Background:Out-of-hospital cardiac arrest (OHCA) in mountainous environments presents substantial logistical challenges, particularly in maintaining high-quality chest compressions during helicopter evacuations. Prolonged interruptions, especially during hoisting, may critically impact neurological outcomes. This study aimed to assess the feasibility and effectiveness of a mechanical chest compression (MCC) device compared to manual compressions during a simulated helicopter hoisting scenario. Methods:This was a prospective, crossover simulation study involving complete mountain rescue teams. Each team completed two scenarios: one using an MCC device (LUCAS-3®) and one using manual chest compressions. Hoisting was performed at two heights (15 m and 30 m). The primary outcome was chest compression fraction (CCF). Secondary outcomes included, compression depth and rate, and overall safety of the procedure. Results are reported as mean ± standard deviation. Results:CCF was significantly higher in the MCC group compared to the manual group (96.6 % ± 0.3 vs. 73.9 % ± 6.6; p = 0.03). Compression rate was more consistently maintained within recommended ranges (103.0 ± 1.4 cpm vs 136.5 ± 8.7 cpm; p = 0.03 ). The guidelines-recommended range for chest compressions was significantly higher with the MCC device (89.5 % ± 9.6 vs 7.5 % ± 6.3; p = 0.03). No adverse safety events were observed. Conclusion:In a simulated mountain rescue setting, the use of a mechanical chest compression device during helicopter hoisting appears feasible, safe and seems to improve chest compression fraction and the rate of guideline-compliant chest compressions.

Avalanches are a major cause of death in mountainous regions, primarily from asphyxia. However, increased recreational activities and climate change may be leading to more traumatic injuries, such as bone fractures, which are currently understudied. This study compared two distinct bone fracture classification systems, to better understand specific injury mechanisms in avalanche victims.We conducted a retrospective analysis of post-mortem CT scans from 13 adult avalanche victims in Grenoble, France, all with at least one bone fracture. Using MIP, MPR, and 3D reconstructions, we systematically classified fractures across ten major anatomical regions, representing the entire body. We analyzed each fracture to determine its traumatic mechanism using both the surgical AO/OTA and the anthropological Galloway et al. (2014) classification systems.The study included 13 individuals (61.5% male; mean age: 37 years), with a total of 265 fractured bones. Fractures were most frequently observed in the thorax (52%), spine (21%), and skull (14%). We found that multiple injury mechanisms, such as impact and compression, often occurred simultaneously. Both classification systems consistently identified six "burst"-type spinal fractures. However, for five open-book pelvic fractures, only the Galloway et al. system precisely described the specific injury mechanism.Our findings indicate that the AO/OTA and Galloway et al. classifications are complementary. The AO/OTA system offers standardized clinical utility, while the Galloway et al. system enhances forensic and anthropological interpretation by elucidating trauma mechanisms. These preliminary insights into bone injury mechanisms in avalanche events emphasize the need for interdisciplinary approaches to improve victim care and safety.

Objective: To provide modern guidelines for management of acute pain in adult emergency patients. Design: A consensus committee of 31 experts from the French Society of Emergency Medicine (Soci & eacute;t & eacute; fran & ccedil;aise de m & eacute;decine d'urgence, SFMU) including 10 pain specialists (national/international publications) was convened. & Agrave; formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. Methods: The aim of this expert panel guidelines is to evaluate the medical treatment of acute pain in emergency medicine intrahospital and extra-hospital. The experts studied questions within 3 domains : 1) Pain assessment guiding indication of its treatment and the organization of the healthcare teams, 2) Pharmacological and non-pharmacological management, and 3) analgesic relay after discharge or inhospitalization. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE (R) methodology. Results: The experts' synthesis work and the application of the GRADE (R) method resulted in 35 recommendations and 1 diagram. Among the formalised recommendations, 5 have high levels of evidence (GRADE 1 +) and 13 have low levels of evidence (GRADE 2 +). For 17 recommendations, the GRADE method could not be applied, resulting in expert opinions. 4 questions did not find any response in the literature. After 2 rounds of scoring and amendment, strong agreement was reached for all the recommendations. Conclusions: There was strong agreement among experts for 35 recommendations to improve practices for acute pain management in adult emergency patients.

Abstract Background The management of avalanche victims in cardiac arrest (CA) is a challenging situation for rescuers. Despite existing specific management algorithms, previous studies have reported poor compliance with international guidelines and incomplete documentation and transmission of the information required for patient management. The Avalanche Victim Resuscitation Checklist (AVRC) was developed in 2014 in response by the International Commission for Mountain Emergency Medicine. Our aim was to assess the impact of the AVRC on the quality of onsite management of critically buried avalanche victims in CA, i.e. the compliance of management with international guidelines and the completeness of documentation of avalanche specific information. Methods We assessed compliance and documentation in a Swiss helicopter emergency medical service (HEMS) between January 2010 and April 2020. Victims buried for more than 24 h were excluded. Results In the 10-year study period, 87 critically buried avalanche victims in CA were treated by the HEMS, 44 of them after the introduction of the AVRC. Enough information was available to assess management compliance in over 90% of cases (n = 79). Inadequate management (n = 25, 32%) and incomplete documentation occurred more often in patients with a long burial duration. After the introduction of the AVRC, the compliance of patient management with the guidelines increased by 36% (from 59 to 95%, p < 0.05) and led to complete documentation of the required information for patient management. Conclusions The use of the AVRC improves the quality of management of critically buried avalanche victims in CA and ensures complete documentation of avalanche specific information. Quality improvement efforts should focus on the management of avalanche victims with a long burial duration. The use of the AVRC enables identification and appropriate treatment of patients with hypothermic cardiac arrest.

Background Mountainous areas pose a challenge for the out-of-hospital cardiac arrest (OHCA) chain of survival. Survival rates for OHCAs in mountainous areas may differ depending on the location. Increased survival has been observed compared to standard location when OHCA occurred on ski slopes. Limited data is available about OHCA in other mountainous areas. The objective was to compare the survival rates with a good neurological outcome of OHCAs occurring on ski slopes (On-S) and off the ski slopes (Off-S) compared to other locations (OL). Methods Analysis of prospectively collected data from the cardiac arrest registry of the Northern French Alps Emergency Network (RENAU) from 2015 to 2021. The RENAU corresponding to an Emergency Medicine Network between all Emergency Medical Services and hospitals of 3 counties (Is & egrave;re, Savoie, Haute-Savoie). The primary outcome was survival at 30 days with a Cerebral Performance Category scale (CPC) of 1 or 2 (1: Good Cerebral Performance, 2: Moderate Cerebral Disability). Results A total of 9589 OHCAs were included: 213 in the On-S group, 141 in the Off-S group, and 9235 in the OL group. Cardiac etiology was more common in On-S conditions (On-S: 68.9% vs Off-S: 51.1% vs OL: 66.7%, p < 0.001), while Off-S cardiac arrests were more often due to traumatic circumstances (OffS: 39.7% vs On-S: 21.7% vs OL: 7.7%, p < 0.001). Automated external defibrillator (AED) use before rescuers' arrival was lower in the Off-S group than in the other two groups (On-S: 15.2% vs OL: 4.5% vs Off-S: 3.7%; p < 0.002). The first AED shock was longer in the Off-S group (median time in minutes: OffS: 22.0 (9.5-35.5) vs On-S: 10.0 (3.0-19.5) vs OL: 16.0 (11.0-27.0), p = 0.03). In multivariate analysis, on-slope OHCA remained a positive factor for 30-day survival with a CPC score of 1 or 2 with a 1.96 adjusted odds ratio (95% confidence interval (CI), 1.02-3.75, p = 0.04), whereas off-slope OHCA had an 0.88 adjusted odds ratio (95% CI, 0.28-2.72, p = 0.82). Conclusions OHCAs in ski-slopes conditions were associated with an improvement in neurological outcomes at 30 days, whereas off-slopes OHCAs were not. Ski-slopes rescue patrols are efficient in improving outcomes.

Introduction: The International Commission for Mountain Emergency Medicine (ICAR MedCom) developed updated recommendations for the management of avalanche victims. Methods: ICAR MedCom created Population Intervention Comparator Outcome (PICO) questions and conducted a scoping review of the literature. We evaluated and graded the evidence using the American College of Chest Physicians system.Results: We included 120 studies including original data in the qualitative synthesis. There were 45 retrospective studies (38%), 44 case reports or case series (37%), and 18 prospective studies on volunteers (15%). The main cause of death from avalanche burial was asphyxia (range of all stud-ies 65-100%). Trauma was the second most common cause of death (5-29%). Hypothermia accounted for few deaths (0-4%).Conclusions and recommendations: For a victim with a burial time < 60 minutes without signs of life, presume asphyxia and provide rescue breaths as soon as possible, regardless of airway patency. For a victim with a burial time > 60 minutes, no signs of life but a patent airway or airway with unknown patency, presume that a primary hypothermic CA has occurred and initiate cardiopulmonary resuscitation (CPR) unless temperature can be measured to rule out hypothermic cardiac arrest. For a victim buried > 60 minutes without signs of life and with an obstructed airway, if core temperature cannot be measured, rescuers can presume asphyxia-induced CA, and should not initiate CPR. If core temperature can be measured, for a victim without signs of life, with a patent airway, and with a core temperature < 30 degrees C attempt resuscitation, regardless of burial duration.

AIMS:The end-tidal carbon dioxide (ETCO2) is frequently measured in cardiac arrest (CA) patients, for management and for predicting survival. Our goal was to study the PaCO2 and ETCO2 in hypothermic cardiac arrest patients.METHODS:We included patients with refractory CA assessed for extracorporeal cardiopulmonary resuscitation. Hypothermic patients were identified from previously prospectively collected data from Poland, France and Switzerland. The non-hypothermic CA patients were identified from two French cohort studies. The primary parameters of interest were ETCO2 and PaCO2 at hospital admission. We analysed the data according to both alpha-stat and pH-stat strategies.RESULTS:We included 131 CA patients (39 hypothermic and 92 non-hypothermic). Both ETCO2 (p < 0.001) and pH-stat PaCO2 (p < 0.001) were significantly lower in hypothermic compared to non-hypothermic patients, which was not the case for alpha-stat PaCO2 (p = 0.15). The median PaCO2-ETCO2 gradient was greater for hypothermic compared to non-hypothermic patients when using the alpha-stat method (46 mmHg vs 30 mmHg, p = 0.007), but not when using the pH-stat method (p = 0.10). Temperature was positively correlated with ETCO2 (p < 0.01) and pH-stat PaCO2 (p < 0.01) but not with alpha-stat PaCO2 (p = 0.5). The ETCO2 decreased by 0.5 mmHg and the pH-stat PaCO2 by 1.1 mmHg for every decrease of 1° C of the temperature. The proportion of survivors with an ETCO2 ≤ 10 mmHg at hospital admission was 45% (9/25) for hypothermic and 12% (2/17) for non-hypothermic CA patients.CONCLUSIONS:Hypothermic CA is associated with a decrease of the ETCO2 and pH-stat PaCO2 compared with non-hypothermic CA. ETCO2 should not be used in hypothermic CA for predicting outcome.

Background As any traumatic event, avalanches could trigger psychological disorders on survivors. Our objectives were to determine the prevalence of post-traumatic stress disorder among avalanche survivors and to evaluate post-traumatic stress disorder risks factors as well as the impact on quality of life. Methods A multicentre study was conducted in victims included in the North Alpine Avalanche Registry from 2014 to 2018. Data were collected through a standard questionnaire during semi-directed phone interviews. The primary outcome was the total score on the Impact of Event Scale Revised. Secondary outcomes were the Mental Component Scale and the Physical Component Scale scores of the Short Form 12 questionnaire. Results During the study period, 132 of 211 victims survived. Among the 107 victims included, 55 (51.4%) phone interviews were obtained. Six patients (10.9, 95% CI 1.76–20.05) had an Impact of Event Scale Revised score ≥ 33 indicating a strong probability for post-traumatic stress disorder. Median Mental Component Scale score was 39.0 (IQR 30.5–46.3) for post-traumatic stress disorder patients and 40.1 (IQR 36.5–43.4) for non post-traumatic stress disorder ( p = 0.76). Median Physical Component Scale score was 39.4 (37.2–44.3) for post-traumatic stress disorder patients and 44.2 (39.1–46.8) for non post-traumatic stress disorder ( p = 0.39). No significant difference in the quality of life in both populations was observed, and no independent risk factors of post-traumatic stress disorder was identified. Conclusion Avalanche accidents may induce post-traumatic stress disorders among survivors in a comparable prevalence to the most traumatic event already studied. Early recognition and preventive measures should be set up in order to reduce the psychological burden in these victims. Trial registration NCT03936738 .

Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients' cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non-asphyxia-related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.

L’hypothermie accidentelle est définie comme une baisse non intentionnelle de la température centrale du corps en dessous de 35 °C. La prévention de l’hypothermie est essentielle. La mesure de la température centrale est nécessaire au diagnostic d’hypothermie et permet d’en juger la sévérité. En présence de signes de vie, et en présence d’une hypothermie pure, l’instabilité hémodynamique apparente ne devrait en principe pas faire l’objet d’une prise en charge spécifique. Un risque d’arrêt cardiaque (AC) est présent si la température chute en dessous de 30–32 °C. En raison du risque d’AC, un patient hypotherme devrait bénéficier de l’application d’un monitoring avant toute mobilisation, laquelle devra être prudente. En cas d’AC, seule la mesure de la température oesophagienne est fiable. Si l’hypothermie est suspectée comme étant potentiellement responsable de l’AC du patient, celui-ci doit être transporté sous réanimation cardiopulmonaire vers un hôpital disposant d’une méthode de réchauffement par circulation extracorporelle (CEC). La valeur de la kaliémie ainsi que les autres paramètres à disposition (âge, sexe, valeur de la température corporelle, durée du low flow, présence d’une asphyxie) permettront de décider de l’indication d’une CEC de réchauffement. Le pronostic des patients victimes d’un AC sur hypothermie est potentiellement excellent, y compris sur le plan neurologique.

b Accidental hypothermia is an unexpected decrease of core temperature (CT) of less than 35 degrees C. A protective strategy from cold exposure is a crucial attitude. Temperature measurement is essential for diagnosing hypothermia and assessing severity. During non-trauma related cold exposure, several adaptive processes will slowly and physiologically affect vital signs. For patients with severe hypothermia and vital signs, hemodynamic and neurological instability should not benefit from any specific treatment. Cardiac arrest (CA) may occur if CT decreases under 30-32 degrees C. Due to high risks of CA during movements (rescue collapse), any hypothermic patient should be monitored for vital signs before any mobilization. Hypothermic patients should always be moved carefully. In case of CA, only oesophagus core temperature measurement is relevant. If hypothermia is suspected to be the cause of CA, continuous cardiopulmonary resuscitation should be performed. Patients should be transported to a medical center with extracorporeal life support (ECLS) facilities. Setting up ECLS will mostly depend on potassium rate but other factors will also have to be taken into account (age, gender, CT value, low flow duration, and possible asphyxia). Hypothermic CA outcome is potentially excellent, along with full neurological recovery.

Intravenous drug infusions in critically ill patients require accurate syringe infusion pumps (SIPs). This is particularly important during transportation of critically ill patients by helicopter emergency medical services (HEMS), where altitude may influence device performance. Because weight is a real concern in HEMS, new low-weight devices are very appealing. The aim of this study was to compare infusion flow rates delivered by low-weight versus standard SIP devices, in the prehospital emergency medicine setting, at different altitudes. We conducted a comparative bench study involving five SIP devices (two standard and three low-weight models) at 300, 1700 and 3000 m altitude. The primary endpoint was the flow rate delivered by SIPs for prespecified values. We used two methods to measure flow. The normative method consisted in measuring weight (method A) and the alternate method consisted in measuring instantaneous flow (method B). Using method A, no significant differences were found in median flow rates and interquartile range depending on device and altitude for a prespecified 10-mL/h flow. However, method B showed that low-weight SIPs delivered multiple sequential boluses with substantial variations (1.2–15.8 mL/h) rather than a prespecified continuous 5-mL/h flow. At 1700 m altitude, the interquartile range of delivered flows increased only for low-weight devices (p for interaction< 0.001). Despite satisfactory normative tests, low-weight SIPs deliver discontinuous flow with potential clinical implications for critically ill patients receiving vasoactive drugs. This study also highlights a thus far unknown negative impact of altitude on SIP function. We believe that normative requirements for SIP approval should be revised accordingly.

Background To date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests. Methods Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL). Results Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were − 1.6 to + 1.7 mmol/L; − 1.18 to + 2.7 mmol/L and − 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium. Conclusions We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement. Trial registration ClinicalTrials.gov Identifier: NCT03096561.

BACKGROUND:Intravenous morphine (IVM) is the most common strong analgesic used in trauma, but is associated with a clear time limitation related to the need to obtain an access route. The intranasal (IN) route provides easy administration with a fast peak action time due to high vascularization and the absence of first-pass metabolism. We aimed to determine whether IN sufentanil (INS) for patients presenting to an emergency department with acute severe traumatic pain results in a reduction in pain intensity non-inferior to IVM.METHODS AND FINDINGS:In a prospective, randomized, multicenter non-inferiority trial conducted in the emergency departments of 6 hospitals across France, patients were randomized 1:1 to INS titration (0.3 μg/kg and additional doses of 0.15 μg/kg at 10 minutes and 20 minutes if numerical pain rating scale [NRS] > 3) and intravenous placebo, or to IVM (0.1 mg/kg and additional doses of 0.05 mg/kg at 10 minutes and 20 minutes if NRS > 3) and IN placebo. Patients, clinical staff, and research staff were blinded to the treatment allocation. The primary endpoint was the total decrease on NRS at 30 minutes after first administration. The prespecified non-inferiority margin was -1.3 on the NRS. The primary outcome was analyzed per protocol. Adverse events were prospectively recorded during 4 hours. Among the 194 patients enrolled in the emergency department cohort between November 4, 2013, and April 10, 2016, 157 were randomized, and the protocol was correctly administered in 136 (69 IVM group, 67 INS group, per protocol population, 76% men, median age 40 [IQR 29 to 54] years). The mean difference between NRS at first administration and NRS at 30 minutes was -4.1 (97.5% CI -4.6 to -3.6) in the IVM group and -5.2 (97.5% CI -5.7 to -4.6) in the INS group. Non-inferiority was demonstrated (p < 0.001 with 1-sided mean-equivalence t test), as the lower 97.5% confidence interval of 0.29 (97.5% CI 0.29 to 1.93) was above the prespecified margin of -1.3. INS was superior to IVM (intention to treat analysis: p = 0.034), but without a clinically significant difference in mean NRS between groups. Six severe adverse events were observed in the INS group and 2 in the IVM group (number needed to harm: 17), including an apparent imbalance for hypoxemia (3 in the INS group versus 1 in the IVM group) and for bradypnea (2 in the INS group versus 0 in the IVM group). The main limitation of the study was that the choice of concomitant analgesics, when they were used, was left to the discretion of the physician in charge, and co-analgesia was more often used in the IVM group. Moreover, the size of the study did not allow us to conclude with certainty about the safety of INS in emergency settings.CONCLUSIONS:We confirm the non-inferiority of INS compared to IVM for pain reduction at 30 minutes after administration in patients with severe traumatic pain presenting to an emergency department. The IN route, with no need to obtain a venous route, may allow early and effective analgesia in emergency settings and in difficult situations. Confirmation of the safety profile of INS will require further larger studies.TRIAL REGISTRATION:ClinicalTrials.gov NCT02095366. EudraCT 2013-001665-16.

Aims: Cardiac arrest related to accidental hypothermia may occur at temperatures below 32 degrees C. Our goal was to describe the clinical characteristics and outcomes of patients who suffered from witnessed hypothermic cardiac arrest (CA) and assess the occurrence of hypothermic CA as a function of patient body temperature. Methods: We conducted a systematic review of the literature on cases of hypothermic CA due to rescue collapse. Patient information data from hypothermic CA patients were collected and combined with additional unpublished data to assess the clinical characteristics and outcome of hypothermic CA patients. Results: A total of 214 patients was included in this systematic review. Of the 206 witnessed hypothermic CA patients with a recorded body temperature, the average body temperature was 23.9 +/- 2.7 degrees C with five patients (2.4%) having a core body temperature of >28 degrees C. The highest temperature of a patient surviving hypothermic witnessed cardiac arrest without other associated risk factors for cardiac arrest was 29.4 degrees C. The first recorded cardiac rhythm was asystole in 33 of the 112 patients (30%) for whom this information was available. The survival rate at hospital discharge of these hypothermic cardiac arrest patients was 73% (153 of 210 patients) and most survivors had favourable neurological outcome (89%; 102 of 105 patients). Conclusions: CA that is solely caused by hypothermia did not occurs for patients with a body temperature >30 degrees C. Our findings provide valuable new information that can be incorporated into the international clinical management guidelines of accidental hypothermia.

It is with great sorrow we reflect on the loss of Dr. Emmanuel Cauchy, our friend and colleague, who died in an avalanche in the Aiguilles Rouges near Chamonix, France, on April 2, 2018. Manu, as he was known by everyone, exemplified a wilderness medicine physician who combined his passion with his profession. It is fitting that we offer this tribute and remembrance in Wilderness & Environmental Medicine.Manu and his wife Dr. Sandra Léal.Manu playing trumpet at Bridal Veil Falls, Telluride, CO.

Abstract Blancher, Marc, François Albasini, Fidel Elsensohn, Ken Zafren, Natalie Hölzl, Kyle McLaughlin, Albert R. Wheeler III, Steven Roy, Hermann Brugger, Mike Greene, and Peter Paal. Management of multi-casualty incidents in mountain rescue: Evidence-based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). High Alt Med Biol. 19:131–140, 2018. Introduction: Multi-Casualty Incidents (MCI) occur in mountain areas. Little is known about the incidence and character of such events, and the kind of rescue response. Therefore, the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) set out to provide recommendations for the management of MCI in mountain areas. Materials and Methods: Details of MCI occurring in mountain areas related to mountaineering activities and involving organized mountain rescue were collected. A literature search using (1) PubMed, (2) national mountain rescue registries, and (3) lay press articles on the internet was performed. The results were analyzed with respect to specific aspects of mountain rescue. Results: We identified 198 MCIs that have occurred in mountain areas since 1956: 137 avalanches, 38 ski lift accidents, and 23 other events, including lightning injuries, landslides, volcanic eruptions, lost groups of people, and water-related accidents. Discussion: General knowledge on MCI management is required. Due to specific aspects of triage and management, the approach to MCIs may differ between those in mountain areas and those in urban settings. Conclusions: Mountain rescue teams should be prepared to manage MCIs. Knowledge should be reviewed and training performed regularly. Cooperation between terrestrial rescue services, avalanche safety authorities, and helicopter crews is critical to successful management of MCIs in mountain areas.

Swol et al.1Swol J. Belohlávek J. Brodie D. et al.Extracorporeal life support in the emergency department: a narrative review for the emergency physician.Resuscitation. 2018; 133: 108-117Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar are to be applauded for presenting Extracorporeal Life Support (ECLS) to emergency physicians, who are in the front line in selecting potential ECLS candidates. In the light of a recently published study2Pasquier M. Hugli O. Paal P. et al.Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: the HOPE score.Resuscitation. 2018; 126: 58-64Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar we would like to add three aspects in the context of ECLS patient selection in accidental hypothermia. The first parameter is the no-flow duration. The authors state that ECLS is “not offered if the no-flow duration is unknown or prolonged to the extent that brain recovery is doubtful”.1Swol J. Belohlávek J. Brodie D. et al.Extracorporeal life support in the emergency department: a narrative review for the emergency physician.Resuscitation. 2018; 133: 108-117Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar In severe accidental hypothermia (<28 °C) the no-flow time where brain recovery is possible can be substantially prolonged (e.g. 20+ min no-flow). Additionally, most often cardiac arrest (CA) has been un-witnessed and the no-flow duration is unknown, e.g. in CA due to avalanche burial, submersion or urban hypothermia. Interestingly, in our study the parameter “un-witnessed CA” (66% of our patients) was not associated with a worse outcome.2Pasquier M. Hugli O. Paal P. et al.Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: the HOPE score.Resuscitation. 2018; 126: 58-64Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar As cooling of the body progresses, oxygen consumption of the brain declines and oxygen requirements may be a tenth compared to normothermia, which is also the basis of surgery in deep hypothermic circulatory arrest and the concept of intermittent CPR.3Gordon L. Paal P. Ellerton J.A. Brugger H. Peek G.J. Zafren K. Delayed and intermittent CPR for severe accidental hypothermia.Resuscitation. 2015; 90: 46-49Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The same reasoning leads to the second parameter, namely, the low-flow duration. In one ECPR study the median CPR-duration was 40 (16–251) min, survival-rate 28.8%.4Chen Y.S. Lin J.W. Yu H.Y. et al.Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.Lancet. 2008; 372: 554-561Abstract Full Text Full Text PDF PubMed Scopus (793) Google Scholar In our study on hypothermic CA patients, CPR duration was longer, median 120 (85–169) min, nevertheless survival to hospital-discharge was substantially higher (37%).2Pasquier M. Hugli O. Paal P. et al.Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: the HOPE score.Resuscitation. 2018; 126: 58-64Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Low-flow in hypothermic CA ECLS patients is associated with survival, but this link is weaker than in normothermic patients. Thirdly, CA rhythm. The authors mention that ECLS re-warming is indicated in hypothermic patients with refractory VT, this may be misleading.1Swol J. Belohlávek J. Brodie D. et al.Extracorporeal life support in the emergency department: a narrative review for the emergency physician.Resuscitation. 2018; 133: 108-117Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar We agree that asystole is a bad prognostic factor in normothermic ECLS patients.4Chen Y.S. Lin J.W. Yu H.Y. et al.Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.Lancet. 2008; 372: 554-561Abstract Full Text Full Text PDF PubMed Scopus (793) Google Scholar However, in hypothermic CA asystole was the presenting rhythm in 32/139 (23%) of the survivors and was not associated with worse outcome.2Pasquier M. Hugli O. Paal P. et al.Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: the HOPE score.Resuscitation. 2018; 126: 58-64Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar The pathophysiology underlying CA due to accidental hypothermia is very specific, this has justified the development of specific management guidelines.5Truhlář A. Deakin C.D. Soar J. et al.European Resuscitation Council guidelines for resuscitation 2015: section 4. Cardiac arrest in special circumstances.Resuscitation. 2015; 95: 148-201Abstract Full Text Full Text PDF PubMed Scopus (602) Google Scholar Swol et al.1Swol J. Belohlávek J. Brodie D. et al.Extracorporeal life support in the emergency department: a narrative review for the emergency physician.Resuscitation. 2018; 133: 108-117Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar state that “few risk models tested in patients who underwent ECMO were assessed in patients who received V-A ECLS support in the ED”.1Swol J. Belohlávek J. Brodie D. et al.Extracorporeal life support in the emergency department: a narrative review for the emergency physician.Resuscitation. 2018; 133: 108-117Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Recently we published the HOPE-score, whose main goal is to predict outcome in hypothermic CA patients who are considerd for ECLS re-warming.2Pasquier M. Hugli O. Paal P. et al.Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: the HOPE score.Resuscitation. 2018; 126: 58-64Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar The HOPE-score may be used in the emergency department (ED) in order to help identify hypothermic CA patients who will most likely benefit from ECPR re-warming. Patients arrested due to hypothermia represent a highly specific subset of ECPR candidates and have high chances of good outcome as compared with normothermic OHCA. The HOPE-score may help to guide decision-making on ECLS installation in hypothermic CA patients in the ED.2Pasquier M. Hugli O. Paal P. et al.Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: the HOPE score.Resuscitation. 2018; 126: 58-64Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar None declared. None.

The data and estimation methods presented in this article are associated with the research article, "Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: a retrospective multi-centre study" [1]. In this article we estimate recommended cut-off values for in-hospital triage with respect to extracorporeal rewarming. With only 6 survivors of 103 patients collected over a period of 20 years the ability to estimate reliable threshold values is limited. In addition, because the number of avalanche victims is also limited, a significantly larger dataset is unlikely to be obtained. We have therefore adapted two non-parametric estimation methods (bootstrapping and exact binomial distribution) to our specific needs and performed a simulations to confirm validity and reliability.

Aim: Intense physical activity, cold and altitude make mountain sports a cause of increased risk of out-of- hospital cardiac arrest (OHCA). The difficulties of pre-hospital management related to this challenging environment could be mitigated by the presence of ski-patrollers in ski areas and use of helicopters for medical rescue. We assess whether this particular situation positively impacts the chain of survival compared to the general population.Methods: Analysis of prospectively collected data from the cardiac arrest registry of the Northern French Alps Emergency Network (RENAU) from 2004 to 2014.Results: 19,341 OHCAs were recorded during the period, including 136 on-slope events. Compared to other OHCAs, on-slope patients were younger (56 [40-65] vs. 66 [52-79] years, p < 0.001) and more often in shockable initial rhythm (41.2% vs 20.1%, p < 0.001). Resuscitation was more frequently started by a witness (43.4% vs 26.8%, p < 0.001) and the time to the first electric shock was shorter (7.5 min vs 14 min, p < 0.001), whereas time to the advanced life support (ALS) rescue arrival did not differ. The 30-day survival rate was higher for on-slope arrests (21.3% vs 5.9%, p < 0.001, RR = 3.61). In multivariate analysis, on-slope CA remained a positive 30-day survival factor with a 2.6 odds ratio (95% confidence interval, 1.42-4.81, p = 0.002).Conclusion: Despite difficult access and management conditions, patients undergoing OHCAs on ski slopes presented a higher survival rate, possibly explained by a healthier population, the efficiency of resuscitation by ski-patrols and similar time to ALS facilities compared to other cardiac arrests. (C) 2017 Elsevier B.V. All rights reserved.