Multiple trauma management in mountain environments - a scoping review
ICAR MedCom · 2020 · Switzerland
Source and licence
- Authors
- G Sumann, D Moens, B Brink et al.
- Title
- Multiple trauma management in mountain environments - a scoping review
- Journal
- Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2020
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC7737289
Licence statement of the original publication
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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Challenges in mountain rescue
- RecommendationsConsider terrain, weather, transport conditions and limited resources when treating a multiple trauma patient in the mountains1C
Rescuer safety
- RecommendationsOn-site safety of rescuers takes precedence over all other considerations (1C). Wear helmets to protect against TBI (1B) and use additional safety equipment to prevent injuries and infections (1C). In a hazardous environment, consider a strategy of ‘grab and go’ rather than ‘stabilise on site.’1C
Airway (A) and cervical spine (c-spine)
- RecommendationsProvide oxygen (2B), especially at high altitude (above 2500 m) (1A). Rescuers should be competent in opening and clearing an airway, and in maintaining a patent airway (1C). Only experienced rescuers should perform prehospital tracheal intubation (1B). Consider advanced airway management if gas exchange is seriously impaired (2B). Be cautious with advanced airway management prior to extrication by hoist, because the artificial airway may be dislodged or the patient may be hypoventilated (1C). Consider using a video laryngoscope and an introducer to facilitate tracheal intubation (1B), or a supraglottic device as an alternative to tracheal intubation (2A) Tracheal intubation of a child should only be performed by an experienced rescuer. Otherwise, ventilate with a bag-valve mask (2B). After establishing an advanced airway, use capnography to confirm correct placement and to maintain normal ventilation (2B). Do not immobilise the c-spine of a blunt trauma patient who does not meet criteria for c-collar placement according to a validated decision rule (1A). Do not immobilise the c-spine of a neurologically intact patient with penetrating trauma (1A). Do not clear the c-spine in children in a prehospital environment (1C). The c-spine may be immobilised using manual in-line stabilisation, a SAM splint, or a cervical collar1B
Breathing (B)
- RecommendationEstablish normal ventilation with lung-protective ventilation and establish normoxia and normocapnia in TBI patients1A
Thoracic injury
- RecommendationsIdentify respiratory distress and use a pulse oximeter (1B). Consider the potential critical expansion of a pneumothorax during helicopter evacuation when substantial elevation gain is necessary (1B). If severe respiratory or circulatory compromise occurs, consider the cause to be a tension pneumothorax. Immediately decompress the pleural cavity (1B) with a minithoracostomy (1B) or pigtail catheter2B
Hypothermia and TBI
- RecommendationsAssess ventilation clinically (1C) and monitor patients with pulse oximetry to minimise hypoxia (1C). Use capnography to maintain normocapnia (1C). Maintain systolic blood pressure ≥ 110 mmHg (2C). Expedite rescue. Do not delay evacuation by attempting to maintain elevation of the head (1C). Administer TXA within 3 h after trauma (1A). Avoid hypothermia1C
Spinal injury
- RecommendationsImmobilise the spine of all multiple trauma patients with altered level of consciousness (1C). Use a clinical decision rule to identify patients at risk from secondary spinal injury and only if positive immobilise the spine (1B). Limit spinal motion with a combination of manual stabilisation, head blocks, and hard or soft transfer devices (1C). Choose techniques that require minimal handling (1C). Do not log roll unstable trauma patients (1C). Consider a vacuum mattress for a long comfortable transfer (1C). Consider a KED or similar device for extrication in a non-horizontal position1C
Environment and exposure (E)
- RecommendationsConsider whether exposure will be helpful. (1C). Sequentially examine by body region, avoiding heat loss and preserving insulating clothing2C
First aid, splinting and immobilisation
- RecommendationsConsider early splinting to reduce pain and blood loss and to facilitate transport (1C). Use splinting devices with which you are familiar (1C). Consider the use of vacuum splints (1C). Transport patients with multiple trauma using vacuum mattresses, rather than spine boards, to avoid additional soft tissue injury1C
Regional Anaesthesia
- RecommendationsConsider nonpharmacologic interventions1C
Hypothermia and temperature management
- RecommendationsIf a suitable thermometer is not available, use the Swiss staging system to estimate core temperature (1C). Epitympanic thermometers using a thermistor are reliable for core temperature monitoring if they are designed for field use in cold environments. There is currently limited availability of suitable thermometers. (1B). In a patient with a secured airway consider core temperature measurement using an oesophageal probe (2A). A hypothermic patient should be extricated from the cold environment and covered by a vapour barrier and whole-body insulation (1C). Rewarming devices should be used in conjunction with vapour barriers and insulation1C
Transport and hospital selection
- RecommendationsExpedite transport (1C). Use a lightweight and stable stretcher(1C). Avoid moving a patient in a vertical position, as this may cause hypotension, especially with significant haemorrhage (1C). Use helicopter transport for a patient with spinal injury or haemodynamic instability (1C). Transport TBI patients by air if this saves time to definitive treatment (1B). Use a helicopter to reach a distant high-level trauma centre, bypassing smaller local hospitals (1B). Balance the benefits of air rescue with the inherent risks1C
Technical procedures
- RecommendationsConsider using POCUS in patients with multiple trauma (2B), but do not delay arrival to hospital. Consider ultrasound to manage a difficult airway (2C), to detect pneumo- and haemothorax and pericardial effusion (1A), and to diagnose fractures (2B) and increased intracerebral pressure (2B). Consider performing a FAST exam on patients in shock (1B). Use POCUS for vascular access (1A) and nerve blocks1A
Abstract
Background: Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.
Objective: To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.
Eligibility criteria: All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.
Sources of evidence: PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.
Charting methods: Evidence was searched according to clinically relevant topics and PICO questions.
Results: Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.
Conclusions: Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
Contents of the original publication
The section headings of the original.
- Introduction
- Methods
- Results
- Discussion
- Injury patterns of patients with multiple trauma in the mountains
- Challenges in mountain rescue
- Rescuer safety
- Critical bleeding (Cr)
- Airway (A) and cervical spine (c-spine)
- Breathing (B)
- Thoracic injury
- Circulation (C)
- Bleeding control
- IV access
- Volume replacement, blood products, and vasopressors
- Disability (D)
- Spinal injury
- Environment and exposure (E)
- First aid, splinting and immobilisation
- Analgesia
- Hypothermia and temperature management
- Transport and hospital selection
- Ultrasound
- Limitations
- Conclusions
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