Hermann Brugger

European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.

uropean Resuscitation Council Guidelines for Resuscitation 2010 ection 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, oisoning, drowning, accidental hypothermia, hyperthermia, asthma, naphylaxis, cardiac surgery, trauma, pregnancy, electrocution asmeet Soara,∗, Gavin D. Perkinsb, Gamal Abbasc, Annette Alfonzod, Alessandro Barelli e, oost J.L.M. Bierens f, Hermann Bruggerg, Charles D. Deakinh, Joel Dunning i, Marios Georgiouj, nthony J. Handleyk, David J. Lockey l, Peter Paalm, Claudio Sandronin, Karl-Christian Thieso, avid A. Zidemanp, Jerry P. Nolanq

Field management of avalanche victims

The median annual mortality from snow avalanches registered in Europe and North America 1981-1998 was 146 (range 82-226); trend stable in Alpine countries (r=-0.29; P=0.24), increasing in North America (r=0.68; P=0.002). Swiss data over the same period document 1886 avalanche victims, with an overall mortality rate of 52.4% in completely-buried, versus 4.2% in partially-, or non-buried, persons. Survival probability in completely-buried victims in open areas (n=638) plummets from 91% 18 min after burial to 34% at 35 min, then remains fairly constant until a second drop after 90 min. Likewise, survival probability for completely-buried victims in buildings or on roads (n=97) decreases rapidly following burial initially, but as from 35 min it is significantly higher than that for victims in open areas, with a maximum difference in respective survival probability (31% versus 7%) from 130 to 190 min (P<0.001). Standardised guidelines are introduced for the field management of avalanche victims. Strategy by rescuers confronted with the triad hypoxia, hypercapnia and hypothermia is primarily governed by the length of snow burial and victims core temperature, in the absence of obviously fatal injuries. With a burial time < or =35 min survival depends on preventing asphyxia by rapid extrication and immediate airway management; cardiopulmonary resuscitation for unconscious victims without spontaneous respiration. With a burial time >35 min combating hypothermia becomes of paramount importance. Thus, gentle extrication, ECG and core temperature monitoring and body insulation are mandatory; unresponsive victims should be intubated and pulseless victims with core temperature <32 degrees C (89.6 degrees F) (prerequisites being an air pocket and free airways) transported with continuous cardiopulmonary resuscitation to a specialist hospital for extracorporeal re-warming.

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

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

BACKGROUND In North America and Europe ∼150 persons are killed by avalanches every year. METHODS The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) systematically developed evidence-based guidelines and an algorithm for the management of avalanche victims using a worksheet of 27 Population Intervention Comparator Outcome questions. Classification of recommendations and level of evidence are ranked using the American Heart Association system. RESULTS AND CONCLUSIONS If lethal injuries are excluded and the body is not frozen, the rescue strategy is governed by the duration of snow burial and, if not available, by the victims core-temperature. If burial time ≤35 min (or core-temperature ≥32 °C) rapid extrication and standard ALS is important. If burial time >35 min and core-temperature <32 °C, treatment of hypothermia including gentle extrication, full body insulation, ECG and core-temperature monitoring is recommended, and advanced airway management if appropriate. Unresponsive patients presenting with vital signs should be transported to a hospital capable of active external and minimally invasive rewarming such as forced air rewarming. Patients with cardiac instability or in cardiac arrest (with a patent airway) should be transported to a hospital for extracorporeal membrane oxygenation or cardiopulmonary bypass rewarming. Patients in cardiac arrest should receive uninterrupted CPR; with asystole, CPR may be terminated (or withheld) if a patient is lethally injured or completely frozen, the airway is blocked and duration of burial >35 min, serum potassium >12 mmol L(-1), risk to the rescuers is unacceptably high or a valid do-not-resuscitate order exists. Management should include spinal precautions and other trauma care as indicated.

Comparison of avalanche survival patterns in Canada and Switzerland

Background Current recommendations for rescue and resuscitation of people buried in avalanches are based on Swiss avalanche survival data. We analyzed Canadian survival patterns and compared them with those from Switzerland. Methods We extracted relevant data for survivors and nonsurvivors of complete avalanche burials from Oct. 1, 1980, to Sept. 30, 2005, from Canadian and Swiss databases. We calculated survival curves for Canada with and without trauma-related deaths as well as for different outdoor activities and snow climates. We compared these curves with the Swiss survival curve. Results A total of 301 people in the Canadian database and 946 in the Swiss database met the inclusion criteria. The overall proportion of people who survived did not differ significantly between the two countries (46.2% [139/301] v. 46.9% [444/946]; p = 0.87). Significant differences were observed between the overall survival curves for the two countries (p = 0.001): compared with the Swiss curve, the Canadian curve showed a quicker drop at the early stages of burial and poorer survival associated with prolonged burial. The probability of survival fell quicker with trauma-related deaths and in denser snow climates. Poorer survival probabilities in the Canadian sample were offset by significantly quicker extrication (median duration of burial 18 minutes v. 35 minutes in the Swiss sample; p < 0.001). Interpretation Observed differences in avalanche survival curves between the Canadian and Swiss samples were associated with the prevalence of trauma and differences in snow climate. Although avoidance of avalanches remains paramount for survival, the earlier onset of asphyxia, especially in maritime snow climates, emphasizes the importance of prompt extrication, ideally within 10 minutes. Protective devices against trauma and better clinical skills in organized rescue may further improve survival.

Part 3: Adult Basic Life Support and Automated External Defibrillation

This Part of the 2015 International Consensus on Cardiopul monary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) presents the consensus on science and treatment recommendations for adult basic life support (BLS) and automated external defibrillation (AED). After the publication of the 2010 CoSTR, the Adult BLS Task Force developed review questions in PICO (population, intervention, comparator, outcome) format.1 This resulted in the generation of 36 PICO questions for systematic reviews. The task force discussed the topics and then voted to prioritize the most important questions to be tackled in 2015. From the pool of 36 questions, 14 were rated low priority and were deferred from this round of evidence evaluation. Two new questions were submitted by task force members, and 1 was submitted via the public portal. Two of these (BLS 856 and BLS 891) were taken forward for evidence review. The third question (368: Foreign-Body Airway Obstruction) was deferred after a preliminary review of the evidence failed to identify compelling evidence that would alter the treatment recommendations made when the topic was last reviewed in 2005.2 Each task force performed a systematic review using detailed inclusion and exclusion criteria, based on the recommendations of the Institute of Medicine of the National Academies.3 With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). Reviewers were unable to identify any relevant evidence for 3 questions (BLS 811, BLS 373, and BLS 348), and the evidence review was not completed in time for a further question (BLS 370). A revised PICO question was developed for the opioid question (BLS 891). The task force reviewed 23 PICO questions for the …

LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescue-a prospective, randomized, cross-over manikin study.

OBJECTIVE High-quality chest-compressions are of paramount importance for survival and good neurological outcome after cardiac arrest. However, even healthcare professionals have difficulty performing effective chest-compressions, and quality may be further reduced during transport. We compared a mechanical chest-compression device (Lund University Cardiac Assist System [LUCAS]; Jolife, Lund, Sweden) and manual chest-compressions in a simulated cardiopulmonary resuscitation scenario during helicopter rescue. METHODS Twenty-five advanced life support-certified paramedics were enrolled for this prospective, randomized, crossover study. A modified Resusci Anne manikin was employed. Thirty minutes of training was allotted to both LUCAS and manual cardiopulmonary resuscitation (CPR). Thereafter, every candidate performed the same scenario twice, once with LUCAS and once with manual CPR. The primary outcome measure was the percentage of correct chest-compressions relative to total chest-compressions. RESULTS LUCAS compared to manual chest-compressions were more frequently correct (99% vs 59%, P < .001) and were more often performed correctly regarding depth (99% vs 79%, P < .001), pressure point (100% vs 79%, P < .001) and pressure release (100% vs 97%, P = .001). Hands-off time was shorter in the LUCAS than in the manual group (46 vs 130 seconds, P < .001). Time until first defibrillation was longer in the LUCAS group (112 vs 49 seconds, P < .001). CONCLUSIONS During this simulated cardiac arrest scenario in helicopter rescue LUCAS compared to manual chest-compressions increased CPR quality and reduced hands-off time, but prolonged the time interval to the first defibrillation. Further clinical trials are warranted to confirm potential benefits of LUCAS CPR in helicopter rescue.

On-site triage of avalanche victims with asystole by the emergency doctor

Asystole in avalanche victims is generally due to asphyxia and not primarily to hypothermia. Hence, on-site establishment of death by asphyxiation would avoid evacuation risks to the rescue party, as well as high costs of transport to, and treatment at, frequently distant specialist centres in cases with a hopeless prognosis. This paper presents a novel differential diagnosis scheme based on burial duration (critical time 45 min) and core temperature (critical level 32 degrees C) of the person on extrication, as well as the presence or absence of an air pocket, facilitating on-site identification of asphyxiated victims. When information regarding an air pocket is uncertain in victims buried longer than 45 min, determination of serum potassium (critical level 10 mmol/l) at the nearest hospital becomes an alternative criterion for triage. The proposed guidelines aim to clarify field decision-making for the emergency doctor with respect to discontinuation of resuscitation and limitation of transferral for cardiopulmonary bypass core rewarming to those patients with presumptive reversible hypothermia.

Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2014 Update

To provide guidance to clinicians, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations.

Prehospital Resuscitation of the Buried Avalanche Victim

In North America and Europe, approximately 150 people die of avalanches per year, and fatalities are presumed to be many times higher in developing countries. Four factors are decisive for survival: grade of burial, duration of burial, presence of an air pocket and a free airway, and severity of trauma. According to Swiss data, the overall mortality rate with avalanche burial is 23%, but it largely depends on the grade of burial. While the mortality rate is 52.4% in completely buried (head below the snow) victims in the Swiss population, it is only 4.2% in partially buried (head free) victims. Additionally, survival in completely buried victims drops to 30% within the first 35 min, initially due to death from lethal trauma, followed by asphyxia in 20-35 min. Thereafter, survival decreases more gradually and victims who are not fatally injured and are able to breath under the snow slowly succumb to hypoxia, hypercapnia, and hypothermia. In the absence of fatal injuries, rescue strategies depend on the duration of burial and the victims core temperature. With a burial time<35 min, survival depends on preventing asphyxia by rapid extrication, adequate airway management, and cardiopulmonary resuscitation. With a burial time>35 min, tackling hypothermia is of utmost importance. Therefore, gentle extrication and continuous core temperature and electrocardiogram monitoring are recommended. Pulseless victims with a patent airway and a core temperature<32°C should receive uninterrupted cardiopulmonary resuscitation and be transported to a hospital with extracorporeal rewarming facilities.