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International Commission for Mountain Emergency Medicine ICAR MEDCOM, Institute of Mountain Emergency Medicine, EURAC Research, Drususallee 1, I-39100 Bozen/Bolzano, Italy
International Commission for Mountain Emergency Medicine ICAR MEDCOM, Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
International Commission for Mountain Emergency Medicine ICAR MEDCOM, Institute of Mountain Emergency Medicine, EURAC Research, Drususallee 1, I-39100 Bozen/Bolzano, Italy
International Commission for Mountain Emergency Medicine ICAR MEDCOM, Division of Emergency Medicine, Stanford University Medical Center, California, 10181 Curvi St., Anchorage, AK, 99507, USA
International Commission for Mountain Emergency Medicine ICAR MEDCOM, Department of Emergency Medicine, Mineral Springs Hospital, Box 400, Bow Avenue, Banff, AB, T1L 1A5, Canada
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 victim's 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.
Avalanches inflict even higher death tolls in developing countries; for instance avalanches claimed 284 lives in South East Anatolia in 1992, >200 in Kashmir in 1995 and 135 in Kashmir in 2012. The total number of persons in avalanche terrain is unobtainable and mortality in these activity groups can only be roughly estimated. The first recommendations for on-site management and transport of avalanche victims, based on survival analyses,
and an International Liaison Committee on Resuscitation (ILCOR) worksheet process were the basis of the recommendations for avalanche resuscitation in the 2010 Resuscitation Guidelines.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
The ICAR MEDCOM sought to systematically develop evidence-based guidelines using a structured worksheet with the mandate to obtain final consensus among the ICAR MEDCOM.
2. Methods
The objectives, inclusion/exclusion criteria, working group and worksheet of 27 Population Intervention Comparator Outcome (PICO) questions (supplementary data) derived from earlier avalanche resuscitation recommendations
were developed by the ICAR MEDCOM at a TOPIC meeting. The electronic database of Medline was searched via PubMed with the search terms (avalanche [All Fields]) and (hypothermia [All Fields]) and the database of EMBASE via OVID with (avalanche {Including Related Terms}) and (hypothermia {Including Related Terms}). The Cochrane Database of Systematic Reviews was searched with the terms (avalanche) and (accidental hypothermia). Additional hand searching of articles, reference texts and reference lists was also performed. All articles relevant to clinical management of victims of snow avalanches and related accidental hypothermia were extracted for further review. These were evaluated for quality and relevance to the PICO questions and recommendations were developed at a SCIENCE meeting. The recommendations were further examined and consensus was reached at a MANUSCRIPT meeting in Åre, Sweden, in October 2011. Classification of recommendations and level of evidence are ranked using the American Heart Association (AHA) system (Table 1).
Table 1Classification of recommendations and level of evidence according to the ACCF/AHA task force on practice guidelines.
Survival depends on the grade and duration of burial and the pathological processes of asphyxia, trauma and hypothermia.
Grade of burial
Analysis of a Swiss sample showed that 39% (735/1886) of victims involved in an avalanche were completely buried, with survival in complete burials (i.e. burial of the head and chest
In Europe the term completely buried refers to burial of at least the head and chest. In North America the term completely buried is reserved for when the individual is totally buried beneath the snow surface and partially buried–critical for when the individual is partially buried with at least the head under the snow surface and with breathing impaired.
Grade of burial is the strongest single factor for survival.
Duration of burial
Biostatistical survival analysis of critically buried victims1 in Switzerland and Canada shows a progressive non-linear reduction in survival as duration of burial increases and distinct phases.
In Switzerland, survival probability remains above 80% until 18 min after burial (“survival phase”) and plummets thereafter to 32% (“asphyxia phase”), whereas the Canadian survival curve shows an earlier and steeper decline from 77% at 10 min to 7% at 35 min, which reflects a greater mortality from trauma and an earlier onset of asphyxia due to denser snow in some regions of Canada
Asphyxia was found to be the most common cause of death in three case series that relied on autopsy, full forensic external examination and/or pre-mortem clinical findings.
confirmed that a patent airway was essential for survival for >35 min of critical burial, with four of the analyzed retrospective studies describing survival to hospital discharge in victims buried >60 min who were found with patent airways. No survivors were reported in any of the 14 case-control and case series for victims with an obstructed airway and >35 min of burial. A prospective, randomized, crossover experimental study found that when breathing into a simulated air pocket subjects achieved a steady state of survivable hypoxia for at least 20 min in 39% (11/28) of uninterrupted tests.
Other prospective experimental studies have indicated that redirecting gas exchange away from an air pocket, such as might occur in avalanche debris with large blocks or an opening to environmental air, improves oxygenation.
Recommendation. If burial >35 min, airway patency should be determined upon exposure of the face (Class I, LOE A).
The ancillary presence of an air pocket should be determined by digging from the side of the victim in order to not harm the victim or destroy the air pocket (Class I, LOE C).
3.1.3 Resuscitation
Resuscitation guidelines recommend standard CPR in hypoxaemic cardiopulmonary arrest.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Ventilation should be combined with chest compressions, as compression-only CPR is inappropriate for avalanche burial.
Recommendations. Factors and decisions are integrated in a management algorithm (Fig. 2) (Class IIa, LOE C).
Fig. 2Management of the buried avalanche victim. In all cases gentle extrication and spinal precautions. Where appropriate core temperature and ECG monitoring, oxygen, insulation, heat packs on trunk; 0.9% NaCl and/or 5% glucose only if an intravenous or intraosseous line can be established within a few minutes; specific trauma care as indicated. 0Clinicians may consider withholding resuscitation at the scene if it increases risk to the rescue team or if the victim is lethally injured or completely frozen. 1If duration of burial is unknown core temperature may substitute. 2Initiate standard ALS including ventilations and chest compressions as indicated. Resuscitation may be terminated in normothermic patients if ALS is not successful after 20 min. Transport victims with concern of respiratory (e.g. pulmonary oedema) or other-system injury to the most appropriate medical centre. 3Hospital capable of advanced external or core rewarming. Patients who present with cardiac instability (ventricular arrhythmias, systolic blood pressure <90 mm Hg) or core-temperature <28 °C should be transported towards ECC rewarming. Defibrillation beyond three attempts may be delayed until core-temperature >30 °C. *If direct transport to ECC rewarming is practical, the nearest ED can be bypassed. If K+ at hospital admission exceeds 12 mmol L−1, consider stopping resuscitation (after excluding crush injuries and consideration of the use of depolarizing paralytics); in an adult with K+ 8–12 mmol L−1 and other factors consistent with non-survival, termination of resuscitation should be considered. ALS, Advanced Life Support; ED, Emergency Department; ICU, Intensive Care Unit; ECC, extracorporeal circulation.
For victims buried <35 min found in cardiac arrest, presume asphyxia and initiate standard CPR with ventilations as soon as the head and chest are free regardless of airway patency (Class I, LOE B).
For victims buried >35 min found in non-asystolic cardiac arrest with a patent airway but who are not hypothermic (≥32 °C), presume asphyxia and initiate standard CPR with ventilations as soon as the head and chest are free (Class IIa, LOE B).
For victims buried >35 min found in asystolic cardiac arrest with an obstructed airway, resuscitation may be initiated but can be terminated if not successful (Class I, LOE A).
3.1.4 Advanced airway
Advanced airway management (e.g. endotracheal intubation and supraglottic airway devices) performed by experienced personnel enables effective ventilation, reduces the likelihood of aspiration for avalanche victims in periarrest
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Supraglottic devices may be more efficient and safer than endotracheal intubation or bag-mask ventilation for less experienced rescuers.
Recommendations. For unresponsive victims advanced airway management should be performed if the rescuer is competent in this skill and if airway management succeeds within a reasonable time (Class I, LOE A).
For rescuers not experienced in advanced airway management, ventilation is most effective with mouth-to-mask or bag-mask techniques (Class I, LOE A).
For a potential survivor with a failed airway, hospital transfer should be hastened with early alert of appropriate support (Class I, LOE C).
3.1.5 Transport
Post-resuscitation care including therapeutic hypothermia is integral to improving survival.
Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Recommendations. If resuscitation is successful or termination-of-CPR criteria are not met (see Termination of CPR) victims should be transported to the nearest hospital, preferably one with intensive care services (Class IIa, LOE C).
Mechanical chest compression devices and therapeutic hypothermia may be considered for prolonged transports (Class IIb, LOE B).
If victims present with signs or concern of respiratory or other system injury they should be transported to the nearest emergency department for advanced assessment and observation (Class I, LOE C).
3.2 Trauma
Trauma was the principal cause of death in 23.5% (48/204) of fatalities in western Canada,
However, in the Canadian sample major trauma, i.e. injury severity score (ISS) >15, was additionally found in 13.0% (12/92) of autopsied “asphyxia” fatalities. Chest trauma represented 45.8% (11/24) of single-system injuries; 52.1% (25/48) were found on the surface or not critically buried.
In the Austrian sample 8.6% (9/105) of fatality cases had an ISS score >13 although only 5.5% (2/36) were ascribed to trauma; the two trauma fatalities were fracture-dislocations of the cervical spine.
Similarly, in the Utah sample trauma was associated with asphyxia in 8.9% (5/56) of fatalities in addition to the 5.4% (3/56) ascribed to trauma alone; autopsies found head, abdominal and limb injuries to be common.
Current resuscitation guidelines emphasize spinal stabilization, chest decompression for tension pneumothorax, haemorrhage control, prompt evacuation to definitive care and consideration of permissive hypotension in the resuscitation of shock.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Recommendations. Rescuers should provide adequate spinal stabilization throughout extrication, on-scene management and transport (Class I, LOE C).
Trauma measures include splinting, insulation and analgesia (Class I, LOE C).
Clinical teams should be skilled and equipped for thoracostomy, tourniquet application, intravenous or intraosseous cannulation with controlled fluid infusion in shock or for medication administration, advanced airway management, cricothyrotomy and antibiotics for open fractures (Class IIa, LOE B).
CPR should be initiated for traumatic cardiopulmonary arrest while searching for and managing treatable causes (Class I, LOE B).
Delay of transport for on-site management should be as short as possible; direct transport to a dedicated trauma centre is preferred (Class I, LOE C).
3.3 Hypothermia
Hypothermia is commonly diagnosed clinically in avalanche victims. A systematic review of five retrospective case series found that hypothermic cardiac arrest is survivable if associated with a patent airway.
The cooling rate during burial is variable but may be accelerated by light clothing, sweating and exhaustion. Hypercapnia and hypoxia may increase cooling rate.
At the maximum rate of 9 °C h−1 a minimum time of 35 min is required for the core-temperature to drop <32 °C and it is therefore concluded that the presence of a patent airway is essential for survival in any victim with a core-temperature <32 °C.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Durrer et al.39 This Swiss staging system was adopted by the 2010 ERC Guidelines for Resuscitation. The clinical signs in the Swiss staging system reflect the effect of hypothermia only. Considering that consciousness can be impaired by asphyxia and trauma, core temperature measurement is necessary to assess the severity of hypothermia.13
13.7°C is the lowest core temperature recorded in a survivor of accidental hypothermia. ALS, advanced life support; CT, core temperature; ECMO/CPB, extracorporeal rewarming/cardiopulmonary bypass; ED, emergency department.
This Swiss staging system was adopted by the 2010 ERC Guidelines for Resuscitation. The clinical signs in the Swiss staging system reflect the effect of hypothermia only. Considering that consciousness can be impaired by asphyxia and trauma, core temperature measurement is necessary to assess the severity of hypothermia.
c If transport delayed >2 h and no signs of trauma that would necessitate anaesthesia.
d 13.7 °C is the lowest core temperature recorded in a survivor of accidental hypothermia.ALS, advanced life support; CT, core temperature; ECMO/CPB, extracorporeal rewarming/cardiopulmonary bypass; ED, emergency department.
For victims in cardiac arrest with a core-temperature <32 °C and a patent or unknown airway initiate resuscitation (Class I, LOE A).
For victims in asystolic cardiac arrest with a core-temperature <32 °C and an obstructed airway, presume asphyxia and withhold resuscitation (Class I, LOE A).
3.3.2 Rescue collapse
Collapse of hypothermic avalanche victims during rescue is associated with lethal arrhythmias, according to case reports.
ECG monitoring may be performed with a monitor-defibrillator or an AED. AED monitoring is best with a device that has a monitor window.
should be applied upon extrication and continued during transport, using maximum amplification if complexes are small (Class I, LOE B).
Mechanical irritation of hypothermic victims should be minimized, avoiding excessive limb extension, rough transport and unnecessary chest compressions (Class I, LOE B).
Transport victims in the horizontal position (Class I, LOE C).
3.3.3 Core-temperature
Accidental hypothermia has been defined as “an unintentional reduction in core-temperature <35 °C.”
Hypothermia is often combined with asphyxia and trauma, rendering clinical signs unreliable. Oesophageal temperatures are more reliable than other temperatures
Alternatively, epitympanic temperatures are reasonably accurate in the non-intubated patient not in cardiac arrest, given a non-obstructed ear canal and correct application including insulation from cold air.
Recommendations. Don’t rely on clinical hypothermia staging alone when asphyxia and/or trauma occur (Class I, LOE C).
Obtain core-temperatures when hypothermia has management significance, with an oesophageal probe in the intubated or epitympanic thermistor probe in the non-intubated victim (Class I, LOE B).
Rectal temperature may be used to gauge hypothermia initially (Class IIa, LOE B).
3.3.4 Insulation
Afterdrop refers to continued decline in temperature after removal from cold. All guidelines recommend insulation from further cooling and most recommend removal of wet clothing,
which may however increase heat loss in a cold, windy environment. Manikin studies found that increasing insulation over wet clothing produced a similar reduction in heat loss compared to removing clothing
Protection against cold in prehospital care: evaporative heat loss reduction by wet clothing removal or the addition of a vapor barrier: a thermal manikin study.
Recommendations. Hypothermic victims should be insulated against further heat loss with dry, low-conductivity, whole-body assemblies covered in a windproof and water-resistant outer shell
These may be purpose-built rescue bags with insulated hoods, or assemblies of blankets enclosed in aluminium foil combined with head protection.
(Class I, LOE B).
Remove wet clothing only if the victim can be insulated effectively; cut clothing cautiously if victim has a hypothermia staging of moderate or worse (Class I, LOE C).
3.3.5 Out-of-hospital rewarming
Applying heat packs may improve comfort although core-temperature may not be increased.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Pulse-oximetry is inaccurate with cold exposure due to peripheral vasoconstriction as well as device malfunction, high altitude and bright ambient light.
Depolarizing neuromuscular paralytics (e.g. succinylcholine) may increase the serum potassium level and affect subsequent decisions.
Recommendation. Consider the impact of depolarizing paralytics on serum potassium if the latter is planned for resuscitation or advanced rewarming decisions (Class I, LOE B).
3.3.8 CPR
In severely hypothermic patients respirations and pulse may be indistinct.
Recommendations. Check carefully for vital signs and ECG activity for up to 1 min (Class IIb, LOE C).
Initiate CPR if signs of life are absent at standard BLS rates (Class IIa, LOE B).
3.3.9 Defibrillation
Defibrillation of severely hypothermic patients (<28 °C) presenting with ventricular fibrillation is unsuccessful in most cases, though defibrillation thresholds vary individually and successful defibrillation with core-temperatures as low as 25.6 °C has been reported.
Due to the paucity of animal and human studies and conflicting results, experts disagree on the application of defibrillation with core-temperatures <30 °C.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
recommend standard defibrillation while rewarming.
Recommendations. Use standard defibrillations when indicated, regardless of core-temperature; repetitions beyond three attempts may be delayed until core-temperature >30 °C and should be avoided if they cause interruption of CPR and/or transport to rewarming (see Transport) (Class IIa, LOE B).
3.3.10 ALS medications
Similar to defibrillation, experts disagree on the effectiveness of advanced life support (ALS) drug therapy with core-temperatures <30 °C.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
allow vasopressors in cardiac arrest. Vasopressors may induce arrhythmias and increase risk of frostbite. Drug metabolism is decreased with low core-temperature.
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
For severely hypothermic victims in cardiac arrest, extracorporeal rewarming resulted in return of spontaneous circulation (ROSC) in 23 of 186 and survival to hospital discharge in 8 of 186 avalanche victims examined in a systematic review of seven case series and reports.
Recommendations. For victims with core-temperature <32 °C but no cardiac instability, i.e. systolic blood pressure ≥90 mmHg and no ventricular arrhythmias, and core-temperature >28 °C, transport to the nearest appropriate hospital for active external and minimally invasive rewarming (i.e. warm environment; chemical, electrical, or forced air heating packs or blankets; warm iv-fluids) is recommended
Hypothermic victims with a patent or unknown airway, with cardiac instability or a core-temperature <28 °C, or in cardiac arrest, should be transported to a centre with ECMO or CPB; if ECMO/CPB is not available transport to an appropriate hospital for alternative active internal rewarming (e.g. thoracic lavage) with continued CPR is recommended (Class I, LOE B).
Notify the ECMO/CPB centre before departure (Class IIa, LOE C).
3.3.12 Serum potassium
Serum potassium was predictive of survival for hypothermic cardiac arrest victims in a systematic review of prognostic factors in avalanche resuscitation,
In accidental hypothermia of any origin the highest admission potassium of a survivor was 11.8 mmol L−1 in a 31-month-old child exposed to freezing weather.
Recommendations. For hypothermic victims in asystolic cardiac arrest where duration of burial or airway patency is unknown or where a decision for prolonged resuscitation or long transport to a centre for ECMO/CPB needs confirmation, a serum potassium <8 mmol L−1 would indicate continued action, >12 mmol L−1 would indicate termination of resuscitation and 8–12 mmol L−1 in an adult victim should be considered with other factors (Class I, LOE A).
Recommendation. Victims of hypothermic cardiac arrest found with a patent or unknown airway and who are otherwise deemed possible survivors should be resuscitated until rewarmed to a core-temperature >32 °C before a final decision is made (Class I, LOE C).
3.4 General measures
3.4.1 Oral fluids
Two Cochrane Systematic Reviews and the practice guideline of the American Society of Anesthesiologists found no evidence of adverse effects from clear fluids up to 2 h prior to surgery in otherwise healthy patients with no abnormal risk of regurgitation or aspiration.
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters.
Recommendations. Alert victims not requiring sedation or anaesthesia within 2 h may drink warmed, clear, calorie-containing, non-alcoholic, non-caffeinated fluids to sustain hydration and spontaneous rewarming (Class IIb, LOE B).
3.4.2 Activity
Recommendation. Alert mildly hypothermic victims (35–32 °C) may exercise to rewarm (Class IIa, LOE C).
3.4.3 Organized rescue
Recommendations. Organized rescue teams should mobilize promptly, ideally by helicopter, and should include clinicians skilled in mountain emergency medicine and be staffed according to the number of buried victims (Class IIa, LOE C).
Dogs and handlers may accompany organized rescue teams to find completely buried victims. Once all victims have been located there is no use for dogs and handlers (Class IIa, LOE C).
All staff should have appropriate safety equipment, especially avalanche transceivers and airbags (Class I, LOE B).
Medical equipment should include core-temperature and ECG monitor/defibrillator devices and appropriate medications; all instruments should be insulated and have fully-charged batteries (Class I, LOE B).
The potential risk to the rescuers must be evaluated, taking less risk after longer burials (Class IIb, LOE C).
3.4.4 Triage
A multiple casualty incident may initially overwhelm rescuers, and limited resources should be allocated to those most likely to survive.
Recommendations. When resources are overwhelmed by multiple victims in cardiac arrest priority should be given to those with a cardiac rhythm, a higher core-temperature and other favourable factors (Class IIb, LOE B).
3.5 Termination of CPR
The very poor survival of patients suffering prehospital normothermic asystolic cardiac arrest has resulted in validated EMS termination-of-resuscitation rules that have been incorporated into a guideline for mountain rescue (Class IIb, LOE C).
Recommendations. Resuscitation may be terminated (or withheld) when rescuer safety is unacceptably high, lethal injuries such as decapitation or truncal transection have occurred, the body is completely frozen, a valid do-not-resuscitate order exists, or limitations in transport or other logistics render resuscitation futile (Class I, LOE C).
Resuscitation may be terminated in unwitnessed cardiac arrest when, after 20 min of resuscitation, there has been no ROSC with no shock advised by AED or only asystole seen on ECG with no hypothermia or other special circumstance warranting extended CPR (Class IIa, LOE A).
4. Conclusions
The algorithm for the management of avalanche victims is shown in Fig. 2. 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 victim's 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, as well as 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 with uninterrupted CPR to an ECMO/CPB rewarming centre. Management should include spinal precautions and other trauma care as indicated.
Conflicts of interest statement
None of the authors have a commercial or industrial conflict of interest. H.B., J.B., B.D., P.P. and K.Z. have published on hypothermia. H.B. receives support as the head of the Institute of Mountain Emergency Medicine, EURAC research.
Acknowledgements
The following ICAR MEDCOM members approved these recommendations at meetings in Longyearbyan (Norway) and Åre (Sweden): Gege Agazzi (Italy); Borislav Aleraj (Croatia); Jeff Boyd (Canada); Bruce Brink (Canada); Douglas Brown (Canada); Hermann Brugger (Italy); Perilif Eduinsson (Sweden); Tore Dahlberg (Norway); John Ellerton (Vice-President, United Kindom); Fidel Elsensohn (President, Austria); Herbert Forster (Germany); Nicole Gantner-Vogt (Principality of Liechtenstein); Andrzod Gorka (Poland); Martin Ivanov (Bulgaria); Alex Kottmann (Switzerland); Xavier Ledoux (France); Volker Lischke (Germany); Mario Milani (Italy); Maria Mizuskovic (Montenegro); Josè Ramòn Morandeira (Spain); Wokiech Moskal (Poland); Maria Antonia Nerin (Spain); Marie Nordgren (Sweden); Einar Ornarnarrson (Iceland); Noriyoshi Ohashi (Japan); Kazue Oshiro (Japan); Peter Paal (Austria); Oliver Reisten (Switzerland); Erik Sandstrom (Sweden); Frederik Sederkuist (Sweden); Haris Sinifakoulis (Greece); Sven Christjar Skaiaa (Norway); Inigo Soteras (Spain); Giacomo Strapazzon (Italy); Günther Sumann (Austria); Oleg Tcholakov (Bulgaria); David Tingay (Australia); Iztok Tomazin (Slovenia); Heidi Vigerust (Norway); David Watson (Canada); Eveline Winterberger (Switzerland); Ken Zafren (Vice-President, USA); Gregoire Zen-Ruffinen (Switzerland). We thank Emily Procter for the help in editing the manuscript.
Appendix A. Supplementary data
The following is the supplementary data to this article:
Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Protection against cold in prehospital care: evaporative heat loss reduction by wet clothing removal or the addition of a vapor barrier: a thermal manikin study.
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters.
☆A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.10.020.
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