Objective.—To determine if serum vascular endothelial growth factor (VEGF) and ultrasonic monitoring of vascular dynamics with dynamic vascular analysis at sea level and high altitude correlate with acute mountain sickness symptoms.

Methods.—Nine volunteers participated in a staged ascent from sea level to 4300 m undergoing complete transcranial Doppler studies with dynamic vascular analysis. Serum VEGF levels, Lake Louise scores, Spielberger-1 scores, Subjective Exercise Experiences Scale positive scores, and Symptom Checklist-90 surveys were collected after 24 hours at each altitude.

Results.—Symptom scores, index of pulsatility, and dynamic flow index differentiated the subjects into 2 distinct groups. Symptomatic subjects had increased VEGF levels at sea level but decreased levels at 4300 m. The dynamic flow index increased in symptomatic subjects at 4300 m compared with the asymptomatic subjects. The mean flow velocity increased in both groups and could not be used to differentiate the subjects.

Conclusions.—Altered vascular physiology is associated with acute mountain sickness. Increased vascular permeability increases vascular capacitance, with an increase in dynamic flow index to meet these demands. Altered vascular dynamics were associated with high-altitude cerebral edema in 1 subject. Dynamic vascular analysis demonstrated altered vascular pathophysiology associated with acute mountain sickness. Changes in VEGF were meaningful when interpreted with the dynamic vascular analysis findings. These physiological findings may help explain the vascular changes associated with hypocarbic hypoxemia at altitude.

Objective.—To study the influence of current trends in alpine sports on the frequency and types of injuries handled by a helicopter-based emergency medical system (HEMS) in a wilderness mountain region.

Methods.—A retrospective review of medical reports at a single emergency helicopter port (Christophorus-1 air rescue) in Innsbruck, Austria, was conducted for comparison between two 3-year periods (1998–2000 and 2001–2003).

Results.—Comparing the two 3-year periods, the proportion of leisure-time injuries leading to HEMS activation increased, whereas the frequency of life-threatening injuries significantly declined (P = .001). There was significant increase in injuries during mountain hiking and rock climbing (P = .002), during swimming (P = .013), and in avalanches (P = .019). Most injuries (70.1%) were recorded for skiers, and 68.3% involved tourists. During the investigation period, the high National Advisory Committee of Aeronautics scores showed a decreasing trend, whereas Glasgow Coma Scale scores and low National Advisory Committee of Aeronautics scores tended to increase (P = .048).

Conclusions.—For the HEMS in this study, there has been an increasing number of calls for help from persons involved in outdoor leisure activities. As the number of life-threatening injuries declines, HEMSs more frequently serve as means of rescue rather than as providers of emergency treatment.

Objective.—The presence of coliform bacteria indicates a watershed risk for harboring microbes capable of causing human disease. We hypothesized that water from watersheds that have different human- or animal-use patterns would have differing risks for the presence of coliform bacteria.

Methods.—Water was collected in wilderness areas of the Sierra Nevada range in California. A total of 60 sites from lakes or streams were selected to statistically differentiate the risk categories: 1) high use by backpackers, 2) high use by pack animals, 3) cattle- and sheep-grazing tracts, and 4) natural areas rarely visited by humans or domestic animals. Water was collected in sterile test tubes and Millipore coliform samplers during the summer of 2004. Water was analyzed at the university microbiology lab, where bacteria were harvested and then subjected to analysis by standardized techniques. Confirmation was performed with a Phoenix 100 bacteria analyzer. Statistical analysis to compare site categories was performed with Fisher exact test.

Results.—Only 1 of 15 backpacker sites yielded coliforms. In contrast, 12 of 15 sites with heavy pack-animal traffic yielded coliforms. All 15 sites below the cattle-grazing areas grew coliforms. Differences between backpacker and cattle or pack-animal areas were significant (P ≤ .05). Only 1 of the 15 wild sites rarely visited by humans grew coliforms. All coliforms were identified as Escherichia coli. All samples grew normal aquatic bacteria of the genera Pseudomonas, Ralstonia, and Serratia and nonpathogenic strains of Yersinia. No correlation could be made with temperature or elevation. Sites below cattle-grazing tracts and pack-animal usage areas tended to have more total bacteria.

Conclusions.—Alpine wilderness water below cattle-grazing tracts or areas used by pack animals are at risk for containing coliform organisms. Areas exclusively used by backpackers were nearly free of coliforms.

Objective.—To evaluate the efficacy of the commercially available product Mitigator Sting and Bite Treatment in reducing the pain after imported fire ant stings.

Methods.—Twenty-four volunteer subjects were exposed to imported fire ant stings on both forearms. The subjects received Mitigator paste on 1 arm and calamine lotion on the opposite arm, in a blinded manner, from 90 seconds to 10 minutes after exposure. Subjects recorded pain on a 100-mm visual analog scale 60 seconds, 20 minutes, and 3 days after exposure. A 2-tailed paired t test was used to compare the difference in reduction of pain over time between the Mitigator-treated arms and the calamine-treated arms.

Results.—At 60 seconds, the mean visual analog scale pain score was 23.9 mm for the Mitigator group and 24.5 mm for the calamine group. At 20 minutes, the mean score was 7.6 mm (Δ = 16.3) for the Mitigator group and 12.7 mm (Δ = 11.8) for the calamine group. At 3 days, the mean score was 2.4 mm (Δ = 21.5) for the Mitigator group and 2.9 mm (Δ = 21.6) for the calamine group. There was no significant difference between groups for change in visual analog scale pain score at 60 seconds, 20 minutes (P = .256), or 3 days (P = .64).

Conclusions.—There was no significant difference in pain relief between calamine and Mitigator for imported fire ant stings.

A case description is presented of a 9-member rowing team whose scull swamped on a small lake in Victoria, Canada, because of a sudden winter storm, which immersed them in 4°C water for 50 minutes until a small rescue boat found them in darkness. Another 13 minutes of cold exposure in 6.7°C air occurred during boat transport to waiting ambulance paramedics. Two rowers died, one from severe hypothermia and the other from drowning as a consequence of cold incapacitation and hypothermia. The 2 coldest rowers, who were transported 8 km to a major hospital, arrived with rectal temperatures of 23.4°C and 25°C; the first was asystolic and the second was unconscious and in sinus bradycardia. Analysis of all the circumstances of this incident provided an opportunity to observe a continuum of responses in a heterogeneous group of rowers at risk of severe hypothermia. Several practical lessons concerning cold-water survival, rescue, and treatment can be learned. The effects of low body mass were associated with greater cooling rate. Diminished neuromuscular performance in the periphery appeared to be independent of body mass. Rough handling during moving of patients with marked hypothermia introduces the risk of producing ventricular fibrillation or cardiac arrest. Unconscious, nonshivering hypothermia victims who are rescued and insulated from cold could have a further afterdrop of 3°C to 4°C. During transport to a hospital, the use of heating devices concentrating on core regions may increase the chance of successful treatment in the hospital. Cardiopulmonary bypass may be indicated for severely hypothermic patients in asystole.

A patient with severe hypothermia presented with an initial rectal temperature of 28.3°C coupled with a hemoglobin of 2.2 g·dL⁻¹ and acute pancreatitis. Although hypothermia decreases oxygen and substrate consumption by tissues and can be cerebro-protective, the ideal rewarming strategy is unclear when the oxygen-delivery system is profoundly deficient, as with severe anemia. In this patient, truncal active external rewarming with a forced-air system, heated inhalation, and slow warmed transfusion yielded a 1.5°C·h⁻¹ rate of rewarming and a good outcome. We discuss the numerous protective and detrimental factors affecting oxygenation and ventilation during hypothermia coupled with profound anemia and the possible etiologic explanations for coexistent hypothermia and pancreatitis.

Compartment syndrome resulting from pitviper envenomation is uncommon in North America; however, when it does occur, early diagnosis, optimal antivenom therapy, and possible surgical decompression are the primary means of preventing the complication of neuropathy. Here, we report a case of a rattlesnake envenomation in the anterior compartment of the lower leg that required high doses of morphine to control pain. Although compartment syndrome was considered a possible outcome, subfascial pressures were not monitored and antivenom was discontinued at 24 hours. At 36 hours, the patient developed dorsal foot numbness and foot drop, and 15 hours later pressures within the anterior compartment were >68 mm Hg. Emergency fasciotomy was performed 59 hours postenvenomation. Peroneal neuropathy was evident after surgery and only partially recovered postoperatively. Earlier monitoring of subfascial pressures and using those pressures as a guide for decisions about time and dose of CroFab antivenom treatment may have permitted earlier surgical treatment after onset of compartment syndrome or even prevented the onset of this condition.

This is a review of Medline and PubMed articles on open fractures published in the English literature between 1945 and April 2005. The emphasis of most published articles has been placed on definitive treatment of these injuries at sophisticated referral hospitals. The prehospital emphasis has been on rapid evacuation and referral to ensure that definitive treatment can be initiated as quickly as possible. Little has been discussed about the management of these injuries in remote settings where evacuation may consume considerably more time. Contemporary recommendations for management of these injuries are reviewed.

In this article we propose guidelines for rational use of automated external defibrillators and public access defibrillators in the mountains. In cases of ventricular fibrillation and pulseless ventricular tachycardia, early defibrillation is the most effective therapy. Easy access to mountainous areas permits visitation by persons with high risks for sudden cardiac death, and medical trials show the benefit of exercising in moderate altitude. The introduction of public access defibrillators in popular areas in the mountains may lead to a reduction of fatal outcome of cardiac arrest. Public access defibrillators should be placed with priority in popular ski areas, in busy mountain huts and restaurants, at mass-participation events, and in remote but often-visited locations that do not have medical coverage. Automated external defibrillators should be available to first-responder groups and mountain-rescue teams. It is important that people know how to perform cardiopulmonary resuscitation and how to use public access defibrillators and automated external defibrillators.