EURAC Institute of Mountain Emergency Medicine

Bolzano, Italy

EURAC Institute of Mountain Emergency Medicine

Bolzano, Italy
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Strapazzon G.,EURAC Institute of Mountain Emergency Medicine | Nardin M.,General Hospital of Bolzano | Zanon P.,General Hospital of Bolzano | Kaufmann M.,Innsbruck Medical University | And 2 more authors.
Annals of Emergency Medicine | Year: 2012

Clinical reports on management and rewarming complications after prolonged avalanche burial are not common. We present a case of an unreported combination of respiratory failure and unexpected spontaneous hypoglycemia during noninvasive rewarming from severe hypothermia. We collected anecdotal observations in a 42-year-old, previously healthy, male backcountry skier admitted to the ICU at a tertiary care center after 2 hours 7 minutes of complete avalanche burial, who presented with a patent airway and a core body temperature of 25.0°C (77.0°F) on extrication. There was no decrease in core body temperature during transport (from 25.0°C [77.0°F] to 24.7°C [76.5°F]). Atrial fibrillation occurred during active noninvasive external rewarming (to 37.0°C [98.6°F] during 5 hours), followed by pulmonary edema and respiratory failure (SaO 2 73% and PaO 2/FIO 2 161 mm Hg), which resolved with endotracheal intubation and continuous positive end-respiratory pressure. Moreover, a marked spontaneous glycemic imbalance (from 22.2 to 1.4 mmol/L) was observed. Despite a possible favorable outcome, clinicians should be prepared to identify and treat severe respiratory problems and spontaneous hypoglycemia during noninvasive rewarming of severely hypothermic avalanche victims. © 2011 American College of Emergency Physicians.

Marland S.,Care Flight | Marland S.,University of Leicester | Ellerton J.,Penrith Health Center | Andolfatto G.,University of British Columbia | And 6 more authors.
CNS Neuroscience and Therapeutics | Year: 2013

The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations. © 2013 John Wiley & Sons Ltd.

Gruber E.,Hospital of Bruneck | Oberhammer R.,Hospital of Bruneck | Balkenhol K.,EURAC Institute of Mountain Emergency Medicine | Strapazzon G.,EURAC Institute of Mountain Emergency Medicine | And 4 more authors.
Resuscitation | Year: 2014

Objective: In some emergency situations resuscitation and ventilation may have to be performed by basic life support trained personnel, especially in rural areas where arrival of advanced life support teams can be delayed. The use of advanced airway devices such as endotracheal intubation has been deemphasized for basically-trained personnel, but it is unclear whether supraglottic airway devices are advisable over traditional mask-ventilation. Methods: In this prospective, randomized clinical single-centre trial we compared airway management and ventilation performed by nurses using facemask, laryngeal mask Supreme (LMA-S) and laryngeal tube suction-disposable (LTS-D). Basic life support trained nurses (n= 20) received one-hour practical training with each device. ASA 1-2 patients scheduled for elective surgery were included (n= 150). After induction of anaesthesia and neuromuscular block nurses had two 90-second attempts to manage the airway and ventilate the patient with volume-controlled ventilation. Results: Ventilation failed in 34% of patients with facemask, 2% with LMA-S and 22% with LTS-D (P<0.001). In patients who could be ventilated successfully mean tidal volume was 240±210ml with facemask, 470±120ml with LMA-S and 470±140ml with LTS-D (P<0.001). Leak pressure was lower with LMA-S (23.3±10.8cm H2O, 95% CI 20.2-26.4) than with LTS-D (28.9±13.9cm·H2O, 95% CI 24.4-33.4; P=0.047). Conclusions: After one hour of introductory training, nurses were able to use LMA-S more effectively than facemask and LTS-D. High ventilation failure rates with facemask and LTS-D may indicate that additional training is required to perform airway management adequately with these devices. High-level trials are needed to confirm these results in cardiac arrest patients. © 2014 Elsevier Ireland Ltd.

Foresta C.,University of Padua | Strapazzon G.,University of Padua | Strapazzon G.,EURAC Institute of Mountain Emergency Medicine | De Toni L.,University of Padua | And 5 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2011

Working Hypothesis: Mutations in the CYP2R1 gene, highly expressed in the testis and encoding vitamin D 25-hydroxylase, result in a vitamin D deficiency and a defective calcium homeostasis leading to rickets. Objective: Our aim was to investigate CYP2R1 expression in pathological testis samples and relate this to vitamin D metabolism in testiculopathic patients. Design, Patients, Setting: Testis samples for in vitro study and 98 young men were transversally evaluated at Padova's Center for Male Gamete Cryopreservation. Methods: CYP2R1 mRNA expression and protein production were evaluated by quantitative RTPCR, Western blot analysis, and immunofluorescence. Hormonal and bone-marker levels, and bone densitometry by dual-energy x-ray absorptiometry, were determined in patients with Sertoli-cellonly syndrome and severe hypospermatogenesis. Results:Wefound a lower gene and protein expression of CYP2R1 in samples with hypospermatogenesis and Sertoli-cell-only syndrome (P < 0.05) and a colocalization with INSL-3, a Leydig cell marker, at immunofluorescence. In all testiculopathic patients 25-hydroxyvitamin D levels were significantly lower and PTH levels higher compared to controls (P < 0.05). Furthermore, testiculopathic patients showed osteopenia and osteoporosis despite normal testosterone levels compared with controls both with increased bone-marker levels and altered dual-energy x-ray absorptiometry in the femoral neck and lumbar spine (for all parameters, P < 0.05). Conclusions: Our data show an association between testiculopathy and alteration of the bone status, despite unvaried androgen and estrogen levels and no other evident cause of vitamin D reduction. Further studies in larger cohorts are needed to confirm our results. Copyright © 2011 by The Endocrine Society.

Boyd J.,Mineral Springs Hospital | Brugger H.,EURAC Institute of Mountain Emergency Medicine | Brugger H.,Innsbruck Medical University | Shuster M.,Mineral Springs Hospital
Resuscitation | Year: 2010

Objective: Avalanche resuscitation will save lives if focussed on victims that have the potential to survive. The purpose of this systematic review was to examine 4 critical prognostic factors for burial victims in cardiac arrest. Methods: Time of burial, airway patency, core temperature and serum potassium level were analyzed as PICO (Patient/population, Intervention, Comparator, Outcome) questions within the 2010 Consensus on Science process of the International Liaison Committee on Resuscitation. The electronic databases of Medline via PubMed, EMBASE via OVID and the Cochrane Database of Systematic Reviews were searched using combinations of the search terms "avalanche", "air pocket", "hypothermia" and "serum potassium" Results: Of 1910 publications that were identified 30 were found relevant. The predictive value for survival of a short time of burial or a patent airway after 35 min of burial is supported by 10 retrospective case-control studies, 4 case series and 2 experimental studies, while no studies are neutral or opposed. A core temperature of less than 32 °C with a patent airway is supported by 2 retrospective case-control studies and 3 case series, while 10 studies are neutral. Serum potassium level is supported by 6 retrospective case-control studies and 3 case reports, while 3 retrospective case-control studies and 1 animal model are neutral. Conclusion: After 35 min of burial, or where the core temperature is less than 32 °C, a patent airway is associated with survival to hospital discharge. A serum potassium of less than 7 mmol/L may be a valuable indicator for survival when other indicators are unclear. These findings should modify the current avalanche resuscitation scheme. © 2010 Elsevier Ireland Ltd.

Paal P.,Innsbruck Medical University | Strapazzon G.,EURAC Institute of Mountain Emergency Medicine | Braun P.,Innsbruck Medical University | Ellmauer P.P.,Innsbruck Medical University | And 7 more authors.
Resuscitation | Year: 2013

Background and aim: The majority of avalanche victims who sustain complete burial die within 35. min due to asphyxia and injuries. After 35. min, survival is possible only in the presence of a patent airway, and an accompanying air pocket around the face may improve survival. At this stage hypothermia is assumed to be an important factor for survival because rapid cooling decreases oxygen consumption; if deep hypothermia develops before cardiac arrest, hypothermia may be protective and prolong the time that cardiac arrest can be survived. The aim of the study was to investigate the combined effects of hypoxia, hypercapnia and hypothermia in a porcine model of avalanche burial. Methods: Eight piglets were anaesthetised, intubated and buried under snow, randomly assigned to an air pocket (. n=. 5) or ambient air (. n=. 3) group. Results: Mean cooling rates in the first 10min of burial were -19.7±4.7°Ch-1 in the air pocket group and -13.0±4.4°Ch-1 in the ambient air group (P=0.095); overall cooling rates between baseline and asystole were -4.7±1.4°Ch-1 and -4.6±0.2°Ch-1 (P=0.855), respectively. In the air pocket group cardiac output (P=0.002), arterial oxygen partial pressure (P=0.001), arterial pH (P=0.002) and time to asystole (P=0.025) were lower, while arterial carbon dioxide partial pressure (P=0.007) and serum potassium (P=0.042) were higher compared to the ambient air group. Conclusion: Our results demonstrate that hypothermia may develop in the early phase of avalanche burial and severe asphyxia may occur even in the presence of an air pocket. © 2012 Elsevier Ireland Ltd.

Strapazzon G.,EURAC Institute of Mountain Emergency Medicine | Procter E.,EURAC Institute of Mountain Emergency Medicine | Paal P.,Innsbruck Medical University | Brugger H.,EURAC Institute of Mountain Emergency Medicine
High Altitude Medicine and Biology | Year: 2014

Core temperature (Tcore) measurement is the only diagnostic tool to accurately assess the severity of hypothermia. International recommendations for management of accidental hypothermia encourage Tcore measurement for triage treatment and transport decisions but they also recognize that lack of equipment may be a limiting factor particularly in the field. The aim of this nonsystematic review is to highlight the importance of field measurement of Tcore and to provide practical guidance for clinicians on pre-hospital temperature measurement in accidental and therapeutic hypothermia. Clinicians should recognize the difference between alternative measurement locations and available thermometers tailoring their decision to the purpose of the measurement (i.e. intermittent vs. continual measurement) and the impact on management decisions. The importance of Tcore measurement in therapeutic hypothermia protocols during early cooling and monitoring of target temperature is discussed. © 2014 Mary Ann Liebert Inc.

Foresta C.,University of Padua | Strapazzon G.,University of Padua | Strapazzon G.,EURAC Institute of Mountain Emergency Medicine | De Toni L.,University of Padua | And 5 more authors.
Journal of Thrombosis and Haemostasis | Year: 2013

Background: Although vascular-calcification mechanisms are only partially understood, the role of circulating calcifying cells and non-collagenous bone matrix proteins in the bone-vascular axis is emerging. In spite of the fact that platelets represent a cellular interface between hemostasis, inflammation and atherosclerosis, and have a myeloid precursor, a possible involvement in the modulation of vascular calcification has rarely been investigated. We investigated if osteocalcin (OC) is released by platelets and described OC expression in patients with carotid artery occlusive disease. Methods: Expression and release of OC were determined by Western blot, immunofluorescence, fluorescence-activated cell sorting (FACS) and ELISA in human resting and activated platelets and megakaryocytes. Co-localization of platelet aggregates, macrophages, OC and calcifications was studied in carotid endarterectomy specimens and normal tissues. Results: Human platelets expressed OC and co-localized with CD63 in δ-granules. Upon activation with an endogenous mechanism, platelets released OC in the extracellular medium. Expression of OC in megakaryocytes suggested lineage specificity. The OC count in circulating platelets and the released amount were significantly higher in patients with carotid artery occlusive disease than in healthy controls (P<0.0001) in spite of similar serum levels. In atherosclerotic plaques, OC strongly overlapped with CD41+ platelets in the early stage of calcification, but this was not seen in normal tissues. CD68+OC+ cells were present at the periphery of the calcified zone. Conclusions: Given the active role played by platelets in the atherosclerotic process, the involvement of OC release from platelets in atherosclerotic lesions and the impact of genetic and cardiovascular risk factors in mediating bone-marrow preconditioning should be investigated further. © 2012 International Society on Thrombosis and Haemostasis.

Haegeli P.,Avisualanche Consulting | Haegeli P.,Simon Fraser University | Falk M.,Inova Q Inc. | Procter E.,EURAC Institute of Mountain Emergency Medicine | And 7 more authors.
Resuscitation | Year: 2014

Aim: Asphyxia is the primary cause of death among avalanche victims. Avalanche airbags can lower mortality by directly reducing grade of burial, the single most important factor for survival. This study aims to provide an updated perspective on the effectiveness of this safety device. Methods: A retrospective analysis of avalanche accidents involving at least one airbag user between 1994 and 2012 in Austria, Canada, France, Norway, Slovakia, Switzerland and the United States. A multivariate analysis was used to calculate adjusted absolute risk reduction and estimate the effectiveness of airbags on grade of burial and mortality. A univariate analysis was used to examine causes of non-deployment. Results: Binomial linear regression models showed main effects for airbag use, avalanche size and injuries on critical burial, and for grade of burial, injuries and avalanche size on mortality. The adjusted risk of critical burial is 47% with non-inflated airbags and 20% with inflated airbags. The adjusted mortality is 44% for critically buried victims and 3% for non-critically buried victims. The adjusted absolute mortality reduction for inflated airbags is -11 percentage points (22% to 11%; 95% confidence interval: -4 to -18 percentage points) and adjusted risk ratio is 0.51 (95% confidence interval: 0.29 to 0.72). Overall non-inflation rate is 20%, 60% of which is attributed to deployment failure by the user. Conclusion: Although the impact on survival is smaller than previously reported, these results confirm the effectiveness of airbags. Non-deployment remains the most considerable limitation to effectiveness. Development of standardized data collection protocols is encouraged to facilitate further research. © 2014 Elsevier Ireland Ltd.

PubMed | EURAC Institute of Mountain Emergency Medicine and Innsbruck Medical University
Type: Journal Article | Journal: Injury | Year: 2016

In remote and mountainous areas, helicopter emergency medical systems (HEMS) are used to expedite evacuation and provide pre-hospital advanced trauma life support (ATLS) in major trauma victims. Aim of the study was to investigate feasibility of ATLS in HEMS mountain rescue missions and its influence on patient condition at hospital admission.58 major trauma victims (Injury Severity Score 16), evacuated by physician staffed HEMS from remote and mountainous areas in the State of Tyrol, Austria between 1.1.2011 and 31.12.2013.Pre-hospital time exceeded 90min in 24 (44%) cases. 31 (53%) patients suffered critical impairment of at least one vital function (systolic blood pressure <90mmHg, GCS <10, or respiratory rate <10 or >30). 4 (6.9%) of 58 patients died prior to hospital admission. Volume resuscitation was restrictive: 18 (72%) of 25 hypotensive patients received 500ml fluids and blood pressure was increased >90mmHg at hospital admission in only 9 (36%) of these 25 patients. 8 (50%) of 16 brain trauma patients with a blood pressure <90mmHg remained hypotensive at hospital admission. Endotracheal intubation was accomplished without major complications in 15 (79%) of 19 patients with a Glasgow Coma Scale score <10. Rope operations were necessary in 40 (69%) of 58 cases and ATLS was started before hoist evacuation in 30 (75%) of them.The frequent combination of prolonged pre-hospital times, with critical impairment of vital functions, supports the need for early ATLS in HEMS mountain rescue missions. Pre-hospital endotracheal intubation is possible with a high success and low complication rate also in a mountain rescue scenario. Pre-hospital volume resuscitation is restrictive and hypotension is reversed at hospital admission in only one third of patients. Prolonged pre-hospital hypotension remains an unresolved problem in half of all brain trauma patients and indicates the difficulties to increase blood pressure to a desired level in a mountain rescue scenario. Despite technical considerations, on-site ATLS is feasible for an experienced emergency physician in the majority of rope rescue operations.

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