Keep Cool but Don't Freeze: The Influence of William J. Mills Jr. on the Treatment of Frostbite.

Dr William J. Mills Jr., an Alaskan orthopedic surgeon, helped establish the current protocols for frostbite treatment and changed a dogma used for more than 140 years that was established by Napoleon's surgeon general of the army, Baron Dominique-Jean Larrey. During Napoleon's 1812 siege of Moscow, Larrey noticed the destructive effects of using open fire heat for warming frozen body parts, so he suggested rubbing snow or immersion in cold water. Dr Mills treated many cold injuries during his medical career. After setting up his medical practice in Anchorage, Alaska, he realized the inefficiency of the established protocols and started researching new treatments for frostbite. Dr Mills followed Meryman's method of rapidly thawing frozen red blood cells in warm water. Mills and his colleagues established a treatment protocol for freezing cold injury that included rapid warming in warm water. These studies resulted in the publication of three key papers in 1960 and 1961. These papers were the first clinical studies that described rapid warming as a treatment. Subsequently, rapid warming, with some variation in water temperatures, has been accepted as the standard of treatment. Due to his outstanding contribution to the treatment of frostbite, he has been referred to as "the nation's leading authority on cold injury." Mills and his colleagues created a new classification system that divided frostbite into two levels, superficial and deep, which was more applicable in clinics than the traditional 4-tier classification. The 2-tier classification is still useful outside of the hospital setting.

Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update.

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention, diagnosis, and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches for managing each form of acute altitude illness that incorporate these recommendations as well as recommendations on how to approach high altitude travel following COVID-19 infection. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in Wilderness & Environmental Medicine in 2010 and the subsequently updated WMS Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness published in 2014 and 2019.

Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update.

To provide guidance to the general public, clinicians, and avalanche professionals about best practices, the Wilderness Medical Society convened an expert panel to revise the evidence-based guidelines for the prevention, rescue, and resuscitation of avalanche and nonavalanche snow burial victims. The original panel authored the Wilderness Medical Society Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents in 2017. A second panel was convened to update these guidelines and make recommendations based on quality of supporting evidence.

History of Avalanches in the Eastern Spanish Pyrenees.

Avalanches have caused injuries and deaths in mountain areas throughout history. We have examined the historical effects of avalanches on communities in the eastern Spanish Pyrenees. Surviving written records began in the year 1444 when an avalanche destroyed the village of Gessa. Many other avalanches since then have destroyed houses and other buildings and have caused injuries and deaths. In the 20th and 21st centuries, many villages evolved from agrarian areas to destinations for winter sports. The first known deaths during winter recreation likely occurred in 1930. Because of avalanche mitigation efforts, including relocating settlements, physical barriers, avalanche control measures, efforts to increase avalanche awareness, and avalanche warnings, avalanches now seldom affect inhabited areas in the eastern Spanish Pyrenees. Avalanche injuries and fatalities are now mainly limited to backcountry skiers and others traveling out of bounds near avalanche-controlled ski resorts.

Survival in a Collapsed Stable for 37 Days After Avalanche Burial in 1755.

In 1755 in Bergemoletto, Italy, an avalanche buried 4 people (2 women, a girl, and a boy) and several animals in a stable. After 37 d in a pitch-dark confined space, 3 of the 4 people were rescued alive. The 3 survivors had only goat milk, a few chestnuts, a few kg of raw kid meat, and meltwater for nutrition. We describe the longest-known survival in an avalanche burial and discuss the medical and psychological problems of the survivors. The boy died. When they were extricated, all 3 survivors were exhausted, cachectic, and unable to stand or walk. They were severely malnourished and were experiencing tingling, tremors, and weakness in the legs; constipation; changes in taste; and amenorrhea. One of the women had persistent eye problems and developed symptoms consistent with post-traumatic stress disorder. The survivors were given slow refeeding. It took from 1 to 6 wk before they could walk. We compare this case to other long-duration burials, especially mining accidents, and describe the rescue and patient care after long-duration burials. This case demonstrates that people can overcome extremely adverse conditions and survive.

Prevention and Treatment of Nonfreezing Cold Injuries and Warm Water Immersion Tissue Injuries: Supplement to Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite.

We convened an expert panel to develop evidence-based guidelines for the evaluation, treatment, and prevention of nonfreezing cold injuries (NFCIs; trench foot and immersion foot) and warm water immersion injuries (warm water immersion foot and tropical immersion foot) in prehospital and hospital settings. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. Treatment is more difficult with NFCIs than with warm water immersion injuries. In contrast to warm water immersion injuries that usually resolve without sequelae, NFCIs may cause prolonged debilitating symptoms, including neuropathic pain and cold sensitivity.

Higher pre-hospital anaesthesia case volumes result in lower mortality rates: implications for mass casualty care.

Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior physician's skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient), circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills may be required to care for patients requiring pre-hospital airway management especially in hazardous environments, such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport decisions.

Survival After Being Wedged in a Crevasse for 16 Hours in Alaska.

We present a case of an un-roped mountaineer who fell into a crevasse during descent from the summit of Denali (Mount McKinley). He was wedged about 20 m deep in the crevasse for a total of 16 h; this included 4.5 h waiting for a rescue team to arrive, and an 11.5 h extrication process. His condition deteriorated and he eventually lost consciousness. Even though the rescue team collectively felt there was little or no chance of survival, they continued until the victim was extricated from the crevasse. He was almost immediately placed in a hypothermia wrap with active warming, loaded on a rescue helicopter, and transported for 1 h 40 min to a hospital in Fairbanks, Alaska. During the flight, he was placed on supplemental oxygen. He was cold to the touch; respiration was detectable, but a pulse was not, and he was responsive to verbal stimuli. Initial bladder temperature in hospital was 26.1°C. He was released from hospital after 14 d and made a full recovery. This case highlights an important mix of preventative and resuscitative lessons regarding crevasse rescue in an isolated location. The lessons include the dangers of travelling un-roped on a crevassed glacier, the challenges of extrication from a confined space, the fact that respirations are often more easily detected than pulses, an extended transport time to medical facilities, and the necessity of trying unorthodox extrication methods. This case emphasized the need to continue extrication and treatment efforts for a cold patient even when survival with hypothermia seems impossible.

Isolated Ptosis Following a Vipera aspis Bite.

In Spain, snakebites are uncommon medical emergencies that cause barely 100 hospitalizations annually. Most of the venomous bites are by snakes of the Viperidae family. Venom from Vipera snakes is reported to have cytotoxic and hematotoxic effects, and neurological effects have also been described. Ptosis (cranial nerve III palsy) is the most common sign, although any cranial nerve can be affected. We describe isolated ptosis, which was very likely after a Vipera aspis bite in the East Catalonian Pyrenees. No antivenom was administered. The ptosis resolved spontaneously within 10 h. Although neurologic findings are usually mild, they indicate a moderate or severe envenomation. Treating snakebites can be challenging for clinicians, especially when there are uncommon clinical manifestations. A toxicologist at a poison center should be consulted to help guide management. Development of local protocols may provide clinical support.

Prehospital Use of Ultrathin Reflective Foils.

Ultrathin reflective foils (URFs) are widely used to protect patients from heat loss, but there is no clear evidence that they are effective. We review the physics of thermal insulation by URFs and discuss their clinical applications. A conventional view is that the high reflectivity of the metallic side of the URF is responsible for thermal protection. In most circumstances, the heat radiated from a well-clothed body is minimal and the reflecting properties of a URF are relatively insignificant. The reflection of radiant heat can be impaired by condensation and freezing of the moisture on the inner surface and by a tight fit of the URF against the outermost layer of insulation. The protection by thermal insulating materials depends mostly on the ability to trap air and increases with the number of covering layers. A URF as a single layer may be useful in low wind conditions and moderate ambient temperature, but in cold and windy conditions a URF probably best serves as a waterproof outer covering. When a URF is used to protect against hypothermia in a wilderness emergency, it does not matter whether the gold or silver side is facing outward.

Witnessed Cardiac Arrest in a Hypothermic Avalanche Victim Completely Buried for 2 Hours.

A 34-y-old skier triggered a wind slab avalanche and was completely buried for over 2 h. After extrication by rescuers, the victim was breathing and conscious. Despite directions from the rescuers against standing up, the victim struggled to free himself and ultimately stood upright before collapsing in cardiac arrest. The rescuers performed cardiopulmonary resuscitation during transport to a nearby trailhead, where a helicopter emergency medical services crew found that the victim was in ventricular fibrillation. After further resuscitative efforts, including advanced life support, the victim was declared dead at the scene. Afterdrop and circumrescue collapse were the most likely triggers of cardiac arrest. This case highlights a need for rescuers, emergency medical services, and hospitals to be prepared to care for victims with hypothermia. To prevent circumrescue collapse, victims with hypothermia should be extricated gently, should not be allowed to stand, and should be placed flat. This may be difficult or impossible, as in this case. Hypothermic victims in cardiac arrest may require prolonged cardiopulmonary resuscitation, preferably with mechanical compressions, during transport to a hospital that has protocols for rewarming using extracorporeal life support. Resuscitation from hypothermic cardiac arrest should not be terminated before the victim has been rewarmed.

Resuscitation of an Unconscious Victim of Accidental Hypothermia in 1805.

In 1805, W.D., a 16-y-old boy, became hypothermic after he was left alone on a grounded boat in Leith Harbour, near Edinburgh, Scotland. He was brought to his own house and resuscitated with warm blankets, smelling salts, and massage by Dr. George Kellie. W.D. made an uneventful recovery. We discuss the pathophysiology and treatment of accidental hypothermia, contrasting treatment in 1805 with treatment today. W.D. was hypothermic when found by passersby. Although he appeared dead, he was rewarmed with help from Dr. Kellie and his assistants over 200 y ago using simple methods. One concept that has not changed is the critical importance of attempting resuscitation, even if it seems to be futile. Don't give up!

Induced Hypothermia to 4.2°C with Neurologically Intact Survival: A Forgotten Case Series.

The lowest recorded core temperature from which a person with accidental hypothermia has survived neurologically intact is 11.8°C in a 2-y-old boy. The lowest recorded temperature from which an adult has been resuscitated neurologically intact is 13.7°C in a 29-y-old woman. The lowest core temperature with survival from induced hypothermia has been quoted as 9°C. We discovered a case series (n=50) from 1961 in which 5 patients with core temperatures below 11.8°C survived neurologically intact. The lowest core temperature in this group was 4.2°C. The authors also presented cardiovascular and other physiologic data at various core temperatures. The patients in the case series showed a wide variation in individual physiological responses to hypothermia. It is not known whether survival from accidental hypothermia is possible with a core temperature below 11.8°C, but this case series suggests that the lower limit for successful resuscitation may be far lower. We advise against using core temperature alone to decide whether a hypothermic patient in cardiac arrest has a chance of survival.

Determination of Death in Mountain Rescue: Recommendations of the International Commission for Mountain Emergency Medicine (ICAR MedCom).

Determination of death requires specific knowledge, training, and experience in most cases. It can be particularly difficult when external conditions, such as objective hazards in mountains, prevent close physical examination of an apparently lifeless person, or when examination cannot be accomplished by an authorized person. Guidelines exist, but proper use can be difficult. In addition to the absence of vital signs, definitive signs of death must be present. Recognition of definitive signs of death can be problematic due to the variability in time course and the possibility of mimics. Only clear criteria such as decapitation or detruncation should be used to determine death from a distance or by laypersons who are not medically trained. To present criteria that allow for accurate determination of death in mountain rescue situations, the International Commission for Mountain Emergency Medicine convened a panel of mountain rescue doctors and a forensic pathologist. These recommendations are based on a nonsystematic review of the literature including articles on determination of death and related topics.

Successful Field Rewarming of a Patient with Apparent Moderate Hypothermia Using a Hypothermia Wrap and a Chemical Heat Blanket.

Hypothermia is a common problem encountered by search and rescue teams. Although mildly hypothermic patients can be rewarmed in the field and can then self-evacuate, the Wilderness Medical Society hypothermia guidelines suggest that a moderately hypothermic patient in the wilderness requires warming in a medical facility. The hypothermia prevention and management kit, developed by the US military, consists of a chemical heat blanket (CHB) and a heat-reflective shell. We present a case in which a hypothermia wrap and the CHB from a hypothermia prevention and management kit were used successfully to rewarm a patient with apparent moderate hypothermia in the field. We are unaware of previous reports of successful field rewarming of a patient with moderate hypothermia. We believe the use of the CHB in conjunction with a hypothermia wrap made field rewarming possible. We recommend that a CHB, along with the components of a hypothermia wrap, be carried by search and rescue teams when a hypothermic patient might be encountered. Although there were no documented core temperatures, we believe this case is consistent with the hypothesis that if a hypothermic patient who is found lying down and shivering is allowed to stand or walk before insulation is applied and before there has been an additional period of 30 min during which the patient continues to shiver, there may be increased afterdrop with deleterious results.

Emergency Airways After Himalayan Black Bear Attacks in Bhutan.

INTRODUCTION: Although bear attacks on humans are uncommon, the incidence has slowly risen as human populations increasingly encroach on wilderness habitat. In the Kingdom of Bhutan, Himalayan black bear attacks occur regularly. Bears preferentially attack the face, often causing injuries that require surgical airway management. We sought to determine how often patients injured by Himalayan black bears required airway management during initial resuscitation. METHODS: We conducted a retrospective review of emergency department and admission records of the 3 referral hospitals in Bhutan. We identified all victims of bear attacks in Bhutan who received emergency airway management, including surgical airway management during the period from August 2013 to December 2017. RESULTS: There were 21 patients who were treated for injuries from bear attacks during the study period. Of these, 12 required emergency airway management. Three patients who required emergency airways (2 intubations, 1 surgical airway) were attacked near a regional referral hospital and received care at that hospital. The remaining 9 patients received care from the helicopter emergency medical services (HEMS) retrieval team (1 intubation, 8 surgical airways). CONCLUSIONS: The use of highly trained HEMS critical care retrieval teams may improve outcomes in critically injured patients who require time-critical airway management in remote areas. Countries such as Bhutan with populations far from emergency and critical care might benefit from the establishment of HEMS critical care retrieval services. HEMS teams providing care while retrieving patients from austere environments should be expert in emergency airway management.

Pediatric High Altitude Cerebral Edema in the Nepal Himalayas.

High altitude cerebral edema (HACE) is a rare complication of ascent to altitudes of over 2500 m (8200 ft). We are not aware of a previously published case report of HACE in a patient under the age of 18 y. We report on 2 cases of suspected HACE in 2 patients, aged 12 and 16 y, who presented to the Manang Himalayan Rescue Association clinic at 3500 m. The 16-y-old patient presented with severe headache, vomiting, and ataxia after rapid ascent to 3800 m. The 12-y-old patient presented with severe headache, vomiting, visual disturbances, and ataxia at 4500 m, which began to resolve with descent to the clinic at 3500 m. Our cases suggest that HACE can occur in children and adolescents. Because there are no specific guidelines for treatment of acute mountain sickness or HACE in patients under the age of 18 y, we recommend treatment as for adults: oxygen, immediate descent, and dexamethasone. Simulated descent in a portable hyperbaric chamber can be used if oxygen is not available and if actual descent is not possible.