Joined: 07 Dec 2004 Posts: 4074 Location: 1608 folio
Posted: Thu Nov 17, 2005 5:53 am Post subject:
skinnyskier wrote:
Maybe fifteen percent of avalanche victims die from trauma. Most of the rest are asphyxiated over 15-35 minutes of burial.
I've seen some data that puts the number in the 20-30% range.
I've found the pulling/snowclaw motion more efficent than the ditch digger throw, especially on inclined slopes. On a slope it's best to remember the easiest/most efficent means of excavation can be sideways, not vertical, and your beacon will show mark the closest distance to the victim, which isn't always up and down.
Joined: 07 Dec 2004 Posts: 1530 Location: after 17 years, 5 months to the day, home again
Posted: Thu Nov 17, 2005 1:14 pm Post subject:
skinnyskier wrote:
If advanced life support isn't at the scene by about ninety minutes after burial you can quit CPR
So am I to understand that there is a belief that if ALS is applied to a burial victim up to an hour and half after the event that there is a chance of successful resuscitation?
I'm all about giving my fellow human a fighting chance but I can't imagine rolling up on a burial recovery 40-80 minutes post event and expect to make a difference with ALS. The patient's body would be hypothermic, possibly hypovolemic due to internal bleeding, acidotic, and poorly ventilated at best. Gastric distention would be out of control, aspiration just about a given. A cold heart is resistant to electrical intervention and the chance of finding IV access would be extremely difficult outside of maybe finding an external jugular access point or intraosseous. Neither of which I would be crazy about if we're still facing the issue of evacuation off the mountain side.
Or am I taking things out of context and it's expected that the first hour or so has been consumed with evacing the patient to an ambulance where we can start rewarming, more postive control of an airway, warmed oxygen and such?
Please tell me my lack of experience in dealing with avy victims is showing through. I would love to hear that there is anecdotal evidence that what I expect to find is not really the case at all.
Am I getting too clinical? Sorry if that's the case...I'm just trying to learn.
Steve _________________ "Those who look outward dream; those who look inward awaken..." - Carl Jung
Fat Boy Mountaineering Club. Take nothing but whippers, leave nothing but craters.
I've never cared for an avalanche victim, so my opinions are based mostly on reading the medical literature but also on what I learned in my Wilderness EMT course, work experience from my years as a paramedic/firefighter and my new life as a cardiologist. Your mileage may vary.
If you look at the Swiss data on survival according to burial time for 1981-1991, there are two inflection points. Survival drops from 91% at 18 minutes to 34% at 35 minutes. This represents acute asphyxiation of victims without an air pocket. The curve then flattens between 35 and 90 minutes representing a "latent" phase for victims buried with an air pocket. Finally, survival drops to only 7% at 130 minutes, which probably reflects death of victims with a closed air pocket from slow asphyxia and hypothermia.
The Swiss view seems to be that a slow, gentle extrication after 35 minutes is mandatory. They show 1/3 to 1/5 survivors in that 35-90 minute range. So I think it's worth trying to resuscitate this group.
Some of them will be unconscious from profound hypothermia but breathing, and need to be intubated before they can get flown out. The group that is pulseless and even more hypothermic would be much harder to resuscitate. I'm sure things like getting ecg electrodes to stick, getting ivs, intubating in a snowfield, etc would be very hard to do.
Joined: 07 Dec 2004 Posts: 1530 Location: after 17 years, 5 months to the day, home again
Posted: Thu Nov 17, 2005 6:00 pm Post subject:
Fair enough. I got my eyes crossed and thought there was advocation for ALS up to 90 minutes after BLS was started. What I think I understand is that you are advocating that any patient removed from a burial lasting up to 90 minutes and unresponsive should be given the benefit of doubt to the greatest degree. If the patient is uncovered after 90 minutes and they are showing no signs of life then studies show that return of self sustained vitals signs is improbable even with ALS intervention.
Realizing of coure that every scenerio will have it's own conditions to factor in, including the rescuers themselves. It would not be fair to the people working so hard to recover the victim to not try at least one or two rounds of ALS, just to give things one last chance.
Such a difficult situation. Hope I am never there.
Steve _________________ "Those who look outward dream; those who look inward awaken..." - Carl Jung
Fat Boy Mountaineering Club. Take nothing but whippers, leave nothing but craters.
Joined: 24 Apr 2005 Posts: 3551 Location: Parked out back
Posted: Thu Nov 17, 2005 7:28 pm Post subject:
skinnyskier wrote:
credentials which I snipped: Your mileage may vary.
If you look at the Swiss data on survival according to burial time for 1981-1991, there are two inflection points. Survival drops from 91% at 18 minutes to 34% at 35 minutes. This represents acute asphyxiation of victims without an air pocket. The curve then flattens between 35 and 90 minutes representing a "latent" phase for victims buried with an air pocket. Finally, survival drops to only 7% at 130 minutes, which probably reflects death of victims with a closed air pocket from slow asphyxia and hypothermia.
The Swiss view seems to be that a slow, gentle extrication after 35 minutes is mandatory. They show 1/3 to 1/5 survivors in that 35-90 minute range. So I think it's worth trying to resuscitate this group.
having resuscitated more than a few hypothermic people, occasionally successfully even IAWTP. Hypothermic heart muscle is very irritable. It doesn't generate electrical impulses well, it doesn't conduct electricity well and is subject to evil rhythms without the benefit of being amenable to drugs and shock, since being hypothermic its refactory to our interventions. The bottom line is to treat these people very gently. Just moving someone can precipitate a malignant, and untreatable therefore fatal rhythm, btdt. Yes dig them out. Yes do cpr, yes feel for a pulse and if you can't feel it do chest compressions. Don't break ribs or the sternum, one only has to compress the chest a bit to produce some perfusion. Do rescue breathing, use a shield and if you don't have one do it anyway. Don't dither over it. Do it. ABC, airway breathing circulation. Reassess, keep it up.
Some of the more useful articles about avalanche fatalities are listed below. Or you can put avalanche death into the seach box in pubmed to get the big list. They show clearly that although there are tremendous forces involved not everyone is killed by trauma, and if you can possibly revive someone by warming, chest compression, rescue breathing than its worth it to try.
Page CE, Atkins D, Shockley LW, Yaron M.
Avalanche deaths in the United States: a 45-year analysis.
Wilderness Environ Med. 1999 Autumn;10(3):146-51.
PMID: 10560307 [PubMed - indexed for MEDLINE]
Johnson SM, Johnson AC, Barton RG.
Avalanche trauma and closed head injury: adding insult to injury.
Wilderness Environ Med. 2001 Winter;12(4):244-7.
PMID: 11769920 [PubMed - indexed for MEDLINE]
Christensen ED, Lacsina EQ. Related Articles, Links
Mountaineering fatalities on Mount Rainier, Washington, 1977-1997: autopsy and investigative findings.
Am J Forensic Med Pathol. 1999 Jun;20(2):173-9. Review.
PMID: 10414660 [PubMed - indexed for MEDLINE]
this is not an exhaustive list and there's a lot that useful that's published in German.
Posted: Fri Nov 18, 2005 6:23 pm Post subject: OPA'S?
first off, i'm an emt-b working in an ED. second, after reading this account two things stood out: 1st, there was only one cpr mask on scene. and 2nd, there wasn't and still hasn't been mention of the usefullness of oral pharyngeal airways (aka oral airways/opa's) http://www.gasnet.org/airway/opt02.htm. after reading this rescue account i went online and ordered a cpr mask and four opa's of different sizes (~$20 w/ shipping) that i hope never to use but have on hand backcountry riding and kayaking. thoughts/ concerns? the mask alone was ~$10 (small price for "health insurance".)
Posted: Fri Nov 18, 2005 9:32 pm Post subject: Re: Account of Berthoud Pass Avy Rescue... read this
Clyde wrote:
Agent 00X wrote:
I do not know exactly what is meant by "pulling apart" but I assume that the author is saying that the cable that holds avalanche probe pole sections together broke, thus no probe.
Likely he meant the locking mechanism or cable were insufficient to prevent stretch/slack.
hmmm.... it sounds almost like they were using tent poles! My probe (and every commercial probe I have looked at shopping) has a plastic coated steel cable, not bungee cord, to hold it together. It doesn't stretch and probably has a tensile strength in excess of 1000 lbs.
Regarding the Lifelink Lexan shovel's suitability, I read in a ski mag that Doug Coombs packs one as his shovel of choice. That seems to me to be a pretty reputable endorsement. My lexan shovel has no problem chopping through "snow" that has been packed and hardened with road salt and sand, then compacted by one of those highway-plow-wielding dump trucks into a 3 ft high ice bank.
Joined: 16 Dec 2004 Posts: 125 Location: Washington State
Posted: Fri Nov 18, 2005 11:10 pm Post subject:
I have a plastic shovel. Whenever I am digging a snowcave or space for a bivy or tent, my shovel ends up laying there unused. After reading this topic, I'm going to buy a new one. Preferrably a metal shovel with an extendable handle.
Sorry to hear that this didn't end well Dibs for trying!!!
"STATE OF ALASKA Cold Injuries Guidelines Alaska Multi-level Version"
This Alaska document and the ICAR guidelines seem to contradict each other regarding how long CPR should be done.
The Alaska text says "If a patient is pulseless (after a check for 60 seconds) and burial time is estimated to be less than 35 minutes, perform CPR for 30 minutes"
The ICAR text says "Cardiopulmonary resuscitation (CPR) must be continued with standard rates and ratios (compression–ventilation ratio 15:2, 100 chest compressions per min) until the patient is re-warmed in a hospital with cardiopulmonary bypass facilities."
Joined: 07 Dec 2004 Posts: 1530 Location: after 17 years, 5 months to the day, home again
Posted: Sat Nov 19, 2005 3:06 am Post subject:
It's past my bedtime and my eyes are starting to cross, but it's an interesting read. What strikes me is the lack of probability in quick and "non jarring" evacuation. Sure, if a slide happens close to a resort with plenty of open roads, communications to get a helicopter, snowmobiles for fast response of an ALS team then of course things stand a better chance. But for the true b/c...things don't look so great.
Supports the saying that an "ounce of prevention is worth a pound of cure".
Steve _________________ "Those who look outward dream; those who look inward awaken..." - Carl Jung
Fat Boy Mountaineering Club. Take nothing but whippers, leave nothing but craters.
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My probe (and every commercial probe I have looked at shopping) has a plastic coated steel cable, not bungee cord, to hold it together. It doesn't stretch and probably has a tensile strength in excess of 1000 lbs.
Dibs for trying!!!