Mountaineering medical events and trauma on Denali, 1992-2011

Frostbite on Denali: a case series and review of treatment options

Frostbite, defined as tissue freezing due to cold weather exposure, is a major risk associated with mountaineering in cold climates. It represents a significant source of morbidity in the climbing population. In 2021, three individuals were evaluated at a single institution after developing frostbite while climbing Denali, Alaska, US. The affected patients were healthy men in the third to sixth decade of their lives, and all experienced frostbite injuries involving the fingers. Among the patients, one individual was unable to descend from the mountain due to the severity of his condition and required medical evacuation. The other men were able to descend without significant difficulty. After leaving the mountain, the patients were treated with thrombolysis, pentoxifylline, hyperbaric oxygen therapy, and/or regional sympathetic blockade. Exposure to cold weather, ascent to high altitudes, and increased mechanisms of heat loss were likely potential risk factors for frostbite injury in these patients. Psychological factors related to the COVID-19 pandemic may have also impacted these individuals' risk for frostbite injury. Prevention is the most effective way to avoid frostbite, and knowledge and understanding of the risks associated with the development of this condition may reduce future occurrences among mountaineers. Since frostbite is not a common diagnosis encountered in patients treated in outpatient wound centres, physicians should maintain awareness of the pathophysiology and treatment options for this condition.

Long-Term Sequelae of Frostbite-A Scoping Review

Frostbite is tissue damage caused by freezing temperatures and constitutes an important cause of morbidity in cold climate zones and high altitude. The direct effects of sub-zero temperatures lead to tissue freezing, electrolyte shifts and pH alterations, microvascular damage, and eventually to cell death. Upon rewarming, inflammatory reperfusion injury and thrombosis may lead to further tissue damage. Several studies and various case reports show that many patients suffer from long-term sequelae such as vasomotor disturbances (associated with susceptibility to refreezing), and neuropathic and nociceptive pain, as well as damage to skeletal structures. There are still many uncertainties regarding the pathophysiology of these sequelae. It has been shown that the transient receptor potential channel (TRP) family plays a role in cold allodynia. Botulinum Toxin type A (BTX-A) injections have been reported to be beneficial in vasomotor and neuropathic disturbances secondary to frostbite. Epidural sympathetic block has been used for short-term treatment of frostbite induced chronic pain. Furthermore, amitriptyline, gabapentinoids, and duloxetine may have some benefits. Frostbite arthritis clinically resembles regular osteoarthritis. In children there is a risk of epiphyseal cartilage damage leading to bone deformities. Despite some promising therapeutic concepts, the scarcity of data on frostbite long-term sequelae in the literature indicates the need of more in-depth studies of this pathology in all its aspects.

Ski-Everest (8848 m) Expedition: Digit Skin Temperature Responses to Cold Immersion May Reflect Susceptibility to Cold Injury

INTRODUCTION

We tested the hypothesis that individual susceptibility to freezing cold injury might be reflected in an attenuated cold-induced vasodilatation (CIVD) response by comparing the CIVD responses of an elite alpinist with a history of freezing cold injury in the feet (case alpinist) with those of an age- and ability- matched noninjured alpinists control group (controls). According to this hypothesis, the vasomotor responses to a CIVD test of the case alpinist would represent a pathophysiological response when compared with the normal physiological response of a noninjured cohort.

METHODS

The case alpinist and the controls in the cohort group conducted a cold water immersion test comprising sequential immersion of a hand and foot for 5 min in 35°C water, followed by a 30-min immersion in 8°C water and a 10-min recovery period in room air. During this test we monitored the finger and toe skin temperatures.

RESULTS

The case alpinist had a significantly attenuated CIVD response and a lower skin temperature in all injured and noninjured digits during immersion (∼2°C lower than in the control group) and an attenuated recovery of finger skin temperatures (∼6°C lower than in the control group).

CONCLUSIONS

The attenuated CIVD response of the case alpinist may reflect a previously unrecognized enhanced susceptibility to frostbite. In addition to the poor vasomotor response observed in the injured toes, he also exhibited a poor vasomotor response in his noninjured fingers. The results of the present study indicate that a test of vasomotor activity during thermal stress may identify individuals predisposed to cold injury.

Cold Susceptibility of Digit Stumps Resulting from Amputation After Freezing Cold Injury in Elite Alpinists

Gorjanc, Jurij, Shawnda A. Morrison, Rok Blagus, and Igor B. Mekjavic. Cold susceptibility of digit stumps resulting from amputation after freezing cold injury in elite alpinists. High Alt Med Biol. 19:185-192, 2018.

AIM

The aim of the study was to assess whether previous freezing cold injury in fingers and/or toes might predispose alpinists to greater risk of further freezing cold injury, primarily due to a greater vasoconstrictor response to cold, resulting in a lower perfusion, reflected in lower skin temperature.

METHODS

Ten elite alpinists (N = 10; 8 male and 2 female) with amputations after freezing cold injury participated in a cold-water (8°C) immersion stress test of the hands and feet. Digit skin temperatures of amputated digits, their noninjured counterparts, noninjured digits of the affected side and noninjured digits of the corresponding side were measured. The skin temperatures were compared during three consecutive phases of the cold stress test: prewarming, cold water immersion, and passive heating.

RESULTS

Amputated toes cooled much faster compared to their uninjured counterparts (n = 26, p < 0.001), and attained lower skin temperatures during the cold exposure test (n = 26, p < 0.001). Higher cooling rate was observed in all the toes on the injured limb compared with the toes on the uninjured limb (n = 40, p < 0.001). In contrast to the toes, the fingers on the injured limb after freezing cold injury were warmer during cooling phase compared to uninjured fingers (n = 15, p < 0.001).

CONCLUSIONS

The lower digit temperatures observed in affected toe stumps during the cold stress test compared to the nonamputated toes may indicate a heightened risk of future freezing cold injury with subsequent cold exposures, as a consequence of less perfusion, reflected in the lower skin temperature. This relationship was not confirmed in the fingers.

Practical Tips for Working as an Expedition Doctor on High-Altitude Expeditions

Brants, Anne, and Tracee Metcalfe. Practical tips for working as an expedition doctor on high-altitude expeditions. High Alt Med Biol. 18:193-198, 2017.-With the explosion of adventure travel over the past decade, there has been a concurrent increase in mountaineering expeditions to extreme elevations, including many of the 8000-m peaks. This trend has created an increased demand for qualified expedition doctors to provide specialized medical advice and care to climbers and expedition staff. This review is intended to help physicians prepare for work on such expeditions. The authors rely heavily on their own experience and discuss the types of work available on high-altitude expeditions; how to identify a safe and reputable guiding company; personal and medical preparation; priorities in selecting or building an appropriate medical kit; and medical conditions commonly encountered on expeditions. The review concludes by considering ethical dilemmas and other difficult issues unique to this work.

Risk Stratification for Athletes and Adventurers in High-Altitude Environments: Recommendations for Preparticipation Evaluation

High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.

Results of a Prospective Observational Study on Mountaineering Emergencies in Western Alps: Mind Your Head

Brustia, Raffaele, Giulia Enrione, Bruna Catuzzo, Luca Cavoretto, Massimo Pesenti Compagnoni, Enrico Visetti, Emmanuel Cauchy, Stefanie Ziegler, and Guido Giardini. Results of a prospective observational study on mountaineering emergencies in Western Alps: mind your head. High Alt Med Biol. 17:116-121, 2016.-

BACKGROUND

In the northern Italian district Valle d'Aosta district during winter and summer season the population can increase up to 170% of the resident population. A prospective monocentric observational registry was held to obtain a precise picture of seasonal mountain-related medical and traumatic major events.

METHODS

From 1st January 2012 to 31st December 2013 all patients admitted to the Aosta Regional Hospital Emergency Room for any event occurred above 2500 m were screened: all those affected by High Altitude Illness, Acute Illness in High Altitude, Trauma, or Cold disease were prospectively included. Activity incidence rate is expressed as the occurrence of mountain-related events per 1000 hours of mountain activity. Event Incidence rate is expressed as the occurrence of new cases per 1000 hours of mountain activity.

RESULTS

Two hundred two patients were included during the study period. Trauma (65.1% vs. 24.6%, p < 0.001) and head commotive injury (48.1% vs. 15.1%, p < 0.001) were more frequent during winter compared to the summer season. High altitude illness (36.9% vs. 9.3%, p < 0.001) and cold pathologies (15.1% vs. 0.1%, p < 0.001) occurred more frequently in summer than in winter. Patients (51.4%) were immediately discharged from emergency room, 8.4% after a 24-hour observation period, and 30.6% required hospitalization. During summer, the event risk is 0.013 per person and 1000 hours of mountain activity, while in winter, event risk amounts to 0.005 per person and 1000 hours of mountain activity.

COMMENTS

High altitude medical events or trauma represent <1% of pathologies observed in the emergency room department of a mountain district in the western Alps. Head commotive injury is the most observed mountain-related event in high altitude, in winter and during ski practice. High altitude illness and cold injuries are observed more frequently in summer, during trekking or climbing activities.

Faculty of Prehospital Care, Royal College of Surgeons Edinburgh guidance for medical provision for wilderness medicine

To support leaders and those involved in providing medical care on expeditions in wilderness environments, the Faculty of Pre-Hospital Care (FPHC) of The Royal College of Surgeons of Edinburgh convened an expert panel of leading healthcare professionals and expedition providers. The aims of this panel were to: (1) provide guidance to ensure the best possible medical care for patients within the geographical, logistical and human factor constraints of an expedition environment. (2) Give aspiring and established expedition medics a 'benchmark' of skills they should meet. (3) Facilitate expedition organisers in selecting the most appropriate medical cover and provider for their planned activity. A system of medical planning is suggested to enable expedition leaders to identify the potential medical risks and their mitigation. It was recognised that the scope of practice for wilderness medicine covers elements of primary healthcare, pre-hospital emergency medicine and preventative medicine. Some unique competencies were also identified. Further to this, the panel recommends the use of a matrix and advisory expedition medic competencies relating to the remoteness and medical threat of the expedition. This advice is aimed at all levels of expedition medic, leader and organiser who may be responsible for delivering or managing the delivery of remote medical care for participants. The expedition medic should be someone equipped with the appropriate medical competencies, scope of practice and capabilities in the expedition environment and need not necessarily be a qualified doctor. In addition to providing guidance regarding the clinical competencies required of the expedition medic, the document provides generic guidance and signposting to the more pertinent aspects of the role of expedition medic.

Counseling for the Wilderness Athlete and Adventurer During a Preparticipation Evaluation for Preparation, Safety, and Injury Prevention

Wilderness sports and adventures continue to increase in popularity. Counseling is an essential element of the preparticipation evaluation (PPE) for athletes in traditional sports. This approach can be applied to and augmented for the wilderness athlete and adventurer. The authors reviewed the literature on counseling during PPEs and gathered expert opinion from medical professionals who perform such PPEs for wilderness sports enthusiasts. The objective was to present findings of this review and make recommendations on the counseling component of a wilderness sports/adventure PPE. The counseling component of a PPE for wilderness sports/adventures should take place after a basic medical evaluation, and include a discussion on sport or activity-specific injury prevention, personal health, travel recommendations, and emergency event planning. Counseling should be individualized and thorough, and involve shared decision making. This should take place early enough to allow ample time for the athlete or adventurer to further prepare as needed based on the recommendations. Resources may be recommended for individuals desiring more information on selected topics.

Preparticipation Evaluation for Climbing Sports

Climbing is a popular wilderness sport among a wide variety of professional athletes and amateur enthusiasts, and many styles are performed across many environments. Potential risks confront climbers, including personal health or exacerbation of a chronic condition, in addition to climbing-specific risks or injuries. Although it is not common to perform a preparticipation evaluation (PPE) for climbing, a climber or a guide agency may request such an evaluation before participation. Formats from traditional sports PPEs can be drawn upon, but often do not directly apply. The purpose of this article was to incorporate findings from expert opinion from professional societies in wilderness medicine and in sports medicine, with findings from the literature of both climbing epidemiology and traditional sports PPEs, into a general PPE that would be sufficient for the broad sport of climbing. The emphasis is on low altitude climbing, and an overview of different climbing styles is included. Knowledge of climbing morbidity and mortality, and a standardized approach to the PPE that involves adequate history taking and counseling have the potential for achieving risk reduction and will facilitate further study on the evaluation of the efficacy of PPEs.

Counseling for the Wilderness Athlete and Adventurer During a Preparticipation Evaluation for Preparation, Safety, and Injury Prevention

Wilderness sports and adventures continue to increase in popularity. Counseling is an essential element of the preparticipation evaluation (PPE) for athletes in traditional sports. This approach can be applied to and augmented for the wilderness athlete and adventurer. The authors reviewed the literature on counseling during PPEs and gathered expert opinion from medical professionals who perform such PPEs for wilderness sports enthusiasts. The objective was to present findings of this review and make recommendations on the counseling component of a wilderness sports/adventure PPE. The counseling component of a PPE for wilderness sports/adventures should take place after a basic medical evaluation, and include a discussion on sport or activity-specific injury prevention, personal health, travel recommendations, and emergency event planning. Counseling should be individualized and thorough, and involve shared decision making. This should take place early enough to allow ample time for the athlete or adventurer to further prepare as needed based on the recommendations. Resources may be recommended for individuals desiring more information on selected topics.

Risk Stratification for Athletes and Adventurers in High-Altitude Environments: Recommendations for Preparticipation Evaluation

High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.

Preparticipation Evaluation for Climbing Sports

Climbing is a popular wilderness sport among a wide variety of professional athletes and amateur enthusiasts, and many styles are performed across many environments. Potential risks confront climbers, including personal health or exacerbation of a chronic condition, in addition to climbing-specific risks or injuries. Although it is not common to perform a preparticipation evaluation (PPE) for climbing, a climber or a guide agency may request such an evaluation before participation. Formats from traditional sports PPEs can be drawn upon, but often do not directly apply. The purpose of this article was to incorporate findings from expert opinion from professional societies in wilderness medicine and in sports medicine, with findings from the literature of both climbing epidemiology and traditional sports PPEs, into a general PPE that would be sufficient for the broad sport of climbing. The emphasis is on low altitude climbing, and an overview of different climbing styles is included. Knowledge of climbing morbidity and mortality, and a standardized approach to the PPE that involves adequate history taking and counseling have the potential for achieving risk reduction and will facilitate further study on the evaluation of the efficacy of PPEs.

A trekker in Nepal with painful skin blisters

The authors present a case of a 27-year-old woman trekker with painful, slightly itchy eruptions on the dorsum of both hands for 5 days. On examination, she had a papulovesicular rash with some haemorrhagic vesicles over the dorsum of her hands and thumbs.

High-altitude mountaineering made safer

Mountains all over the world are attracting a steadily growing number of visitors due to the increasing number of cheap flights; the construction of new roads, railways, and cable cars; and commercial offers of trekking tours and expeditions to attempt even the world's highest peaks. However, one must not forget that mountains are typically inhospitable areas characterised by cold and hypoxic environments and rapidly changing weather and track conditions associated with a relatively high risk of accidents and emergencies. Beside the objective hazards, subjective hazards, for example physical fitness and health status, mountaineering skills, and equipment, contribute substantially to the risk. Whereas in some regions, for example the Alps, rescue operations and medical emergency interventions can be performed rapidly and effectively, this is absolutely not the case in most of the very remote areas and on very high mountains. Therefore, the understanding of the risk associated with the various modes of mountaineering as well as knowledge about how to optimise prevention is of the utmost importance. Ultimately, it is the informed mountaineer who has to decide whether the risks are acceptable or not. Continuing joint efforts of scientists, medical and alpine institutions, expedition organisers, and mountaineers will help to make high-altitude mountaineering safer.