The rescued hand
A man survives for 23 hours under an avalanche and his treatment sets new standards.
In one of the longest-lasting avalanche burials with survivors ever documented, a man was rescued from the snow mass after 23 hours. He had a core temperature of 23 degrees Celsius and severe frostbite on one hand. The courageous actions of the medical team treating him at Bolzano hospital not only saved his life and his hand, but also set new protocols for the treatment of hypothermic avalanche victims with frostbite.
The spectacular circumstances of the rescue
The case took place on January 2023 in the South Tyrolean Alps. The family of a 53-year-old, who had not returned from a ski tour in the Dolomites reported him missing that evening. The mountain rescue team began the search during the night, but only had clues as to the routes the missing man might have taken, and the night-time search flights were unsuccessful. It was not until the next morning, a rescue team spotted an avalanche cone from the helicopter with a hand sticking out and waving. Within a few minutes following the sighting, the buried man was rescued. After 23 hours buried in about one meter of snow, the victim had an extremely low core temperature of 23.1 degrees Celsius. Upon rescue, the man was drowsy and not fully responsive, but his vital functions were stable.
A cautionary tale from the past and new priorities in therapy
The buried victim was taken to the intensive care unit at the Bolzano Central Hospital. Under the direction of primary physician Marc Kaufmann, an expert in the treatment of critically hypothermic patients due to his many years as a senior physician at the University Hospital in Innsbruck, work began immediately on warming the body up again. When Hermann Brugger, emergency physician for many years and founder of the Institute of Mountain Emergency Medicine at Eurac Research, learned that the buried victim had been found with one hand outside the snow where the air temperature at the burial site at an altitude of 2,300 meters above sea level had been minus 8 degrees Celsius, he recalled an almost identical case: “There had been an avalanche accident in Switzerland where a young man had been buried with one hand outside the snow. Unfortunately, his hand had to be removed due to the frostbite he had suffered. In the current case of the South Tyrolean victim, the right hand had also suffered severe frostbite and was extremely vulnerable.” The hand which had been the decisive factor in the search team discovering the buried victim in time, was at stake.
To date, there are no precise recommendations for the treatment of frostbite in severely hypothermic patients. However, we believe that drug therapy for frostbite must be started as early as possible in parallel with the vital process of warming the body back up.
Marc Kaufmann, South Tyrolean Healthcare Service
After reaching a “safe” core body temperature of over 30 degrees Celsius, the medical team in the intensive care unit began treating the frostbite with medication just a few hours after admission. “It was probably thanks to the early treatment that the frostbitten hand could be saved without the patient losing a single fingertip. It was a huge success,” summarizes Brugger. Until now, the combination of avalanche burial and severe frostbite is rare and has not been much investigated in research literature. As a result, there is no reliable evidence as to whether and how medication used for frostbite works in a hypothermic body. Until now, the priority in treatment had always been to completely warm up the body again. In the case in Switzerland, it took some time after the victim’s body temperature had been returned to normal before the patient was transferred to a level one trauma center, where the therapy for frostbite took place in a second step. In the end, his hand could no longer be saved, “It was a cautionary tale for us,” says Brugger, who was involved in the investigation of the Swiss accident. “So far, there are no precise recommendations for the treatment of frostbite in severely hypothermic patients. However, we believe that drug therapy for frostbite should be started as early as possible and in parallel with the vital process of warming the body back up, because in these cases the greater risk of permanent damage comes not from hypothermia but from frostbite," says Kaufmann. Even though the pain in his hand requires treatment, the fact that the South Tyrolean avalanche victim survived despite the extreme circumstances proves the medical team in Bolzano right. “It may be possible to start treating frostbite in avalanche victims even earlier. We don’t yet know how much leeway there is.” says Brugger.
The outcome was spectacularly positive despite the long burial time, the very low body temperature, and the extreme frostbite.
Hermann Brugger, Eurac Research
In the current case, the protocol followed had initially been drawn up in Bruneck/Brunico under the direction of frostbite specialists Elisabeth Gruber, Rosmarie Gruber and Werner Beikircher. The protocol covers the treatments of both vasodilation and thrombolysis, which affect blood clotting. “The drugs used to treat frostbite are always associated with a certain risk of bleeding. Hypothermia itself also influences blood clotting and inhibits it. Therefore, both factors increase the risk of the brain or other organs bleeding,” explains Elisabeth Gruber, intensive care physician at the regional intensive care unit and experienced pain therapist. “In this case, thrombolytic therapy was administered directly into the brachial artery. As a result, it has less of a systemic effect, but rather acts directly on the frostbite,” explains Gruber. After ten days, the patient was discharged. It took another ten months before the right hand and all the individual fingers were fully functional again.
The drugs used to treat frostbite are always associated with a certain risk of bleeding. Hypothermia itself also influences blood clotting and inhibits it. Therefore, both factors increase the risk of the brain or other organs bleeding.
Elisabeth Gruber, Intensive care physician
How research results are put into practice
“This outcome was spectacularly positive despite the long burial period, the very low body temperature, and the extreme frostbite.” says Brugger who goes on to emphasize: “This was possible because the tight cooperation between our research institute and the medical services here in South Tyrol means that findings from our research can flow directly into treatment.” The Institute of Mountain Emergency Medicine at Eurac Research has set up registers for trauma, hypothermia and frostbite in which cases from the entire Alpine region and beyond are systematically collected with details of the accident, treatments and outcomes. The information is used for research purposes but is also accessible to anyone involved in mountain rescue. “I will soon be reporting on this case at an international conference at the University of Aberdeen in Scotland. This means that the topic will soon be discussed by international experts in the field of avalanche medicine,” concludes Brugger.
The case was scientifically analyzed by the medical team of the South Tyrolean Medical Service and the Institute of Mountain Emergency Medicine of Eurac Research and published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.
Link to the scientific publication "Prolonged critical avalanche burial for nearly 23 h with severe hypothermia and severe frostbite with good recovery: a case report": https://doi.org/10.1186/s13049-024-01184-3
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