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 1Clear Consciousness With Shivering C° = 35 – 32Stage 1Clear Consciousness With Shivering C° = 35 – 32 Stage 2Impaired Consciousness Without Shivering32 – 28Stage 2Impaired Consciousness Without Shivering32 – 28 Stage 3Unconsciousness 28 – 24Stage 3Unconsciousness 28 – 24 Stage 4 Apparent Death 24 - 15 ?Stage 4 Apparent Death 24 - 15 ? Stage 5Death due to Irreversible Hypothermia <15 ?Stage 5Death due to Irreversible Hypothermia <15 ? Stage 1Clear Consciousness With Shivering C° = 35 – 32Stage 1Clear Consciousness With Shivering C° = 35 – 32 Stage 2Impaired Consciousness Without Shivering32 – 28Stage 2Impaired Consciousness Without Shivering32 – 28 Stage 3Unconsciousness 28 – 24Stage 3Unconsciousness 28 – 24 Stage 4 Apparent Death 24 - 15 ?Stage 4 Apparent Death 24 - 15 ? Stage 5Death due to Irreversible Hypothermia <15 ?Stage 5Death 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:PliableNot pliable ECG: V fib or AsystoleAsystole Core temperature: Above 15°Celsius (?) Below 15°Celsius (?) Serum Potassium: (in the nearest hospital) Below 12 mmol /l Above 12 mmol/l STAGE 4 STAGE 5 Clinical findings: No vital signs No vital signs Chest: Compressible Not compressible Abdominal muscles:PliableNot pliable ECG: V fib or AsystoleAsystole 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) Short burial (35 min)  RAPID EXTRACTION Prolonged burial (>35 min) Prolonged burial (>35 min)  CAUTIOUS EXTRACTION Short burial (35 min) Short burial (35 min)  RAPID EXTRACTION Prolonged burial (>35 min) 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.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).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.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.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. Get the emergency physician and/or paramedic to the scene immediately on location, not just on recovery.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).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.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.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).Change wet clothing without unnecessary movements (cutting). Hot sweet drinks as long as swallow reflex preserved.Hot sweet drinks as long as swallow reflex preserved. Nearest hospital with intensive-care unit.Nearest hospital with intensive-care unit. Change wet clothing without unnecessary movements (cutting).Change wet clothing without unnecessary movements (cutting). Hot sweet drinks as long as swallow reflex preserved.Hot sweet drinks as long as swallow reflex preserved. Nearest hospital with intensive-care unit.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 hoursadmit to hospital for close observation for 24 hoursbecause respiratory complications can arise later (aspiration pneumonia, pulmonary oedema)respiratory complications can arise later (aspiration pneumonia, pulmonary oedema) Note that when a victim has been completely buried, even if they are conscious: admit to hospital for close observation for 24 hoursadmit to hospital for close observation for 24 hoursbecause respiratory complications can arise later (aspiration pneumonia, pulmonary oedema)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.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.Be ready to commence resuscitation. Hospital with intensive care unit and hypothermia experience or (preferably) unit with cardiopulmonary bypass.Hospital with intensive care unit and hypothermia experience or (preferably) unit with cardiopulmonary bypass. 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.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.Be ready to commence resuscitation. Hospital with intensive care unit and hypothermia experience or (preferably) unit with cardiopulmonary bypass.Hospital with intensive care unit and hypothermia experience or (preferably) unit with cardiopulmonary bypass.

11. Patient not breathing Exclude obvious fatal injuries.Exclude obvious fatal injuries. Start cardiopulmonary resuscitation, intubate the patient.Start cardiopulmonary resuscitation, intubate the patient. Check burial time and/or core temperature.Check burial time and/or core temperature. Asystole: triage only by the emergency physician or paramedic, aiming to differentiate hypothermia stage IVAsystole: 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. Exclude obvious fatal injuries.Exclude obvious fatal injuries. Start cardiopulmonary resuscitation, intubate the patient.Start cardiopulmonary resuscitation, intubate the patient. Check burial time and/or core temperature.Check burial time and/or core temperature. Asystole: triage only by the emergency physician or paramedic, aiming to differentiate hypothermia stage IVAsystole: 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 timeBurial time Core temperatureCore temperature Air pocketAir pocket Airway.Airway. Criteria: Burial timeBurial time Core temperatureCore temperature Air pocketAir pocket Airway.Airway.

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