The highest priorities for the mountain rescue team, including paramedics and doctors are to keep the airway open, to avoid large movements of the victim’s body and to avoid further heat loss.

If several buried victims must be treated simultaneously, the supportive care of surviving patients takes priority over resuscitation of buried ones without vital signs.

Treatment of the patients should take place in an area protected from the wind, either in the rescue pit or in a medical tent, in order to minimize heat loss due to low outside temperatures and wind.

If a victim is dug out alive, treatment of hypothermia is the most important medical measure (table 2). Even at the site of the accident, the degree of hypothermia should be evaluated according to the Swiss classification system (table 1). Core temperature can be measured, even by non-medical rescue personnel, using an epitympanic membrane (measurement by means of a soft probe inside the external auditory canal).

Although one must take into consideration that epitympanic temperature measurement may give falsely low readings, it provides a general indication of temperature trends during transport.

Table 1: Swiss classification of hypothermia.
As soon as possible, initiate cardiac monitoring to detect ventricular fibrillation or other arrhythmias provoked during extrication and patient transport.

Oxygen administration is mandatory because hypothermic avalanche victims may also be hypoxic and adequate oxygenation is an effective means of protecting against further heat loss.

The administration of drugs is not recommended in hypothermia stages III-IV due to the danger of provoking arrhythmias. In stage I-II, ACLS drugs may be administered, but with longer intervals between doses than in normothermic patients.

Volume therapy is not always necessary. If intravenous access is established, then infusion of D5NS is recommended.

Establishing intravenous access at the site of an accident in hypothermia can be dispensed with if it is too difficult because of peripheral vasoconstriction or if it would take too much time.

At core temperatures below 28° C (82.4° F) electrical defibrillation is generally unsuccessful in terminating ventricular fibrillation. After three unsuccessful attempts at defibrillation, patients with persistent ventricular fibrillation should be treated with uninterrupted CPR until they have been rewarmed.

If the patient is cardiac arrest (Stage IV), the mountain rescue team must start CPR and continue it until they hand the victim over to a subsequent rescue team or to the emergency physician.

Table 2: Initial treatment for hypothermic avalanche victims - depending on severity: Prehospital treatment of hypothermia of all stages is based on three basic principles: 1. extrication and positioning the victim with minimal movement, 2. protection from wind, 3. insulation. An awake patient who can swallow safely (Stage I or II) can be given hot, sweet drinks (without alcohol). An unconscious hypothermic patient (stage III) must be placed in a stable position on one side, if not intubated by the emergency doctor. In addition to insulation, supplemental oxygen can protect against further heat loss. When the patient is pulseless and apneic (stage IV), CPR must be continued without interruption until the patient reaches a hospital capable of cardiopulmonary bypass. The lay rescuer who begins CPR must continue it, in any event, until care is transfered to the subsequent rescue team or to the emrgency physician. If a buried victim is found pulseless and hypothermic, but with an air pocket, resuscitation must be continued until the patient is rewarmed in a hospital setting.

Figure 3: Algorithm for treatment of avalanche victims. * If transport to a hospital with cardiopulmonary bypass capability is not logistically possible, transport to the nearest hospital to determine serum potassium. Reprinted by permission of Elsevier Science from: Brugger H, Durrer B, Adler-Kastner L, Falk M, Tschirky F. Field management of avalanche victims. Resuscitation 2001;51:7-15,.