and nor-moventilation while hypo- and hyperventilation result in pooreroutcome29

Recommendations Rescuers should provide adequate spinalstabilization throughout extrication on-scene management andtransport (Class I LOE C)

Trauma measures include splinting insulation and analgesia(Class I LOE C)

Clinical teams should be skilled and equipped for thoracostomytourniquet application intravenous or intraosseous cannulationwith controlled fluid infusion in shock or for medication admin-

istration advanced airway management cricothyrotomy andantibiotics for open fractures (Class IIa LOE B)

CPR should be initiated for traumatic cardiopulmonary arrestwhile searching for and managing treatable causes (Class I LOE B)

scitati

ttacttm

ahtebiatawlt

rsasaprpp

H Brugger et al Resu

Delay of transport for on-site management should be as short asossible direct transport to a dedicated trauma centre is preferredClass I LOE C)

3 Hypothermia

Hypothermia is commonly diagnosed clinically in avalanche vic-ims A systematic review of five retrospective case series foundhat hypothermic cardiac arrest is survivable if associated with

patent airway12 Hypothermia is rarely listed as the principalause of death as post-mortem signs are limited and asphyxia andrauma are frequently concomitant16 At low core-temperatureshe brain tolerates cardio-circulatory arrest gt5 min without per-

anent damage93031

31 Cooling rateThe cooling rate during burial is variable but may be acceler-

ted by light clothing sweating and exhaustion Hypercapnia andypoxia may increase cooling rate2332 This combination has beenermed the ldquotriple H syndromerdquo18 although the interactions are notlucidated A maximum cooling rate of 9 C hminus1 was found during aurial of 100 min31 while lesser cooling rates have been reported

n other case series and reports33ndash35 and in experimental human36

nd animal studies23 At the maximum rate of 9 C hminus1 a minimumime of 35 min is required for the core-temperature to drop lt32 Cnd it is therefore concluded that the presence of a patent air-ay is essential for survival in any victim with a core-temperature

32 C12ndash14

Recommendations (See Table 2 for the management of victimst different stages of hypothermia and Fig 2 for the managementf avalanche victims)

For victims in cardiac arrest with a core-temperature lt32 C and patent or unknown airway initiate resuscitation (Class I LOE A)

For victims in asystolic cardiac arrest with a core-temperature32 C and an obstructed airway presume asphyxia and withholdesuscitation (Class I LOE A)

32 Rescue collapseCollapse of hypothermic avalanche victims during rescue is

ssociated with lethal arrhythmias according to case reports3135

echanical stimulation has been shown to produce lethal arrhyth-ias in a porcine model of hypothermia37 A core-temperature of

2 C is considered the threshold for ventricular fibrillation38

Recommendations ECG monitoring2 should be applied uponxtrication and continued during transport using maximum ampli-cation if complexes are small (Class I LOE B)

Mechanical irritation of hypothermic victims should be min-mized avoiding excessive limb extension rough transport andnnecessary chest compressions (Class I LOE B)

Transport victims in the horizontal position (Class I LOE C)

33 Core-temperatureAccidental hypothermia has been defined as ldquoan unintentional

eduction in core-temperature lt35 Crdquo131538 Hypothermia may betaged using the ldquoSwiss stagingrdquo system (based on clinical findingss well as core temperatures)131539 which corresponds with theystem of Danzl38 Hypothermia is often combined with asphyxiand trauma rendering clinical signs unreliable Oesophageal tem-eratures are more reliable than other temperatures40 and are

ecommended in intubated patients133841 Alternatively epitym-anic temperatures are reasonably accurate in the non-intubatedatient not in cardiac arrest given a non-obstructed ear canal and

2 ECG monitoring may be performed with a monitor-defibrillator or an AED AEDonitoring is best with a device that has a monitor window

on 84 (2013) 539ndash 546 543

correct application including insulation from cold air1042 In a coldenvironment only thermistor-based not infrared-based epitym-panic thermometers correlate well with core-temperature42 Inhuman studies epitympanic brain and bladder temperatures corre-lated well43 while rectal temperatures lagged behind oesophagealtemperatures during rewarming3640

Recommendations Donrsquot rely on clinical hypothermia stagingalone when asphyxia andor trauma occur (Class I LOE C)

Obtain core-temperatures when hypothermia has managementsignificance with an oesophageal probe in the intubated or epitym-panic thermistor probe in the non-intubated victim (Class I LOEB)

Rectal temperature may be used to gauge hypothermia initially(Class IIa LOE B)

334 InsulationAfterdrop refers to continued decline in temperature after

removal from cold All guidelines recommend insulation from fur-ther cooling and most recommend removal of wet clothing4111538

which may however increase heat loss in a cold windy environ-ment Manikin studies found that increasing insulation over wetclothing produced a similar reduction in heat loss compared toremoving clothing44 and that a windproof outer wrap over theinsulation assembly is necessary45

Recommendations Hypothermic victims should be insulatedagainst further heat loss with dry low-conductivity whole-bodyassemblies covered in a windproof and water-resistant outer shell3

(Class I LOE B)Remove wet clothing only if the victim can be insulated effec-

tively cut clothing cautiously if victim has a hypothermia stagingof moderate or worse (Class I LOE C)

335 Out-of-hospital rewarmingApplying heat packs may improve comfort although core-

temperature may not be increased46 Warmed humidified oxygenprovides limited benefit1314 Warmed infused fluids provide onlyminimal contribution to rewarming with a hypothetical rise of03 C Lminus1 of 40 C fluid47 and are difficult to keep warm in the field

Recommendations Apply safe heat sources such as coveredchemical heat packs to the trunk (Class IIb LOE B)

Maintain infusate at 38ndash42 C (Class IIb LOE B)

336 OxygenAdequate oxygenation may help reduce the risk of post-rescue

collapse as it is known to improve myocardial stability38 Pulse-oximetry is inaccurate with cold exposure due to peripheralvasoconstriction as well as device malfunction high altitude andbright ambient light48

Recommendations Apply supplemental oxygen to significantlyhypothermic victims (Class IIb LOE C)

Pulse-oximetry may be unreliable (Class IIb LOE B)

337 Advanced airwayAdvanced airway placement provides oxygenation and airway

protection from aspiration and is low risk for triggering malig-nant arrhythmias49 Depolarizing neuromuscular paralytics (egsuccinylcholine) may increase the serum potassium level and affectsubsequent decisions

Recommendation Consider the impact of depolarizing paralyt-ics on serum potassium if the latter is planned for resuscitation oradvanced rewarming decisions (Class I LOE B)

3 These may be purpose-built rescue bags with insulated hoods or assemblies ofblankets enclosed in aluminium foil combined with head protection

544 H Brugger et al Resuscitation 84 (2013) 539ndash 546

Table 2Staging and management of hypothermic avalanche victims

CT Swiss staginga Danzlb Treatment Transfer

35ndash32 C Hypothermia Iconscious shivering

Mild hypothermia bull Move activelybull Drink warm sweetened fluidsc

bull Insulation

Nearest ED

32ndash28 C Hypothermia IIimpaired consciousness withoutshivering

Moderate hypothermia bull Gently extricate and immobilize horizontallybull Continuously monitor with ECG and coretemperaturebull Full body insulationbull Apply chemical heat packs to trunkbull Administer oxygenbull Place iv or io line without considerablydelaying transport

Stable circulation hospitalwith active rewarmingfacilitiesUnstable circulation hospitalwith ECMOCPB

28ndash24 C Hypothermia IIIunconscious

Severe hypothermia Additionally -bull Protect upper airway Recovery position or ifreasonable advanced airway managementbull Try to avoid depolarizing paralytic agentsbull Withhold or carefully dose drugs (slowmetabolism)

lt24 Cd Hypothermia IVno vital signs

Severe and profound(lt20 C) hypothermia

Additionally -bull Standard CPRbull Avoid excessive defibrillation attempts

Hospital with ECMOCPB

a Durrer et al39 This Swiss staging system was adopted by the 2010 ERC Guidelines for Resuscitation The clinical signs in the Swiss staging system reflect the effectof hypothermia only Considering that consciousness can be impaired by asphyxia and trauma core temperature measurement is necessary to assess the severity ofhypothermia13

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

c If transport delayed gt2 h and no signs of trauma that would necessitate anaesthd 137 C is the lowest core temperature recorded in a survivor of accidental hypoLS advanced life support CT core temperature ECMOCPB extracorporeal rewar

38 CPRIn severely hypothermic patients respirations and pulse may be

ndistinctRecommendations Check carefully for vital signs and ECG activ-

ty for up to 1 min (Class IIb LOE C)Initiate CPR if signs of life are absent at standard BLS rates (Class

Ia LOE B)

39 DefibrillationDefibrillation of severely hypothermic patients (lt28 C) pre-

enting with ventricular fibrillation is unsuccessful in most caseshough defibrillation thresholds vary individually and success-ul defibrillation with core-temperatures as low as 256 C haseen reported50 Due to the paucity of animal and human stud-

es and conflicting results experts disagree on the application ofefibrillation with core-temperatures lt30 C1314 The 2010 ERC-uidelines13 recommend a maximum of three defibrillations at30 C while the 2010 AHA-guidelines14 recommend standardefibrillation while rewarming

Recommendations Use standard defibrillations when indicatedegardless of core-temperature repetitions beyond three attemptsay be delayed until core-temperature gt30 C and should be

voided if they cause interruption of CPR andor transport toewarming (see Transport) (Class IIa LOE B)

310 ALS medicationsSimilar to defibrillation experts disagree on the effectiveness of

dvanced life support (ALS) drug therapy with core-temperatures30 C1314 The 2010 ERC-guidelines13 recommend no ALS drugshile the 2010 AHA-guidelines14 allow vasopressors in car-iac arrest Vasopressors may induce arrhythmias and increase

isk of frostbite Drug metabolism is decreased with low core-emperature51

Recommendation It may be reasonable to consider vasopressorsoncurrently with rewarming strategies (Class IIb LOE B)

iacardiopulmonary bypass ED emergency department

3311 TransportFor hypothermic victims with a perfusing rhythm active exter-

nal rewarming such as forced-air rewarming is successful131438

For severely hypothermic victims in cardiac arrest extracorporealrewarming resulted in return of spontaneous circulation (ROSC)in 23 of 186 and survival to hospital discharge in 8 of 186avalanche victims examined in a systematic review of seven caseseries and reports12 Complications after extracorporeal rewarm-ing commonly include pulmonary oedema3152 which may explainimproved survival with extracorporeal membrane oxygenation(ECMO) compared to cardiopulmonary bypass (CPB)52

Recommendations For victims with core-temperature lt32 C butno cardiac instability ie systolic blood pressure ge90 mmHg andno ventricular arrhythmias and core-temperature gt28 C trans-port to the nearest appropriate hospital for active external andminimally invasive rewarming (ie warm environment chemicalelectrical or forced air heating packs or blankets warm iv-fluids)is recommended15 (Class I LOE B)

Hypothermic victims with a patent or unknown airway withcardiac instability or a core-temperature lt28 C or in cardiac arrestshould be transported to a centre with ECMO or CPB if ECMOCPBis not available transport to an appropriate hospital for alternativeactive internal rewarming (eg thoracic lavage) with continued CPRis recommended (Class I LOE B)

Notify the ECMOCPB centre before departure (Class IIa LOE C)

3312 Serum potassiumSerum potassium was predictive of survival for hypothermic

cardiac arrest victims in a systematic review of prognostic factorsin avalanche resuscitation12 with higher levels and poorer survivalin asphyxiated victims The highest admission serum potassium

with ROSC was 8 mmol Lminus18 while the highest level with survivalwas 64 mmol Lminus133 In accidental hypothermia of any origin thehighest admission potassium of a survivor was 118 mmol Lminus1 in a31-month-old child exposed to freezing weather53

scitati

awaltiv

Recommendations For hypothermic victims in asystolic cardiacrrest where duration of burial or airway patency is unknown orhere a decision for prolonged resuscitation or long transport to

centre for ECMOCPB needs confirmation a serum potassium8 mmol Lminus1 would indicate continued action gt12 mmol Lminus1 wouldndicate termination of resuscitation and 8ndash12 mmol Lminus1 in an adultictim should be considered with other factors (Class I LOE A)

313 PrognosisAsphyxia markedly reduces survival in hypothermic car-

iac arrest despite extracorporeal rewarming6ndash852 The lowestore-temperature reported to date for a survivor of accidentalypothermia is 137 C in a victim trapped in a waterfall gully30

nd 19 C in a victim of avalanche burial5

Recommendation Victims of hypothermic cardiac arrest foundith a patent or unknown airway and who are otherwise deemedossible survivors should be resuscitated until rewarmed to a core-emperature gt32 C before a final decision is made (Class I LOE)

4 General measures

41 Oral fluidsTwo Cochrane Systematic Reviews and the practice guideline

f the American Society of Anesthesiologists found no evidence ofdverse effects from clear fluids up to 2 h prior to surgery in oth-rwise healthy patients with no abnormal risk of regurgitation orspiration54

Recommendations Alert victims not requiring sedation or anaes-hesia within 2 h may drink warmed clear calorie-containingon-alcoholic non-caffeinated fluids to sustain hydration andpontaneous rewarming (Class IIb LOE B)

42 ActivityRecommendation Alert mildly hypothermic victims (35ndash32 C)

ay exercise to rewarm (Class IIa LOE C)

43 Organized rescueRecommendations Organized rescue teams should mobilize

romptly ideally by helicopter and should include clinicianskilled in mountain emergency medicine and be staffed accordingo the number of buried victims (Class IIa LOE C)

Dogs and handlers may accompany organized rescue teams tond completely buried victims Once all victims have been locatedhere is no use for dogs and handlers (Class IIa LOE C)

All staff should have appropriate safety equipment especiallyvalanche transceivers and airbags (Class I LOE B)

Medical equipment should include core-temperature and ECGonitordefibrillator devices and appropriate medications all

nstruments should be insulated and have fully-charged batteriesClass I LOE B)

The potential risk to the rescuers must be evaluated taking lessisk after longer burials (Class IIb LOE C)

44 TriageA multiple casualty incident may initially overwhelm rescuers

nd limited resources should be allocated to those most likely tourvive55

Recommendations When resources are overwhelmed by multi-le victims in cardiac arrest priority should be given to those with

cardiac rhythm a higher core-temperature and other favourableactors (Class IIb LOE B)

on 84 (2013) 539ndash 546 545

35 Termination of CPR

The very poor survival of patients suffering prehospital nor-mothermic asystolic cardiac arrest has resulted in validated EMStermination-of-resuscitation rules that have been incorporatedinto a guideline for mountain rescue (Class IIb LOE C)56

Recommendations Resuscitation may be terminated (or with-held) when rescuer safety is unacceptably high lethal injuries suchas decapitation or truncal transection have occurred the body iscompletely frozen a valid do-not-resuscitate order exists or lim-itations in transport or other logistics render resuscitation futile(Class I LOE C)

Resuscitation may be terminated in unwitnessed cardiac arrestwhen after 20 min of resuscitation there has been no ROSC withno shock advised by AED or only asystole seen on ECG with nohypothermia or other special circumstance warranting extendedCPR (Class IIa LOE A)

4 Conclusions

The algorithm for the management of avalanche victims isshown in Fig 2 If lethal injuries are excluded and the body is notfrozen the rescue strategy is governed by the duration of snowburial and if not available by the victimrsquos core-temperature Ifburial time le35 min (or core-temperature ge32 C) rapid extrica-tion and standard ALS is important If burial time gt35 min andcore-temperature lt32 C treatment of hypothermia including gen-tle extrication full body insulation ECG and core-temperaturemonitoring is recommended as well as advanced airway manage-ment if appropriate Unresponsive patients presenting with vitalsigns should be transported to a hospital capable of active externaland minimally invasive rewarming such as forced air rewarm-ing Patients with cardiac instability or in cardiac arrest (with apatent airway) should be transported with uninterrupted CPR to anECMOCPB rewarming centre Management should include spinalprecautions and other trauma care as indicated

Conflicts of interest statement

None of the authors have a commercial or industrial conflict ofinterest HB JB BD PP and KZ have published on hypother-mia HB receives support as the head of the Institute of MountainEmergency Medicine EURAC research

Acknowledgements

The following ICAR MEDCOM members approved these rec-ommendations at meetings in Longyearbyan (Norway) and Aringre(Sweden) Gege Agazzi (Italy) Borislav Aleraj (Croatia) Jeff Boyd(Canada) Bruce Brink (Canada) Douglas Brown (Canada) Her-mann Brugger (Italy) Perilif Eduinsson (Sweden) Tore Dahlberg(Norway) John Ellerton (Vice-President United Kindom) FidelElsensohn (President Austria) Herbert Forster (Germany) NicoleGantner-Vogt (Principality of Liechtenstein) Andrzod Gorka(Poland) Martin Ivanov (Bulgaria) Alex Kottmann (Switzerland)Xavier Ledoux (France) Volker Lischke (Germany) Mario Milani(Italy) Maria Mizuskovic (Montenegro) Josegrave Ramograven Morandeira(Spain) Wokiech Moskal (Poland) Maria Antonia Nerin (Spain)Marie Nordgren (Sweden) Einar Ornarnarrson (Iceland) NoriyoshiOhashi (Japan) Kazue Oshiro (Japan) Peter Paal (Austria)Oliver Reisten (Switzerland) Erik Sandstrom (Sweden) Frederik

Sederkuist (Sweden) Haris Sinifakoulis (Greece) Sven ChristjarSkaiaa (Norway) Inigo Soteras (Spain) Giacomo Strapazzon (Italy)Guumlnther Sumann (Austria) Oleg Tcholakov (Bulgaria) David Tin-gay (Australia) Iztok Tomazin (Slovenia) Heidi Vigerust (Norway)

5 scitati

avid Watson (Canada) Eveline Winterberger (Switzerland) Kenafren (Vice-President USA) Gregoire Zen-Ruffinen (Switzerland)e thank Emily Procter for the help in editing the manuscript

ppendix A Supplementary data

Supplementary data associated with this article can beound in the online version at httpdxdoiorg101016resuscitation201210020

eferences

1 Etter HJReport of the avalanche subcommission at the general meeting of theinternational commission for Alpine rescue 2010

2 Stethem C Jamieson B Schaerer P Liverman D German D Walker S Snowavalanche hazard in Canada ndash a review Nat Hazards 200328487ndash515

3 Falk M Brugger H Adler-Kastner L Avalanche survival chances Nature199436821

4 Brugger H Durrer B Adler-Kastner L Falk M Tschirky F Field management ofavalanche victims Resuscitation 2001517ndash15

5 Althaus U Aeberhard P Schupbach P Nachbur BH Muhlemann W Manage-ment of profound accidental hypothermia with cardiorespiratory arrest AnnSurg 1982195492ndash5

6 Schaller MD Fischer AP Perret CH Hyperkalemia A prognostic factor duringacute severe hypothermia JAMA 19902641842ndash5

7 Locher T Walpoth B Pfluger D Althaus U Accidental hypothermia inSwitzerland (1980ndash1987)mdashcase reports and prognostic factors Schweiz MedWochenschr 19911211020ndash8

8 Mair P Kornberger E Furtwaengler W Balogh D Antretter H Prognostic markersin patients with severe accidental hypothermia and cardiocirculatory arrestResuscitation 19942747ndash54

9 Walpoth BH Walpoth-Aslan BN Mattle HP et al Outcome of survivors of acci-dental deep hypothermia and circulatory arrest treated with extracorporealblood warming N Engl J Med 19973371500ndash5

0 Brugger H Durrer B Adler-Kastner L On-site triage of avalanche victims withasystole by the emergency doctor Resuscitation 19963111ndash6

1 Brugger H Durrer B On-site treatment of avalanche victims ICAR-MEDCOM-recommendation High Alt Med Biol 20023421ndash5

2 Boyd J Brugger H Shuster M Prognostic factors in avalanche resuscitation asystematic review Resuscitation 201081645ndash52

3 Soar J Perkins GD Abbas G et al European Resuscitation Council Guidelines forResuscitation 2010 Section 8 Cardiac arrest in special circumstances Electrolyteabnormalities poisoning drowning accidental hypothermia hyperthermiaasthma anaphylaxis cardiac surgery trauma pregnancy electrocution Resus-citation 2010811400ndash33

4 Vanden Hoek TL Morrison LJ Shuster M et al Part 12 cardiac arrestin special situations 2010 American Heart Association Guidelines for Car-diopulmonary Resuscitation and Emergency Cardiovascular Care Circulation2010122S829ndash61

5 Brown D Brugger H Boyd J Paal P Accidental hypothermia New Engl J Med20123671930ndash8

6 Boyd J Haegeli P Abu-Laban RB Shuster M Butt JC Patterns of death amongavalanche fatalities a 21-year review CMAJ 2009180507ndash12

7 Haegeli P Falk M Brugger H Etter HJ Boyd J Comparison of avalanche survivalpatterns in Canada and Switzerland CMAJ 2011183789ndash95

8 Brugger H Sumann G Meister R et al Hypoxia and hypercapnia during respi-ration into an artificial air pocket in snow implications for avalanche survivalResuscitation 20035881ndash8

9 Hohlrieder M Brugger H Schubert HM Pavlic M Ellerton J Mair P Pattern andseverity of injury in avalanche victims High Alt Med Biol 2007856ndash61

0 McIntosh SE Grissom CK Olivares CR Kim HS Tremper B Cause of death inavalanche fatalities Wilderness Environ Med 200718293ndash7

1 Grissom CK Radwin MI Harmston CH Hirshberg EL Crowley TJ Respirationduring snow burial using an artificial air pocket JAMA 20002832266ndash71

2 Radwin MI Grissom CK Scholand MB Harmston CH Normal oxygenation andventilation during snow burial by the exclusion of exhaled carbon dioxideWilderness Environ Med 200112256ndash62

3 Paal P Strapazzon G Braun P et al Factors affecting survival from avalancheburialmdasha randomized prospective porcine pilot study Resuscitation 2012 [Epubahead of print]

4 Bernhard M Bottiger BW Out-of-hospital endotracheal intubation of traumapatients straight back and forward to the gold standard Eur J Anaesthesiol20112875ndash6

5 Neumar RW Otto CW Link MS et al Part 8 adult advanced cardio-vascular life support 2010 American Heart Association Guidelines forCardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation2010122S729ndash67

6 Deakin CD Nolan JP Soar J et al European Resuscitation Council Guidelinesfor Resuscitation 2010 Section 4 Adult advanced life support Resuscitation2010811305ndash52

7 Schmid F [The pathogenesis of pulmonary edema after being buried by anavalanche] Schweiz Med Wochenschr 19811111441ndash5

on 84 (2013) 539ndash 546

8 Kragh Jr JF Walters TJ Baer DG et al Survival with emergency tourniquet useto stop bleeding in major limb trauma Ann Surg 20092491ndash7

9 Davis DP Peay J Sise MJ et al Prehospital airway and ventilation man-agement a trauma score and injury severity score-based analysis J Trauma201069294ndash301

0 Gilbert M Busund R Skagseth A Nilsen PA Solbo JP Resuscitation from acci-dental hypothermia of 137 C with circulatory arrest Lancet 2000355375ndash6

1 Oberhammer R Beikircher W Hormann C et al Full recovery of an avalanchevictim with profound hypothermia and prolonged cardiac arrest treated byextracorporeal re-warming Resuscitation 200876474ndash80

2 Grissom CK Radwin MI Scholand MB Harmston CH Muetterties MC BywaterTJ Hypercapnia increases core temperature cooling rate during snow burial JAppl Physiol 2004961365ndash70

3 Locher T Walpoth B Differential diagnosis of circulatory failure in hypothermicavalanche victims retrospective analysis of 32 avalanche accidents SchweizRundsch Med Prax 1996851275ndash82

4 Putzer G Schmid S Braun P Brugger H Paal P Cooling of six centigrades in anhour during avalanche burial Resuscitation 2010811043ndash4

5 Strapazzon G Beikircher W Procter E Brugger H Electrical heart activityrecorded during prolonged avalanche burial Circulation 2012125646ndash7

6 Grissom CK Harmston CH McAlpine JC et al Spontaneous endogenous coretemperature rewarming after cooling due to snow burial Wilderness EnvironMed 201021229ndash35

7 Grueskin J Tanen DA Harvey P Santos FD Richardson III WH Riffenburgh RHA pilot study of mechanical stimulation and cardiac dysrhythmias in a porcinemodel of induced hypothermia Wilderness Environ Med 200718133ndash7

8 Danzl DF Accidental hypothermia In Auerbach PS editor Wilderness medicine6th ed Philadelphia Mosby 2012 p 116ndash42

9 Durrer B Brugger H Syme D International Commission for Mountain Emer-gency Medicine The medical on-site treatment of hypothermia ICAR-MEDCOMrecommendation High Alt Med Biol 2003499ndash103

0 Hayward JS Eckerson JD Kemna D Thermal and cardiovascular changes dur-ing three methods of resuscitation from mild hypothermia Resuscitation19841121ndash33

1 Brugger H Oberhammer R Adler-Kastner L Beikircher W The rate of coolingduring avalanche burial a ldquoCorerdquo issue Resuscitation 200980956ndash8

2 Locher T Merki B Eggenberger P Walpoth B Hilfiker O Measurement of coretemperature in the field comparison of two ldquotympanicrdquo measuring methodswith esophageal temperature In Proceedings International Congress of Moun-tain Medicine 1997 p 56

3 Camboni D Philipp A Schebesch KM Schmid C Accuracy of core tempera-ture measurement in deep hypothermic circulatory arrest Interact CardiovascThorac Surg 20087922ndash4

4 Henriksson O Lundgren P Kuklane K Holmer I Naredi P Bjornstig U Protectionagainst cold in prehospital care evaporative heat loss reduction by wet clothingremoval or the addition of a vapor barrier a thermal manikin study PrehospDisaster Med 20122753ndash8

5 Henriksson O Lundgren JP Kuklane K Holmer I Bjornstig U Protection againstcold in prehospital care-thermal insulation properties of blankets and rescuebags in different wind conditions Prehosp Disaster Med 200924408ndash15

6 Lundgren P Henriksson O Naredi P Bjornstig U The effect of active warmingin prehospital trauma care during road and air ambulance transportation - aclinical randomized trial Scand J Trauma Resusc Emerg Med 20111959

7 Paal P Beikircher W Brugger H Avalanche emergencies Review of the currentsituation Anaesthesist 200655314ndash24

8 Luks AM Swenson ER Pulse oximetry at high altitude High Alt Med Biol201112109ndash19

9 Danzl DF Pozos RS Auerbach PS et al Multicenter hypothermia survey AnnEmerg Med 1987161042ndash55

0 Thomas R Cahill CJ Successful defibrillation in profound hypothermia (corebody temperature 256 C) Resuscitation 200047317ndash20

1 Heier T Caldwell JE Impact of hypothermia on the response to neuromuscularblocking drugs Anesthesiology 20061041070ndash80

2 Ruttmann E Weissenbacher A Ulmer H et al Prolonged extracorpo-real membrane oxygenation-assisted support provides improved survival inhypothermic patients with cardiocirculatory arrest J Thorac Cardiovasc Surg2007134594ndash600

3 Dobson J Burgess J Resuscitation of severe hypothermia by extracorporealrewarming in a child J Trauma 199640483ndash5

4 American Society of Anesthesiologists Committee Practice guidelines forpreoperative fasting and the use of pharmacologic agents to reduce therisk of pulmonary aspiration application to healthy patients undergoingelective procedures an updated report by the American Society of Anesthe-siologists Committee on Standards and Practice Parameters Anesthesiology2011114495ndash511

5 Bogle LB Boyd JJ McLaughlin KA Triaging multiple victims in an avalanchesetting the Avalanche Survival Optimizing Rescue Triage algorithmic approachWilderness Environ Med 20102128ndash34

6 Paal P Milani M Brown D Boyd J Ellerton J Termination of cardiopulmonaryresuscitation in mountain rescue High Alt Med Biol 201213200ndash8

7 Canadian Avalanche Association Observation guidelines and recording stan-

dards for weather snowpack and avalanches Revelstoke Canada CanadianAvalanche Association 2007

8 Greene E Atkins D Birkeland K et al Snow weather and avalanches observa-tional guidelines for Avalanche Programs in the United States Pagosa SpringsCO American Avalanche Association 2010

Bogle avalanche triage 2010pdf

Triaging Multiple Victims in an Avalanche Setting The Avalanche Survival Optimizing Rescue Triage Algorithmic Approach

Introduction

Concept development

The AvSORT algorithm

Limitations

Acknowledgments

References

Putzer LUCAS manual CPR heli 2013pdf

LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescuemdasha prospective randomized

1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References

Zafren avalanche triage 2010pdf

Avalanche Triage Are Two Birds in the Bush Better Than One in the Hand

To the Editor

References

Brugger avalanche resuscitation 2012pdf

Resuscitation of avalanche victims Evidence-based guidelines of the international commission for mountain emergency medic

1 Introduction

2 Methods

3 Findings and recommendations

Survival probability

Grade of burial

Duration of burial

31 Asphyxia

311 Expediency

312 Duration of burial and airway patency

313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma

321 On-site management

33 Hypothermia

331 Cooling rate

332 Rescue collapse

333 Core-temperature

334 Insulation

335 Out-of-hospital rewarming

336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation

3310 ALS medications

3311 Transport

3312 Serum potassium

3313 Prognosis

34 General measures

341 Oral fluids

342 Activity

343 Organized rescue

344 Triage


4 Conclusions


Acknowledgements

Appendix A Supplementary data


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Verwenden Sie zum Oumlffnen bitte die aktuelle Version von CIB pdf brewerdie Sie kostenlos von unserer Webseite herunterladen koumlnnen wwwcibde

2013_ICAR MEDCOM minutes_Bolrtf

2013_ICAR MEDCOM minutes_Bolxml

Readmetxt

International Commission

for Mountain Emergency Medicine

ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf

ICAR MEDCOM 2013 MINUTES BOLCROATIA

Thursday October 17 2013

Welcome

President Fidel Elsensohn welcomed the members of the Commission

Attending see appendix

Apologies Nicole Gantner-Vogt Kazue Oshiro Herbert Forster Guumlnther Sumann Theohearis Sinifakoulis Peter Mair Rick de Decker Arthur Morgan Tore Dahlberg

Introductions Introductions of new and old members

Minutes of the last meeting

The minutes from the Spring meeting were approved without changes

Internet platform

Fidel mentioned the internet platform and encouraged all members to register

httpwwwstage4usicar

Financial Report and Bank Account

Our balance is euro 853196 No change since last meeting

Presidentrsquos report



Founding of the Bulgarian Mountain Medicine Society in SofiaLectures from Hermann Peter and Fidel

Spring meeting in Bad Toumllz (see minutes)

Meetings of the Executive Board The new proposes for proposed to the Bylaws will be presented at the Assembly of Delegates

Next yearrsquos meeting is in South Lake Tahoe 6-10 October 2014

The 2015 meeting will be in Ireland

Elections of officers All officers were elected for another term

Fidel Elsensohn - President

John Ellerton ndash Vice President and President-Elect

Ken Zafren ndash Vice President

Report of Nepalese Mountain Rescue Project

Fidel gave a report of the Mountain Rescue training in Kathmandu in May 2013

New papers published submitted or in press

No papers submitted at this time

Diploma in Mountain Medicine

John Ellerton discussed the new regulations of the ICAR MEDCOM UIAA MEDCOM ISMM This will be a topic at the ISMM meeting in Bolzano in May 2015

There are currently about 25 courses worldwide The process of evaluating courses will need to be changed to accommodate this large number The syllabus will need to be updated

There was a discussion about methods to ensure that others can verify whether someone holds a diploma

There was a discussion about assessment of courses

Currently certification is for life There was a discussion about whether individuals should be required to renew their diplomas

The final topic regarded charging the courses in order to support the administrative committee

Papers in preparation

Modular First Aid Kit for Alpinists Mountain Guides and Alpinist Physicians (title has been modified) Reisten O Soteras I Wiget

The paper will be revised and the revised version will be presented at the Spring meeting

Analgesia in the mountains and remote areas Ellerton J Paal P et al

Evidence-based recommendations for canyoning rescue Soteras I Strapazzon G

Avalanche triage form Blancher M Kotkman A

Alpine trauma registry Strapazzon G

German data collection Muumlller N


Short communications

Ladislav Kotrusz Medical Training in Slovak Mountain Rescue

The level of medical education is excellent but the organization plans to improve the training for medical care in mountain rescue

Giancelso Agazzi A valanche rescue 1909

The Laghi Gemelli (Twin Lakes) Pass avalanche of December 7 1909 buried a group of 7 mountaineers killing one victim The depth of the snow that slid was 2 meters A compact layer above slid on a poorly compacted deep layer The group sat out a blizzard for 2 days at the hut before attempting to cross the pass Six of the eight were on foot while 2 were on skis One turned around due to cold feet They were accompanied by a mountain guide at the hut The guide refused to lead the group over the pass because of dangerous snow conditions


Volker Lischke Medical simulation training in helicopter-assisted mountain rescue operations

Various personnel must work together randomly assorted In order to improve performance a training center was established The goal was to promote skill level behavior which is much faster than rule-level behavior The training facility in Bad Toumllz Germany includes a maneuverable helicopter simulator and a cable car on cables Volker described the results of the initial training involving rescuers including doctors from all over Germany

Alex Kottman Avalanche Victim Resuscitation Checklist (flowchart)

Further discussion The modified checklist was accepted

Manuel Genswein Survival chance optimized procedures in rescue and how to minimize injuries during evacuation

Manuel presented an algorithm designed to conserve resources by concentrating efforts on avalanche victims with higher chance of survival Many patients have little hope of survival Once rescuers have identified a patient with little chance of survival if resources are limited only a short course of CPR is provided If unsuccessful rescuers then shift efforts to victims with higher survival chances including victims who are still buried A second flowchart prioritizes evacuation of multiple victims depending on the expected survival benefit of transport to medical care A third flowchart ldquoPriorities and elementary procedures in basic level companion rescuerdquo presents a flowchart for companion rescue including the need to call or go for help prioritizing rescue attempts and resuscitation of multiple victims

Jeff Boyd Avalanche triage

Jeff presented a case of 17 school children buried of whom 7 were rescued by 2 mountain guides who happened to be on a slope above the valley where the avalanche ran One of the rescued victims dug out and saved 3 other victims Two deeply buried victims were found by organized rescuers with obstructed airways The esophageal temperatures of the these two dead victims were both above 32degC This led to the development of Canadian AvSAR ndash Rescue triage

In a multiple casualty incident (MCI) resources are overwhelmed Priority ndash modified ndash survival probabilities ndash ldquogreatest good for the greatest numberrdquo Modified ndash rather than ldquoreverserdquo ndash triage Jeff presented the algorithm from the paper by Bogle et al in Wilderness and Environmental Medicine the AvSORT algorithm Patients with severe injuries who are not breathing would be managed expectantly


Joint preconference in Lake Tahoe

Fidel announced a joint conference of the Medical Commission and the Avalanche Commission to discuss mass casualty incidents The main theme of the conference in Lake Tahoe is mass casualty incidents

Mountain Rescue Book ndash Iztok Tomazin


FORTHCOMING EVENTS


2014 October 5-10 ICAR General Assembly Lake Tahoe Nevada USA

2015 May dates to be determined Spring meeting Ticino Switzerland (Oliver Reisten and Gregoire Zen-Ruffinen)

2015 ICAR General Assembly Ireland

2016 ICAR MedCom Spring meeting Cape Town South Africa

CLOSING

Fidel closed the meeting

MINUTES TAKEN BEI KEN ZAFREN

2013_ICAR MEDCOM minutes_Bolrtf

100 100 1 0 0 0 0 0 75 600 1 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 4 0 CDokumente und EinstellungenFidelEigene DateienDatenB_IKARB_MINUTES2013~E2013_ICAR MEDCOM minutes_Bolpdf _e 0 0 iexploreexe s 0 0 1 1 0 100 0 0 ~E407tmp 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 15 0 0 1 12632256 1 0 1 12632256 0 0 1 12632256 Baker case Ken Zafren 32 1 -805 18871 29253 16620 27551 18924 7993 23163 STYLEnormal1FONTTimes12000STYLEheading 11FONTCambria14Bold5496145STYLEheading 22FONTCambria13Bold79129189STYLEheading 33FONTCambria12Bold79129189STYLEheading 44FONTCambria12BoldItalic79129189STYLEheading 55FONTCambria12366397STYLEheading 66FONTCambria12Italic366397STYLEheading 77FONTCambria12Italic646464STYLEheading 88FONTCambria10646464STYLEheading 99FONTCambria10Italic646464STYLEindex 11FONTTimes12000STYLEindex 21FONTTimes12000STYLEindex 31FONTTimes12000STYLEindex 41FONTTimes12000STYLEindex 51FONTTimes12000STYLEindex 61FONTTimes12000STYLEindex 71FONTTimes12000STYLEindex 81FONTTimes12000STYLEindex 91FONTTimes12000STYLEtoc 11FONTTimes12000STYLEtoc 21FONTTimes12000STYLEtoc 31FONTTimes12000STYLEtoc 41FONTTimes12000STYLEtoc 51FONTTimes12000STYLEtoc 61FONTTimes12000STYLEtoc 71FONTTimes12000STYLEtoc 81FONTTimes12000STYLEtoc 91FONTTimes12000STYLENormal Indent1FONTTimes12000STYLEfootnote text1FONTTimes10000STYLEcomment text1FONTTimes10000STYLEheader1FONTTimes12000STYLEfooter1FONTTimes12000STYLEindex heading1FONTCambria12Bold000STYLEcaption1FONTTimes9Bold79129189STYLEtable of figures1FONTTimes12000STYLEenvelope address1FONTCambria12000STYLEenvelope return1FONTCambria10000STYLEendnote text1FONTTimes10000STYLEtable of authorities1FONTTimes12000STYLEmacro1FONTConsolas10000STYLEtoa heading1FONTCambria12Bold000STYLEList1FONTTimes12000STYLEList Bullet1FONTTimes12000STYLEList Number1FONTTimes12000STYLEList 21FONTTimes12000STYLEList 31FONTTimes12000STYLEList 41FONTTimes12000STYLEList 51FONTTimes12000STYLEList Bullet 21FONTTimes12000STYLEList Bullet 31FONTTimes12000STYLEList Bullet 41FONTTimes12000STYLEList Bullet 51FONTTimes12000STYLEList Number 21FONTTimes12000STYLEList Number 31FONTTimes12000STYLEList Number 41FONTTimes12000STYLEList Number 51FONTTimes12000STYLETitle1FONTCambria26235493STYLEClosing1FONTTimes12000STYLESignature1FONTTimes12000STYLEBody Text1FONTTimes12000STYLEBody Text Indent1FONTTimes12000STYLEList Continue1FONTTimes12000STYLEList Continue 21FONTTimes12000STYLEList Continue 31FONTTimes12000STYLEList Continue 41FONTTimes12000STYLEList Continue 51FONTTimes12000STYLEMessage Header1FONTCambria12000STYLESubtitle1FONTCambria12Italic79129189STYLESalutation1FONTTimes12000STYLEDate1FONTTimes12000STYLEBody Text First Indent1FONTTimes12000STYLEBody Text First Indent 21FONTTimes12000STYLENote Heading1FONTTimes12000STYLEBody Text 21FONTTimes12000STYLEBody Text 31FONTTimes8000STYLEBody Text Indent 21FONTTimes12000STYLEBody Text Indent 31FONTTimes8000STYLEBlock Text1FONTCalibri12Italic79129189STYLEDocument Map1FONTTahoma8000STYLEPlain Text1FONTConsolas105000STYLEE-Mail-Signatur1FONTTimes12000STYLEz-Formularbeginn1FONTArial8000STYLEz-Formularende1FONTArial8000STYLEHTML Normal1FONTTimes New Roman12000STYLEHTML Address1FONTTimes12Italic000STYLEHTML Preformatted1FONTConsolas10000

2013_ICAR MEDCOM minutes_Bolxml

Diese Datei wurde mit Microsoftreg Word 2007(12066625003) - CIB pdf brewer 2526 erzeugt1313Verwenden Sie zum Oumlffnen bitte die aktuelle Version von CIB pdf brewer13die Sie kostenlos von unserer Webseite herunterladen koumlnnen wwwcibde

Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





Founding of the Bulgarian Mountain Medicine Society in SofiaLectures from Hermann Peter and Fidel

Spring meeting in Bad Toumllz (see minutes)

Meetings of the Executive Board The new proposes for proposed to the Bylawswill be presented at the Assembly of Delegates

Next yearrsquos meeting is in South Lake Tahoe 6-10 October 2014The 2015 meeting will be in Ireland

Elections of officers All officers were elected for another termFidel Elsensohn - PresidentJohn Ellerton ndash Vice President and President-ElectKen Zafren ndash Vice President

Report of Nepalese Mountain Rescue ProjectFidel gave a report of the Mountain Rescue training in Kathmandu in May 2013

New papers published submitted or in pressNo papers submitted at this time

Diploma in Mountain MedicineJohn Ellerton discussed the new regulations of the ICAR MEDCOM UIAAMEDCOM ISMM This will be a topic at the ISMM meeting in Bolzano in May 2015There are currently about 25 courses worldwide The process of evaluating courses will need to be changed to accommodate this large number The syllabus will need to be updatedThere was a discussion about methods to ensure that others can verify whether someone holds a diplomaThere was a discussion about assessment of coursesCurrently certification is for life There was a discussion about whether individuals should be required to renew their diplomasThe final topic regarded charging the courses in order to support the administrative committee

Papers in preparation

Modular First Aid Kit for Alpinists Mountain Guides and Alpinist Physicians (title has been modified) Reisten O Soteras I WigetThe paper will be revised and the revised version will be presented at the Spring meeting

Analgesia in the mountains and remote areas Ellerton J Paal P et al

FORTHCOMING EVENTS

ANylirfCtsbrttv

ONCEPTS

vimodos

tttsivs

ntroduction

oncept development

TlutuejlA

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

he AvSORT algorithm

Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





FORTHCOMING EVENTS

ANylirfCtsbrttv

ONCEPTS

vimodos

tttsivs

ntroduction

oncept development

TlutuejlA

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

he AvSORT algorithm

Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





FORTHCOMING EVENTS

ANylirfCtsbrttv

ONCEPTS

vimodos

tttsivs

ntroduction

oncept development

TlutuejlA

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

he AvSORT algorithm

Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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Welcome






































































CLOSING







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ICAR MEDCOM

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Welcome






































































CLOSING





FORTHCOMING EVENTS

ANylirfCtsbrttv

ONCEPTS

vimodos

tttsivs

ntroduction

oncept development

TlutuejlA

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

he AvSORT algorithm

Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





ANylirfCtsbrttv

ONCEPTS

vimodos

tttsivs

ntroduction

oncept development

TlutuejlA

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

he AvSORT algorithm

Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





ANylirfCtsbrttv

ONCEPTS

vimodos

tttsivs

ntroduction

oncept development

TlutuejlA

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

he AvSORT algorithm

Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





TlutuejlA

wsasditi5

Hwwrcafiloav

swvsrr

csmAaboshlalf

Tfartmksdcjftodnt

he AvSORT algorithm

Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

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Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

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Welcome






































































CLOSING





Fgf ith

Conscious

Breathing

Start CPR intubate

Asytole

with i

Hypothermia III

35 min an

essed t

E D P A TIE NT

lt 32deg C

ithe orary bypass

s or uncertain

rmiste c

pornte

al wiencmon

teg (m p

tagieme

redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





redimvmc5pdcatotsop

aTibfot

piclfltc

loisrctpccrtimcilhu

ovflbumagttsrmitoao

HECSCAPM

n this study

Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





Walking

Breathing

No or unsure

Airpocket present

Buried gt 35 min

WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





WamutiitwtsgcAams

imitations

cknowledgments

eferences

229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





229ndash233

Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

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Welcome






































































CLOSING







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ICAR MEDCOM

ikar_medcom-logojpg

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Welcome






































































CLOSING





Brief Report

1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

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Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





1 Introduction

11 Background

12 Importance

2 Methods

22 Participants

23 Intervention

386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





386 G Putzer et al

24 Outcome measures

3 Results

31 Primary outcome

4 Discussion

5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





5 Limitations

388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





388 G Putzer et al

LUCAS Group

6 Conclusions

Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





Acknowledgments

References

TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

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Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

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Welcome






































































CLOSING





TIMpwrcwf

lhsbwci

bbsihvwuar

wdtufiwarsr

agshrwgtds

tttCMtatwdsraa

ddlmaSmsdcatiTtt

dAtciaaIacc

v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





v3scfpcl

nil1nmpbH

aaldquotsswldquofoe

eferences

ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





ECG13 Asystole13

Vital13 Signs13

lt3213 Core13 Temp13 13 ____13 13 __degC13

Airway13

ge3213

FIRST13 AID13

YES13 NO13

NO13YES13Patent13

Patent13

Serum13 K+13

gt12 mmolL-113

YES13 NO13

Patient ID 13

Face13 exposure 13 13 13 13 13 13 13 ____13 13 ____13

_____13 min13 (lt32)13(ge32)13

Air13 Pocket13 13

ECLS13

CPR13 13

ALS13 ALS13

STOP13

le12mmolL-113

or unknown13

Vital13 Signs13

YES13 NO13

or unknown13

Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





Air13 Pocket13

Yes13 ___13 x13 ___13 x13 ___13 (cm)13

13 Time13 be

tween13 bu

rial13 and

If13 du

n13 core13 tempe

rature13 m

ay13 sub

sNtute13 using13

oesoph

ageal13 or13 ep

itympanic13 (the

perature13

R13 can13 be

13 with

held13 if13 unaccep

r13 total13

body13 frozen

13 or13 ob

Non13 trun

cal13 transsecNon

)13 13 PaN

ents13 who

13 present13 with

tricular13

arrhythm

13 pressure13 lt90m

rature13

lt28degC13 shou

possibility13

13 if13 K+

13 at13 h

ospital13 adm

ission

13 exceeds13 12m

molL-shy‐1 13 con

r13 stop

ping13

resuscita

Non13 (aer13 exlud

13 con

n13 of13 th

e13 use13 of13

ith13 K

+ =13 8-shy‐1213 mmolL-shy‐1 13 a

nd13 other13

13 non

n13 shou

be13 con

reviaN

Pat13 ID13 =13 PaN

ent13 Ide

nNty13

CPR13 =13 Cardiopu

ary13 Re

suscita

port13 13

ECLS=13 Extracorpo

real13 Life13 Sup

port13 (C

ardiop

embrane13 OxygenaNo

Rescue

13 Service13

Base13

13 13 13 13 13 13 13 AVA

E13 VICT

COM13 Ko4

n13 A13 B

lancher13 M

oyd13 J13 Brug

ger13 H

DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





DOI 101097CCM0b013e3182a643bc

Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





Boue et al

2 ranged

2 48 mm Hg Paco

2 38 mm

2 (69 mm Hg) Paco

2 (26 mm

2 (74 mm Hg) and

Temperature (degC)

32ndash28

28ndash24

HT = hypothermia

Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

ikar_medcom-logojpg

file_0wmf



Welcome






































































CLOSING





Online Case Report

Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







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Boue et al

KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



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Welcome






































































CLOSING





KAEHRR

Resuscitation

esuscitation great

r t i c l e i n f o

a b s t r a c t

1 Introduction

5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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CLOSING





5 scitati

bwfosLwitiMlc

Methods

urvival probability

rade of burial

on 84 (2013) 539ndash 546

Duration of burial

31 Asphyxia

first 35 min3417

care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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care care

on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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CLOSING





on 84 (2013) 539ndash 546

32 Trauma

scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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Welcome






































































CLOSING







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Welcome






































































CLOSING





scitati

ttacttm

ahtebiatawlt

rsasaprpp

3 Hypothermia

anent damage93031

32 C12ndash14

on 84 (2013) 539ndash 546 543

bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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Welcome






































































CLOSING







Readmetxt



ICAR MEDCOM

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Welcome






































































CLOSING





bull Insulation

Nearest ED

b Danzl38

esiatherm

A ming

stfbidgltd

altwdrt

Ia LOE B)

scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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scitati

awaltiv

4 General measures

on 84 (2013) 539ndash 546 545

4 Conclusions

Acknowledgements

5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



ICAR MEDCOM

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Welcome






































































CLOSING







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ICAR MEDCOM

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Welcome






































































CLOSING





5 scitati

eferences

on 84 (2013) 539ndash 546


Introduction

Concept development


Limitations

Acknowledgments

References



1 Introduction

11 Background

12 Importance


2 Methods


22 Participants

23 Intervention

24 Outcome measures


3 Results

31 Primary outcome


4 Discussion

5 Limitations

6 Conclusions

Acknowledgments

References



To the Editor

References



1 Introduction

2 Methods



Grade of burial

Duration of burial

31 Asphyxia

311 Expediency


313 Resuscitation

314 Advanced airway

315 Transport

32 Trauma


33 Hypothermia

331 Cooling rate

332 Rescue collapse


334 Insulation


336 Oxygen

337 Advanced airway

338 CPR

339 Defibrillation


3311 Transport


3313 Prognosis

34 General measures

341 Oral fluids

342 Activity


344 Triage


4 Conclusions


Acknowledgements







Readmetxt



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Documents

ICAR MEDCOM 2013 MINUTES, BOL,CROATIA · Fidel gave a report of the Mountain Rescue training in Kathmandu in May 2013. New papers published, submitted or in press No papers submitted

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