Please cite this article in press as: Boué Y, et al. Survival after avalanche-induced cardiac arrest. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.06.015 ARTICLE IN PRESS G Model RESUS 6054 1–5 Resuscitation xxx (2014) xxx–xxx Contents lists available at ScienceDirect Resuscitation j ourna l h o me pa g e : www.elsevier.com/locate/resuscitation Clinical paper Survival after avalanche-induced cardiac arrest  Yvonnick Boué a,b,c , Jean-Franc ¸ ois Payen a,b,c , Julien Brun a , Sébastien Thomas a , Q1 Albrice Levrat d , Marc Blancher e , Guillaume Debaty e , Pierre Bouzat a,b,c,∗ a Pole Anesthésie-Réanimation, Hôpital Michallon, Grenoble F-38043, France b Université Joseph Fourier, Grenoble Institut des Neurosciences, Grenoble F-38043, France c INSERM, U836, Grenoble F-38042, France d Service réanimation, Centre Hospitalier Région d’Annecy, Metz-Tessy, F-74370, France e Service Urgences-SAMU-SMUR, Hopital Michallon, Grenoble F-38043, France a r t i c l e i n f o Article history: Received 18 April 2014 Received in revised form 4 June 2014 Accepted 6 June 2014 Keywords: Cardiac arrest Avalanche Burial Hypothermia a b s t r a c t Aim: Criteria to prolong resuscitation after cardiac arrest (CA) induced by complete avalanche burial are critical since profound hypothermia could be involved. We sought parameters associated with survival in a cohort of victims of complete avalanche burial. Methods: Retrospective observational study of patients suffering CA on-scene after avalanche burial in the Northern French Alps between 1994 and 2013. Criteria associated with survival at discharge from the intensive care unit (ICU) were collected on scene and upon admission to Level-1 trauma center. Neurological outcome was assessed at 3 months using cerebral performance category score. Results: Forty-eight patients were studied. They were buried for a median time of 43 min (25–76 min; 25–75th percentiles) and had a pre-hospital body core temperature of 28.0 ◦ C (26.0–30.7). Eighteen patients (37.5%) had pre-hospital return of spontaneous circulation and 30 had refractory CA. Rewarming of 21 patients (43.7%) was performed using extracorporeal life support. Eight patients (16.7%) survived and were discharged from the ICU, three (6.3%) had favorable neurological outcome at 3 months. Pre- hospital parameters associated with survival were the presence of an air pocket and rescue collapse. On admission, survivors had lower serum potassium concentrations than non-survivors: 3.2 mmol/L (2.7–4.0) versus 5.6 mmol/L (4.2–8.0), respectively (P < 0.01). They also had normal values for prothrombin and activated partial thromboplastin compared to non-survivors. Conclusions: Our findings indicate that survival after avalanche burial and on-scene CA is rarely associated with favorable neurological outcome. Among criteria associated with survival, normal blood coagulation on admission warrants further investigation. © 2014 Published by Elsevier Ireland Ltd. 1. Introduction In North America and Europe, 150 patients are killed by avalanche burial every year, which corresponds to a mortality rate of 52% following complete burial. 1 There are three main causes of cardiac arrest (CA) following avalanche burial: asphyxia, severe trauma and/or profound hypothermia. 2,3 Asphyxia is the leading cause of death and poor neurological outcome, 2–5 although severe trauma can also lead to death or unfavorable outcome. 3–5 While less  A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.06.015. ∗ Corresponding author at: Pôle d’Anesthésie-Réanimation, Hôpital Albert Michal- lon, BP 217, F-38043 Grenoble, France. E-mail address: PBouzat@chu-grenoble.fr (P. Bouzat). frequent, 2,3 CA induced by isolated profound hypothermia is asso- ciated with better neurological recovery regardless the duration of burial. 6–9 In clinical practice, the exact cause of CA may be unclear because CA and profound hypothermia can be independently present in an avalanche burial situation. This may lead to futile prolonged resus- citation in the emergency room (ER), including extracorporeal life support (ECLS) rewarming, and inevitably raises the question of the usefulness of such treatments for all patients. In this regard, international guidelines recommend the termination of cardiopul- monary resuscitation (CPR) in buried patients with asystole if they are lethally injured or completely frozen, if the airway is packed with snow and the burial duration exceeds 35 min. 2 A serum potas- sium concentration higher than 12 mmol/L on hospital admission is another criterion used to terminate CPR. In view of the difficulties faced in the ER making a medical decision on this group of patients, http://dx.doi.org/10.1016/j.resuscitation.2014.06.015 0300-9572/© 2014 Published by Elsevier Ireland Ltd. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47