Background
Methods
Study design and population
Database, variables, and definitions
Study aim
Statistical analysis
Results
Search and rescue characteristics | |
Avalanche accidents requiring a winch operation, n (%) | 121 (29) |
Avalanche accidents with at least one victim located by professional rescuers, n (%) a | 38 (49) |
Avalanche accidents with at least one victim extricated from the avalanche by professional rescuers, n (%) b | 34 (31) |
Avalanche victims (n = 596) | |
Involved persons per avalanche accident, median (IQR; range) | 1 (1–2; 0–15) |
Injured persons per avalanche accident, median (IQR; range) | 1 (1–1; 0–7) |
Completely buried victims per avalanche accident, median (IQR; range) c | 1 (1–1; 0–5) |
Avalanche accidents with multiple casualties, n (%) d | 134 (32) |
Avalanche accidents with multiple completely buried casualties, n (%) c,e | 37 (14) |
Cardio-respiratory arrest victims (n = 172) | |
Avalanche accidents with one victim in cardiac arrest, n (%) | 121 (29) |
Avalanche accidents with multiple victims in cardiac arrest, n (%) | 20 (5) |
overall | NACA severity score | P value | |||||
---|---|---|---|---|---|---|---|
1–3 | 4 | 5 | 6 | 7 | |||
Injured patients, n (%) a | 515 | 239 (40) | 84 (14) | 20 (3) | 54 (9) | 118 (20) | |
Distribution of the patients with a given presumptive diagnosis in the different NACA score categories | |||||||
n (%) percentages are expressed by row | |||||||
Trauma |
278 (54)
| 172 (62) | 62 (22) | 8 (3) | 7 (3) | 29 (10) | < 0.001 |
Head |
80 (16)
| 33 (41) | 18 (23) | 5 (6) | 5 (6) | 19 (24) | |
Spinal |
48 (9)
| 17 (35) | 16 (33) | 2 (4) | 0 (0) | 13 (27) | |
Thoracic |
49 (10)
| 17 (35) | 18 (37) | 1 (2) | 4 (8) | 9 (18) | |
Abdominal |
14 (3)
| 5 (36) | 3 (21) | 1 (7) | 2 (14) | 3 (21) | |
Pelvic |
31 (6)
| 11 (35) | 12 (39) | 1 (3) | 1 (3) | 6 (19) | |
Femur |
50 (10)
| 27 (54) | 16 (32) | 2 (4) | 0 (0) | 5 (10) | |
Extremity (except femur) |
142 (28)
| 105 (74) | 33 (23) | 2 (1) | 0 (0) | 2 (1) | |
Hypothermia |
186 (36)
| 75 (40) | 47 (25) | 17 (9) | 27 (15) | 20 (11) | < 0.001 |
Asphyxia |
102 (20)
| 2 (2) | 3 (3) | 3 (3) | 26 (25) | 68 (67) | < 0.001 |
Miscellaneous b |
16 (3)
| 7 (44) | 2 (13) | 1 (6) | 2 (13) | 4 (25) | 0.973 |
Patients of each NACA score category for whom the given monitoring, procedure or treatment was done | |||||||
n (%), percentages are expressed by column | |||||||
Monitoring |
194 (38)
| ||||||
Pulse oximetry | 123 (24) | 34 (14) | 47 (56) | 12 (60) | 25 (46) | 5 (4) | < 0.001 |
ECG monitoring | 103 (20) | 2 (1) | 12 (14) | 5 (25) | 37 (69) | 47 (40) | < 0.001 |
Non-invasive blood pressure measurement | 46 (9) | 8 (3) | 16 (19) | 6 (30) | 14 (26) | 2 (2) | < 0.001 |
Oesophageal temperature measurement | 39 (8) | 4 (2) | 1 (1) | 1 (5) | 17 (31) | 16 (14) | < 0.001 |
End tidal CO2 measurement c | 25 (5) | 0 (0) | 0 (0) | 0 (0) | 21 (39) | 4 (3) | < 0.001 |
Immobilisation, splinting, dressing |
173 (33)
| ||||||
Vacuum mattress | 140 (27) | 48 (20) | 49 (58) | 13 (65) | 25 (46) | 5 (4) | < 0.001 |
Cervical collar | 57 (11) | 17 (7) | 18 (21) | 7 (35) | 10 (19) | 5 (4) | < 0.001 |
Peripheral splint | 17 (3) | 10 (4) | 6 (7) | 0 (0) | 0 (0) | 1 (1) | 0.056 |
Dressing/haemostasis | 16 (3) | 7 (3) | 8 (10) | 1 (5) | 0 (0) | 0 (0) | 0.002 |
Pelvic sling | 1(0.2) | 0 (0) | 1 (1) | 0 (0) | 0 (0) | 0 (0) | 0.273 |
Procedures and treatments |
327 (55)
| ||||||
Oxygen administration (facemask or nasal cannula) | 160 (31) | 14 (6) | 42 (50) | 19 (95) | 42 (78) | 43 (36) | < 0.001 |
Peripheral venous catheter insertion | 127 (25) | 38 (16) | 40 (48) | 12 (60) | 19 (35) | 18 (15) | < 0.001 |
External rewarming (hot packs and/or electric blanket) | 109 (21) | 48 (20) | 40 (48) | 11 (55) | 10 (19) | 0 (0) | < 0.001 |
Chest compression d | 88 (17) | 0 (0) | 0 (0) | 0 (0) | 45 (83) | 43 (36) | < 0.001 |
Orotracheal intubation | 77 (15) | 0 (0) | 0 (0) | 1 (5) | 44 (81) | 32 (27) | < 0.001 |
Ventilation e | 110 (21) | 0 (0) | 3 (4) | 4 (20) | 52 (96) | 51 (43) | < 0.001 |
Defibrillation | 21 (4) | 0 (0) | 0 (0) | 0 (0) | 14 (26) | 7 (6) | < 0.001 |
Intraosseous access f | 18 (7) | 0 (0) | 1 (2) | 0 (0) | 11 (38) | 6 (11) | < 0.001 |
Mechanical chest compression g | 13 (12) | 0 (0) | 0 (0) | 0 (0) | 10 (71) | 3 (14) | < 0.001 |
Pneumothorax decompression | 1(0.2) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (1) | 0.498 |
Dislocation reduction or fracture realignment | 7 (1) | 0 (0) | 3 (4) | 1 (5) | 1 (2) | 2 (2) | 0.074 |
Infusions h | 67 (12) | 11 (5) | 19 (23) | 7 (35) | 23 (43) | 7 (6) | < 0.001 |
Pharmaceutical agents i | 125 (24) | 24 (10) | 38 (45) | 7 (35) | 30 (56) | 26 (22) | < 0.001 |
Patients of each NACA score category who were transported to the given destination j | |||||||
n (%), percentages are expressed by column | |||||||
ECLS Trauma centre | 61 (12) | 7 (3) | 22 (26) | 7 (35) | 24 (44) | n.r. | < 0.001 |
Non-ECLS Trauma centre | 69 (13) | 28 (12) | 15 (18) | 6 (30) | 18 (33) | n.r. | < 0.001 |
Non-trauma centre hospital | 272 (53) | 166 (70) | 47 (56) | 7 (35) | 12 (22) | n.r. | < 0.001 |
Overall | Cardiac arrest victims | ||
---|---|---|---|
Clinical exposure to avalanche accidents and victims, median (IQR, range) | |||
Annual avalanche accidents per HEMS base a | 1.1 (0.5–2.5; 0.1–7.8) | – | |
Annual avalanche victims per HEMS base a | 1.5 (0.5–3.3;0.1–10.6) | 0.5 (0.1–1.1;0–3.3) | |
Avalanche victims per physician over the study period b | 2 (1–4;1–18) | 1 (0–1;0–10) | |
Avalanche victims per paramedic over the study period b | 4 (1–10.5;1–69) | 1 (0–3;0–20) | |
Number of HEMS bases who intervened for an annual mean of: n (%) a | |||
0 mission | 0 | – | |
< 1 mission/year | 5 (38) | – | |
1–4 missions/year | 6 (46) | – | |
5–8 missions/year | 2 (15) | – | |
Number of HEMS bases who transported an annual mean of: n (%) a | |||
0 victim | 0 | 2 (15) | |
< 1 victim/ year | 5 (38) | 7 (54) | |
1–4 victims/year | 5 (38) | 4 (31) | |
5–11 victims/year | 3 (23) | 0 | |
During the study period, number of HEMS physicians who managed respectively: n (%) b | |||
0 victim | not available | 90 (48) | |
1 victim | 89 (48) | 61 (33) | |
2–5 victims | 66 (35) | 32 (17) | |
6–10 victims | 22 (12) | 3 (2) | |
11–20 victims | 9 (5) | 0 | |
During the study period, number of HEMS paramedics who managed respectively: n (%) b | |||
0 victim | not available | 22 (34) | |
1 victim | 18 (28) | 15 (23) | |
2–5 victims | 20 (31) | 19 (30) | |
6–10 victims | 10 (16) | 3 (5) | |
11–20 victims | 8 (13) | 5 (8) | |
21–30 victims | 4 (6) | 0 | |
31–60 victims | 3 (5) | 0 | |
61–90 victims | 1 (2) | 0 |
Discussion
Technical requirements of HEMS avalanche rescue missions
Medical requirements of HEMS avalanche rescue missions
Clinical exposure to avalanche rescue missions and victims
Identifying areas to focus on for quality improvement interventions
Area | Goals | Interventions | Target |
---|---|---|---|
HEMS operations, search & technical rescue | Optimize avalanche rescue readiness to improve time efficiency (reduce time to extrication) while maintaining or increasing safety | Checklist for daily control of the personal safety equipment (clothes, avalanche beacon, AvaLung) | Providers |
Checklist for daily control of the avalanche rescue material (Helicopter external avalanche beacon, RECCO® device, probes, shovels) | Providers | ||
Use of a standard operating procedure for avalanche rescue missions | Providers | ||
The HEMS physician systematically wears a harness for avalanche rescue missions | HEMS physician | ||
Regular training of winch procedures | Providers | ||
Achieve a high level of performance in locating and digging out avalanche victims to reduce time to extrication | Regular specific field training including single and multiple burial scenarios | Providers | |
Medical management | Improve quality level of avalanche victim management | Dissemination of guidelines, up-to-date algorithm and clinical practice recommendations at the beginning of the winter season | Providers |
Continuous audit of avalanche rescue missions and feedback to HEMS providers | Topic expert, project leader | ||
Standard operating procedure for the management of avalanche victims in cardiac arrest | Providers | ||
Targeted training delivered via workshops and field training at the beginning of the winter season | Providers | ||
Indoor medical management simulation | Providers | ||
Improve adequacy to the algorithm | Use of the Avalanche Victim Resuscitation Checklist | Providers | |
Improve quality of information transmission on site and to the hospital teams | Use of the Avalanche Victim Resuscitation Checklist | Providers | |
Data collection | Improve quality & completeness of data in our database for avalanche rescue missions | Development of a template for uniform data documentation and reporting for avalanche rescue missions through a consensus process (minimal data set) | Expert panel |
Continuous quality improvement | Measure and improve quality | Development of quality indicators for avalanche rescue missions and management of avalanche victims through a consensus process | Topic experts, providers, relevant stakeholders |
Monitoring of quality indicators & reporting to the crews | Quality manager |