Letter to the Editor
HIGH ALTITUDE MEDICINE & BIOLOGY Volume 13, Number 4, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/ham.2012.1072
Pulmonary Edema after Complete Avalanche Burial Guenther Sumann,1,2 Gabriel Putzer,3 Hermann Brugger,2,4 and Peter Paal 3,4
A
48-year-old female backcountry skier was completely buried by an avalanche 50 cm under snow and was extricated by her companions after *20–30 min. At arrival of the emergency physician by helicopter, the victim was just extricated, agitated, and in respiratory distress. She had a Glasgow Coma Scale (GCS) of 14, pulse oximetry of 86%, heart rate of 130 min - 1, and epitympanic core body temperature of 32.0C. (Gilbert Metraux, Crissier, Switzerland) The patient was placed into a thermo-rescue-bag, received 6 Lmin - 1 oxygen by facemask and was transported to the hospital by helicopter. The patient arrived in the emergency room 31 min after the beginning of prehospital treatment. There she had a GCS of 15, central cyanosis, tachypnea and coughing, and a pulse oximetry of 92% (with 6 Lmin - 1 oxygen), heart rate of 120 min - 1, blood pressure of 120/70mmHg and an epitympanic core body temperature of 33.8C. (Ototemp 3000 Special Duty, Exergen, Watertown, MA) According to the Innsbruck emergency room algorithm, a head-trunk CT-scan was performed, which showed bilateral alveolar fluid accumulation consistent with lung contusions and pulmonary edema. No other pathologies were detected. At 40 min postadmission, the patient became severely dyspnoic and showed clinical signs of pulmonary edema. After anesthetization and endotracheal intubation, the patient was ventilated with an inspiratory oxygen fraction (Fio2) of 1.0 and positive endexpiratory pressure (PEEP) of 10 mbar. (1 mbar = 1.02 cm H2O) Arterial oxygen partial pressure was 73.6 mmHg and arterial carbon dioxide partial pressure was 56.2 mmHg. While there was no evidence for cardiac dysfunction, a chest x-ray showed bilateral pulmonary edema (Fig. 1A). The patient was transferred to the ICU and rewarmed within 2 hours by external forced air rewarming blankets. Within 3 hours, the oxygenation improved markedly and Fio2 was reduced to 0.35. After 8 hours of ventilation, the patient was breathing spontaneously on continuous positive airway pressure (CPAP). After 16 h, she was extubated and breathing sufficiently with supplemental oxygen and intermittent CPAP therapy; the chest x-ray revealed no residual pulmonary edema. On day three, respiratory function was stable and oxygenation and chest x-ray (Fig. 1B) were normal. The patient was discharged from the hospital, and she recovered quickly at home. The patient was athletic and her medical history was unremarkable, apart from the avalanche burial.
Pulmonary edema has been reported in a 51-year-old female who sustained complete avalanche burial for approximately 20 min with a core body temperature of 32C at
FIG. 1. Chest x-ray shows bilateral pulmonary edema (A). On day three, chest x-ray was normal (B).
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Department of Anesthesiology and Intensive Care Medicine, District Hospital of Voecklabruck, Voecklabruck, Austria. International Commission for Mountain Emergency Medicine (ICAR MEDCOM). 3 Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria. 4 EURAC Institute of Mountain Emergency Medicine, Bozen/Bolzano, Italy. 2
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296 extrication and who recovered with diuretics and CPAP only. (Schmid, 1981) Recently, a 42-year-old male with pulmonary edema during forced-air rewarming from 24.7C core body temperature after complete burial for more than 2 hours has also been reported (Strapazzon et al., 2011). The incidence and the risk of pulmonary edema after avalanche burial are uncertain and are very likely under-reported. The etiology of post-burial pulmonary edema is unclear but may be a combination of negative-pressure pulmonary edema (Fremont et al., 2007), hypoxia-induced pulmonary artery hypertension, and hypoxia-induced left heart insufficiency. When caring for a complete avalanche burial patient, the potential injury pattern (Hohlrieder et al., 2007), the current treatment guidelines (Brugger et al., 2011), and the risk of a pulmonary edema must be considered. Thus, the patient should be transferred to a hospital that is capable of treating pulmonary edema with oxygen administration and positive-pressure ventilation. In conclusion, we report a female patient who was completely buried by an avalanche for 20–30 min and who developed severe respiratory failure due to pulmonary edema. More research is needed to evaluate post-avalanche burial pulmonary edema. Disclosure Statement The authors have no competing interests or financial ties to disclose.
SUMANN ET AL. References Brugger H, Paal P, and Boyd J. (2011). Prehospital resuscitation of the buried avalanche victim. High Alt Med Biol 12:199–205. Fremont RD, Kallet RH, Matthay MA, and Ware LB. (2007). Postobstructive pulmonary edema: A case for hydrostatic mechanisms. Chest 131:1742–1746. Hohlrieder M, Brugger H, Schubert HM, Pavlic M, Ellerton J, and Mair P. (2007). Pattern and severity of injury in avalanche victims. High Alt Med Biol 8:56–61. Schmid F. (1981). [The pathogenesis of pulmonary edema after being buried by an avalanche]. Schweiz Med Wochenschr 111:1441–1445 [Article in German]. Strapazzon G, Nardin M, Zanon P, Kaufmann M, Kritzinger M, and Brugger H. (2012). Respiratory failure and spontaneous hypoglycemia during noninvasive rewarming from 24.7 degrees C (76.5 degrees F) core body temperature after prolonged avalanche burial. Ann Emerg Med 60:193–196.
Address correspondence to: Dr. Guenther Sumann Department of Anesthesiology and Intensive Care Medicine District Hospital of Voecklabruck Dr. Wilhelm Bock Str. 1 4840 Voecklabruck Austria E-mail:
[email protected]
