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Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines
G Model
ARTICLE IN PRESS
RESUS-7041; No. of Pages 2
Resuscitation xxx (2017) xxx.e1–xxx.e2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines Sir, In 2014, the International Commission of Mountain Emergency Medicine (ICAR MEDCOM) has developed and published the Avalanche Victim Resuscitation Checklist (AVRC) for the out-of-
hospital management of avalanche victims.1 In 2015, the European Resuscitation Council (ERC) Resuscitation guidelines included for the first time an algorithm for the treatment of avalanche victims.2 To be consistent with the new ERC guidelines which include some substantial modifications, the AVRC has been updated and approved by ICAR MEDCOM in Borovets, Bulgaria, in fall 2016 (Fig. 1, Supplementary Fig. S1 in the online version, at DOI: 10.1016/ j.resuscitation.2017.01.008).
Fig. 1. Avalanche Victim Resuscitation Checklist. The white section is addressed to a Basic Life Support trained first responder, the red section to an Advanced Life Support trained health care provider. Patient ID = Patient Identity; CPR = Cardiopulmonary Resuscitation; BLS = Basic Life Support; ALS = Advanced Life Support; ECLS = Extracorporeal Life Support (Cardiopulmonary Bypass/Extracorporeal Membrane Oxygenation). (a) Time between burial and uncovering the face. (b) If duration of burial is unknown, core temperature using an esophageal probe may substitute in patients in cardiac arrest. (c) CPR can be withheld if unacceptable level of risk for the rescuer, total body frozen or obvious lethal trauma (decapitation, truncal transection). (d) If K+ at hospital admission exceeds 8 mmol l−1 consider terminating resuscitation (after excluding crush injuries and consideration of the use of depolarizing paralytics). Patients who present with cardiac instability (ventricular arrhythmias, systolic blood pressure <90 mmHg) or core temperature <30 ◦ C should be transported towards hospital with ECLS rewarming possibility. http://dx.doi.org/10.1016/j.resuscitation.2017.01.008 0300-9572/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Kottmann A, et al. Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines. Resuscitation (2017), http://dx.doi.org/10.1016/j.resuscitation.2017.01.008
G Model RESUS-7041; No. of Pages 2 xxx.e2
ARTICLE IN PRESS Letter to the Editor / Resuscitation xxx (2017) xxx.e1–xxx.e2
The main adjustments made to the AVRC concern the adaption of the cutoffs proposed by the ERC guidelines 2015, which have been revised as follows: 30 ◦ C for the core temperature threshold below which a hypothermic cardiac arrest may occur and 60 min for the respective threshold for the duration of complete burial above which a hypothermic cardiac arrest may occur; and 8 mmol/l for the serum potassium level above which survival from avalanche burial is considered unlikely. We also took the opportunity to make some improvements in the AVRC. First, we modified the order of the triage boxes “ECG”, “Airway Patent” and “Core Temperature”. Prioritisation of the ECG monitoring will allow the emergency medical personnel to detect patients with pulseless electric activity as early as possible (ideally during extrication and before removal) to monitor a possible Peri Rescue Collapse, which is increasingly recognized as a positive predictive value.3,4 Further on, it has been highlighted that core temperature should be measured immediately after extrication with every avalanche victim in cardiac arrest. Core temperature is of utmost importance, regardless of the duration of burial (cooling rate after extrication can be much higher than in the snow). In special circumstances, a high cooling rate of 9.4 ◦ C/h has been reported, so that a temperature <30 ◦ C may be reached in 60 min.5 These modifications are intended to make the AVRC more realistic and practicable in the field. The use of the AVRC is increasing worldwide among avalanche rescuers and the first feedbacks are encouraging. Preliminary (unpublished) data suggest that the use of the AVRC increases the adherence to the ERC guidelines as well as the information transfer from the accident site to the hospital. The new AVRC 2015 has been translated in numerous languages which are free for download along with a teaching presentation on the ICAR webpage (http://www.alpine-rescue.org/xCMS5/WebObjects/nexus5. woa/wa/icar?menuid=1066&rubricid=243&articleid=11284). Conflict of interest statement All authors declare no financial or personal conflict of interest. Acknowledgments To all ICAR MEDCOM members who participated in the project. References
2. Truhlar A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 4. Cardiac arrest in special circumstances. Resuscitation 2015, http://dx.doi.org/10.1016/j.resuscitation.2015.07.017. 3. Boue Y, Payen JF, Brun J, et al. Survival after avalanche-induced cardiac arrest. Resuscitation 2014;85:1192–6, http://dx.doi.org/10.1016/j.resuscitation. 2014.06.015. 4. Pasquier M, Blancher M, Zen Ruffinen G, Hugli O. Does rescue collapse mandate a paradigm shift in the field management of avalanche victims? High Alt Med Biol 2015;16:171–2, http://dx.doi.org/10.1089/ham.2015.0012. 5. Pasquier M, Moix PA, Delay D, Hugli O. Cooling rate of 9.4 degrees C in an hour in an avalanche victim. Resuscitation 2015;93:e17–8, http://dx.doi.org/10.1016/ j.resuscitation.2015.05.009.
Alexandre Kottmann a,b,c,d,e,∗ Swiss Air Ambulance Rega, Switzerland b Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Switzerland c Emergency Service, University Centre Hospital, Lausanne, Switzerland d Swiss Society for Mountain Medicine, Switzerland e International Commission for Mountain Emergency Medicine ICAR MEDCOM a
Marc Blancher a,b,c Emergency Department, University Hospital of Grenoble, France b French Mountain Rescue Association ANMSM, France c International Commission for Mountain Emergency Medicine ICAR MEDCOM a
Mathieu Pasquier a,b Emergency Service, University Centre Hospital, Lausanne, Switzerland b International Commission for Mountain Emergency Medicine ICAR MEDCOM a
Hermann Brugger a,b EURAC Institute of Mountain Emergency Medicine, Italy b International Commission for Mountain Emergency Medicine ICAR MEDCOM a
∗ Corresponding
author at: Rega, Swiss Air Ambulance, Departement Medizin, P.O. Box 1414, CH - 8058 Zurich Airport, Switzerland. 29 December 2016
1. Kottmann A, Blancher M, Spichiger T, et al. The Avalanche Victim Resuscitation Checklist, a new concept for the management of avalanche victims. Resuscitation 2015;91:e7–8, http://dx.doi.org/10.1016/j.resuscitation.2015.03.009.
Please cite this article in press as: Kottmann A, et al. Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines. Resuscitation (2017), http://dx.doi.org/10.1016/j.resuscitation.2017.01.008
ARTICLE IN PRESS
RESUS-7041; No. of Pages 2
Resuscitation xxx (2017) xxx.e1–xxx.e2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines Sir, In 2014, the International Commission of Mountain Emergency Medicine (ICAR MEDCOM) has developed and published the Avalanche Victim Resuscitation Checklist (AVRC) for the out-of-
hospital management of avalanche victims.1 In 2015, the European Resuscitation Council (ERC) Resuscitation guidelines included for the first time an algorithm for the treatment of avalanche victims.2 To be consistent with the new ERC guidelines which include some substantial modifications, the AVRC has been updated and approved by ICAR MEDCOM in Borovets, Bulgaria, in fall 2016 (Fig. 1, Supplementary Fig. S1 in the online version, at DOI: 10.1016/ j.resuscitation.2017.01.008).
Fig. 1. Avalanche Victim Resuscitation Checklist. The white section is addressed to a Basic Life Support trained first responder, the red section to an Advanced Life Support trained health care provider. Patient ID = Patient Identity; CPR = Cardiopulmonary Resuscitation; BLS = Basic Life Support; ALS = Advanced Life Support; ECLS = Extracorporeal Life Support (Cardiopulmonary Bypass/Extracorporeal Membrane Oxygenation). (a) Time between burial and uncovering the face. (b) If duration of burial is unknown, core temperature using an esophageal probe may substitute in patients in cardiac arrest. (c) CPR can be withheld if unacceptable level of risk for the rescuer, total body frozen or obvious lethal trauma (decapitation, truncal transection). (d) If K+ at hospital admission exceeds 8 mmol l−1 consider terminating resuscitation (after excluding crush injuries and consideration of the use of depolarizing paralytics). Patients who present with cardiac instability (ventricular arrhythmias, systolic blood pressure <90 mmHg) or core temperature <30 ◦ C should be transported towards hospital with ECLS rewarming possibility. http://dx.doi.org/10.1016/j.resuscitation.2017.01.008 0300-9572/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Kottmann A, et al. Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines. Resuscitation (2017), http://dx.doi.org/10.1016/j.resuscitation.2017.01.008
G Model RESUS-7041; No. of Pages 2 xxx.e2
ARTICLE IN PRESS Letter to the Editor / Resuscitation xxx (2017) xxx.e1–xxx.e2
The main adjustments made to the AVRC concern the adaption of the cutoffs proposed by the ERC guidelines 2015, which have been revised as follows: 30 ◦ C for the core temperature threshold below which a hypothermic cardiac arrest may occur and 60 min for the respective threshold for the duration of complete burial above which a hypothermic cardiac arrest may occur; and 8 mmol/l for the serum potassium level above which survival from avalanche burial is considered unlikely. We also took the opportunity to make some improvements in the AVRC. First, we modified the order of the triage boxes “ECG”, “Airway Patent” and “Core Temperature”. Prioritisation of the ECG monitoring will allow the emergency medical personnel to detect patients with pulseless electric activity as early as possible (ideally during extrication and before removal) to monitor a possible Peri Rescue Collapse, which is increasingly recognized as a positive predictive value.3,4 Further on, it has been highlighted that core temperature should be measured immediately after extrication with every avalanche victim in cardiac arrest. Core temperature is of utmost importance, regardless of the duration of burial (cooling rate after extrication can be much higher than in the snow). In special circumstances, a high cooling rate of 9.4 ◦ C/h has been reported, so that a temperature <30 ◦ C may be reached in 60 min.5 These modifications are intended to make the AVRC more realistic and practicable in the field. The use of the AVRC is increasing worldwide among avalanche rescuers and the first feedbacks are encouraging. Preliminary (unpublished) data suggest that the use of the AVRC increases the adherence to the ERC guidelines as well as the information transfer from the accident site to the hospital. The new AVRC 2015 has been translated in numerous languages which are free for download along with a teaching presentation on the ICAR webpage (http://www.alpine-rescue.org/xCMS5/WebObjects/nexus5. woa/wa/icar?menuid=1066&rubricid=243&articleid=11284). Conflict of interest statement All authors declare no financial or personal conflict of interest. Acknowledgments To all ICAR MEDCOM members who participated in the project. References
2. Truhlar A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 4. Cardiac arrest in special circumstances. Resuscitation 2015, http://dx.doi.org/10.1016/j.resuscitation.2015.07.017. 3. Boue Y, Payen JF, Brun J, et al. Survival after avalanche-induced cardiac arrest. Resuscitation 2014;85:1192–6, http://dx.doi.org/10.1016/j.resuscitation. 2014.06.015. 4. Pasquier M, Blancher M, Zen Ruffinen G, Hugli O. Does rescue collapse mandate a paradigm shift in the field management of avalanche victims? High Alt Med Biol 2015;16:171–2, http://dx.doi.org/10.1089/ham.2015.0012. 5. Pasquier M, Moix PA, Delay D, Hugli O. Cooling rate of 9.4 degrees C in an hour in an avalanche victim. Resuscitation 2015;93:e17–8, http://dx.doi.org/10.1016/ j.resuscitation.2015.05.009.
Alexandre Kottmann a,b,c,d,e,∗ Swiss Air Ambulance Rega, Switzerland b Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Switzerland c Emergency Service, University Centre Hospital, Lausanne, Switzerland d Swiss Society for Mountain Medicine, Switzerland e International Commission for Mountain Emergency Medicine ICAR MEDCOM a
Marc Blancher a,b,c Emergency Department, University Hospital of Grenoble, France b French Mountain Rescue Association ANMSM, France c International Commission for Mountain Emergency Medicine ICAR MEDCOM a
Mathieu Pasquier a,b Emergency Service, University Centre Hospital, Lausanne, Switzerland b International Commission for Mountain Emergency Medicine ICAR MEDCOM a
Hermann Brugger a,b EURAC Institute of Mountain Emergency Medicine, Italy b International Commission for Mountain Emergency Medicine ICAR MEDCOM a
∗ Corresponding
author at: Rega, Swiss Air Ambulance, Departement Medizin, P.O. Box 1414, CH - 8058 Zurich Airport, Switzerland. 29 December 2016
1. Kottmann A, Blancher M, Spichiger T, et al. The Avalanche Victim Resuscitation Checklist, a new concept for the management of avalanche victims. Resuscitation 2015;91:e7–8, http://dx.doi.org/10.1016/j.resuscitation.2015.03.009.
Please cite this article in press as: Kottmann A, et al. Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines. Resuscitation (2017), http://dx.doi.org/10.1016/j.resuscitation.2017.01.008