AVY SAVVY

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AVY SAVVY

• MEDICAL CARE OF THE AVALANCHE SURVIVOR
• KEVIN HANRAHAN

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DISCLOSURE

• I have/had an affiliation (financial or
  otherwise) with a commercial organization that
  may have a direct or indirect connection to the
  content of my presentation.
• Medical Director for Sunshine Village Ski Resort
  in Banff, Alberta for the past 20 years.
• No other commercial interests but I am open to
  lucrative offers.

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Objectives

• Outline bystander first aid interventions.
• Discuss the role of the arriving field medics and
  medical direction for EMS/Flight crews.
• Outline a framework for triaging and treating the
  avalanche survivor for primary and tertiary
  hospital care providers based on the best
  available evidence.
• Discuss some statistics on avalanche rescue
  devices.
• NOT
• - avalanche awareness or avoidance.
• - location and extrication of avalanche victims.

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Case 1

• March 22, 2007.
• 27 y m RC, a professional ski patroller doing
  avalanche control work.
• Trapped for 4 minutes under a size 2.5 avalanche
  on the Tomahawk run in the Silver City area of
  Sunshine Village Ski Resort near Banff, Alberta
• Rescued by coworkers who found him with airway
  packed in snow, helmet strap choking him,
  unconscious and firmly entombed in very hard snow
  slab.
• Avalanches are classed 1-5 with 1 being a
  relatively harmless slough, 2 potentially burying
  a person and 3 burying a car or small building,
  etc

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Case 2

• February 19th 2005.
• 29 y m WMand 62 y m JD both skiers caught in
  a backcountry avalanche in Europe.
• WM buried to 3 meters and extricated after 100
  minutes, found to be unconscious, breathing into
  a small air pocket.
• JD found after 105 minutes, unconscious,
  asystolic with airway packed in snow, pronounced
  dead at scene.

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EPIDEMIOLOGY(the boring stuff)

• Approx. 150 avalanche deaths/yr in the 17
  countries reporting to the International
  Commission for Alpine Rescue(ICAR).(2)
• On average 11 deaths/yr in the last 30 years in
  Canada but between 1998-2007 has inc. to 14/yr.
• Mostly due to increased visitation to backcountry
  areas by snowmobilers, and to a lesser extent,
  skiers.
• Actual rate probably decreased.

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THIS YEAR

• 24 deaths (May 22)
• 18 snowmobilers
• 4 out of bounds skiers
• 1 heli-cat skier
• 1 other (hiker/climber)
• 0 backcountry skiers
• Complex snowpack year and not all groups heading
  warnings(1)

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More Boring Stuff

• Several factors influence fatality duration of
  burial, injuries, air pocket, extent of burial,
  luck.
• 55 on foot (or skis) and 38 mechanized
  travelers. (snowmobilers/heli).
• About 80 chance of surviving an avalanche if
  buried. 51 complete, 95.6 if partial burial or
  unburied.(1)????

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CAUSE OF DEATH
TRAUMA
ASPHYXIATION
??HYPOXIA/HYPERCAPNIA/HYPOTHERMIA??
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CAUSE OF DEATH

• NA vs. Europe
• Trauma in Canada 24 of fatalities(16)
• 13 of asphyxia deaths had ISS gt15
• Chest(46),Head(42),
• neck(8), abdo(4)
• 5.6 in Europe(?10)17
• 5.4 in Utah (?9)18

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Burial Time Graph
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AIR POCKET

• Any space around the victims nose/mouth
  considered an air pocket.
• Difficult to determine presence with digging
  activities.
• If no snow in upper airway then consider an air
  pocket to have been present.
• Absence of vital signs gt35m and evidence of an
  air pocket are indications for continued
  resuscitation.
• rescue death

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RC AvalancheSilver City Sunshine Village
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RC Avalanche
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RC Contd

• 1318(0m)-avalanche occurs.(3)
• 1318-1322(4m)-coworker skis to site, searches,
  finds patients face 40cm into snow pack.
• Pts face blue packed with snow/ice, helmet
  strap tight around neck with snow packed into
  helmet.
• Airway swept, helmet released, shallow
  spontaneous breathing, unresponsive.
• 1326(8m)-c-spine controlled by snow pack, color
  improving, responsive to pain, raccoon eyes.
• 1329(11m)-Other patrollers arrive to finish
  extrication.
• 1342(22m)-GCS 8(1/2/5), moved to helicopter LZ by
  toboggan.
• 1350(30m)-helicopter departs Banff Hospital(small
  town emergency facility).

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RC EMS Report

• 1354(34m)- VS109/m,135/88,26/m,GCS 15, cold.
• 27y m, healthy, no meds, all-pen.
• Spinal precautions. R eye hematoma.
• C/T spine pain, no deficit.
• L chest pain, AEbilat, LUQ tender.

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Banff Mineral Springs Emergency

• Hemodynamically stable.
• Clinical basal skull .
• Clinical suspicion of C-spine injury.
• Initial lab/x-ray normal.
• Gross hematuria.
• L flank contusion with LUQ tenderness.
• Transferred to Foothills Hospital (tertiary) by
  ground ambulance with continued spinal
  precautions.(4)

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Foothills Emergency

• Illegible ED record (even to me!)(5)
• C2 hangmans , R occipital condyle , R C6
  facet .
• CHI, R scapula , T12 burst , posterior 5th rib
  , pulmonary contusion.
• Discharged 2 weeks later.
• Back working as a ski patroller with some
  residual pain/PTSD issues.

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WM AVALANCHE
Beacons, yes Signal, no
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WM 29 Y M

• Group of amateur ski mountaineers climbing a peak
  in the Eastern Alps of Northern Italy.(6)
• 09359(0m)-slab avalanche, uninjured companions
  call for help by cell and 3 helicopters
  dispatched.
• 2 ED MDs, rescue teams dogs and handlers sent.
• 1115(1h40m)- WM found by probing at 3m depth.
• Hard snow pack formed an air pocket 2-4L in front
  of face, breathing and unconscious.
• 1118(1h43m)- group leader (JD) found with airway
  sealed by snow, asystolic.
• Pronounced dead at scene in accordance with ICAR
  MEDCOM recommendations. (7)

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WM Contd

• 1115(1h40m)- carotid pulse 60/m, temp 22c.
• GCS- 7.
• IV established, propofol 0.7mg/kg,succ 1.47
  mg/kg.
• Endotracheally intubated.
• 1210(2h35m)-External heat packs, packaged for
  Heli transport.
• 1211(2h36m)-V-fib, failed defib (bad batteries).
• Transported to Bruneck Hospital, no CPR en-route.

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Bruneck Hospital

• 1215(2h40m)-Repeat defib attempt on arrival.
• 1216(2h41m)- CPR commenced.
• 1216- bloodwork drawn.
• 1220(2h45m)- transferred Innsbruck Medical
  University
• VBG
• ph-6.87 K 4.3
• pO2-23.3 Lactate- 11.7
• pCO2-111 BGL- 15.2
• Base excess 12.3

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Innsbruck Medical University ED

• 1320(3h45m)-VF persists, defib fails.
• 1345(4h10m)- to OR for extracorporeal rewarming,
  temp 24c.(esophageal).
• 1445(5h10m)- defibrillation successful,temp
  34.5c.
• 1645(7h10m)- transferred ICU, temp 36.3c,
  pulmonary edema requiring ECMO x 3/7.

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Innsbruck Contd

• 5/7 later-conscious, extubated
• 17/7 later-d/c from Bruneck with complete
  physical and mental recovery.
• Passed university exams short time later.
• Good reason for smiling

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ON SCENE FIRST AID

• May seem obvious sitting in this lecture theater.
• Mark the time and locate face/head asap and
  identify presence/absence of air pocket.
• lt35 min Standard BLS care with spinal/trauma
  care.

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PREHOSPITAL CARE

• Usually too late in Canada to be effective.
• dogs and docs by air Euro Model.
• Assess risk to team vs. chance of rescue.
• Triage multiple burials to those with VS/air
  pocket.
• Blankets, thermometer, chemical hot packs,
  hot/sweet tea.
• ALS care should be at head as soon as visible to
  ascertain air pocket and manage airway.
• gt35 minutes w/o air pocket-pronounce.
• Clinical temp as part of vitals.

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Dogs and Docs by Air?
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CLOSER LOOK
BELL 212
First Aid Kit
Cardiac Surgeon
Anesthetist
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PREHOSPITAL CONTD

• Warm/dry O2 via ET as per ACLS Hypothermia
  guidelines if (when!) gt35 minutes if had air
  pocket.(11)
• Assume trauma, c-spine, etc.
• IV if does not delay transport gt5mins.
• Intubation does not increase arrhythmia
  generation. (12)
• Insulate to protect from further heat loss.
• Transport to hospital capable of bypass.

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Standard trauma precautions and care for all
avalanche victims
(8)
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HYPOTHERMIA

• Difficult to get accurate temp in the field.
• Swiss Classification(9)
• Stages
• 1-32-35c responsive/shiver
• 2-28-32c semiconscious
• 3-24-28c unresponsive
• 4-lt24c no signs of breathing

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POST TRAUMATIC STRESS DISORDER

• 28 In 1 study.
• Up to 41 if completely buried.
• 18 symptoms last gt1 year.
• CISM for party, rescuers.
• Case 1 still has issues.
• Case 2 admits to none.

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References

• 1.The Canadian Avalanche Association, The
  Canadian Avalanche Centre, 110 Mackenie Ave. P.O.
  Box 2759, Revelstoke, B.C., V0E 2S0,
  www.avalanche.ca.
• 2. Brugger H, Durrer B, Time is Life-Medical
  Training in Avalanche Rescue, IKAR-CISA Video,
  2006
• 3. Personal Communication with Leahey, T, Ski
  Patrol Supervisor, Sunshine Village Ski Area,
  Banff, Alta.
• 4. Review of RM chart, Mineral Springs
  Hospital,Banff, Alta.
• 5. Review of RM chart, Foothills Medical Centre,
  Calgary, Alta.
• 6. Oberhammer R, Werner B, et al, Full Recovery
  of an avalanche victim with profound hypothermia
  and prolonged cardiac arrest treated by
  extracorporeal re-warming, Resuscitation (2007).
• 7. Brugger H, Durrr B, On-site treatment of
  avalanche victims, ICAR MEDCOM recommendation.
  High Alt Med Biol, 20023421-5.
• 8. Brugger H, Durrer B, Field management of
  avalanche victims, Resuscitation 2001517-15.
• 9. Durrer B, Hypothermia in the Mountains,
  Austrian Journal of Sports Medicine, (1991),
  250-54
• 10. Larach MG, Accidental Hypothermia, The Lancet
  (1995), 345493-498.
• 11. ACLS Guidelines, Hypothermia, Circulation.
  2005 112IV-136-IV-138
• 12. Schneider SM, Hypothermia from recognition
  to rewarming. Emerg Med Reports, 1992131-20
• 13. Brugger H, Time is Life, DVD, IKAR, 2002.
• 14. Brugger H, et al, The Impact of Avalanche
  Rescue Devices on Survival, Resuscitation,
  2007.06.002.
• 15. Jamieson B, Geloesetzer T, Avalanche Deaths
  in Canada, Vol 4, 1984-1996, Canadian Avalanche
  Association, 1996.
• 16. Boyd J, Haegeli P, et al, Patterns of death
  among avalanche fatalities a 21 year review,
  CMAJ, 2009, March, 180(5).
• 17. Hohlriede M, Brugger H, et al, Pattern and
  severity of injury in avalanche victims, High
  Altitude Medical Biology, 2007, Spring8(1)56-61
• 18. Mcintosh SE, Grissom CK, Cause of death in
  avalanche fatalities, Wilderness Environmental
  Medicine, 2007, Winter 18(4)293-7

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Avalanche Survival Technology
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AVALANCHE PROBES, SHOVELS, BEACONS

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TRANSCEIVERS

• Multiple manufacturers with multiple features.
• Most important factor is knowing equipment and
  how to use it efficiently (e.g.. practice)
• Austrian study with 135 completely buried ski
  tourers with and without beacons.
• Median burial time decreased 170 - 20min
  (plt.001)(13).
• Mortality decreased from 79-50 (plt.001).
• RR reduction 29, NNT3.45

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AVALUNG TM

• SCUBA type mouthpiece with valve directing
  exhaled gases to back, inhalation valve with
  filter on front.
• 2005- 33 tests and 3 accidents.
• No deaths
• ? Get it in your mouth.
• ? Keep it in your mouth.
• ? Group able to find you in one piece.
• ?aspirate the mouth piece.

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ABSTM AVALANCHE AIRBAG
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ABSTM AIRBAG

• 1991-2004, 77 reports of actual use.(n111)
• 1 death, 76 involvements alive.
• 9 had malfunction or didnt activate.
• 10 completely buried but bag visible.
• 25 w/o airbags in same incidents.
• 12 buried completely, 9 deaths.
• Decreases burial from 47 to 13 (lt.001)(13).
• Decreases mortality from 35 to 1.3 (plt.001).
• RR reduction 33.7, NNT2.97

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Newer Airbag

• May protect head and thorax
• Compressed air v CO2 or nitrogen
• (easier to refill, deflates to supplement air
  pocket)
• Minimal research so far

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The Impact of Avalanche Rescue Devices on
Survival (Brugger,Boyd,et al)

• n1504, Switzerland/Austria
• AIRBAGS
• 2.9 mortality v. 18.9, p0.026 in those with
  airbags v. not.(RR 16, NNT6.25)
• TRANSCEIVERS
• Burial time 25 v. 125 min in those with
  transceivers, plt.001.
• Mortality 55.2 v. 70.6, plt.001(RR 15.4,
• NNT6.49)
• Resuscitation , 2007(14)

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GLADIATOR EFFECT
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10 COMMANDMENTS

• Dont leave early, search the surface.

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10 COMMANDMENTS

• Dont leave early, search the surface.
• Only rescuers on the slope.

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10 COMMANDMENTS

• Dont leave early, search the surface.
• Only rescuers on the slope.
• Dont move the probe.

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10 COMMANDMENTS

• Dont leave early, search the surface.
• Only rescuers on the slope.
• Dont move the probe.
• Dig obliquely.Dig large.

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10 COMMANDMENTS

• Dont leave early, search the surface.
• Only rescuers on the slope.
• Dont move the probe.
• Dig obliquely.Dig large.
• ALS care as soon as the face is found.

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10 COMMANDMENTS CONTD

• 6. Air pocket evaluation, train everyone.

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10 COMMANDMENTS CONTD

• 6. Air pocket evaluation, train everyone.
• 7. No large/fast movements.

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10 COMMANDMENTS CONTD

• 6. Air pocket evaluation, train everyone.
• 7. No large/fast movements.
• 8. Intubate or side lie if protecting own airway.

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10 COMMANDMENTS CONTD

• 6. Air pocket evaluation, train everyone.
• 7. No large/fast movements.
• 8. Intubate or side lie if protecting own airway.
• 9. Dead is dead, dont risk team/resources.

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10 COMMANDMENTS CONTD

• 6. Air pocket evaluation, train everyone.
• 7. No large/fast movements.
• 8. Intubate or side lie if protecting own airway.
• 9. Dead is dead, dont risk team/resources.
• 10. Hypothermic with air pocket not dead till
  warm and dead (even in arrest).
• In Canada think about trauma

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The Consequences
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The End
www.provinz.bz.it/avalanche
www.ikar-cisa.org www.avalanche.ca
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