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Cardiac arrest on a ski slope

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.39058.661528.59 (Published 14 December 2006) Cite this as: BMJ 2006;333:1276
  1. Sarah Davies, respiratory registrar, Northampton General Hospital (sarah.davies{at}doctors.org.uk),
  2. Tarek F T Antonios, senior lecturer and consultant physician in cardiovascular and general medicine, St George's University of London (t.antonios{at}sgul.ac.uk)

    In December 2005 the Resuscitation Council (UK) published revised guidelines and treatment algorithms following widespread research and debate at international conferences. These were the first changes for five years. The most noticeable change for adult resuscitation in basic and advanced life support is an increase in the ratio of compressions to ventilations of 30:2. Other noticeable changes in advanced life support are the delivery of only one shock at 360 J monophasic or 150-360 J biphasic if the patient is in a shockable rhythm and a period of two minutes cardiopulmonary resuscitation until each pulse check, regardless of the rhythm.

    On a recent skiing holiday in a major Alpine resort, one of the authors was about to leave the slopes for the day to embark on some après ski when a friend came running to her and said, “A man has collapsed.” She went round the corner and found an unconscious man with his wife who was just commencing mouth to mouth resuscitation. The author was then joined by two German nurses, one British paediatric nurse, one French dentist, and a British nursing student.

    As the most experienced medical professional, the author led this ad hoc international cardiac arrest team. The French dentist provided some airway manoeuvres and assisted the patient's wife with the timing of mouth to mouth ventilation. The student nurse went to call for assistance and to locate an automatic external defibrillator. The nurses and the author shared the responsibilities for delivering chest compressions. All were familiar with the European Resuscitation Council Guidelines. The team debated initially about whether to adopt the new 30:2 ratio for chest compressions to ventilation, but felt more comfortable with the more practised 15:2 ratio, with which the whole team was more familiar. Our team communicated well—in French, German, and English. We all knew what we were expected to do, because of the standard guidelines.

    Sadly, we were unable to locate an automatic external defibrillator in the first aid room. We were on the top of the mountain, a cable car journey from either of the two local towns. The patient remained lying in the snow, as we were unable to move him.

    After eight minutes the emergency helicopter arrived with a defibrillator, medical equipment, a doctor, and a paramedic. The patient was in ventricular fibrillation and was shocked twice into sinus rhythm with a good output. The paediatric nurse was able to comfort the patient's wife and explain what was happening to her husband. We then proceeded to obtain intravenous access and anaesthetise the patient. During this time he experienced a tachyarrhythmia and was shocked back into sinus rhythm. However, he later became bradycardic and then lost his cardiac output again, requiring further cardiopulmonary resuscitation. A German anaesthetist and surgeon happened to be passing by and assisted further with cardiopulmonary resuscitation and intubation. Forty five minutes following his initial cardiac arrest the patient was anaesthetised and intubated. He had a stable pulse and blood pressure and was transferred to the local hospital by helicopter.

    This experience highlighted several points. Firstly, internationally recognised guidelines are important. The existence of these enabled medical personnel from different backgrounds and countries to address the situation with the same purpose and priorities. The guidelines assisted us in working together and helped avoid the potential communication difficulties of a multilingual experience. Secondly, accessibility to healthcare facilities, importantly access to automatic external defibrillators, is of paramount importance, especially in remote locations that have a large number of people. As we all learn, “time is myocardium,” thus the most effective management for our patient would have been immediate defibrillation. We were perhaps fortunate that we had several people all able to perform effective cardiopulmonary resuscitation. I doubt that I would have delivered effective cardiopulmonary resuscitation for eight minutes if I had been the only person in attendance that day. Thirdly, it is important to quickly identify people's level of skill and experience, thus enabling the employment of available personnel in the most appropriate and effective way. There are 12 000 cardiac arrests in public places each year in the UK, according to the Department of Health (www.dh.gov/PolicyAndGuidance/HealthAndSocialCareTopics/CoronaryHeartDisease/CoronaryPromotionProject/fs/en).

    Downhill skiing is the most popular winter sport in the world. It is considered to be a serious trigger for sudden cardiac deaths in those with previous myocardial infarction, and also in those with hypertension, known coronary heart disease, or with poor adaptation to strenuous exercise (Int J Sports Med. 2000 Nov;21:613-5). In a retrospective study of skiing associated deaths in the Snowy Mountains, Australia (Med J Aus 1988 Dec 5-19;149:615-8), 29 deaths were reported; eight due to trauma, 15 due to cardiovascular causes, and six due to hypothermia. There are also reports in the literature of successful resuscitation occurring during downhill skiing (Anaesthesist 2006 Jan;55:41-4). Between the winter months of 2002-2004 there were three reported cases of non-traumatic cardiac arrest in Tyrol, Austria. Ski patrol members initially resuscitated all patients with automatic external defibrillators. Two were alive at hospital admission and one was discharged without neurological damage (Anasthesiol Intensivmed Notfallmed Schmerzther. 2005 Mar;40:150-5).Clearly, accessibility to an automatic external defibrillator is of paramount importance, as is training. Many personnel, from ski patrollers to cable car operators, are employed on ski slopes. A study carried out in Pennsylvania showed successful training of ski patrollers to perform resuscitation using automatic external defibrillators with satisfactory skill retention at the end of the season (Prehosp Emerg Care 2002 Jul-Sep;6:325-9). This gives good weight to the argument that more automatic external defibrillators should be made available in the UK and in Europe, especially in isolated areas with relatively large numbers of people. It also shows that in these areas it is beneficial to train non-medical people to operate automatic external defibrillators.

    We therefore support the suggestion that automatic external defibrillators should be placed in public areas and that non-medical personnel should be trained to operate them. Internationally recognised guidelines are useful in providing a standardised approach to patient care and helping in overcoming language difficulties in international circumstances.

    Downhill skiing is considered to be a serious trigger for sudden cardiac deaths . . . accessibility to an automatic external defibrillator is of paramount importance, as is training

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