John Ellerton

Ketamine: use in anesthesia.

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.

Delayed and intermittent CPR for severe accidental hypothermia

INTRODUCTION Cardiac arrest (CA) in patients with severe accidental hypothermia (core temperature <28 °C) differs from CA in normothermic patients. Maintaining CPR throughout the prehospital period may be impossible, particularly during difficult evacuations. We have developed guidelines for rescuers who are evacuating and treating severely hypothermic CA patients. METHODS A literature search was performed. The authors used the findings to develop guidelines. RESULTS Full neurological recovery is possible even with prolonged CA if the brain was already severely hypothermic before CA occurred. Data from surgery during deep hypothermic CA and prehospital case reports underline the feasibility of delayed and intermittent CPR in patients who have arrested due to severe hypothermia. CONCLUSIONS Continuous CPR is recommended for CA due to primary severe hypothermia. Mechanical chest-compression devices should be used when available and CPR-interruptions avoided. Only if this is not possible should CPR be delayed or performed intermittently. Based on the available data, a patient with a core temperature <28 °C or unknown with unequivocal hypothermic CA, evidence supports alternating 5 min CPR and ≤5 min without CPR. With core temperature <20 °C, evidence supports alternating 5 min CPR and ≤10 min without CPR.

Immobilization and Splinting in Mountain Rescue

Immobilization and splinting of fractures are essential to reduce morbidity and mortality in mountain rescue. Therefore, members of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) debated the results of a literature review carried out by the authors. Focusing on common immobilization and splinting techniques relevant to mountain rescue, a consensus document was formulated. Pain relief of appropriate speed of onset and strength should be available on scene. Spinal immobilization is recommended for all casualties that have sustained head or spine injury. The preferred method is a vacuum mattress with an appropriately sized rigid cervical collar. In such casualties, only those in an unsafe environment or with time-critical injuries should be evacuated before spinal immobilization is performed. In some casualties, the cervical spine may be cleared and a cervical collar may be omitted. In the presence of hemodynamic instability and where there is a suspicion of a fractured pelvis, an external compression splint should be applied. Splinting of a femoral shaft fracture is important to limit pain and life-threatening blood loss. If time allows, extremity fractures should be adequately splinted and, if the practitioner is skilled, a displaced fracture or joint dislocation should be reduced on scene with the use of appropriate analgesia.

The use of analgesia in mountain rescue casualties with moderate or severe pain

Objectives To assess the effectiveness of analgesia used in mountain rescue (MR) in casualties with moderate or severe pain. To determine if a verbal numeric pain score is practical in this environment. To describe the analgesic strategies used by MR. Design Prospective, descriptive study. Setting Fifty-one MR teams in England and Wales. The study period was 1 September 2008 to 31 August 2010. Participants 92 MR casualties with a pain scoreof 4/10 or greater. Main outcome 38% of casualties achieved a pain reduction of 50% or greater in their initial score at 15 min and 60.2% had achieved this at handover. Results The initial pain score was 8 (median), reducing to 5 at 15 min and 3 at handover. The mean pain reduction was 2.5±2.4 at 15 min and 3.9±2.5 at handover. 80 casualties (87%) were treated with an opioid and seven had two different opioids administered. Seven main strategies were identified in which the principal agent was entonox, intramuscular opioid, oral analgesia, fentanyl lozenge, intranasal or intravenous opioid. The choice of strategy varied with the skills of the casualty carer. Conclusions Pain should be assessed using a pain score. When possible, intravenous opioid is the gold standard to achieve early and continuing pain control in patients with moderate or severe pain. Entonox and oral analgesics, as sole agents, have limited use in moderate or severe pain. Intranasal opioid and fentanyl lozenge are effective, and appropriate in MR. Research priorities include bioavailability in different environmental conditions and patients satisfaction with their pain management.

Current Status of Medical Training in Mountain Rescue in America and Europe

Limited medical training of mountain rescuers may adversely affect the outcome of casualties. Thus, this study evaluated medical training of mountain rescuers in countries associated with the International Commission of Mountain Emergency Medicine. A questionnaire was completed by 33 mountain rescue services from 18 countries in America and Europe. First-aid topics taught most often are (absolute values, percentage): chest compression, hypothermia, cold injuries (32 of 33 organization 97%); avalanche rescue, first-aid kit of rescuer, cervical collar (31, 94%); hemorrhagic shock, automated blood pressure measurement, wound dressing (30, 91%); and heat injuries and SAM SPLINT (29, 88%). Cardiopulmonary resuscitation manikins are used in 32 (97%) organizations, and in 17 (52%) organizations manikins have feedback functionality. After training, exams are compulsory in 27 (83%) organizations. Yearly retraining is done in 12 (36%) organizations; 22 (67%) organizations would like to increase medical training. The study shows high variability in the medical training programs among the surveyed organizations and the need to improve medical education. The authors recommend standardization of medical training and examinations on an international level. Additional topics tailored to the typical injury and illness patterns of a particular area should supplement this core training. Training should be performed by highly qualified instructors on a yearly basis.

Severe accidental hypothermia

Few UK emergency departments have a hypothermia protocol. This must change

Factors impacting on the activation and approach times of helicopter emergency medical services in four Alpine countries

BackgroundThe outcome of severely injured or ill patients can be time dependent. Short activation and approach times for emergency medical service (EMS) units are widely recognized to be important quality indicators. The use of a helicopter emergency medical service (HEMS) can significantly shorten rescue missions especially in mountainous areas. We aimed to analyze the HEMS characteristics that influence the activation and approach times.MethodsIn a multi-centre retrospective study, we analyzed 6121 rescue missions from nine HEMS bases situated in mountainous regions of four European countries.ResultsWe found large differences in mean activation and approach times among HEMS bases. The shortest mean activation time was 2.9 minutes; the longest 17.0 minutes. The shortest mean approach time was 10.4 minutes; the longest 45.0 minutes. Short times are linked (p < 0.001) to the following conditions: helicopter operator is not state owned; HEMS is integrated in EMS; all crew members are at the same location; doctors come from state or private health institutions; organization performing HEMS is privately owned; helicopters are only for HEMS; operation area is around 10.000 km2; HEMS activation is by a dispatching centre of regional government who is in charge of making decisions; there is only one intermediator in the emergency call; helicopter is equipped with hoist or fixed line; HEMS has more than one base with helicopters, and one team per base; closest neighboring base is 90 km away; HEMS is about 20 years old and has more than 650 missions per year; and modern helicopters are used.ConclusionsAn improvement in HEMS activation and approach times is possible. We found 17 factors associated with shorter times.

Should helicopters have a hoist or ‘long-line’ capability to perform mountain rescue in the UK?

Objectives To determine how far mountain rescue casualties in the UK have to be carried and the impact of adding a hoist or ‘long-line’ to helicopters operating in this environment. Design Retrospective analysis of mountain rescue incidents. Setting Pre-hospital, mountain rescue service based in Patterdale, English Lake District. Participants Casualties between 1 January 2006 and 31 December 2008 that required stretcher evacuation. Casualties directly accessible by a road ambulance were excluded. Main outcome The horizontal and vertical distance of the evacuation route to an agreed helicopter-landing site, and its technical character. Direct access to the incident site by a helicopter with a hoist or long-line capability was determined. Results 119 casualties were identified. The median horizontal and vertical evacuation distances were 250 m and −30 m respectively. The proposed manual carrying distances were ≤100 m in 33/119 (28%), between 101 and 400 m in 60/119 (50%) and >400 m in 26/119 (22%) of casualties. 13/119 (11%) casualties were in a position where direct access to the incident site would not have been possible with a helicopter equipped with a hoist or long-line. 31/119 (26%) casualties required a technical evacuation with the use of ropes. Conclusions Using the criteria that all casualties requiring a technical rescue or >400 m evacuation route to an appropriate helicopter-landing site, 34% of casualties could have been rescued using a hoist or long-line with an expected reduction in the pre-hospital time. Helicopters working in UK mountain rescue should be equipped to international standards.

Fluid Management in Traumatic Shock: A Practical Approach for Mountain Rescue

Sumann, Günther, Peter Paal, Peter Mair, John Ellerton, Tore Dahlberg, Gregoire Zen-Ruffinen, Ken Zafren, and Hermann Brugger. Fluid management in traumatic shock: a practical approach for mountain rescue. High Alt. Med. Biol. 10:71-75, 2009.-The management of severe injuries leading to traumatic shock in mountains and remote areas is a great challenge for emergency physicians and rescuers. Traumatic brain injury may further aggravate outcome. A mountain rescue mission may face severe limitations from the terrain and required rescue technique. The mission may be characterized by a prolonged prehospital care time, where urban traumatic shock protocols may not apply. Yet optimal treatment is of utmost importance. The aim of this study is to establish scientifically supported recommendations for fluid management that are feasible for the physician or paramedic attending such an emergency. A nonsystematic literature search was performed; the results and recommendations were discussed among the authors and accepted by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Diagnostic and therapeutic strategies are discussed, as well as limitations on therapy in mountain rescue. An algorithm for fluid resuscitation, derived from the recommendations, is presented in Fig. 1. Focused on the key criterion of traumatic brain injury, different levels of blood pressure are presented as a goal of therapy, and the practical means for achieving these are given.

Eye Problems in Mountain and Remote Areas: Prevention and Onsite Treatment—Official Recommendations of the International Commission for Mountain Emergency Medicine ICAR MEDCOM

Abstract Although eyes are not frequently injured in the mountains, they are exposed to many adverse factors from the environment. This article, intended for first responders, paramedics, physicians, and mountaineers, is the consensus opinion of the International Commission for Mountain Emergency Medicine (ICAR-MEDCOM). Its aim is to give practical advice on the management of eye problems in mountainous and remote areas. Snow blindness and minor injuries, such as conjunctival and corneal foreign bodies, could immobilize a person and put him or her at risk of other injuries. Blunt or penetrating trauma can result in the loss of sight in the eye; this may be preventable if the injury is managed properly. In almost all cases of severe eye trauma, protecting the eye and arranging an immediate evacuation are necessary. The most common eye problems, however, are due to ultraviolet light and high altitude. People wearing contact lenses and with previous history of eye diseases are more vulnerable. Any sight-threatening eye problem or unexplained visual loss at high altitude necessitates descent. Wearing appropriate eye protection, such as sunglasses with sidepieces and goggles with polarized or photochromic lenses, could prevent most of the common eye problems in mountaineering.