Guidelines for Mountain Rescue During the COVID-19 Pandemic: Official Guidelines of the International Commission for Alpine Rescue.

Roy, Steven, Inigo Soteras, Alison Sheets, Richard Price, Kazue Oshiro, Simon Rauch, Don McPhalen, Maria Antonia Nerin, Giacomo Strapazzon, Myron Allen, Alistair Read, and Peter Paal. Guidelines for mountain rescue during the COVID-19 pandemic: official guidelines of the International Commission for Alpine Rescue. High Alt Med Biol. 22: 128-141, 2021. Background: In mountain rescue, uncertainty exists on the best practice to prevent coronavirus disease 2019 (COVID-19) transmission. The aim of this work was to provide a state-of-the-art overview of the challenges caused by the COVID-19 pandemic in mountain rescue. Methods: Original articles or reviews, published until December 27, 2020 in Cochrane COVID-19 Study Register, EMBASE, PubMed, and Google Scholar were included. Articles were limited to English, French, German, or Spanish with the article topic COVID-19 or other epidemics, addressing transmission, transport, rescue, or cardiopulmonary resuscitation. Results: The literature search yielded 6,190 articles. A total of 952 were duplicates and 5,238 were unique results. After exclusion of duplicates and studies that were not relevant to this work, 249 articles were considered for this work. Finally, 72 articles and other sources were included. Conclusions: Recommendations are provided for protection of the rescuer (including screening, personal protective equipment [PPE], and vaccination), protection of the patient (including general masking if low risk, specific PPE if high risk), equipment hygiene (including disinfection after every mission), use of single-use products, training and medical measures under COVID-19 precautions, and psychological wellbeing of rescuers during the COVID-19 pandemic. Adapted COVID-19 precautions for low-and-medium-income countries are also discussed.

A novel inline PEEP valve design for differential multi-ventilation.

BACKGROUND: Ventilator sharing is one option to emergently increase ventilator capacity during a crisis but has been criticized for its inability to adjust for individual patient needs. Newer ventilator sharing designs use valves and restrictors to control pressures for each patient. A key component of these designs is an inline Positive End Expiratory Pressure (PEEP) Valve but these are not readily available. Creating an inline PEEP valve by converting a standard bag-valve-mask PEEP valve is possible with the addition of a 3D printed collar. METHODS: This was a feasibility study assessing the performance and safety of a method for converting a standard PEEP valve into an inline PEEP valve. A collar was designed and printed that covers the exhaust ports of the valve and returns exhaled gases to the ventilator. RESULTS: The collar piece was simple to print and easily assembled with the standard PEEP valve. In bench testing it successfully created differential pressures in 2 simulated expiratory limbs without leaking to the atmosphere at pressures greater than 60 cm of H2O. CONCLUSION: Our novel inline PEEP valve design shows promise as an option for building a safer ventilator sharing system.

Inline Positive End-Expiratory Pressure Valves: The Essential Component of Individualized Split Ventilator Circuits.

BACKGROUND: As resources are overwhelmed with the coronavirus disease 2019 pandemic, multiple approaches to produce individualized split-ventilator designs have emerged. These designs attempt to address the significant limitations and safety concerns of coventilation practices by allowing practitioners to adjust pressure settings for individual patients connected with specialized circuits to a single ventilator. The critical component in virtually all individualized circuit designs is the adjustable inline positive end-expiratory pressure valve. METHODS: We reviewed the literature on the mechanics of inline positive end-expiratory pressure valve function, the implications and considerations for advanced application of inline positive end-expiratory pressure valves in individualized circuits, available methods of adapting commercial positive end-expiratory pressure valves in the resource-restricted setting, and major caveats of the use of inline positive end-expiratory pressure valves. RESULTS AND CONCLUSIONS: The function of adjustable inline positive end-expiratory pressure valves in advanced individualized ventilator circuits has not been described. Adjustable inline positive end-expiratory pressure valves are critical to individualized circuit reliability and patient safety when attempting to extend ventilator capacity in the setting of extreme ventilator shortages. Adjustable inline positive end-expiratory pressure valves provide a means to reduce delivered peak inspiratory pressure to an individual patient circuit, a method to increase positive end-expiratory pressure for an individual patient circuit, and act as an one-way valve to ensure unidirectional gas flow through the divided circuit. Adjustable inline positive end-expiratory pressure valves can be adapted from commercial valves or printed de novo when commercial options are unavailable. Noncommercial sourcing of ventilator components should only be considered in the setting of extreme ventilator shortages under the supervision of a knowledgeable anesthesiologist or intensivist.

Chemical Heat Packs as an Intervention to Prolong Ultrasound Battery Runtime.

INTRODUCTION: Point-of-care ultrasonography is a burgeoning field of practice and study. Although point-of-care ultrasonography has started to penetrate the field of wilderness medicine, its use in cold environments is often limited by poor battery performance. In the current study, we investigated the effect of chemical foot warmers on battery runtime of handheld ultrasound machines in cold weather. METHODS: This prospective study used a balanced, crossover randomization design to compare handheld ultrasound machines exposed to cold weather with and without the application of chemical foot warmers. Time to power off, ambient temperature, air humidity, and wind speed were recorded for each trial and compared in a mixed-effects model analysis of variance. RESULTS: Ultrasound machines showed significantly decreased functional battery life with decreasing temperature (P<0.01) and increasing wind speed (P=0.01). Addition of the chemical foot warmer resulted in a statistically significant increase in handheld ultrasound machine runtime compared with controls (P<0.001). Overall machine runtime was increased by approximately 21.8 min (95% CI 16.2-27.3). CONCLUSIONS: The application of chemical foot warmers to handheld ultrasound machines exposed to cold environments prolongs usable battery life and, consequently, may allow for extended scanning time in austere and remote environments.

Management of Multi-Casualty Incidents in Mountain Rescue: Evidence-Based Guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).

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.

Histological Underpinnings of Grey Matter Changes in Fibromyalgia Investigated Using Multimodal Brain Imaging.

Chronic pain patients present with cortical gray matter alterations, observed with anatomical magnetic resonance (MR) imaging. Reduced regional gray matter volumes are often interpreted to reflect neurodegeneration, but studies investigating the cellular origin of gray matter changes are lacking. We used multimodal imaging to compare 26 postmenopausal women with fibromyalgia with 25 healthy controls (age range: 50-75 years) to test whether regional gray matter volume decreases in chronic pain are associated with compromised neuronal integrity. Regional gray matter decreases were largely explained by T1 relaxation times in gray matter, a surrogate measure of water content, and not to any substantial degree by GABAA receptor concentration, an indirect marker of neuronal integrity measured with [18F] flumazenil PET. In addition, the MR spectroscopy marker of neuronal viability, N-acetylaspartate, did not differ between patients and controls. These findings suggest that decreased gray matter volumes are not explained by compromised neuronal integrity. Alternatively, a decrease in neuronal matter could be compensated for by an upregulation of GABAA receptors. The relation between regional gray matter and T1 relaxation times suggests decreased tissue water content underlying regional gray matter decreases. In contrast, regional gray matter increases were explained by GABAA receptor concentration in addition to T1 relaxation times, indicating perhaps increased neuronal matter or GABAA receptor upregulation and inflammatory edema. By providing information on the histological origins of cerebral gray matter alterations in fibromyalgia, this study advances the understanding of the neurobiology of chronic widespread pain. SIGNIFICANCE STATEMENT: Regional gray matter alterations in chronic pain, as detected with voxel-based morphometry of anatomical magnetic resonance images, are commonly interpreted to reflect neurodegeneration, but this assumption has not been tested. We found decreased gray matter in fibromyalgia to be associated with T1 relaxation times, a surrogate marker of water content, but not with GABAA receptor concentration, a surrogate of neuronal integrity. In contrast, regional gray matter increases were partly explained by GABAA receptor concentration, indicating some form of neuronal plasticity. The study emphasizes that voxel-based morphometry is an exploratory measure, demonstrating the need to investigate the histological origin of gray matter alterations for every distinct clinical entity, and advances the understanding of the neurobiology of chronic (widespread) pain.

Elderly women have blunted response to resistance training despite reduced antagonist coactivation.

PURPOSE: To test the ability of a combination high-velocity/high-resistance training program to enhance knee extensor muscle strength, power, nervous activation of muscle, and muscle activation time in inactive women and compare the response to training between young and old women. METHODS: The study involved 49 inactive women, with young (18-33 yr, n = 25) and old (65-84 yr, n = 24) distributed to training and control groups using blocked randomization. Electrically evoked muscle twitches were measured for the knee extensors; then maximal, voluntary, isometric knee extensions were performed in a visually cued reaction time (RT) task, followed by 8 wk of explosive resistance training. RESULTS: Training increased peak torque (+12%, P = 0.03) and reduced antagonist coactivation (-13%, P = 0.02) similarly for both age groups. Young training group increased the rate of torque development by 34% compared to young controls (-7%), old training (+9%), and old controls (+8%) (P = 0.002). Young training group increased impulse by 53%, which was greater than young controls (-11%), old training (+12%), and old controls (+9%) (P = 0.001). Resistance training did not change electrically evoked twitch, RT (premotor time, motor time, or reaction time), or nervous activation measures (onset EMG amplitude or rate of EMG rise). CONCLUSIONS: Explosive force training was ineffective at enhancing muscle twitch characteristics, neural drive, or RT in young or old women. It did enhance peak muscle force in both young and old, modulated through a reduction in antagonist coactivation. Older participants showed less of an improvement in the rate of torque development and contractile impulse than young, indicating either that this sample of older women had a reduced capacity to develop muscle power or that the 8-wk isokinetic resistance training program used in this study was not a sufficient stimulus for adaptation.

Explosive force and fractionated reaction time in elderly low- and high-active women.

PURPOSE: The purpose of this study was to determine whether muscle power, activation time, and neuromuscular stimulation are related to physical activity patterns in older women. METHODS: Forty women (65-84 yr) were assigned to high-active (HA) and low-active (LA) groups on the basis of a historical activity questionnaire, and then they performed a series of maximal, voluntary, isometric knee extensions in a visually cued RT task. Fractionated RT measures were taken using three landmarks in the data: the presentation of the visual stimulus, the beginning of the EMG burst, and the initiation of force development. The rate and magnitude of neural stimulation were taken from surface EMG. RESULTS: Peak torque was 15% greater, rate of torque development was 26% greater, motor time was 17% shorter, rate of EMG rise was 25% faster, and onset EMG magnitude was 15% greater in HA than in LA subjects (P<0.05). CONCLUSION: These results indicate that older women with a history of vigorous activity can generate greater force, power, and motor output in comparison with their less active peers. The lower-body mass index of the HA subjects and 310% greater volume of physical activity are likely to account for the enhanced neuromuscular function seen. It is plausible that in addition to aging, physical inactivity is responsible for a large portion of the loss of neuromuscular function seen in older adults.

Intercollegiate Wrestling Injuries.

Time loss from participation is often used to define injury, but one physician uses different criteria in evaluating wrestlers.

Evaluation and Treatment of the Stable Ankle Sprain.

Simple, prompt treatment for the sprained ankle, combined with a comprehensive rehabilitation program, speed recovery and help prevent reinjury.