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

Survival of hypothermic avalanche victims with cardiac arrest is rare. This report describes full recovery of a 29-year-old backcountry skier completely buried for 100 min at 3.0m (9.8 ft) depth. On extrication he was unconscious, but breathing spontaneously into an air pocket; core body temperature measured 22.0 degrees C (71.6 degrees F). He was intubated and ventilated on site. Ventricular fibrillation commenced during helicopter transportation, whereby chest compression was lacking for 15 min. At the nearest hospital continuous cardiopulmonary resuscitation was initiated, but defibrillation failed. Tympanic core body temperature measurement confirmed life-threatening hypothermia of 21.7 degrees C (71.1 degrees F) and serum K(+) was 4.3 mmol/l, necessitating transferral to a hospital with cardiopulmonary bypass facilities. Defibrillation finally succeeded following re-warming, by femoral veno-arterial bypass, to 34.5 degrees C (94.1 degrees F). Total duration of cardiac arrest was 150 min. The patient developed pulmonary oedema, treated by extracorporeal membrane oxygenation, but progressed well and was discharged from hospital on day 17, fit to resume professional and social activities. Follow-up cerebral magnetic resonance imaging 2 years after avalanche burial demonstrated only minimal changes attributable to unrelated, prior cranial trauma. Extensive neurological and psychological investigations gave excellent results. This report confirms previous literature that an air pocket with patent airways is essential for survival of a completely buried avalanche victim after 35 min and endorses the recommended management strategies of the International Commission for Mountain Emergency Medicine ICAR MEDCOM. In particular, all hypothermic victims extricated with an air pocket and free airways must be treated optimistically, even despite prolonged cardiac arrest. This remarkable case documents the fastest drop in core temperature ever recorded during snow burial, namely 9.0 degrees C (16.2 degrees F)/h, and the second-lowest reversible core temperature in avalanche literature.

Hypoxia and hypercapnia during respiration into an artificial air pocket in snow: implications for avalanche survival.

Snow avalanche case reports have documented the survival of skiers apparently without permanent hypoxic sequelae, after prolonged complete burial despite there being only a small air pocket on extrication. We investigated the underlying pathophysiological changes in a prospective, randomised 2 x 2 crossover study in 12 volunteers (28 tests) breathing into an artificial air pocket (1- or 2-l volume) in snow. Peripheral SpO(2), ETCO(2), arterialised capillary blood variables, air pocket O(2) and CO(2), snow density, and snow conditions at the inner surface of the air pocket were determined. SpO(2) decreased from a median of 99% (93-100%) to 88% (71-94%; P<0.001) within 4 min of breathing into the air pocket; the reduction was greater at 1 l, than 2 l, volume air pocket (P=0.013, intention to treat P=0.003) and correlated to snow density (r=0.50, P=0.021, partial correlation coefficient). ETCO(2) rose simultaneously from median 5.07 kPa (3.47-6.93 kPa) to 6.8 kPa (5.87-8.27 kPa; P<0.001), with consequent respiratory acidosis. Despite premature interruption due to hypoxia (SpO(2)