In mountain environments, multiple trauma, a life-threatening injury involving at least one body region with an injury severity score (ISS) ≥16, may be associated with increased prehospital time, a higher risk of accidental hypothermia, and a lower systolic blood pressure compared to urban trauma. In a survey from Scotland,78.4% of survivors were traumatised (n = 622), but only 12(3.6%) had sustained multiple trauma, indicating that multiple trauma is a rare condition. However, a multiple trauma patient requires more resources. Treatment costmay exceed US$ 1 million and quality of life and capacity to work are often permanently impaired. Outcome from multiple trauma on a mountain may be worse than in an urban environment. It is necessary to optimise prehospital care of multiple trauma patients to avoid poor outcomes related
to delayed or incorrect treatment. No specific
guidelines exist for the management of multiple
trauma in mountain environments. Despite
numerous medical and technological advances,
care of multiple trauma patients in a mountain
environment remains challenging. Bad weather,
difficult terrain, poor visibility, and limited rescue
personnel and transport options may affectpatient
outcomes. Every rescue is different. Rescuers
mustexercise flexibility in selecting the transport
options bestsuited to each case. The objective of
this review is to provide evidence-based guidance
to assist rescuers in themanagement of multiple
trauma in mountainenvironments.
Accidents in the mountains create challenges that
are not found in most urban scenarios. Trauma
victims canbe difficult to locate and extricate
because of the terrain.Bad weather can impede
rescue efforts and limit the deliveryof on-site
patient care. Environmental factors maydemand
deviation from normal patterns of care providedin
an urban environment. Evacuation to definitive
carecan be greatly delayed due to travel over
difficult terrainand bad weather. Medical response
in mountainous terraincan also be greatly delayed
compared to an urban setting. Mountain victims
may not receive care within the same time frame
as in an urban setting because of the location. This
article focuses on helicopter supported mountain
rescue missions because in many developed
countries (e.g. Austria > 98%), as well as in
some developing countries, the large majority of
multiple trauma patients are rescued by HEMS.
Ground based mountain rescue services are
still necessary during conditions that prevent
helicopter flights, such as bad weather, darkness,
when night vision goggles are not available, and
high altitude. Technical possibilities and human
resources may be very limited during ground
rescue missions. In ground rescue missions,
only basic equipment may be available. The
physical and psychological challenges may be
extraordinary. Trauma mortality is not necessarily
higher with prehospital times longer than 60
min except for patients in haemorrhagic shock.
The goal is to provide the best possible care
throughout the rescue effort, given the unique
situation and based on the principles described in
these recommendations.
Recommendations: Consider terrain, weather,
transport conditions and limited resources when
treating a multiple trauma patient in the mountains.
The safety of the rescuers is the first principle of
rescue (Fig. 1). Rescuers should be able to move
safely in hazardous mountain terrain. Helmets can
reduce the likelihood and severity of traumatic brain
injury (TBI). Mountain rescuers should wear helmets
to protect against TBI and should use additional safety
equipment to prevent injuries. On-site patient care may
be hazardous to both patients and rescuers, because
of steep or slippery terrain, rock, ice or snowfall,
avalanches, and low visibility. Rescuers must consider
potential hazards including transport to and from the
scene, access to the scene, clothing and equipment
for the rescuers, and reliable communications
with other agencies and team members. Rescuers
must also use personal protection from body fluid
exposures and be prepared to handle immediate
life threatening conditions. The decision to
stabilise on site and prepare for transport’ versus
a ‘grab and go’ approach will necessarily be made
on a case-bycase basis. In hazardous conditions,
it may be necessary to evacuate a casualty from
the accident site as rapidly as possible before any
medical treatment has been given, even if there are
critical injuries.
Recommendations: On-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)
In contrast to patients with multiple trauma in
military operations, patients in the mountains with
multiple trauma very rarely sustain life threatening
limb haemorrhage that can be treated with
relatively simple measures, such as a tourniquet.
Rather, these patients often sustain blunt injuries
with bleeding from internal organ injuries that can
only be treated surgically (e.g. by damage control
surgery or interventional radiology). In patients
with multiple trauma, control of massive external
haemorrhage with methods such as compression,
haemostatic agents, or tourniquets, takes priority
over other components of ABCDE because massive
external haemorrhage leads to death most rapdily.
In tactical or military medicine this is known as
the critical bleeding or the exsanguination ABCDE
approach (crABCDE or XABCDE).
Maintaining an open airway is the second essential
step in the treatment of trauma patients. Oxygen
is recommended for trauma patients, especially at
high altitude (above 2500 m), in order to preserve
normoxia. Available oxygen may be limited,
especially during long or technically difficult
rescues. A suction device must be ready at all
times. An obstructed airway requires immediate
airway management. To open the airway, the initial
action should be a jaw thrust, avoiding excessive
movement of the cervical spine. Indications for
advanced airway management include apnoea,
agonal respirations, severe thoracic trauma,
and TBI with seriously impaired gas exchange.
Advanced airway management prior to extrication
by hoist or long line carries a risk of dislodging
the airway device or hypoventilating the patient.
Providing a definitive airway can be difficult. Video
laryngoscopy with a bougie may facilitate tracheal
intubation. Prehospital tracheal intubation should
only be performed by experienced rescuers. In
austere environments, use of supraglottic devices
may be superior to tracheal intubation . When a
definitive airway is required and tracheal intubation
is not possible, creation of a surgical airway with
a cricothyrotomy may be necessary if supraglottic
airway insertion and bag-valve mask ventilation fail.
Ventilation with a bag-valve mask or a supraglottic
airway is often as effective as tracheal intubation.
Immediately after establishment of an advanced
airway (a tracheal tube or supraglottic airway),
capnography should be used to confirm correct
placement and to achieve normal ventilation.
In prolonged rescue missions, bag-valve mask
ventilation should only serve as a bridge to a
protected airway. Immobilisation of the c-spine is
not necessarily recommendedfor all blunt trauma
patients (Table 2) and should not be performed
in neurologically intact patientswith penetrating
trauma. A clinical decisionrule, such as NEXUS or
the Canadian C-spineRule, should be usedto avoid
secondary spinal injury. Prehospital clearance
of the c-spine in children(≤8 years, although not
uniformly defined) is not recommended. Methods
to immobilise the c-spinemay include manual in-
line stabilisation, SAM splints, orcervical collars.
Cervical collars must be applied correctly, with
special attention to maintaining venousreturn .
Spinal injury is covered underDisability
Recommendations: Provide 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 patientmay be hyperventilated (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 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 inline
stabilisation, a SAM splint, or a cervical collar (1B).
Normoxia and normocapnia are optimal to
support physiological organ function. Ventilatory
support is desirable if the patient is not able to
maintain normoxia with supplementary oxygen or
if hypercapnia may have deleterious effects, as in a
hypoventilating patient with TBI. With the lowest
possible oxygen flow to preserve supplies, aim for
oxygen saturation ≥94% (88% in patients with
chronic pulmonary disease). Avoid hyperoxia, as it
may decrease survival. Once an advanced airway is
established, normal ventilation should be achieved
with lung-protective ventilation according to
ideal body weight, monitored by end-tidal carbon
dioxide measurement (capnometry) and pulse
oximetr. Acute respiratory failure after severe
trauma may be caused by a severe chest injury,
such as flail chest, lung contusions or lacerations,
or tension pneumothorax. Acute respiratory
failure may also occur after TBI or spinal trauma,
because of respiratory paralysis, aspiration, or
airway obstruction secondary to decreased level of
consciousness.
Recommendation: Establish normal ventilation
with lung-protective ventilation and establish
normoxia and normocapnia in TBI patients (1A).
Multiple trauma is frequently associated with blunt
thoracic trauma. The main symptoms of blunt
thoracic trauma are pain and difficulty breathing.
Initial assessment should include pulse oximetry
and assessment of breathing to identify respiratory
distress. Severe pain from fractured ribs may
compromise ventilation Effective analgesia and
oxygen administration may improve ventilation
and oxygenation. A noncritical pneumothorax or
haemothorax may remain undiagnosed without
risk to the patient. Consideration must be given to
the expansion of trapped gas in the pneumothorax
if the helicopter must gain substantial elevation
during the evacuation. If oxygenation does not
improve or deteriorates and severe respiratory
or circulatory compromise occurs, it is critical to
diagnose a tension pneumothorax and to perform
an immediate decompression of the pleural cavity.
Needle decompression in the second or third
intercostal space in the midclavicular line can be
rapidly and easily performed as the first step in
treatment, but has a considerably higher failure
rate than tube thoracostomy. Tube thoracostomy is
superior to needle decompression, althoughit is not
without risks. Pigtail catheters are increasinglyused
because they are minimally invasive andhave a
lower complication rate than tube thoracostomy.
They may become the prehospital intervention
of choicein uncomplicated pneumothorax.
The prehospitaluse of aminithoracostomy,
a skin incision followed by blunt finger
dissection without a trocar, may have the lowest
complication rate, but can create a sucking
chest wound in a nonventilated patient. Massive
haemothoraxmay cause both severe respiratory
distress and significant blood loss, necessitating
immediate evacuation to a trauma centre. In
several HEMS systems, thoracostomiesare
performed routinely in anaesthetizedpatients
receiving positive pressure ventilation. In
remotemountain emergency operations, during
a long rescue, a thoracostomy may be required as
a lifesavingprocedure without positive pressure
ventilation. If athoracostomy is performed on a
patient without a tensionpneumothorax, negative
pressure ventilation (spontaneous breathing) may
lead to accumulation of a simple pneumothorax
with respiratory compromise.
Recommendations: Identify 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 aminithoracostomy (1B) or pigtail catheter
(2B).
Severe haemorrhage is the second leading cause
of death, after TBI. Decreased cardiac output and
blood pressure reduce tissue oxygen delivery.
Prioritise haemorrhage control. Maintain
oxygenation and perfusion using clinical and
ultrasonographic findings with a goal of mean
arterial blood pressure
(MAP) ~ 65 mmHg in previously normotensive
patients.
Pulse oximetry and blood pressure often are
readily obtainable. Perfusion can be measured
clinically by assessing consciousness and capillary
refill (limited in cold and with anaemia). Blood
pressure measurement only provides a surrogate
marker of perfusion and oxygen delivery. With no
compressible haemorrhage, allow for permissive
hypotension and prioritise rapid transport
First, attempt direct manual compression.
Continued extremity bleeding should
be controlled with a tourniquet. Modern
tourniquets can decrease haemorrhage,
prevent shock, decrease limb loss caused
by ischaemia, and permit rapid extrication.
Mortality increases if tourniquet use is delayed
until trauma-centre arrival. Windlass-style
tourniquets (eg CAT or SOFTT tourniquets)
are optimal. Tourniquets are superior to direct
pressure in severe extremity exsanguination.
Usually they are left in place for 2-6 h. It
is best to release the tourniquet only after
arrival to definitive care. Tourniquet-related
complications are rare for tourniquets applied
less than 2 h. Complications may also be related
to degree of tissue injury. There are anecdotal
reports describing complications. Some
guidelines recommend checking for bleeding
every two hours. Control of non-compressible
haemorrhage with expandable sponges is a
novel method. Junctional tourniquets may
control haemorrhage in inguinal and axillary
areas where standard tourniquets are not
effective . Temporary aortic occlusion with
resuscitative balloon occlusion of the aorta
(REBOA) has been described for internal
abdominopelvic haemorrhage, but substantial
training and resources are required. REBOA is
a complex technique, which only a few highly
advanced HEMS may be able to offer. The
use of ultrasound may make REBOA more
accurate and safer. The technique and pitfalls
have been reviewed in detail elsewhere. Pelvic
binders close the pelvic ring Pelvic binders
may have an effectiveness of 70% in stabilizing
the pelvis. Training is required. Binders must
be carefully positioned to be effective.
Recommendations: General principles. Stop
haemorrhage (1A) and maintain oxygenation
and perfusion (MAP ≥65 mmHg in previously
normotensive patients) (1C). With uncontrolled
haemorrhage, allow permissive hypotension
(1B). Rapid transport may be critical (1B).
Bleeding Control. Nonpharmacologic methods.
First, attempt direct manual compression (1A).
For uncontrolled extremity bleeding use a
modern tourniquet with a windlass to control
bleeding (1B) and facilitate extrication (1B).
Release the tourniquet only after arrival to
definitive care (2B). Do not release the tourniquet
to check bleeding (2C). Consider control of non
compressibletruncal haemorrhage with expandable
sponges and junctional tourniquets for axillary and
inguinal areas (2C). For pelvic fractures, use a pelvic
binder to close the pelvic ring (2C).
The combination of TBI and multiple trauma is a
predictor of poor outcome.
Increases in the severity and duration of secondary
insults correlate with worse outcomes. Maintaining
an open airway may help to minimise secondary
brain injury. In severe TBI, supplementary oxygen
may help to avoid secondary brain injury. If the
rescuers have only basic skills, simple airway
procedures may improve survival. Tracheal
intubation has caused increased mortality in some
trauma systems, probably because rescuers lacked
adequate airway management skills Improved
outcomes have been reported for tracheal
intubation in severe TBI when experienced
providers deliver care using rapid sequence
intubation with neuromuscular blocking agents.
Ventilation should be assessed clinically (rate,
depth, effort). Patients should be monitored
by pulse oximetry and waveform capnography.
Hypoxia (SpO2 ≤ 94%), hyperventilation (ETCO2
< 35 mmHg – < 4.5 kPa) and hypoventilation
(ETCO2 > 45 mmHg – > 6 kPa) are associated
with worse outcomes. Achieving normocapnia in
patients with multiple trauma can be challenging.
Continuous monitoring with capnography can
reduce hypo and hyperventilation in TBI patients.
Rescuers should attempt to maintain normoxia
(SpO2 95-98%) and normocapnia (ETCO2 35-45
mmHg – 4.5-6 kPa at sea level).
It is essential to control haemorrhage in order to
minimise secondary TBI caused by hypotension.
The injured brain loses autoregulation, resulting
in secondary ischaemic damage. Hypotension
(systolic blood pressure [SBP] < 110 mmHg)
increases morbidity and mortality in TBI. Mortality is
higher when hypoxia and hypotension are combined.
Outcomes worsen with more episodes, increased
severity, and longer duration of hypotension. In
TBI, the traditional definition of shock (SBP < 90
mmHg) underestimates the effect of hypotension.
Patients with moderate to severe TBI should be
considered hypotensive with SBP < 110 mmHg. In a
retrospective registry study, mortality increased 4.8%
for every 10 mmHg decrease in SBP when SBP was
< 110 mmHg. In critical patients with TBI,a target
SBP of 120 mmHg effectively minimised secondary
insults. The target SBP for cerebral resuscitation
in TBI should be ≥110 mmHg. In multiple-trauma
patients with TBI, the need to maintain cerebral
perfusion pressure with increased SBP conflicts
with the use of permissive hypotension. This conflict
has not been studied in adults. In children timely
haemodynamic resuscitation, to treat TBI, improves
outcomes. The use of hypertonic saline rather
than standard fluids does not improve outcomes
In the mountains, especially on ground rescue
missions, small volumes of hypertonic saline may
be more practical than standard fluids. The value
of prehospital vasopressors remains uncertainbut
they may be helpful to maintain adequate SBP.
Temperature management to avoid hypothermia
improves haemorrhage control to minimise
secondary injuries.
Recommendations: Assess 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 byattempting to maintain elevation
of the head (1C). AdministerTXA within 3 h after
trauma (1A). Avoidhypothermia (1C).
Management of patients with multiple trauma in
mountain environments can be demanding. Safety
of the rescuers and the victim has priority. Use of
crABCDE with haemorrhage control first is critical.
This should be followed by basic first aid, splinting,
immobilisation, analgesia and insulation. Duration
of 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, such as POCUS, may
be beneficial. Treatment should be continued during
transport
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