Simon Rauch

Physician staffed helicopter emergency medical systems can provide advanced trauma life support in mountainous and remote areas

INTRODUCTION In remote and mountainous areas, helicopter emergency medical systems (HEMS) are used to expedite evacuation and provide pre-hospital advanced trauma life support (ATLS) in major trauma victims. Aim of the study was to investigate feasibility of ATLS in HEMS mountain rescue missions and its influence on patient condition at hospital admission. PATIENTS 58 major trauma victims (Injury Severity Score ≥16), evacuated by physician staffed HEMS from remote and mountainous areas in the State of Tyrol, Austria between 1.1.2011 and 31.12.2013. RESULTS Pre-hospital time exceeded 90min in 24 (44%) cases. 31 (53%) patients suffered critical impairment of at least one vital function (systolic blood pressure <90mmHg, GCS <10, or respiratory rate <10 or >30). 4 (6.9%) of 58 patients died prior to hospital admission. Volume resuscitation was restrictive: 18 (72%) of 25 hypotensive patients received ≤500ml fluids and blood pressure was increased >90mmHg at hospital admission in only 9 (36%) of these 25 patients. 8 (50%) of 16 brain trauma patients with a blood pressure <90mmHg remained hypotensive at hospital admission. Endotracheal intubation was accomplished without major complications in 15 (79%) of 19 patients with a Glasgow Coma Scale score <10. Rope operations were necessary in 40 (69%) of 58 cases and ATLS was started before hoist evacuation in 30 (75%) of them. CONCLUSIONS The frequent combination of prolonged pre-hospital times, with critical impairment of vital functions, supports the need for early ATLS in HEMS mountain rescue missions. Pre-hospital endotracheal intubation is possible with a high success and low complication rate also in a mountain rescue scenario. Pre-hospital volume resuscitation is restrictive and hypotension is reversed at hospital admission in only one third of patients. Prolonged pre-hospital hypotension remains an unresolved problem in half of all brain trauma patients and indicates the difficulties to increase blood pressure to a desired level in a mountain rescue scenario. Despite technical considerations, on-site ATLS is feasible for an experienced emergency physician in the majority of rope rescue operations.

Cooling rate for triage decisions should exclude post-extrication cooling in avalanche victims

In a recent letter, Pasquier et al.1 present a highly interesting ase of suspected severe hypothermia after complete avalanche urial of 35 min. The patient was resuscitated and transported to hospital with extracorporeal rewarming facilities according to nternational recommendations.2 CPR was performed continuously ntil extracorporeal rewarming, but the patient did not survive and rreversible hypothermia was suspected as the cause of death. Core emperature (28.4 ◦C) was measured pre-hospitally in the esophaus, as recommended,3 though two aspects of the case should be nterpreted cautiously. Firstly, the cooling rate (9.4 ◦C h−1) was calulated from the time between burial and the first core temperature easurement at 55 min after burial. This not only assumes an initial ore temperature of 37 ◦C (which would depend on the degree of hysical exertion, sweating, clothing, hypoglycaemia, etc.), but also ncludes post-extrication cooling when the patient was exposed to ow ambient temperature (−12 ◦C) and received cardiopulmonary esuscitation by companions and 12 min later by an ALS team, likely ithout measures to prevent further heat loss. Thus, this reported verall cooling rate does not differentiate the degree of cooling durng burial from that after extrication. Previous studies have shown hat the cooling rate during burial is lower than after extrication,4,5 nd we suspect this would have been true also in this case with he victim buried at a depth of 1 m. Therefore, the time until the ictim’s core temperature was 32 ◦C is likely too short because it as estimated with the overall cooling rate. Secondly, the victim ad no vital signs at extrication (by companions) 35 min after initial urial, when a higher core temperature is expected, and was asysolic 47 min after burial, which seems to implicate asphyxia rather han hypothermia as the cause of death. The highest cooling rate previously reported (9 ◦C h−1) was meaured at extrication in a patient with stable circulation and a carotid ulse.6 Such cases suggest that cooling may indeed be rapid in ome patients; however, until we can reliably distinguish temperaure profiles during burial and subsequent interventions, estimated ooling rates are still biased by measurement site, environmental

Advanced airway management in hoist and longline operations in mountain HEMS – considerations in austere environments: a narrative review This review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM)

BackgroundProviding sufficient oxygenation and ventilation is of paramount importance for the survival of emergency patients. Therefore, advanced airway management is one of the core tasks for every rescue team. Endotracheal intubation is the gold standard to secure the airway in the prehospital setting. This review aims to highlight special considerations for advanced airway management preceding human external cargo (HEC) evacuations.MethodsWe systematically searched MEDLINE, EMBASE, and PubMed in August 2017 for articles on airway management and ventilation in patients before hoist or longline operation in HEMS. Relevant reference lists were hand-searched.ResultsThree articles with regard to advanced airway management and five articles concerning the epidemiology of advanced airway management in hoist or longline rescue missions were included. We found one case report regarding ventilation during hoist operations.The exact incidence of advanced airway management before evacuation of a patient by HEC is unknown but seems to be very low (< 5%). There are several hazards which can impede mechanical ventilation of patients during HEC extractions: loss of equipment, hyperventilation, inability to ventilate and consequent hypoxia, as well as inadequacy of monitoring.ConclusionsAdvanced airway management prior to HEC operation is rarely performed. If intubation before helicopter hoist operations (HHO) and human cargo sling (HCS) extraction is considered by the rescue team, a risk/benefit analysis should be performed and a clear standard operating procedure (SOP) should be defined. Continuous and rigorous training including the whole crew is required. An international registry on airway management during HEC extraction would be desirable.

Implementation of a mechanical CPR device in a physician staffed HEMS – a prospective observational study

In this prospective, observational study we describe the incidence and characteristics of out of hospital cardiac arrest (OHCA) cases who received mechanical CPR, after the implementation of a mechanical CPR device (LUCAS 2; Physio Control, Redmond, WA, USA) in a physician staffed helicopter emergency medical service (HEMS) in South Tyrol, Italy. During the study period (06/2013–04/2016), 525 OHCA cases were registered by the dispatch centre, 271 (51.6%) were assisted by HEMS. LUCAS 2 was applied in 18 (6.6%) of all HEMS-assisted OHCA patients; ten were treated with LUCAS 2 at the scene only, and eight were transported to hospital with ongoing CPR. Two (11.1%) of the 18 patients survived long term with full neurologic recovery. In seven of eight patients transferred to hospital with ongoing CPR, CPR was ceased in the emergency room without further intervention. Retrospectively, all HEMS-assisted OHCA cases were screened for proposed indication criteria for prolonged CPR. Thirteen patients fulfilled these criteria, but only two of them were transported to hospital. Based on these results, we propose a standard operating procedure for HEMS-assisted patients with refractory OHCA in a region without hospitals with ECLS capacity.

Frostbite Injuries in the Austrian Alps: A Retrospective 11-Year National Registry Study

OBJECTIVES Frostbite is a cold injury mostly affecting the extremities. The objective of this study was to reveal the incidence of frostbite injuries in the Austrian Alps, to search for frostbite risk factors, and thereby optimize prevention and treatment. METHODS Out-of-hospital data in the National Registry of Alpine Accidents from January 1, 2005, to December 31, 2015, were screened for frostbite injuries. Cases in the registry were merged with clinical data from the major trauma center in western Austria, Innsbruck Medical University Hospital, and statistically analyzed. RESULTS Documented in the National Registry are 114,595 injured persons in the 11-year study period. Thirty-one frostbite cases were documented nationwide, 18 (58%) of which occurred in the western states of Austria and were therefore potentially referred to the Innsbruck Medical University Hospital. Six (19.6%) patients were female. Frostbite was almost exclusively related to fingers and toes (90% of cases). CONCLUSIONS Frostbite injuries in the Austrian Alps are rare. With an incidence of 0.07/100,000, three to four clinically relevant frostbite injuries occur annually. Men are at greater risk for frostbite injuries than women. Fingers and toes are at greatest risk. Proper preparation of outdoor activities and cold-protective gear can help prevent frostbite injuries.

Indoor accidental hypothermia in the elderly: an emerging lethal entity in the 21st century

Matsuyama et al report on the characteristics and outcomes of accidental hypothermia. In total, 537 patients were finally included in the analysis, which makes it one of the largest patient cohorts on accidental hypothermia hitherto.1 Until now, most studies on accidental hypothermia focused on rural and mountain areas because it is a well-known entity in those environments. Most readers will have lively pictures in mind of persons affected outdoors by cold, for example, people being buried in avalanches, immersed in freezing water (remember the Titanic catastrophe with 1522 victims) or incapacitated by cold and frostbites to hands and feet (nearly 1 million combatants died of hypothermia in World Wars I and II and the Korean War).2 Urban accidental hypothermia in contrast is subtle, rarely visible, as people often tend to be affected indoors, and suffer from other underlying diseases, which may be more eye-catching. Accidental hypothermia triggered by cold has been defined as primary accidental hypothermia, in contrast to secondary hypothermia, which is considered to be triggered by or at least associated with other underlying diseases (table 1). The Matsuyama study is one of the few studies assessing accidental hypothermia in an urban area, and it is only the second study reporting a predominant incidence of …

Pre-hospital times and clinical characteristics of severe trauma patients: A comparison between mountain and urban/suburban areas

Objective We investigated pre‐hospital times, clinical characteristics and therapeutic interventions in multisystem trauma patients injured in mountainous areas in comparison to both urban and suburban trauma patient admissions. Methods Pre‐hospital and in‐hospital data collected from trauma patients included in the International Alpine Trauma Register (IATR) hosted in Bolzano, Italy (aged 16–80 yr with an ISS ≥ 16), were compared with trauma patient data published from those urban and suburban areas included in the Trauma Register DGU® (TR‐DGU) of the German Trauma Society. Results A total of 94 patients from the IATR and 11,020 patients from the TR‐DGU met the inclusion criteria. Due to longer treatment‐free intervals (mean 59.1 vs. 19.7 min), total out‐of‐hospital time was reportedly longer in individuals injured in mountainous areas, compared to urban/suburban areas (117.4 ± 142.9 vs. 68.7 ± 28.6 min, p = 0.002), despite the more frequent helicopter rescue (93% vs. 40%, p < 0.001). 57% of IATR patients were hypothermic at hospital arrival, mean ISS was higher (38.5 ± 15.8 vs. 28.6 ± 12.2, p < 0.001) and patients with a systolic blood pressure (SBP) ≤90 mm Hg were more frequent (27% vs. 15%, p = 0.005), yet less patients had received volume therapy (82% vs. 93%, p = 0.001). However, overall no difference in hospital mortality was observed (11% vs. 17%, p = 0.159). Conclusion Trauma incidents in mountainous areas commonly feature significantly increased out‐of‐hospital time which is associated with a more severe ISS, higher risk of accidental hypothermia and more frequent hypotension compared to urban/suburban trauma. Nonetheless, the mortality rate of IATR patients is comparable to urban/suburban trauma patients.

Notfallmedizin im alpinen Gelände – Schock-, Schmerztherapie und Atemwegssicherung

Rescue operations in mountain and remote areas pose special challenges for the rescue team and often differ substantially from rescue missions in the urban environment. Given the growing sports and leisure activities in mountains, incidence of alpine emergencies is expected to rise further. The following article describes the treatment of haemorrhagic shock, analgesic therapy and airway management in mountain rescue.Rettungseinsatze im alpinen Gelande stellen das Rettungsteam vor besondere Herausforderungen und unterscheiden sich oft wesentlich von urbanen Rettungseinsatzen. Angesichts der zunehmenden Sport- und Freizeitaktivitaten in den Bergen ist mit einer weiteren Zunahme von alpinen Notfallen zu rechnen. Nachfolgend wird auf spezielle Aspekte der alpinen Notfallmedizin wie die Therapie des hamorrhagischen Schocks, die Analgesie sowie das Atemwegsmanagement eingegangen.