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Tanaka S, Nakagawa K, Kanagawa Y, Katsurahara T, Kozakai K, Tsuhako K, Yoshikawa F, Gotoh S, Osanai K, Sono M, Inoue H, Sakanashi S, Takahashi H, Tanaka H. Quality of Cardiopulmonary Resuscitation in Avalanche Victims with a Single Rescuer: A Prospective, Crossover, Manikin Pilot Study. High Alt Med Biol 2024; 25:60-67. [PMID: 38364189 DOI: 10.1089/ham.2023.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
Tanaka, Shota, Koshi Nakagawa, Yosuke Kanagawa, Takashi Katsurahara, Kazuki Kozakai, Ken Tsuhako, Fumitaka Yoshikawa, Soh Gotoh, Kensuke Osanai, Madoka Sono, Hironori Inoue, Shuji Sakanashi, Hiroyuki Takahashi, and Hideharu Tanaka. Quality of cardiopulmonary resuscitation in avalanche victims with a single rescuer: a prospective, crossover, manikin pilot study. High Alt Med Biol. 25:60-67, 2024. Background: Winter outdoor recreational activities such as off-piste skiing have gained popularity and, as a result, the number of avalanche-related deaths has increased. However, the quality of cardiopulmonary resuscitation (CPR) at avalanche sites remains unclear. Our study compared the quality of CPR performed in a simulated avalanche burial on a snowy mountain with that performed indoors. Methods: Ten prehospital health care providers participated in the crossover pilot study. Various methods, including over-the-head CPR (OTH-CPR) and standard CPR, were used to perform avalanche resuscitation, with five rescue breaths, followed by 30 chest compressions and two breaths. The quality CPR was judged by four variables of chest compression and ventilation. Results: The OTH-CPR performed indoors was better in quality: 5.33% [95% confidence interval (CI) -14.2 to 3.5] higher in adequate compression depth (94.3 ± 10.6% on the snow vs. 99.3 ± 1.1% indoors), 3.4% [95% CI -16.1 to 22.9] higher in adequate compression rate (70.4 ± 38.0% vs. 76.1 ± 35.7%), and 2.3% [95% CI -6.4 to 1.72] higher in adequate recoil (96.9 ± 4.8% vs. 99.2 ± 1.6%) than OTH-CPR on the snow. In terms of ventilation quality, OTH-CPR performed indoors had a 50% higher ventilation score [95% CI -73.0 to -27.0] than OTH-CPR on the snow (1.4 ± 4.3% vs. 45.9 ± 32.6%, Cohen's d = -1.81). Conclusions: Chest compression quality was slightly impaired in the avalanche scenarios on the snow than in indoor settings. Asphyxiation is the main cause of avalanche-related deaths; however, low ventilation quality was observed on snow compared with the indoor setting.
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Affiliation(s)
- Shota Tanaka
- Research Institute of Disaster Management and EMS, Kokushikan University, Tama City, Tokyo, Japan
| | - Koshi Nakagawa
- Graduate School of Emergency Medical System, Kokushikan University, Tama City, Tokyo, Japan
| | - Yosuke Kanagawa
- School of Emergency Medical Science, Meiji University of Integrative Medicine, Kyoto, Japan
| | - Takashi Katsurahara
- Graduate School of Emergency Medical System, Kokushikan University, Tama City, Tokyo, Japan
| | - Kazuki Kozakai
- Graduate School of Emergency Medical System, Kokushikan University, Tama City, Tokyo, Japan
| | - Ken Tsuhako
- Department of Sports Medicine, Kokushikan University, Tama City, Tokyo, Japan
| | - Fumitaka Yoshikawa
- Research Institute of Disaster Management and EMS, Kokushikan University, Tama City, Tokyo, Japan
| | - Soh Gotoh
- Japan Emergency Medical System Co., Ltd., Miyazaki, Japan
| | | | - Madoka Sono
- Graduate School of Emergency Medical System, Kokushikan University, Tama City, Tokyo, Japan
| | - Hironori Inoue
- Graduate School of Emergency Medical System, Kokushikan University, Tama City, Tokyo, Japan
| | - Shuji Sakanashi
- Department of Sports Medicine, Kokushikan University, Tama City, Tokyo, Japan
| | - Hiroyuki Takahashi
- Research Institute of Disaster Management and EMS, Kokushikan University, Tama City, Tokyo, Japan
- Department of Sports Medicine, Kokushikan University, Tama City, Tokyo, Japan
| | - Hideharu Tanaka
- Research Institute of Disaster Management and EMS, Kokushikan University, Tama City, Tokyo, Japan
- Graduate School of Emergency Medical System, Kokushikan University, Tama City, Tokyo, Japan
- Department of Sports Medicine, Kokushikan University, Tama City, Tokyo, Japan
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Van Tilburg C, Paal P, Strapazzon G, Grissom CK, Haegeli P, Hölzl N, McIntosh S, Radwin M, Smith WWR, Thomas S, Tremper B, Weber D, Wheeler AR, Zafren K, Brugger H. Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update. Wilderness Environ Med 2024; 35:20S-44S. [PMID: 37945433 DOI: 10.1016/j.wem.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/03/2023] [Accepted: 05/10/2023] [Indexed: 11/12/2023]
Abstract
To provide guidance to the general public, clinicians, and avalanche professionals about best practices, the Wilderness Medical Society convened an expert panel to revise the evidence-based guidelines for the prevention, rescue, and resuscitation of avalanche and nonavalanche snow burial victims. The original panel authored the Wilderness Medical Society Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents in 2017. A second panel was convened to update these guidelines and make recommendations based on quality of supporting evidence.
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Affiliation(s)
- Christopher Van Tilburg
- Occupational Medicine, Mountain Clinic, and Emergency Medicine, Providence Hood River Memorial Hospital, Hood River, OR
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | - Peter Paal
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Giacomo Strapazzon
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Colin K Grissom
- Department of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT
| | | | - Natalie Hölzl
- International Commission for Alpine Rescue
- German Association of Mountain and Expedition Medicine, Munich, Germany
| | - Scott McIntosh
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | | | - William Will R Smith
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
- University of Washington School of Medicine, Seattle, WA
| | - Stephanie Thomas
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | | | - David Weber
- Intermountain Life Flight, Salt Lake City, UT
| | - Albert R Wheeler
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
| | - Ken Zafren
- International Commission for Alpine Rescue
- Himalayan Rescue Association, Kathmandu, Nepal
- Stanford University Medical Center, Palo Alto, CA
| | - Hermann Brugger
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
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Pasquier M, Strapazzon G, Kottmann A, Paal P, Zafren K, Oshiro K, Artoni C, Van Tilburg C, Sheets A, Ellerton J, McLaughlin K, Gordon L, Martin RW, Jacob M, Musi M, Blancher M, Jaques C, Brugger H. On-site treatment of avalanche victims: Scoping review and 2023 recommendations of the international commission for mountain emergency medicine (ICAR MedCom). Resuscitation 2023; 184:109708. [PMID: 36709825 DOI: 10.1016/j.resuscitation.2023.109708] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The International Commission for Mountain Emergency Medicine (ICAR MedCom) developed updated recommendations for the management of avalanche victims. METHODS ICAR MedCom created Population Intervention Comparator Outcome (PICO) questions and conducted a scoping review of the literature. We evaluated and graded the evidence using the American College of Chest Physicians system. RESULTS We included 120 studies including original data in the qualitative synthesis. There were 45 retrospective studies (38%), 44 case reports or case series (37%), and 18 prospective studies on volunteers (15%). The main cause of death from avalanche burial was asphyxia (range of all studies 65-100%). Trauma was the second most common cause of death (5-29%). Hypothermia accounted for few deaths (0-4%). CONCLUSIONS AND RECOMMENDATIONS For a victim with a burial time ≤ 60 minutes without signs of life, presume asphyxia and provide rescue breaths as soon as possible, regardless of airway patency. For a victim with a burial time > 60 minutes, no signs of life but a patent airway or airway with unknown patency, presume that a primary hypothermic CA has occurred and initiate cardiopulmonary resuscitation (CPR) unless temperature can be measured to rule out hypothermic cardiac arrest. For a victim buried > 60 minutes without signs of life and with an obstructed airway, if core temperature cannot be measured, rescuers can presume asphyxia-induced CA, and should not initiate CPR. If core temperature can be measured, for a victim without signs of life, with a patent airway, and with a core temperature < 30 °C attempt resuscitation, regardless of burial duration.
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Affiliation(s)
- M Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy; Medical University Innsbruck, Innsbruck, Austria; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zurich, Switzerland.
| | - A Kottmann
- Swiss Air Ambulance - Rega, Zurich Airport, Switzerland; Emergency Department, Lausanne University Hospital, Lausanne, Switzerland; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University Salzburg, Austria; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zurich, Switzerland
| | - K Zafren
- Department of Emergency Medicine, Alaska Native Medical Center Anchorage, Alaska, USA; Department of Emergency Medicine Stanford University Medical Center Stanford, CA, USA; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - K Oshiro
- Cardiovascular Department, Mountain Medicine, Research, & Survey Division, Hokkaido Ohno Memorial Hospital, Hokkaido, Japan; Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - C Artoni
- ICAR Avalanche Rescue Commission, Zürich, Switzerland.
| | - C Van Tilburg
- Providence Hood River Memorial Hospital, Hood River, Oregon, USA; Mountain Rescue Association, USA; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA; University of Colorado Wilderness and Environmental Medicine Fellowship Faculty, Aurora, CO, USA; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - J Ellerton
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - K McLaughlin
- Canmore Hospital, Alberta, Canada; University of Calgary, Canada; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - L Gordon
- Department of Anaesthesia, University Hospitals of Morecambe Bay Trust, Lancaster, England; Langdale Ambleside Mountain Rescue Team, England; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - R W Martin
- Mountain Rescue Association, USA; ICAR Avalanche Rescue Commission, Zürich, Switzerland.
| | - M Jacob
- Bavarian Mountain Rescue Service, Bad Tölz, Germany; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - M Musi
- Emergency Department, University of Colorado, Aurora, Colorado, USA; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - M Blancher
- Department of Emergency Medicine, University Hospital of Grenoble Alps Grenoble, France; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.
| | - C Jaques
- Lausanne University Medical Library, Lausanne, Switzerland.
| | - H Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy; Medical University Innsbruck, Innsbruck, Austria; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zurich, Switzerland.
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Prevention of Hypothermia in the Aftermath of Natural Disasters in Areas at Risk of Avalanches, Earthquakes, Tsunamis and Floods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031098. [PMID: 35162119 PMCID: PMC8834683 DOI: 10.3390/ijerph19031098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 11/17/2022]
Abstract
Throughout history, accidental hypothermia has accompanied natural disasters in cold, temperate, and even subtropical regions. We conducted a non-systematic review of the causes and means of preventing accidental hypothermia after natural disasters caused by avalanches, earthquakes, tsunamis, and floods. Before a disaster occurs, preventive measures are required, such as accurate disaster risk analysis for given areas, hazard mapping and warning, protecting existing structures within hazard zones to the greatest extent possible, building structures outside hazard zones, and organising rapid and effective rescue. After the event, post hoc analyses of failures, and implementation of corrective actions will reduce the risk of accidental hypothermia in future disasters.
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On-Site Medical Management of Avalanche Victims-A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910234. [PMID: 34639535 PMCID: PMC8507645 DOI: 10.3390/ijerph181910234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/18/2021] [Accepted: 09/19/2021] [Indexed: 12/26/2022]
Abstract
Avalanche accidents are common in mountain regions and approximately 100 fatalities are counted in Europe each year. The average mortality rate is about 25% and survival chances are mainly determined by the degree and duration of avalanche burial, the patency of the airway, the presence of an air pocket, snow characteristics, and the severity of traumatic injuries. The most common cause of death in completely buried avalanche victims is asphyxia followed by trauma. Hypothermia accounts for a minority of deaths; however, hypothermic cardiac arrest has a favorable prognosis and prolonged resuscitation and extracorporeal rewarming are indicated. In this article, we give an overview on the pathophysiology and on-site management of avalanche victims.
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Wallner B, Strapazzon G, Brugger H. Is there any reason for prone cardiopulmonary resuscitation in avalanche victims? Resuscitation 2021; 167:198-199. [PMID: 34480977 PMCID: PMC8428892 DOI: 10.1016/j.resuscitation.2021.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 10/26/2022]
Affiliation(s)
- Bernd Wallner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy.
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC Research, Medical University Innsbruck, Austria; International Commission for Mountain Emergency Medicine ICAR MEDCOM, Drususallee 1, 39100 Bolzano, Italy.
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Medical University Innsbruck, Austria; International Commission for Mountain Emergency Medicine ICAR MEDCOM, Drususallee 1, 39100 Bolzano, Italy.
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Wallner B, Moroder L, Salchner H, Mair P, Wallner S, Putzer G, Strapazzon G, Falk M, Brugger H. CPR with restricted patient access using alternative rescuer positions: a randomised cross-over manikin study simulating the CPR scenario after avalanche burial. Scand J Trauma Resusc Emerg Med 2021; 29:129. [PMID: 34481521 PMCID: PMC8418718 DOI: 10.1186/s13049-021-00944-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023] Open
Abstract
Background The aim of this manikin study was to evaluate the quality of cardiopulmonary resuscitation (CPR) with restricted patient access during simulated avalanche rescue using over-the-head and straddle position as compared to standard position. Methods In this prospective, randomised cross-over study, 25 medical students (64% male, mean age 24) performed single-rescuer CPR with restricted patient access in over-the-head and straddle position using mouth-to-mouth ventilation or pocket mask ventilation. Chest compression depth, rate, hand position, recoil, compression/decompression ratio, hands-off times, tidal volume of ventilation and gastric insufflation were compared to CPR with unrestricted patient access in standard position. Results Only 28% of all tidal volumes conformed to the guidelines (400–800 ml), 59% were below 400 ml and 13% were above 800 ml. There was no significant difference in ventilation parameters when comparing standard to atypical rescuer positions. Participants performed sufficient chest compressions depth in 98.1%, a minimum rate in 94.7%, correct compression recoil in 43.8% and correct hand position in 97.3% with no difference between standard and atypical rescuer positions. In 36.9% hands-off times were longer than 9 s. Conclusions Efficacy of CPR from an atypical rescuer position with restricted patient access is comparable to CPR in standard rescuer position. Our data suggest to start basic life-support before complete extrication in order to reduce the duration of untreated cardiac arrest in avalanche rescue. Ventilation quality provided by lay rescuers may be a limiting factor in resuscitation situations where rescue ventilation is considered essential.
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Affiliation(s)
- Bernd Wallner
- Department of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University Hospital, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. .,Institute of Mountain Emergency Medicine, Eurac Research, Viale Druso 1, 39100, Bolzano, Italy.
| | - Luca Moroder
- Department of Anaesthesiology and Critical Care Medicine, Hospital of Bolzano, Lorenz Böhler Strasse 5, 39100, Bolzano, Italy
| | - Hannah Salchner
- Department of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University Hospital, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University Hospital, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Stefanie Wallner
- Department of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University Hospital, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gabriel Putzer
- Department of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University Hospital, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Viale Druso 1, 39100, Bolzano, Italy
| | - Markus Falk
- Institute of Mountain Emergency Medicine, Eurac Research, Viale Druso 1, 39100, Bolzano, Italy.,eScience, Sonnenstrasse 11, 39031, Bruneck, Italy
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Viale Druso 1, 39100, Bolzano, Italy
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Strapazzon G, Schweizer J, Chiambretti I, Brodmann Maeder M, Brugger H, Zafren K. Effects of Climate Change on Avalanche Accidents and Survival. Front Physiol 2021; 12:639433. [PMID: 33912070 PMCID: PMC8072472 DOI: 10.3389/fphys.2021.639433] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Avalanches are major natural hazards in snow-covered mountains, threatening people and infrastructure. With ongoing climate change, the frequency and types of snow avalanches may change, affecting the rates of avalanche burial and survival. With a wetter and warmer snow climate, consequences of burial may become more severe. In this review, we assess the potential effects of climate change on the frequency and characteristics of avalanches. We then discuss how these changes might affect the survival rates of subjects buried by avalanches and might influence the responses of search and rescue (SAR) teams and health care providers. While climate change is inevitable, the effects on avalanches remain elusive. The frequency of human triggered avalanches may not change, because this depends largely on the number and behavior of winter recreationists. Blunt trauma and secondary injuries will likely become more frequent as terrain roughness is expected to rise and snow cover to become thinner. Higher snow densities in avalanche debris will likely interfere with the respiration of completely buried victims. Asphyxia and trauma, as causes of avalanche death, may increase. It is unlikely that SAR and health care providers involved in avalanche rescue will have to change their strategies in areas where they are already established. The effects of climate change might foster the expansion of mitigation strategies and the establishment of mountain rescue services in areas subject to increased avalanche hazards caused by changes in snow cover and land use.
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Affiliation(s)
- Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - Jürg Schweizer
- WSL Institute for Snow and Avalanche Research SLF, Davos, Switzerland
| | - Igor Chiambretti
- AINEVA Interregional Association for Coordination and Documentation of Snow and Avalanche Problems, Trento, Italy
| | - Monika Brodmann Maeder
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,Department of Emergency Medicine, Inselspital University Hospital Bern and Bern University, Bern, Switzerland
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland.,Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK, United States.,Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, United States
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