Which board will carry out the ICAR test?
Update avalanche medicine and cold damage 2019
of Christoph Tannhof
Also this year, organized by the German Society for Mountain and Expedition Medicine, the new course on avalanche medicine and cold injuries took place from January 23rd to 27th.
In view of the previous large snowfalls on the north side of the Alps, which regionally led to the highest avalanche warning level 5, a highly topical topic for every doctor who is interested in mountain sports and mountain medicine.
There were also a number of “repeat offenders” among the participants.
The course leader Dr. Ulrich Steiner (anesthetist and mountain guide) supported by the veteran of mountain medicine Dr. Wolfgang Schaffert (internist and emergency doctor) as well as Jan Mersch and Pauli Trenkwalder as psychologists and mountain guides, Dr. Simon Rauch (internist, emergency doctor, research group EURAC Bolzano) as well as Stefan Mertelseder and Stefan Hochstaffl as flight rescuers and anesthetists and dog handlers and training supervisor in Austria for the training of mountain rescuers. It is difficult to imagine more expertise.
After the allocation of the rooms in the Bergsteigerhotel Lamm, run by Petra and Patrick in a very hospitable manner, a program discussion and, as a result, a very good dinner, the theoretical part began, which dealt with the following topics over the entire period:
Risk management, avalanches or avalanche avoidance:
A risk reduction is possible by answering the following three questions:
Danger level according to the avalanche report, slope steepness and favorable or unfavorable slope exposure / shape, which are ultimately the basis of the SnowCard developed by Jan Mensch.
The answer requires appropriate basic knowledge and skills. Good tour planning from a safety point of view starts at home and should be checked on site and individually at fixed checkpoints. Most of the avalanche accidents documented so far could have been prevented by observing these rules ...
Essential for the development of the slab avalanche (classic skier avalanche) is a structural break within a weak layer in the snow cover, which propagates. In addition to the weak layer, bound snow and a slope of more than 30 degrees are basic requirements.
Post-traumatic stress disorder or trauma term in connection with avalanche burial:
A crisis is characterized by the subjectively lack of coping options.
For avalanche victims and those involved in accidents, traumatic crises that are caused by the death or serious injuries of those involved are primarily relevant. 4 different reaction patterns can be distinguished:
- the immediate fear and stress response
- the acute stress reaction (2 days to 4 weeks post-traumatic)
- post-traumatic stress disorder and
- post-traumatic adjustment disorder
The diagnostic criteria for post-traumatic stress disorder PTSD according to DSM IV include persistent reliving, persistent avoidance and / or flattening of reactivity and increased arousal. The first steps towards crisis intervention are:
Connect, explore, and intervene.
Pathophysiology of avalanche burial:
The criteria of burial duration, free airways and degree of injury are decisive for survival after a burial. In the case of a complete burial, the mortality is 52%. For partially buried avalanche victims with free airways, the chances of survival are significantly better. In the case of a complete burial, the mortality depends largely on the duration: if the rescue can be carried out in up to 18 minutes, the probability of survival is 80% - after 30 minutes it is only 30%.
In addition to trauma injuries, the number one cause of death is usually asphyxia due to the obstruction of the airways with snow. For a longer survival, free airways and a cavity in front of the airway are absolute basic requirements. In the further course the triple H syndrome develops consisting of hypothermia, hypoxia and hypercapnia.
In summary, the most common cause of death with a burial duration of less than 60 minutes is asphyxia, above which hypothermic cardiac arrest is possible.
When the head is exposed, one minute should be searched for vital signs. Hypothermic patients must be monitored continuously. Careless positioning measures can quickly trigger malignant rhythm disturbances if the cold blood of the body shell is mixed with the still warm blood of the body trunk (afterdrop!).
Defibrillation is rarely effective at temperatures below 30 degrees. Therefore, no more than three defibrillation attempts should be made. Medication administration is just as meaningless at temperatures below 30 degrees.
If a deeply hypothermic patient (<28 degrees) has to be transported away terrestrially, intermittent resuscitation can be carried out at five minute intervals.
Frostbite and generalized hypothermia:
Frostbite, which occurs predominantly in the extremities, is stage-dependent (1-4) and is associated with increasing tissue trauma up to necrosis. The established first treatment is rapid rewarming in a water bath (38 to 42 ° C) for 20 minutes. This absolutely requires effective, if possible opiate-based analgesia. In addition, hemodilution, inhibition of platelet aggregation (ASA or ibuprofen), heparin and the intravenous administration of prostacyclins are effective. Renewed exposure to cold after warming must be avoided at all costs, as this leads to irreversible damage. The further course and, if necessary, the extent of a necessary amputation can often only be decided after weeks.
Generalized hypothermia is divided into 4 levels, which are accompanied by an increasing reduction in consciousness and vital functions. The lowest measured and survived core body temperature was 13.7 degrees!
Reheating is not possible at the alpine emergency site. External heat supply (chemical heat packs, etc.) and adequate insulation are used to prevent further cooling. Further management will be decided depending on the starting temperature and the cardiorespiratory situation.
Triage criteria for treating avalanche victims:
The duration of the burial and the presence or absence of free airways are decisive for further action. Depending on this, the further procedure takes place according to the checklist developed by ICAR MEDCOM (Fig. 1), which also includes the selection of a suitable aftercare clinic. In particular, the scarce resources to one E.xtra C.orporal L.ife S.upport can be used in a targeted manner when using the algorithm.
The principle still applies that severely hypothermic avalanche victims with free airways can only be declared dead after rewarming at the ECLS and no successful resuscitation.
In a very balanced relationship between theory and practice, practical training took place in the field on all days. In groups that were very well and homogeneously combined by the instructors and mountain guides, realistic destinations in the very diverse and scenic tour area around the Brenner Pass were selected after joint tour planning using avalanche conditions or weather reports, maps and a view from the window.
The risk assessment in the terrain was trained on site, which sometimes deviated significantly from what was expected and, depending on this, the route planning. Digging snow profiles and performing the E.xtended C.compression Tests created an understanding of the complexity of the snowpack, which can be transferred to the 10 hazard patterns used and which contributes to a more precise prediction of the risk of avalanches.
In the station operation, the search for buried subjects using an avalanche transceiver and probe was supplemented by a simulated use of dogs - thanks to Stefan and Sky - practiced and demonstrated.
Incidentally, the following remark is allowed: long and steep ascents - partly through an icy foehn storm, rewarded by descents in the finest powder, also delight the hearts of alpinists and alpinists.
On the last day of the course, a large avalanche drill took place. In a very realistic and professionally created scenario, four people buried, some of them without an avalanche transceiver, had to be searched for, and based on the information given about the duration of the burial, core body temperature, the presence of a respiratory cavity, spontaneous breathing or circulation and any injuries, they had to be rescued and treated first. A decision also had to be made about transport or the necessary equipment to a clinic suitable for subsequent care (extracorporeal rewarming).
The big difference between the small groups and the whole group became apparent. This could be explained by the unwillingness to lead or to be led. A clarification of the tasks in the event of an incident before the start of a tour can create a binding nature and thus save the life of the accident victim.
In summary, it is an absolutely worthwhile event for every colleague who is out and about in the mountains in winter.
Contact to the author:
Dr. Christoph Tannhof
Medical Clinic III
Johanniter Hospital Rheinhausen
Kreuzacker 1-7, 47228 Duisburg, Germany
Here you can register for the next avalanche course.
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