In the event of an avalanche, the primary focus is on locating buried persons – by sight, sound, avalanche transceiver and probe – and excavating them. When digging out survivers, once the body is located, the first area to concentrate on is the head. It is vital to ensure a supply of oxygen as quickly as possible.

Autoren: Plattner, Dahlmann

The first aid measures that first responders need to carry out on-site after excavating survivors are quite complex and should be practiced regularly, in just the same way as searching with an avalanche transceiver needs to be practiced.

Here, we take you through three possible scenarios which you might be faced with following an avalanche burial and explain what first aid measures you should undertake.

These are based on the proven ABCDE approach, which is commonly employed by first responders.

German version says ‘Im Gegensatz zu Verschütteten-Suche  – is this correct? Seems like both methods need to be practiced

ABCDE approach

Situation 1
responsive

Situation 2
not responsive, but breathing

Situation 3
not responsive
and not breathing

ABCDE-Schema

Situation 1
ansprechbar

Situation 2
nicht ansprechbar, aber Atmung

Situation 3
nicht ansprechbar und keine Atmung

Airways

Stabilise the neck/cervical spine
head tilt chin lift
head tilt chin lift

B  Breathing

check upper body for injuries treat accordingly

check upper body for injuries
treat accordingly

5 initial rescue breaths CPR

C  Circulation

check for further injuries & stop any bleeding
Heat loss

check for further injuries & stop any bleeding
Heat loss?

CPR (Coronary Pulmonary Resuscitation) 30:2

D  Disability

Head injury
Head injury?

E  Else

improve environment and heat retention
reassure & empathise

improve environment and heat retention

reassess regularly and adapt treatment accordingly

ABCDE-approach

The ABCDE approach is a proven method for treating casualties in an emergency, whether as a paramedic or layperson. In mountain settings in particular, this systematic approach to assessing an injured person gives the first responder a confident approach and prioritises the correct order in which to administer first aid. It is as follows:

A for Airways
B for Breathing
C for Circulation
D for Disability
E for Environment/ Else

Situation 1: Victim is responsive

If the victim is responsive, there is less need for urgent immediate action. Continue carefully digging them out of the snow, and then begin running through the ABCDE approach. There is also no need to hurriedly transport the victim anywhere.

A Since the victim can talk, there is no cause for concern about their airways being clear. But because of the force of the impact of the avalanche, care should be taken with the neck. Try to stabilise the cervical spine area by supporting it with your hands.

B For B (Breathing) assess the frequency and strength of the victim’s breathing to check for any injuries to the chest. Make the victim as comfortable as possible.

For C (Circulation) check for injuries and stop any bleeding. Internal bleeding cannot be assessed or treated. It is extremely important to keep the victim warm/ prevent heat loss: That’s because haemostasis (blood clotting) only functions well if the body temperature is as close to normal as possible – shivering is a warning sign here.

So, clear away snow from around the head of the victim, put a hat on their head (if not already wearing one) raise their jacket hood, and cover them with a down jacket.

D (Disability/neurological status) is about checking the victim’s neurological functions, because avalanches can causehead injuries.

E (Environment, Else) improve the victim’s exposure and heat retention with a bivouac bag, space blanket or similar. How much effort is required here depends on when the professional rescue services are due to arrive: The shorter the waiting time (helicopter on its way), the less important it is to make big changes to the victim’s environment. If the head is in an awkward position, you might consider repositioning onto a freshly shovelled area, so it is aligned with the victim’s body, making sure this is done with minimal manipulation (neck vertebrae).

Victim is unresponsive (Situation 2 & 3)

In this scenario, there are two options:

  • Victim breathing (normally)
  • Victim not breathing (normally)
“Breathing normally” means: Once airways have been cleared if necessary (from snow, vomit etc.) and the chin has been lifted, breathing is assessed by looking, listening, and feeling for air exchange and establishing whether there is regular movement of the chest cavity at sufficient intervals (10 x/ minute or more). If in doubt or uncertain, the victim is to be categorised as ‘not breathing’.

“Not breathing normally” means: Breaths are either too infrequent (fewer than 9x/ minute), barely visible (chest does not rise and fall) or too fast (more than 30x/ minute). If the chest rises and falls at a normal pace, but you cannot feel any breath/ vapour against the the back of your hand, inspect and clear the airways once again from obstructions like snow, vomit etc., and check the chin is correctly lifted to extend the airways in a straight line.

If normal breathing cannot be ascertained, CPR (cardiopulmonary resuscitation) should be initiated.

Both scenarios require immediate appropriate action, because the victim’s life is in danger. However, it is important not to rush or go into ‘action mode’, but to proceed calmly, quickly and effectively. As with any first aid situation, and in the mountains in general, slow and steady wins the race.

In contrast to situation 1 the rest of the body is excavated as fast as possible because the first aid measures in this case can only be carried out on the person if they are on level ground or a prepared area of snow (compressed).

Situation 2: Victim is unresponsive, but breathing (normally)

Work through the ABCDE protocol. The emphasis here is on A for clearing the airways from obstructions and ideally performing a chin lift (also known as head tilt chin lift).

Then concentrate on B (breathing) by repeatedly asking yourself whether their breathing rate is still sufficient.

For C (circulation), proceed as in Situation 1 (victim is responsive), and likewise with D (disability) and E (environment).

Using the head tilt chin lift to keep airways clear. Photos: argonaut.pro

In this particular case, the airway needs to be manually assisted to remain open, and there is a risk of breathing deteriorating at any moment.

Therefore:

  • The person holding the victim’s head cannot move from this position.
  • Attempt to put the victim into the recovery position (or on their back with the option of performing a log roll).
  • Prepare for CPR (solid or compressed ground).
  • Clear away any remaining snow from the victim as quickly as possible and carefully reposition them on a prepared flattened surface – also known as rapid rescue.

Thereafter, keep running through the ABCDE procedure and look for further injuries or abnormalities (especially bleeding in C – heat preservation is vital here and head injuries in D).

Situation 3: Victim is unresponsive and not breathing (normally)

If (normal) breathing cannot be ascertained, begin CPR (cardiopulmonary resuscitation).

If the answer to the following two questions is no, you are facing a worst case scenario:

  • Can the victim respond? No, no response.
  • Is the victim breathing? No, not breathing.

Now the following are of utmost priority:

  • A and B breathing
  • Thoracic compressions in C

After checking for breathing, immediately begin administering rescue breaths. Use the classic mouth-to-mouth resuscitation method (even better would be using a pocket face mask) : Carry out five rescue breaths initially. Once the five breaths have been administered, if there is someone with you to help, they should immediately start with 30 chest compressions — and continue with CPR at a rate of 30:2 compression to breath ratio (if alone, you will have to do both the breathing and compressions).

In avalanche situations it is sometimes difficult to perform thoracic compressions on the snow because the undergound needs to be firm. Ideally this would occur on a preapred surface that has been shovelled or stomped flat to compress the snow.

Resuscitation is now performed as normal using 30:2 CPR, for which three people is an ideal team size: A ‘monitor’ at the head of the victim, monitoring the situation and feeding back to the ‘compressors’. The compressors should swap positions every two minutes and work hard and fast.

Effective CPR must be carefully coordinated with pauses in thoracic compression only for administering air. If there is an AED (Automatic External Defibrillator) in the vicinity, for instance at a mountain hut, lift station etc. then immediately arrange for the AED to be brought to the scene of the accident and deployed.

Ideally, an AED should be used for all CPR attempts.

Plain-speaking

There are a few myths on the subject of administering first aid after an avalanche burial that persist and keep doing the rounds… So here are a few hard facts:

  • CPR is always initiated according to the above table unless there is danger to rescuers, or the casualty has sustained lethal injuries (e.g. severed trunk).
  • The issue of what further treatment should be administered is not the responsibility of first aiders.
  • Prevent any further undercooling/ hypothermia is of the greatest importance.
  • Shivering is a warning sign that hypothermia is setting in, but if the shivering stops, you are facing an even bigger emergency.
  • Hypothermic patients can be moved if necessary to take further measures (making sure they are moved in an aligned, level position).
  • A ‘breathing hole’ in the snow is not what is meant, only whether the airways (mouth/throat) are free of snow/ice, i.e. whether breathing is physically possible. Continue working through ABCDE as normal. When handing over to professional rescue services, carefully describe what you did in A and B in order for them to breathe.
  • When administering CPR, the victim should be lying on their back on a hard surface, because in order to perform chest compressions it is important to have solid resistance. While organising this, only administer rescue breaths to the victim. It is better to delay the start of chest compressions than to perform inefficient compressions.