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1. Guidelines for the management and triage of avalanche victims, particularly with regard to the possibility of deep hypothermia following prolonged burial.Adapted for the New Zealand environment from the original IKAR-CISA recommendations by P Davis 2002 www.ikar-cisa.org

2. Staging of Hypothermia • Stage 1 Clear Consciousness With Shivering C° = 35 – 32 • Stage 2 Impaired Consciousness Without Shivering 32 – 28 • Stage 3 Unconsciousness 28 – 24 • Stage 4 Apparent Death 24 - 15 ? • Stage 5 Death due to Irreversible Hypothermia < 15 ?

3. Dead or Alive? STAGE 4 STAGE 5 Clinical findings: No vital signs No vital signs Chest: Compressible Not compressible Abdominal muscles: Pliable Not pliable ECG: V fib or Asystole Asystole Core temperature: Above 15°Celsius (?) Below 15°Celsius (?) Serum Potassium: (in the nearest hospital) Below 12 mmol /l Above 12 mmol/l

4. Principles of extrication • Short burial (35 min)  RAPID EXTRACTION • Prolonged burial (>35 min)  CAUTIOUS EXTRACTION

5. Location and extraction of the patient • Get the emergency physician and/or paramedic to the scene immediately on location, not just on recovery. • Look out for an air pocket (= any cavity in front of the mouth and nose, no matter how small, provided the airway is clear). • Avoid any destruction of an existing air pocket during extrication! Don't dig vertically from above but diagonally from the side in direction of the buried victim. • Absolutely avoid unnecessary movements of trunk and of main joints (shoulder, hip and knee). If movements cannot be avoided, carry them out as slowly as possible.

7. Patient alert or drowsy • Change wet clothing without unnecessary movements (cutting). • Hot sweet drinks as long as swallow reflex preserved. • Nearest hospital with intensive-care unit.

8. Note that when a victim has been completely buried, even if they are conscious: • admit to hospital for close observation for 24 hours because • respiratory complications can arise later (aspiration pneumonia, pulmonary oedema)

9. Patient unconscious • Intubation: whether a hypothermia stage III patient has to be intubated at the site of the accident or not, is still a matter of discussion. The risk of further heat loss during the time of treatment and transport has to be evaluated. • Be ready to commence resuscitation. • Hospital with intensive care unit and hypothermia experience or (preferably) unit with cardiopulmonary bypass.

11. Patient not breathing • Exclude obvious fatal injuries. • Start cardiopulmonary resuscitation, intubate the patient. • Check burial time and/or core temperature. • Asystole: triage only by the emergency physician or paramedic, aiming to differentiate hypothermia stage IV (HT IV) from asphyxia, and to bring patients with HT IV to a hospital with cardiopulmonary bypass for rewarming.

13. Asystole or Stage IV? Criteria: • Burial time • Core temperature • Air pocket • Airway.

15. Triage Of Avalanche Victims With Asystole • Obvious lethal injury • Burial time greater than 35 mins • Core temperature 32°C or greater • Absence of air pocket • Asystole = DEATH

16. Practical prevention of further heat loss in the field a) 2 to 3 chemical hot packs near the heart on thorax and upper part of abdomen, not directly on the skin. b) Before removing the patient prepare the stretcher with 2 wool blankets and 1 aluminium foil blanket. c) On removing the patient avoid excessive movements. d) Wrap up the patient closely packed in the blankets and in the aluminium foil blanket. e) Cap (30 - 50 % of body heat gets lost over the head).