To the Editor:
There is no denying that early death from snow burial is often due to asphyxia, as is death from drowning. However, we would like to highlight that the Wilderness Medical Society (WMS) clinical practice guidelines pertaining to these situations differ.1,2 Although the guidelines discourage hands-only cardiopulmonary resuscitation (CPR) and emphasize ventilation during standard CPR in drowning, this is not a recommendation in the snow burial guidelines.
WMS guidelines reflect the excellent work performed over the past few decades to determine the survivability of snow burial. One of the most significant factors is the cut-off time for survivability for victims of snow burial without an air pocket. Prognosis for survival is dismal if burial is prolonged, but with improved training, awareness, and technology, many snow burial victims are dug out quickly. For these patients, the WMS guidelines put little emphasis on the basic life support (BLS) resuscitation of a victim in cardiac arrest rescued within 60 min. Identifying an ice-plug or lack of air pocket does prompt rescuers to identify and, hopefully, clear the obstruction, but this is a subtlety that could be missed by nonmedical or companion rescuers. What is notably missing from the snow burial guidelines is the emphasis on ventilation during CPR. The WMS drowning guidelines, on the other hand, specifically state that BLS care must include ventilation. Why not add the same recommendations for snow burial victims without an air pocket who are in cardiac arrest and rescued within the first few minutes of burial?
The International Liaison Committee on Resuscitation CPR guidelines changed its recommendations regarding CPR in 2010. 3 During the last decade, priority has been on circulation, and then on airway and breathing, as the focus of BLS training. Hands-only CPR has also been promoted with the hope that chest compression-only CPR is better than no CPR. The American Heart Association (AHA) 2020 guidelines recommended that emergency call takers providing telecommunicator CPR instruct callers to perform hands-only CPR. 4 Providing hands-only CPR is obviously not ideal in special resuscitation situations involving asphyxia. The 2010 AHA guideline highlights did address this and indicated that CPR for drowning patients must include artificial respiration. 3 However, by 2020 those recommendations were no longer highlighted but buried in section 3 part 9.5. 5
Shortly after the 2010 AHA guidelines were published, the International Commission for Alpine Rescue Medical Committee considered hands-only CPR not appropriate and recommended ventilation during CPR for the resuscitation of avalanche victims. 6
The influence of the WMS guidelines is significant, as can be seen in the 2020 AHA recommendations, which specifically mention the WMS drowning guidelines as a supplemental reference. 5 Suggestions from the WMS that include specific wording regarding snow burial victims could foreseeably be included in the AHA recommendations also. The WMS should emphasize CPR with ventilation in snow burial victims in cardiac arrest and work with organizations such as the Canadian and American Avalanche Associations to highlight this among their target groups. We need to guide the companion rescuer because it will be the on-scene bystander who must conduct the immediate rescue sequence and resuscitation.
As our colleague and coauthor of the drowning guidelines Dr. Sempsrott pointed out, drowning victims are still drowning after they are rescued from the water. The drowning process has not stopped until adequate ventilation has begun. If this is true for drowning, why then should it not apply to asphyxia related to snow burial?