Critically buried avalanche victims can develop severe hypothermia in less than 60 minutes

Abstract Background A major challenge in the management of avalanche victims in cardiac arrest is differentiating hypothermic from non-hypothermic cardiac arrest, as management and prognosis differ. Duration of burial with a cutoff of 60 min is currently recommended by the resuscitation guidelines as a parameter to aid in this differentiation This, because the fastest cooling rate under the snow reported so far is 9.4°C per hour, suggesting that it would take >60 min to cool below 30°C, which is the temperature threshold below which a hypothermic cardiac arrest can occur. Case presentation We describe a case with a cooling rate of 14°C per hour, assessed on site with an oesophageal temperature probe. The patient was transported under continuous mechanical CPR to an ECLS facility and rewarmed with VA-ECMO, although his HOPE score was 3 % only. After three days he developed brain death and became an organ donor. Conclusions With this case we would like to underline three important aspects: first, whenever possible, core body temperature should be used instead of burial duration to make triage decisions. Second, the HOPE score, which is not well validated for avalanche victims, had a good discriminatory ability in our case. Third, although extracorporeal rewarming was futile for the patient, he donated his organs. Thus, even if the probability of survival of a hypothermic avalanche patient is low based on the HOPE score, ECLS should not be withheld by default and the possibility of organ donation should be considered.