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The Avalanche Victim Resuscitation Checklist, a new concept for the management of avalanche victims
Resuscitation 91 (2015) e7–e8
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor The Avalanche Victim Resuscitation Checklist, a new concept for the management of avalanche victims Sir, The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) established official consensus guidelines on the onsite treatment of avalanche victims in 2002 and 2013.1 These aim to inform basic and advanced life support providers of the best evidence-based management, as selected severely hypothermic victims in cardiac arrest can survive with a good neurologic outcome even after several hours of burial.2 Key parameters for an avalanche victim in cardiac arrest are duration of burial, airway patency, core temperature and the initial ECG rhythm.3 However a recent study in the European Alps showed poor adherence with the ICAR MEDCOM guidelines for avalanche
victims with out-of-hospital cardiac arrest (OHCA) in the period 1987–2009.4 Data of key parameters were incomplete, overall survival was very low, and initiation of CPR was lower than expected for patients with long burials and patent airways. The reasons to initiate or withhold resuscitation remained unclear in the majority of cases. Deficiencies in awareness of the guidelines by bystanders, first responders and hospital personnel, and the transfer of essential information from the accident site to hospital may have been partially responsible for the poor outcome. Although existing management guidelines are simple, utilizing the theoretical knowledge and making the right decisions can be very challenging in the stressful environment of an avalanche where major decisions, such as starting or withholding resuscitation, are being taken. Furthermore, it is to be expected that as the number of victims in the avalanche increases the more difficult it is to maintain adherence to guidelines both for BLS and ALS providers. Information collection and onward flow to the hospital
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; ALS = Advanced Life Support; ECLS = extracorporeal life support (cardiopulmonary bypass/extracorporeal membrane oxygenation). * Time between burial and uncovering the face; ** if duration of burial is unknown, core temperature may be substituted using esophageal or epitympanic (thermistor-based sensor) temperature; *** patients who present with cardiac instability (ventricular arrhythmias, systolic blood pressure <90 mmHg) or core temperature <28 ◦ C should be transported towards hospital with ECLS rewarming possibility; **** if K+ at hospital admission exceeds 12 mmol L−1 consider stopping resuscitation (after excluding crush injuries an consideration of the use of depolarising paralytics); in an adult with K+ = 8–12 mmol L−1 and other factors consistent with non-survival, termination of resuscitation should be considered. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.) http://dx.doi.org/10.1016/j.resuscitation.2015.03.009 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
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Letter to the Editor / Resuscitation 91 (2015) e7–e8
are also likely to deteriorate as, in Crew Resource Terms, ‘chaos’ replaces ‘order’. This is especially true in a mass casualty incident. The checklist concept has been promoted by the World Health Organization since 2008, and has received much attention due to its potential to improve quality of patient care.5 We used this concept to create an Avalanche Victim Resuscitation Checklist (Figs. 1, S1 and S2). It is based on the best available evidence and the standards required of medical checklists.3,4 Together with standardized teaching material, the checklist was approved by the ICAR MEDCOM in 2013. It is a practical tool, designed to improve adherence to guidelines and the transfer of information from accident site to and through the hospital phases. The correct use of the checklist is described in the supplementary file (S3), an AudioSlide presentation and a teaching presentation (LINK). The working group emphasizes that classroom training and simulations in the field by organized rescue teams are fundamental for the correct and efficient use. As a new concept for the management of avalanche victims, we plan to do validation studies to assess its impact on survival and on appropriate resuscitation decisions including reducing futile resuscitation attempts. Data collected will be available for further studies on management of avalanche victims. 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 and to Emily Procter for editing. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.resuscitation.2015.03.009. References
d
International Commission for Mountain Emergency Medicine ICAR MEDCOM, Switzerland
Marc Blancher a,b,c Emergency Department, University Hospital of Grenoble, boulevard de la chantourne, BP 217, 38043 Grenoble Cedex 9, France b French Mountain Rescue Association ANMSM, France c International Commission for Mountain Emergency Medicine ICAR MEDCOM, France a
Thierry Spichiger Swiss Air Ambulance Rega, Swiss Alpine Rescue, P.O. Box 1414, CH-8058 Zurich Airport, Switzerland Fidel Elsensohn International Commission for Mountain Emergency Medicine ICAR MEDCOM, Schloesslestrasse 36, Roethis A-6832, Austria a
Dominique Létang a,b Association Nationale pour l’Étude de la Neige et des Avalanches ANENA, 15, rue Ernest Calvat, Grenoble F-38000, France b ICAR Avalanche Commission, France
Jeff Boyd a,b,c International Commission for Mountain Emergency Medicine ICAR MEDCOM, Canada b International Federation of Mountain Guides, Switzerland c Department of Emergency Medicine, Mineral Springs Hospital, Box 400, Bow Avenue, Banff, AB T1L 1A5, Canada a
Giacomo Strapazzon a,b EURAC Institute of Mountain Emergency Medicine, Drususallee 1, I-39100 Bozen/Bolzano, Italy b International Commission for Mountain Emergency Medicine ICAR MEDCOM, Italy a
John Ellerton a,b International Commission for Mountain Emergency Medicine ICAR MEDCOM, United Kingdom b Birbeck Medical Group, Penrith, Cumbria CA10 3AZ, United Kingdom a
1. Brugger H, Durrer B, Elsensohn F, et al. Resuscitation of avalanche victims: evidence-based guidelines of the international commission for mountain emergency medicine (ICAR MEDCOM): intended for physicians and other advanced life support personnel. Resuscitation 2013;84:539–46. 2. Boué Y, Payen JF, Torres JP, Blancher M, Bouzat P. Full neurologic recovery after prolonged avalanche burial and cardiac arrest. High Alt Med Biol 2014;15:522–3. 3. Boyd J, Brugger H, Shuster M. Prognostic factors in avalanche resuscitation: a systematic review. Resuscitation 2010;81:645–52. 4. Strapazzon G, Plankensteiner J, Mair P, Ruttmann E, Brugger H. Triage and survival of avalanche victims with out-of-hospital cardiac arrest in Austria between 1987 and 2009. Resuscitation 2012;83:e81. 5. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9.
Kottmann a,b,c,d,∗
Alexandre Swiss Air Ambulance Rega, P.O. Box 1414, CH-8058 Zurich Airport, Switzerland b Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Switzerland c Swiss Society for Mountain Medicine, Switzerland
a
Hermann Brugger a,b EURAC Institute of Mountain Emergency Medicine, Drususallee 1, Bozen/Bolzano I-39100, Italy b International Commission for Mountain Emergency Medicine ICAR MEDCOM, Italy a
∗ Corresponding author at: Rega, Swiss Air Ambulance, Departement Medizin, P.O. Box 1414, CH-8058 Zurich Airport, Switzerland. E-mail address: [email protected] (A. Kottmann)
31 December 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor The Avalanche Victim Resuscitation Checklist, a new concept for the management of avalanche victims Sir, The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) established official consensus guidelines on the onsite treatment of avalanche victims in 2002 and 2013.1 These aim to inform basic and advanced life support providers of the best evidence-based management, as selected severely hypothermic victims in cardiac arrest can survive with a good neurologic outcome even after several hours of burial.2 Key parameters for an avalanche victim in cardiac arrest are duration of burial, airway patency, core temperature and the initial ECG rhythm.3 However a recent study in the European Alps showed poor adherence with the ICAR MEDCOM guidelines for avalanche
victims with out-of-hospital cardiac arrest (OHCA) in the period 1987–2009.4 Data of key parameters were incomplete, overall survival was very low, and initiation of CPR was lower than expected for patients with long burials and patent airways. The reasons to initiate or withhold resuscitation remained unclear in the majority of cases. Deficiencies in awareness of the guidelines by bystanders, first responders and hospital personnel, and the transfer of essential information from the accident site to hospital may have been partially responsible for the poor outcome. Although existing management guidelines are simple, utilizing the theoretical knowledge and making the right decisions can be very challenging in the stressful environment of an avalanche where major decisions, such as starting or withholding resuscitation, are being taken. Furthermore, it is to be expected that as the number of victims in the avalanche increases the more difficult it is to maintain adherence to guidelines both for BLS and ALS providers. Information collection and onward flow to the hospital
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; ALS = Advanced Life Support; ECLS = extracorporeal life support (cardiopulmonary bypass/extracorporeal membrane oxygenation). * Time between burial and uncovering the face; ** if duration of burial is unknown, core temperature may be substituted using esophageal or epitympanic (thermistor-based sensor) temperature; *** patients who present with cardiac instability (ventricular arrhythmias, systolic blood pressure <90 mmHg) or core temperature <28 ◦ C should be transported towards hospital with ECLS rewarming possibility; **** if K+ at hospital admission exceeds 12 mmol L−1 consider stopping resuscitation (after excluding crush injuries an consideration of the use of depolarising paralytics); in an adult with K+ = 8–12 mmol L−1 and other factors consistent with non-survival, termination of resuscitation should be considered. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.) http://dx.doi.org/10.1016/j.resuscitation.2015.03.009 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
e8
Letter to the Editor / Resuscitation 91 (2015) e7–e8
are also likely to deteriorate as, in Crew Resource Terms, ‘chaos’ replaces ‘order’. This is especially true in a mass casualty incident. The checklist concept has been promoted by the World Health Organization since 2008, and has received much attention due to its potential to improve quality of patient care.5 We used this concept to create an Avalanche Victim Resuscitation Checklist (Figs. 1, S1 and S2). It is based on the best available evidence and the standards required of medical checklists.3,4 Together with standardized teaching material, the checklist was approved by the ICAR MEDCOM in 2013. It is a practical tool, designed to improve adherence to guidelines and the transfer of information from accident site to and through the hospital phases. The correct use of the checklist is described in the supplementary file (S3), an AudioSlide presentation and a teaching presentation (LINK). The working group emphasizes that classroom training and simulations in the field by organized rescue teams are fundamental for the correct and efficient use. As a new concept for the management of avalanche victims, we plan to do validation studies to assess its impact on survival and on appropriate resuscitation decisions including reducing futile resuscitation attempts. Data collected will be available for further studies on management of avalanche victims. 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 and to Emily Procter for editing. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.resuscitation.2015.03.009. References
d
International Commission for Mountain Emergency Medicine ICAR MEDCOM, Switzerland
Marc Blancher a,b,c Emergency Department, University Hospital of Grenoble, boulevard de la chantourne, BP 217, 38043 Grenoble Cedex 9, France b French Mountain Rescue Association ANMSM, France c International Commission for Mountain Emergency Medicine ICAR MEDCOM, France a
Thierry Spichiger Swiss Air Ambulance Rega, Swiss Alpine Rescue, P.O. Box 1414, CH-8058 Zurich Airport, Switzerland Fidel Elsensohn International Commission for Mountain Emergency Medicine ICAR MEDCOM, Schloesslestrasse 36, Roethis A-6832, Austria a
Dominique Létang a,b Association Nationale pour l’Étude de la Neige et des Avalanches ANENA, 15, rue Ernest Calvat, Grenoble F-38000, France b ICAR Avalanche Commission, France
Jeff Boyd a,b,c International Commission for Mountain Emergency Medicine ICAR MEDCOM, Canada b International Federation of Mountain Guides, Switzerland c Department of Emergency Medicine, Mineral Springs Hospital, Box 400, Bow Avenue, Banff, AB T1L 1A5, Canada a
Giacomo Strapazzon a,b EURAC Institute of Mountain Emergency Medicine, Drususallee 1, I-39100 Bozen/Bolzano, Italy b International Commission for Mountain Emergency Medicine ICAR MEDCOM, Italy a
John Ellerton a,b International Commission for Mountain Emergency Medicine ICAR MEDCOM, United Kingdom b Birbeck Medical Group, Penrith, Cumbria CA10 3AZ, United Kingdom a
1. Brugger H, Durrer B, Elsensohn F, et al. Resuscitation of avalanche victims: evidence-based guidelines of the international commission for mountain emergency medicine (ICAR MEDCOM): intended for physicians and other advanced life support personnel. Resuscitation 2013;84:539–46. 2. Boué Y, Payen JF, Torres JP, Blancher M, Bouzat P. Full neurologic recovery after prolonged avalanche burial and cardiac arrest. High Alt Med Biol 2014;15:522–3. 3. Boyd J, Brugger H, Shuster M. Prognostic factors in avalanche resuscitation: a systematic review. Resuscitation 2010;81:645–52. 4. Strapazzon G, Plankensteiner J, Mair P, Ruttmann E, Brugger H. Triage and survival of avalanche victims with out-of-hospital cardiac arrest in Austria between 1987 and 2009. Resuscitation 2012;83:e81. 5. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9.
Kottmann a,b,c,d,∗
Alexandre Swiss Air Ambulance Rega, P.O. Box 1414, CH-8058 Zurich Airport, Switzerland b Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Switzerland c Swiss Society for Mountain Medicine, Switzerland
a
Hermann Brugger a,b EURAC Institute of Mountain Emergency Medicine, Drususallee 1, Bozen/Bolzano I-39100, Italy b International Commission for Mountain Emergency Medicine ICAR MEDCOM, Italy a
∗ Corresponding author at: Rega, Swiss Air Ambulance, Departement Medizin, P.O. Box 1414, CH-8058 Zurich Airport, Switzerland. E-mail address: [email protected] (A. Kottmann)
31 December 2014