Search

Background: A major challenge in the management of avalanche victims in cardiac arrest is differentiating hypothermic from non-hypothermic cardiac arrest, as management and prognosis differ. Duration of burial with a cutoff of 60 min is currently recommended by the resuscitation guidelines as a parameter to aid in this differentiation However, the fastest cooling rate under the snow reported so far is 9.4 °C per hour, suggesting that it would take 45 min to cool below 30 °C, which is the temperature threshold below which a hypothermic cardiac arrest can occur., Case Presentation: We describe a case with a cooling rate of 14 °C per hour, assessed on site with an oesophageal temperature probe. This is by far the most rapid cooling rate after critical avalanche burial reported in the literature and further challenges the recommended 60 min threshold for triage decisions. The patient was transported under continuous mechanical CPR to an ECLS facility and rewarmed with VA-ECMO, although his HOPE score was 3% only. After three days he developed brain death and became an organ donor., Conclusions: With this case we would like to underline three important aspects: first, whenever possible, core body temperature should be used instead of burial duration to make triage decisions. Second, the HOPE score, which is not well validated for avalanche victims, had a good discriminatory ability in our case. Third, although extracorporeal rewarming was futile for the patient, he donated his organs. Thus, even if the probability of survival of a hypothermic avalanche patient is low based on the HOPE score, ECLS should not be withheld by default and the possibility of organ donation should be considered., (© 2023. The Author(s).)

Introduction: The International Commission for Mountain Emergency Medicine (ICAR MedCom) developed updated recommendations for the management of avalanche victims., Methods: ICAR MedCom created Population Intervention Comparator Outcome (PICO) questions and conducted a scoping review of the literature. We evaluated and graded the evidence using the American College of Chest Physicians system., Results: We included 120 studies including original data in the qualitative synthesis. There were 45 retrospective studies (38%), 44 case reports or case series (37%), and 18 prospective studies on volunteers (15%). The main cause of death from avalanche burial was asphyxia (range of all studies 65-100%). Trauma was the second most common cause of death (5-29%). Hypothermia accounted for few deaths (0-4%)., Conclusions and Recommendations: For a victim with a burial time ≤ 60 minutes without signs of life, presume asphyxia and provide rescue breaths as soon as possible, regardless of airway patency. For a victim with a burial time > 60 minutes, no signs of life but a patent airway or airway with unknown patency, presume that a primary hypothermic CA has occurred and initiate cardiopulmonary resuscitation (CPR) unless temperature can be measured to rule out hypothermic cardiac arrest. For a victim buried > 60 minutes without signs of life and with an obstructed airway, if core temperature cannot be measured, rescuers can presume asphyxia-induced CA, and should not initiate CPR. If core temperature can be measured, for a victim without signs of life, with a patent airway, and with a core temperature < 30 °C attempt resuscitation, regardless of burial duration., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: Space travel is expected to grow in the near future, which could lead to a higher burden of sudden cardiac arrest (SCA) in astronauts. Current methods to perform cardiopulmonary resuscitation in microgravity perform below earth-based standards in terms of depth achieved and the ability to sustain chest compressions (CC). We hypothesised that an automated chest compression device (ACCD) delivers high-quality CC during simulated micro- and hypergravity conditions., Methods: Data on CC depth, rate, release and position utilising an ACCD were collected continuously during a parabolic flight with alternating conditions of normogravity (1 G), hypergravity (1.8 G) and microgravity (0 G), performed on a training manikin fixed in place. Kruskal-Wallis and Mann-Withney U test were used for comparison purpose., Results: Mechanical CC was performed continuously during the flight; no missed compressions or pauses were recorded. Mean depth of CC showed minimal but statistically significant variations in compression depth during the different phases of the parabolic flight (microgravity 49.9 ± 0.7, normogravity 49.9 ± 0.5 and hypergravity 50.1 ± 0.6 mm, p < 0.001)., Conclusion: The use of an ACCD allows continuous delivery of high-quality CC in micro- and hypergravity as experienced in parabolic flight. The decision to bring extra load for a high impact and low likelihood event should be based on specifics of its crew's mission and health status, and the establishment of standard operating procedures., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background Helicopter emergency medical services personnel operating in mountainous terrain are frequently exposed to rapid ascents and provide cardiopulmonary resuscitation (CPR) in the field. The aim of the present trial was to investigate the quality of chest compression only (CCO)-CPR after acute exposure to altitude under repeatable and standardized conditions. Methods and Results Forty-eight helicopter emergency medical services personnel were divided into 12 groups of 4 participants; each group was assigned to perform 5 minutes of CCO-CPR on manikins at 2 of 3 altitudes in a randomized controlled single-blind crossover design (200, 3000, and 5000 m) in a hypobaric chamber. Physiological parameters were continuously monitored; participants rated their performance and effort on visual analog scales. Generalized estimating equations were performed for variables of CPR quality (depth, rate, recoil, and effective chest compressions) and effects of time, altitude, carryover, altitude sequence, sex, qualification, weight, preacclimatization, and interactions were analyzed. Our trial showed a time-dependent decrease in chest compression depth ( P =0.036) after 20 minutes at altitude; chest compression depth was below the recommended minimum of 50 mm after 60 to 90 seconds (49 [95% CI, 46-52] mm) of CCO-CPR. Conclusions This trial showed a time-dependent decrease in CCO-CPR quality provided by helicopter emergency medical services personnel during acute exposure to altitude, which was not perceived by the providers. Our findings suggest a reevaluation of the CPR guidelines for providers practicing at altitudes of 3000 m and higher. Mechanical CPR devices could be of help in overcoming CCO-CPR quality decrease in helicopter emergency medical services missions. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04138446.

Accidental hypothermia (AH) in Mediterranean countries often is underestimated. AH should be suspected in patients also in moderate climates throughout all seasons. Compared with other countries, the mortality rate due to AH in Spain is low, and hypothermia rarely is recognized and treated. The case of a patient who experienced cardiac arrest due to severe AH and was resuscitated for more than six hours using extracorporeal life support recently was published. Herein that case is reviewed, with the anesthetic management during cannulation detailed. In addition, the authors highlight how the application of extracorporeal cardiopulmonary resuscitation guidelines is different in AH patients, how in-hospital (HOPE score) triage criteria should be applied, and how the establishment of clear standard operating procedures and education strategies should be promoted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The aim of this manikin study was to evaluate the quality of cardiopulmonary resuscitation (CPR) with restricted patient access during simulated avalanche rescue using over-the-head and straddle position as compared to standard position., Methods: In this prospective, randomised cross-over study, 25 medical students (64% male, mean age 24) performed single-rescuer CPR with restricted patient access in over-the-head and straddle position using mouth-to-mouth ventilation or pocket mask ventilation. Chest compression depth, rate, hand position, recoil, compression/decompression ratio, hands-off times, tidal volume of ventilation and gastric insufflation were compared to CPR with unrestricted patient access in standard position., Results: Only 28% of all tidal volumes conformed to the guidelines (400-800 ml), 59% were below 400 ml and 13% were above 800 ml. There was no significant difference in ventilation parameters when comparing standard to atypical rescuer positions. Participants performed sufficient chest compressions depth in 98.1%, a minimum rate in 94.7%, correct compression recoil in 43.8% and correct hand position in 97.3% with no difference between standard and atypical rescuer positions. In 36.9% hands-off times were longer than 9 s., Conclusions: Efficacy of CPR from an atypical rescuer position with restricted patient access is comparable to CPR in standard rescuer position. Our data suggest to start basic life-support before complete extrication in order to reduce the duration of untreated cardiac arrest in avalanche rescue. Ventilation quality provided by lay rescuers may be a limiting factor in resuscitation situations where rescue ventilation is considered essential., (© 2021. The Author(s).)

Roy, Steven, Inigo Soteras, Alison Sheets, Richard Price, Kazue Oshiro, Simon Rauch, Don McPhalen, Maria Antonia Nerin, Giacomo Strapazzon, Myron Allen, Alistair Read, and Peter Paal. Guidelines for mountain rescue during the COVID-19 pandemic: official guidelines of the International Commission for Alpine Rescue. High Alt Med Biol . 22: 128-141, 2021. Background: In mountain rescue, uncertainty exists on the best practice to prevent coronavirus disease 2019 (COVID-19) transmission. The aim of this work was to provide a state-of-the-art overview of the challenges caused by the COVID-19 pandemic in mountain rescue. Methods: Original articles or reviews, published until December 27, 2020 in Cochrane COVID-19 Study Register, EMBASE, PubMed, and Google Scholar were included. Articles were limited to English, French, German, or Spanish with the article topic COVID-19 or other epidemics, addressing transmission, transport, rescue, or cardiopulmonary resuscitation. Results: The literature search yielded 6,190 articles. A total of 952 were duplicates and 5,238 were unique results. After exclusion of duplicates and studies that were not relevant to this work, 249 articles were considered for this work. Finally, 72 articles and other sources were included. Conclusions: Recommendations are provided for protection of the rescuer (including screening, personal protective equipment [PPE], and vaccination), protection of the patient (including general masking if low risk, specific PPE if high risk), equipment hygiene (including disinfection after every mission), use of single-use products, training and medical measures under COVID-19 precautions, and psychological wellbeing of rescuers during the COVID-19 pandemic. Adapted COVID-19 precautions for low-and-medium-income countries are also discussed.

Aims: This study aimed to determine the time needed for one or two companion rescuers to access, extricate, and deliver cardiopulmonary resuscitation (CPR) to a fully buried manikin during a simulated avalanche burial scenario. Materials and Methods: In this randomized, single-blinded study, 18 medical students were required to extricate a manikin manually from a simulated avalanche burial of 1 m in depth, either alone or in teams of two. Each participant performed three consecutive tests with the manikin in three different positions in random order. Results: Median time to first manikin contact was 2.5 minutes, median time to airway access 7.2 minutes, and median time to standard position for CPR 10.1 minutes. Overall, the number of rescuers (one compared to two rescuers, 10.5 minutes vs. 9.3 minutes; p  = 0.686) and the burial position of the manikin (10.8 minutes vs. 10.6 minutes vs. 8.8 minutes; p  = 0.428) had no influence on extrication times. Preexisting training (6.1 minutes vs. 11.0 minutes p  = 0.006) and a learning effect obtained during the experiments (12.4 minutes the first test vs. 9.3 in the third test; p  = 0.017) improved all extrication times. Conclusion: It takes an average of 7 minutes after location of a simulated avalanche victim, buried at a depth of 1 m, to free the airway, plus a further 3 minutes to initiate CPR in standard supine position. This is more than two-thirds of the 15 minutes considered necessary for successful companion avalanche rescue. Even minimal training significantly reduced extrication times. These findings emphasize the importance of regular practice in specific extrication techniques that should be part of any training in avalanche companion rescue.

We describe full neurologic recovery from accidental hypothermia with cardiac arrest despite the longest reported duration of mechanical cardiopulmonary resuscitation (CPR) and extracorporeal life support (8 hours, 42 minutes). Clinical data and blood samples were obtained from emergency medical services (EMS) and the intensive care department. A 31-year-old man experienced a witnessed hypothermic cardiac arrest with a core temperature of 26°C (78.8°F) during a summer thunderstorm; he received mechanical CPR for 3 hours and 42 minutes, followed by 5 hours of extracorporeal life support. The use of a standard operating procedure that integrates a technical mountain rescue performed by EMS, optimizes prolonged CPR to the hub hospital, and enables prompt placement of extracorporeal life support is described and discussed. Three months postaccident, the patient had recovered completely (Cerebral Performance Category score of 1) and resumed normal daily life. Neurologically intact survival from hypothermic cardiac arrest is common, suggesting that aggressive resuscitation measures are warranted. There is a need for the establishment of a clear standard operating procedure and multiteam education and training to further optimize the patient survival chain from on-site triage and treatment to inhospital extracorporeal life support and postresuscitation care., (Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Aim: The aim of this study is to describe the prehospital management and outcome of avalanche patients with out-of-hospital cardiac arrest in Tyrol, Austria, for the first time since the introduction of international guidelines in 1996., Patients and Methods: This study involved a retrospective analysis of all avalanche accidents involving out-of-hospital cardiac arrest between 1996 and 2009 in Tyrol, Austria., Results: A total of 170 completely buried avalanche patients were included. Twenty-eight victims were declared dead at the scene. Of 34 patients with short burial, cardiopulmonary resuscitation (CPR) was performed in 27 (79%); 15 of these patients (56%) were transported to hospital with ongoing CPR and four patients were rewarmed with extracorporeal circulation; no patient survived. Of 108 patients with long burial, 49 patients had patent or unknown airway status; CPR was performed in 25 of these patients (51%) and 14 patients (29%) were transported to hospital. Four patients were rewarmed, but only one patient with witnessed cardiac arrest survived. Since the introduction of guidelines in 1996, there has been a marginally significant increase in the rate of documenting airway assessment, but no change in documenting the duration of burial or CPR., Conclusion: CPR is continued to hospital admission in patients with short burial and asphyxial cardiac arrest, but withheld or terminated at the scene in patients with long burial and possible hypothermic cardiac arrest. Insufficient transfer of information from the accident site to the hospital may partially explain the poor outcome of avalanche victims with out-of-hospital cardiac arrest treated with emergency cardiac care.

Background: This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest., Methods: The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review., Results: The hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 °C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care., Conclusions: Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.

Background and Aim: Limited data are available concerning the impact of CPR interventions on cerebral oxygenation during hypothermic cardiac arrest. We therefore studied cerebral perfusion pressure (CPP), brain tissue oxygen tension (PbtO2), cerebral venous oxygen saturation (ScvO2) and regional cerebral oxygen saturation (rSO2) in an animal model of hypothermic CPR. We also assessed the correlation between rSO2 and CPP, PbtO2 and ScvO2 to clarify whether near-infrared spectroscopy (NIRS) may be used to non-invasively monitor changes in cerebral oxygenation during hypothermic CPR., Methods: Nine pigs were surface-cooled to a core temperature of 28°C and underwent a period of asphyxia before cardiac arrest was induced. After 2min of untreated cardiac arrest they were resuscitated for 45min. CPP, PbtO2, ScvO2 and rSO2 were monitored after periods of stable external chest compression, a short interruption of CPR and after epinephrine administration., Results: During external chest-compressions before adrenalin administration CPP, PbtO2, ScvO2 and rSO2 increased in parallel and changes in rSO2 closely correlated with changes in CPP (r=.844; p<.001) and ScvO2 (r=.868; p<.001). After adrenaline administration CPP and PbtO2 increased, ScvO2 decreased and rSO2 values did not change and there was no significant correlation between rSO2 and CPP, PbtO2, or ScvO2., Conclusion: In this animal model of hypothermic cardiac arrest adrenaline was associated with an increase in global cerebral oxygen extraction despite an increase in CPP. Discrepancies in the time course of PbtO2 and ScvO2 suggest differences in regional oxygen metabolism after adrenalin. rSO2 values correlated closely with CPP and ScvO2 only during periods of external chest compression without adrenaline administration., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Aim of the Study: Automated external defibrillation (AED) and public access defibrillation (PAD) have become cornerstones in the chain of survival in modern cardiopulmonary resuscitation. Most studies of AED and PAD have been performed in urban areas, and evidence is scarce for sparsely populated rural areas. The aim of this review was to review the literature and discuss treatment strategies for out-of-hospital cardiac arrest in rural areas., Methods: A Medline search was performed with the keywords automated external defibrillation (617 hits), public access defibrillation (256), and automated external defibrillator public (542). Of these 1415 abstracts and additional articles found by manually searching references, 92 articles were included in this nonsystematic review., Results: Early defibrillation is crucial for survival with good neurological outcome after cardiac arrest. Rapid defibrillation can be a challenge in sparsely populated and remote areas, where the incidence of cardiac arrest is low and rescuer response times can be long. The few studies performed in rural areas showed that the introduction of AED programs based on a 2-tier emergency medical system, consisting of Basic Life Support and Advanced Life Support teams, resulted in a decrease in collapse-to-defibrillation times and better survival of patients with out-of-hospital cardiac arrest., Conclusions: In rural areas, introducing AED programs and a 2-tier emergency medical system may increase survival of out-of-hospital cardiac arrest patients. More studies on AED and PAD in rural areas are required., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: High-quality chest-compressions are of paramount importance for survival and good neurological outcome after cardiac arrest. However, even healthcare professionals have difficulty performing effective chest-compressions, and quality may be further reduced during transport. We compared a mechanical chest-compression device (Lund University Cardiac Assist System [LUCAS]; Jolife, Lund, Sweden) and manual chest-compressions in a simulated cardiopulmonary resuscitation scenario during helicopter rescue., Methods: Twenty-five advanced life support-certified paramedics were enrolled for this prospective, randomized, crossover study. A modified Resusci Anne manikin was employed. Thirty minutes of training was allotted to both LUCAS and manual cardiopulmonary resuscitation (CPR). Thereafter, every candidate performed the same scenario twice, once with LUCAS and once with manual CPR. The primary outcome measure was the percentage of correct chest-compressions relative to total chest-compressions., Results: LUCAS compared to manual chest-compressions were more frequently correct (99% vs 59%, P < .001) and were more often performed correctly regarding depth (99% vs 79%, P < .001), pressure point (100% vs 79%, P < .001) and pressure release (100% vs 97%, P = .001). Hands-off time was shorter in the LUCAS than in the manual group (46 vs 130 seconds, P < .001). Time until first defibrillation was longer in the LUCAS group (112 vs 49 seconds, P < .001)., Conclusions: During this simulated cardiac arrest scenario in helicopter rescue LUCAS compared to manual chest-compressions increased CPR quality and reduced hands-off time, but prolonged the time interval to the first defibrillation. Further clinical trials are warranted to confirm potential benefits of LUCAS CPR in helicopter rescue., (Copyright © 2013 Elsevier Inc. All rights reserved.)