Colin Grissom, M.D. "New Hope For Surviving the Avalanche"
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9
extricated. If endotracheal intubation is required for the unconscious apneic patient not
yet fully extricated from snow burial then the inverse intubation technique
20
may be
required. In this technique the laryngoscope is held in the right hand while straddling the
patient's body and facing the head and face. The laryngoscope blade is inserted so as to
visualize the larynx and cords by leaning over the patient's head, and then the
endotracheal tube is passed through the cords with the left hand.
After an adequate airway and breathing are established and supplemental oxygen
provided, the circulation is assessed. The conscious patient is assumed to have a
perfusing rhythm, and further treatment is directed at treating mild hypothermia and
traumatic injuries. If the patient is found unconscious but has a pulse, they may have
moderate or severe hypothermia and should be handled gently to avoid precipitating
ventricular fibrillation (VF). In addition to the treatment of hypothermia described below,
medical treatment of the unconscious avalanche burial victim with a pulse is focused on
ensuring adequate oxygenation and ventilation, either non-invasively with a bag-valve-
mask device or by endotracheal intubation if clinically indicated, and immobilizing the
spinal column for transport and treating any obvious signs of trauma. Intravenous access
may be obtained and warmed isotonic fluids infused.
If a pulse is not present after opening the airway and ventilating the patient then
cardiopulmonary resuscitation (CPR) is begun. Before CPR is initiated, however, careful
evaluation for the presence of a pulse should occur. Avalanche burial victims are
hypothermic which causes peripheral vasoconstriction making the pulse difficult to
palpate. In addition, moderate to severe hypothermia causes depression of respiration and
bradycardia. Before initiating CPR, palpation for a pulse should be done for a period of
30 to 45 seconds after the airway is opened and assisted ventilations are begun. Severe
hypothermia makes the pulse difficult to detect, and CPR initiated on a severely
hypothermic patient who actually has a perfusing rhythm may cause VF. If
electrocardiographic monitoring is available then the cardiac rhythm is assessed, or
alternatively an automatic external defibrillator may be applied. If the rhythm is VF then
up to three defibrillations are attempted in the moderate or severely hypothermic patient
with a core body temperature less than 30 ° C
1
. If these are unsuccessful then further
attempts at defibrillation are done only after rewarming. Drugs usually administered as
part of advanced cardiac life support (ACLS) are not effective below core body
temperatures of about 30 ° C, and may accumulate to toxic levels with a rebound effect as
rewarming occurs
1
. If the patient is hypothermic but has a core body temperature greater
than 30 ° C, then the standard ACLS protocol is followed with longer intervals between
administration of drugs.
The likelihood of successful resuscitation of an avalanche burial victim who is in
cardiac arrest at the time of extrication depends on whether cardiac arrest occurred from
asphyxiation or from hypothermia. In burials of less than one hour with a core body
temperature of greater than 30 ° C resuscitation is unlikely to be successful because death
has most likely occurred from asphyxiation. Avalanche victims extricated from burials of
greater than one hour who have no signs of life, but who are severely hypothermic (core
temperature < 30 ° C) and have an air pocket for breathing, may be considered for
transport to a medical facility with capability for extracorporeal rewarming (Figure 5). It
may be difficult to determine if an air pocket for breathing is present as an avalanche
burial victim is extricated, in which case an air pocket is assumed to have been present
