HIGH ALTITUDE MEDICINE & BIOLOGY Volume 15, Number 4, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/ham.2014.1082
Full Neurologic Recovery after Prolonged Avalanche Burial and Cardiac Arrest Yvonnick Boue´, MD,1,2 Jean-Franc¸ois Payen, MD, PhD,1–3 Jean-Pierre Torres, MD,4 Marc Blancher, MD,4 and Pierre Bouzat, MD, PhD1–3
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urvival with full neurologic recovery after prolonged complete avalanche burial and cardiac arrest (CA) is extremely rare. It mainly depends on the presence of severe hypothermia and onset of cardiac arrest after extrication from avalanche burial (Paal et al., 2012). We describe here two case reports with full neurologic recovery following CA and prolonged complete avalanche burial. A 17-year-old male backcountry skier was completely buried by an avalanche in the French Alps (Valmeinier, Savoie, France) and was only extricated by the rescue team after 6 hours due to bad weather conditions. After extrication, an air pocket was noted and the patient had no obvious sign of trauma. He had a Glasgow Coma Scale (GCS) of 4 (verbal score of 2), a heart rate of 27 beats/min, a systolic blood pressure of 55 mmHg, and an epitympanic temperature of 22C immediately after extrication. The rate of cooling
during avalanche burial was estimated around - 2.3C/hour. After tracheal intubation and mechanical ventilation, the patient was transported to the regional level I trauma centre. Ventricular fibrillation occurred at hospital admission in the emergency room. The occurrence of CA, described as rescue collapse, was triggered by further cooling and transfer of the patient. Rectal temperature was 21.1C on hospital admission. Cardiopulmonary resuscitation (CPR) was continued for 20 min until extracorporeal membrane oxygenation (ECMO) with veno-arterial femoral access was performed. On admission, before extracorporeal life support was initiated, arterial serum potassium was 4 mmol/L, arterial oxygen partial pressure (Pao2) 360 mmHg, arterial carbon dioxide partial pressure (Paco2) 36 mmHg, pH 7.26, and arterial serum lactate was measured at 4.6 mmol/L. After 4 days spent in the intensive care unit (ICU), the patient made a full neurologic recovery
FIG. 1. Recordings of the cardiac monitor recorder with GPS capability in the second case report. Avalanche burial began 7 hours before patient’s extrication with a sudden recorded acceleration and loss of altitude (white arrow). Extrication performed by rescue team is also reported in the graph (black arrow). Heart rate monitor failed to record cardiac rhythm due to probes’ misplacement. Skin temperature is also shown (from 20C before avalanche burial to 11C under the snow). HR, heart rate; Temp, temperature. 1
Pole Anesthe´sie-Re´animation, Hoˆpital Michallon, Grenoble, France. Universite´ Joseph Fourier, Grenoble, France. 3 INSERM U836, Grenoble, France. 4 Service Urgences-SAMU-SMUR, Hopital Michallon, Grenoble, France. 2
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with a Cerebral Performance Category (CPC) score of 1 (Phelps et al., 2013). The second case report was a 41-year-old male touring skier completely buried under an avalanche in the French Alps (Chartreuse, Ise`re, France). The patient underwent 7 hours of snow burial as attested by his cardiac monitor recorder with GPS capability (Fig. 1). After extrication by the rescue team, the patient had a GCS of 6 (motor score of 4) without airway obstruction or severe trauma, and a rectal temperature of 23.3C immediately after extrication (estimated rate of cooling 1.8C/hour). CA with asystole occurred during the extrication procedure. CPR was continued for 50 min until ECMO was initiated in the emergency room. On admission, before ECMO was performed, the patient had arterial serum potassium of 2.8 mmol/L, Pao2 of 330 mmHg, Paco2 of 55 mmHg, pH of 7.19, and serum lactate of 7 mmol/ L. After 5 days spent in the ICU, the patient had full neurologic recovery with a CPC score of 1. These two clinical case reports indicate that survival with full neurologic recovery is possible despite prolonged duration of complete avalanche burial and CA. Although the survival probability decreases dramatically after complete avalanche burial, it is estimated around 7% 130 minutes after the insult (Brugger et al., 2001). The etiology of cardiac arrest after several hours of complete burial could be related to profound hypothermia, a condition known to provide good neurologic recovery (Boue et al., 2014a). One of the key factors in survival for the two case reports was witnessed cardiac arrest after extrication from avalanche burial. Other factors such as the presence of air pockets and a low serum potassium concentration on admission might be associated with a better outcome (Boue et al., 2014b). In fact, high serum potassium concentration is associated with cardiac arrest due to asphyxia during avalanche burial. Accordingly, the two avalanche victims in this report had normal potassium values, since cardiac arrest was not due to asphyxia. Hypothermia-induced CA, without trauma or asphyxia, represents a specific condition with possible successful neu-
523
rologic recovery despite prolonged duration of burial. These examples emphasize that searching for avalanche victims should not be abandoned prematurely after complete avalanche burial. Author Disclosure Statement
No competing financial interests exist. References
Boue Y, Lavolaine J, Bouzat P, Matraxia S, Chavanon O, and Payen JF. (2014a). Neurologic recovery from profound accidental hypothermia after 5 hours of cardiopulmonary resuscitation. Crit Care Med 42:e167-70. Boue Y, Payen JF, Brun J, Thomas S, Levrat A, Blancher M, Debaty G, and Bouzat P. (2014b). Survival after avalancheinduced cardiac arrest. Resuscitation 85:1192–1196. Brugger H, Durrer B, Adler-Kastner L, Falk M, and Tschirky F. (2001). Field management of avalanche victims. Resuscitation 51:7–15. Paal P, Milani M, Brown D, Boyd J, and Ellerton J (2012). Termination of cardiopulmonary resuscitation in mountain rescue. High Alt Med Biol 13:200–208. Phelps R, Dumas F, Maynard C, Silver J, and Rea T. (2013). Cerebral Performance Category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med 41: 1252–1257.
Address correspondence to: Dr Pierre Bouzat Poˆle d’Anesthe´sie-Re´animation Hoˆpital Albert Michallon, BP 217 F-38043 Grenoble France E-mail: [email protected] Received July 16, 2014; accepted in final form August 25, 2014.
Full Neurologic Recovery after Prolonged Avalanche Burial and Cardiac Arrest Yvonnick Boue´, MD,1,2 Jean-Franc¸ois Payen, MD, PhD,1–3 Jean-Pierre Torres, MD,4 Marc Blancher, MD,4 and Pierre Bouzat, MD, PhD1–3
S
urvival with full neurologic recovery after prolonged complete avalanche burial and cardiac arrest (CA) is extremely rare. It mainly depends on the presence of severe hypothermia and onset of cardiac arrest after extrication from avalanche burial (Paal et al., 2012). We describe here two case reports with full neurologic recovery following CA and prolonged complete avalanche burial. A 17-year-old male backcountry skier was completely buried by an avalanche in the French Alps (Valmeinier, Savoie, France) and was only extricated by the rescue team after 6 hours due to bad weather conditions. After extrication, an air pocket was noted and the patient had no obvious sign of trauma. He had a Glasgow Coma Scale (GCS) of 4 (verbal score of 2), a heart rate of 27 beats/min, a systolic blood pressure of 55 mmHg, and an epitympanic temperature of 22C immediately after extrication. The rate of cooling
during avalanche burial was estimated around - 2.3C/hour. After tracheal intubation and mechanical ventilation, the patient was transported to the regional level I trauma centre. Ventricular fibrillation occurred at hospital admission in the emergency room. The occurrence of CA, described as rescue collapse, was triggered by further cooling and transfer of the patient. Rectal temperature was 21.1C on hospital admission. Cardiopulmonary resuscitation (CPR) was continued for 20 min until extracorporeal membrane oxygenation (ECMO) with veno-arterial femoral access was performed. On admission, before extracorporeal life support was initiated, arterial serum potassium was 4 mmol/L, arterial oxygen partial pressure (Pao2) 360 mmHg, arterial carbon dioxide partial pressure (Paco2) 36 mmHg, pH 7.26, and arterial serum lactate was measured at 4.6 mmol/L. After 4 days spent in the intensive care unit (ICU), the patient made a full neurologic recovery
FIG. 1. Recordings of the cardiac monitor recorder with GPS capability in the second case report. Avalanche burial began 7 hours before patient’s extrication with a sudden recorded acceleration and loss of altitude (white arrow). Extrication performed by rescue team is also reported in the graph (black arrow). Heart rate monitor failed to record cardiac rhythm due to probes’ misplacement. Skin temperature is also shown (from 20C before avalanche burial to 11C under the snow). HR, heart rate; Temp, temperature. 1
Pole Anesthe´sie-Re´animation, Hoˆpital Michallon, Grenoble, France. Universite´ Joseph Fourier, Grenoble, France. 3 INSERM U836, Grenoble, France. 4 Service Urgences-SAMU-SMUR, Hopital Michallon, Grenoble, France. 2
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RECOVERY AFTER AVALANCHE
with a Cerebral Performance Category (CPC) score of 1 (Phelps et al., 2013). The second case report was a 41-year-old male touring skier completely buried under an avalanche in the French Alps (Chartreuse, Ise`re, France). The patient underwent 7 hours of snow burial as attested by his cardiac monitor recorder with GPS capability (Fig. 1). After extrication by the rescue team, the patient had a GCS of 6 (motor score of 4) without airway obstruction or severe trauma, and a rectal temperature of 23.3C immediately after extrication (estimated rate of cooling 1.8C/hour). CA with asystole occurred during the extrication procedure. CPR was continued for 50 min until ECMO was initiated in the emergency room. On admission, before ECMO was performed, the patient had arterial serum potassium of 2.8 mmol/L, Pao2 of 330 mmHg, Paco2 of 55 mmHg, pH of 7.19, and serum lactate of 7 mmol/ L. After 5 days spent in the ICU, the patient had full neurologic recovery with a CPC score of 1. These two clinical case reports indicate that survival with full neurologic recovery is possible despite prolonged duration of complete avalanche burial and CA. Although the survival probability decreases dramatically after complete avalanche burial, it is estimated around 7% 130 minutes after the insult (Brugger et al., 2001). The etiology of cardiac arrest after several hours of complete burial could be related to profound hypothermia, a condition known to provide good neurologic recovery (Boue et al., 2014a). One of the key factors in survival for the two case reports was witnessed cardiac arrest after extrication from avalanche burial. Other factors such as the presence of air pockets and a low serum potassium concentration on admission might be associated with a better outcome (Boue et al., 2014b). In fact, high serum potassium concentration is associated with cardiac arrest due to asphyxia during avalanche burial. Accordingly, the two avalanche victims in this report had normal potassium values, since cardiac arrest was not due to asphyxia. Hypothermia-induced CA, without trauma or asphyxia, represents a specific condition with possible successful neu-
523
rologic recovery despite prolonged duration of burial. These examples emphasize that searching for avalanche victims should not be abandoned prematurely after complete avalanche burial. Author Disclosure Statement
No competing financial interests exist. References
Boue Y, Lavolaine J, Bouzat P, Matraxia S, Chavanon O, and Payen JF. (2014a). Neurologic recovery from profound accidental hypothermia after 5 hours of cardiopulmonary resuscitation. Crit Care Med 42:e167-70. Boue Y, Payen JF, Brun J, Thomas S, Levrat A, Blancher M, Debaty G, and Bouzat P. (2014b). Survival after avalancheinduced cardiac arrest. Resuscitation 85:1192–1196. Brugger H, Durrer B, Adler-Kastner L, Falk M, and Tschirky F. (2001). Field management of avalanche victims. Resuscitation 51:7–15. Paal P, Milani M, Brown D, Boyd J, and Ellerton J (2012). Termination of cardiopulmonary resuscitation in mountain rescue. High Alt Med Biol 13:200–208. Phelps R, Dumas F, Maynard C, Silver J, and Rea T. (2013). Cerebral Performance Category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med 41: 1252–1257.
Address correspondence to: Dr Pierre Bouzat Poˆle d’Anesthe´sie-Re´animation Hoˆpital Albert Michallon, BP 217 F-38043 Grenoble France E-mail: [email protected] Received July 16, 2014; accepted in final form August 25, 2014.
