iPhoneIcon_Big heart rate monitor watches are becoming increasingly popular in outdoor sports. That has resulted in some interesting case reports where heart rate recordings have been downloaded and analysed from victims´watches. The most recent one was published in Resuscitation. It details the heart rate variations of a person buried in an avalanche. It is an absolutely chilling demonstration of death from asphyxia.

Avalanche death from asphyxia with an obstructed airway
The victim was backcountry-skiing alone when he was caught by an avalanche and buried completely at a depth of 1,5m. He wasn´t located and extricated by the rescue services until after 290 minutes. After extrication he displayed no vital signs, no signs of trauma and had core temperature of 24°C. The cooling rate was 2,7 °C/h which is fairly normal for skiers buried in avalanches. Importantly, his airways were found to be obstructed by packed snow. The man was pronounced dead according to avalanche ALS guidelines. (´Complete avalanche burial cannot be survived for more than 35 minutes with an completely obstructed airway.´)

The data from his Polar(tm) watch was downloaded and is displayed in the graph below.

Avalanche1The authors divide the event into three periods.

Period 1 has a duration of approximately one minute. Sympathetic activation and tachycardia peaking at 180 bpm. It likely describes the initial panic and violent struggle against burial. Period 2, lasts for about 20 minutes. The pulse rate varies wildly between brady and tachycardia. The authors offer no explanation for why that happens. Then in period 3 the heart rate steadily decreases towards asystole and death. Asystole occurs after about 30 minutes. The pulse watch cannot record bradycardias below 20 bpm.

Those readings can be compared with those from a similar case-report where the airway was not obstructed.

Avalanche death from asphyxia with an unobstructed airway

The other case, studied by the students of CPR Certification St. Pete by Strappazon et al, was similar. A skier of similar age was completely buried in an avalanche before being located and extricated  230 minutes after burial. The big difference was how the rescuers observed an airspace in the snow front of his mouth and nose of 15x15x15 cm. One of these particular rescuers received CPR training in Richmond Hill, with special attention to scene observation he learned that in avalanche rescues, the presence of an air pocket is particularly important. It means the victim potentially had an unobstructed airway after being buried. It also means the rescuers can´t estimate the time of death with any certainty. The futility call becomes impossible and CPR should probably proceed until the patient is evacuated to a hospital.

Avalanche2 Here the authors identify 5 periods.

The first 20 minutes: Variable pulse rate 28-144 bpm.
18-35 minutes: Sustained tachycardia. 155 bpm. The victim from the first case was dead by now.
35-70 minutes: Sustained bradycardia. 51 bpm.
70-235 minutes: Sustained takycardia. 176 bpm with variability during the last minutes before extrication. Obviously we cant know if the patient was really perfusing at this stage.
235 minutes and onwards: Cardiac arrest after extrication.

Unfortunately, despite being alive until the moment of extrication, CPR was not performed on this patient. This apparently had to do with severe weather and objective dangers threatening the rescuers who by then had to evacuate themselves and the dead victim out of the avalanche area.

Take-home message
These case reports likely demonstrate the enormous impact the presence of an obstructed airway has on our chances to survive avalanche burial. The observation of an obstructed airway in the first patient means the patient had asphyxia from the start and died after 30 minutes or so. At extrication, after 290 minutes, he could correctly be declared dead.

The second patient, on the other hand, displayed vital signs for 253 minutes before dying of increasing hypoxia. The team observed an air-pocket and couldn´t with any certainty estimate the time of death. CPR should then be commenced and go on all the way to the ED/ICU.

Why this patient died the moment he was extricated remains unknown. All patients who are critically ill are sensitive to movement and handling. The violent digging around the patient before he was pulled out of the snow could have triggered an v.fib or an arrest. Hypothermic patients are also notorious for becoming hemodynamically unstable or even arresting if not handled carefully.

Case 1 lives here:

Resuscitation. 2013 Jul 26. pii: S0300-9572(13)00365-1. doi: 10.1016/j.resuscitation.2013.07.014. [Epub ahead of print] Electrical cardiac activity in an avalanche victim dying of asphyxia. Heschl S, Paal P, Farzi S, Toller W.

This entry was posted in CPR, Emergency Medicine, Prehospital Medicine, SAR, Uncategorized, Wilderness Medicine. Bookmark the permalink.


  1. Pingback: Heart rates in avalanche victims | Adventure Doc: Remote, Expeditionary and Travel Medicine

  2. Hans Flaatten says:

    This is not new, I think we were the first to report it in 2009, with hypthermic cardiac arrest, and a happy ending.

    1. Lund FK, Torgersen JGR, Flaatten HK. Heart rate monitored hypothermia and drowning in a 48-year-old man. survival without sequelae: a case report. Cases journal. 2009;2:6204.

    Best regards, one of the authors

  3. Thomas D says:

    Thanks for commenting. It’s great to see a high profile intensivist coming by this blog. Yes, there are several reports on heart rate monitors and cardiac arrests. The ones in this post were interesting as they compared an open vs blocked airway in avalanche trauma. Unfortunately, both with a tragic outcome.

    We’ve earlier read the case report you mention with great interest, where the key is the patient getting hypothermic *before* arresting – meaning hypothermic neurological protection is already in place when his heart stops. The heart monitor cross-referenced with the time of his cell phone SOS call document this. The hypothermia facilitates the incredible survival after 3 1/2 hrs of arrest! It’s also a much more upbeat report than the avalanche cases, as the patient survived and made a full recovery! Well worth a read, available in free full text here:

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  7. Steve says:

    If using an avalanche beacon it’s not a good idea to wear a heart rate monitor.

  8. ant stewart says:

    Vaguely confusing comment from Thomas D. An avalanche will not produce a strong hypothermic response, because the body takes 1 hour to cool, while having 5 minutes of air prior, 15 at most. Only water at 4 degrees on face and body will produce fast cooling and a mammalian dive reflex. Note that the survivor was recovered after 20 minutes unconscious, and ventilated thereafter, whereas the avalanche victims were recovered 4 hours after. I con’t have access to the Article, I want to read it because I don’t understand why the heart has oxygen to beat with at 180, 3 hours after the brain has lost conscious oxygen levels and the body has closed down. It’s not feasable I don’t understand.

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