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Abstract Background The 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. Methods In a multi-centre retrospective study, we analyzed 6121 rescue missions from nine HEMS bases situated in mountainous regions of four European countries. Results We 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. Conclusions An improvement in HEMS activation and approach times is possible. We found 17 factors associated with shorter times.

Background: Suspension syndrome describes a multifactorial cardio-circulatory collapse during passive hanging on a rope or in a harness system in a vertical or near-vertical position. The pathophysiology is still debated controversially., Aims: The International Commission for Mountain Emergency Medicine (ICAR MedCom) performed a scoping review to identify all articles with original epidemiological and medical data to understand the pathophysiology of suspension syndrome and develop updated recommendations for the definition, prevention, and management of suspension syndrome., Methods: A literature search was performed in PubMed, Embase, Web of Science and the Cochrane library. The bibliographies of the eligible articles for this review were additionally screened., Results: The online literature search yielded 210 articles, scanning of the references yielded another 30 articles. Finally, 23 articles were included into this work., Conclusions: Suspension Syndrome is a rare entity. A neurocardiogenic reflex may lead to bradycardia, arterial hypotension, loss of consciousness and cardiac arrest. Concomitant causes, such as pain from being suspended, traumatic injuries and accidental hypothermia may contribute to the development of the Suspension Syndrome. Preventive factors include using a well-fitting sit harness, which does not cause discomfort while being suspended, and activating the muscle pump of the legs. Expediting help to extricate the suspended person is key. In a peri-arrest situation, the person should be positioned supine and standard advanced life support should be initiated immediately. Reversible causes of cardiac arrest caused or aggravated by suspension syndrome, e.g., hyperkalaemia, pulmonary embolism, hypoxia, and hypothermia, should be considered. In the hospital, blood and further exams should assess organ injuries caused by suspension syndrome., (© 2023. The Author(s).)

Decisions in the management and rescue of avalanche victims are complex and must be made in difficult, sometimes dangerous, environments. Our goal was to identify indicators for quality measurement in the management and rescue of avalanche victims. The International Commission for Mountain Emergency Medicine (ICAR MedCom) convened a group of internal and external experts. We used brainstorming and a five-round modified nominal group technique to identify the most relevant quality indicators (QIs) according to the National Quality Forum Measure Evaluation Criteria. Using a consensus process, we identified a set of 23 QIs to measure the quality of the management and rescue of avalanche victims. These QIs may be a valuable tool for continuous quality improvement. They allow objective feedback to rescuers regarding clinical performance and identify areas that should be the foci of further quality improvement efforts in avalanche rescue.

Aims: We aimed to describe evidence-based options for prehospital analgesia, and to offer practical advice to physicians and nonphysicians working in mountain rescue., Methods: A literature search was performed; the results and recommendations were discussed among the authors. Four authors considered a scenario. The final article was discussed and approved by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) in October 2013., Results and Recommendations: Many health care providers fail to recognize, assess, and treat pain adequately. Assessment scales and treatment protocols should be implemented in mountain rescue services to encourage better management of pain. Specific training in assessing and managing pain is essential for all mountain rescuers. Persons administrating analgesics should receive appropriate detailed training. There is no ideal analgesic that will accomplish all that is expected in every situation. A range of drugs and delivery methods will be needed. Thus, an 'analgesic module' reflecting its users and the environment should be developed. The number of drugs carried should be reduced to a minimum by careful selection and, where possible, utilizing drugs with multiple delivery options. A strong opioid is recommended as the core drug for managing moderate or severe pain; a multimodal approach may provide additional benefits.

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., (© 2013 John Wiley & Sons Ltd.)

The aim was to establish scientifically supported recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue, which can be applied by physicians and nonphysicians. A literature search was performed; the results and recommendations were discussed among the authors, and finally approved by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) in October 2011. 4166 abstracts were reviewed; of these, 96 were relevant for this article and are included in this literature review. In mountain rescue, CPR may be withheld or terminated in a patient with absent vital signs when the risk is unacceptable to the rescuer, the rescuer is exhausted or in extreme environments where CPR is not possible or any of the following apply: decapitation; truncal transection; whole body incinerated, decomposed, or frozen solid; avalanche victim in asystole with obstructed airway and burial time >35 min. Also, CPR may be terminated when all of the following criteria apply: unwitnessed loss of vital signs, no return of spontaneous circulation during 20 min of CPR, no shock advised at any time by AED or only asystole on ECG, and no hypothermia or other special circumstances warranting extended CPR. In situations where transport is not possible, mitigation of special circumstances is not possible, and further resuscitation is futile, CPR should be terminated. Medical directors of rescue teams should interpret these recommendations in the context of local conditions and laws, and create team-specific training and protocols for determining when to withhold and terminate CPR in a patient with absent vital signs.

We conducted a survey of equipment in medical backpacks for mountain rescuers and mountain emergency physicians. The aim was to investigate whether there are standards for medical equipment in mountain rescue organizations associated with the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). A questionnaire was completed by 18 member organizations from 14 countries. Backpacks for first responders are well equipped to manage trauma, but deficiencies in equipment to treat medical emergencies were found. Paramedic and physicians' backpacks were well equipped to provide advanced life support and contained suitable drugs. We recommend that medical backpacks should be equipped in accordance with national laws, the medical emergencies in a given region, and take into account the climate, geography, medical training of rescuers, and funding of the organization. Automated external defibrillator provision should be improved. The effects of temperature on the drugs and equipment should be considered. Standards for training in the use and maintenance of medical tools should be enforced. First responders and physicians should only use familiar tools and drugs.

The purpose of this article is to establish medical recommendations for safe and effective Helicopter Emergency Medical Systems (HEMS) in countries with a dedicated mountain rescue service. A nonsystematic search was undertaken and a consensus among members of International Commission for Mountain Emergency Medicine (ICAR Medcom) was reached. For the severely injured or ill patient, survival depends on approach time and quality of medical treatment by high-level providers. Helicopters can provide significant shortening of the times involved in mountain rescue. Safety is of utmost importance and everything possible should be done to minimize risk. Even in the mountainous environment, the patient should be reached as quickly as possible (optimally<20 min) and provided with on-site and en-route medical treatment according to international standards. The HEMS unit should be integrated into the Emergency Medical System of the region. All dispatchers should be aware of the specific problems encountered in mountainous areas. The nearest qualified HEMS team to the incident site, regardless of administrative boundaries, should be dispatched. The 'air rescue optimal crew' concept with its flexibility and adaptability of crewmembers ensures that all HEMS tasks can be performed. The helicopter and all equipment should be appropriate for the conditions and specific for mountain related emergencies. These recommendations, agreed by ICAR Medcom, establish recommendations for safe and effective HEMS 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.

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.

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.

Cardiopulmonary resuscitation in the mountains usually has to be performed under difficult and hostile circumstances and sometimes for extended periods of time. Therefore, mountain rescuers should have the ability and the appropriate equipment to perform prolonged, efficient, and safe ventilation. Members of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) discussed the results of a literature review, focusing on the advantages and disadvantages of common ventilation techniques in basic life support and their training methods with specific respect to use in mountain rescue, and recommendations were proposed. Bystanders fear the potential risk of infection and lack the willingness to perform mouth-to-mouth ventilation, though the risk of infection is low. Mouth-to-mouth ventilation remains the standard technique for bystander ventilation and, in the absence of a barrier device, bystanders should not hesitate to ventilate a patient by this technique. For mountain rescue teams, we encourage the use of a barrier device for artificial ventilation. Mouth-to-mask ventilation devices are most likely to fulfill the requirements of being safe, simple, and efficient in the hands of a basic-trained rescuer. The use of a mouth-to-mask ventilation device is recommended for out-of-hospital ventilation in the mountains and should be part of the mountain rescuer's standard equipment. Bag-valve-mask ventilation is efficient, if performed by well-trained rescuers, but it leads to a low ventilation quality in the hands of a less experienced rescuer. It should be emphasized that regular training every 6 to 12 months is necessary to perform proper ventilation.

In avalanche accidents, the significance of major trauma as a cause of morbidity and mortality is controversial. The aim of this retrospective study is to determine the severity and pattern of injury in avalanche victims admitted to the University Hospital of Innsbruck between 1996 and 2005. A total of 49 significant injuries were found in 105 avalanche victims; the most frequent were of the extremities (n = 20), the chest (n = 18), and the spine (n = 7). In contrast, cerebral (n = 2), abdominal visceral (n = 1), and pelvic trauma (n = 1) were rare. The severity of injury was minor or moderate in most patients, with only 9 (8.6%) being severely or critically injured. Of 105 (34.3%) avalanche victims, 36 died. Autopsy was performed in 30 of 36 nonsurvivors. The cause of death in the remaining 6 victims was concluded from clinical, radiological, and electrophysiological findings. Trauma was responsible for deaths of only 2 avalanche victims (5.6%); both had cervical spine fractures with dislocation leading to death. One death was due to hypothermia, whereas the remaining 33 fatalities (91.7%) were due to asphyxia. The incidence of life-threatening or lethal trauma was well below 10%. Asphyxia is by far the most important reason for death. Deaths from trauma were solely due to isolated cervical injuries, demonstrating that the cervical spine may be a region at particular risk in avalanche victims.