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ON A BITTER COLD Saturday, Bill, 47, had just cruised down an expert ski run and was gliding over the flat, icy run-out at the bottom. Suddenly he heard skis scraping over ice directly behind him and was hit hard, causing him to fall. Bill wasn't wearing a helmet. Bill's skiing companion, a nurse, sent another skier to call for help.
When the ski patrol arrived, scene safety became the first priority because skier density was heavy, increasing collision risk. One ski patroller was stationed above the scene to direct other skiers away from the accident.
Upon initial assessment, Bill was unresponsive and lying in a supine position. His airway, breathing, and circulation (ABCs) were intact. The patrollers established manual inline spine stabilization (holding the neck stable so it doesn't move).
While Bill's level of consciousness improved, his speech remained confused and repetitive. The secondary survey revealed minor bleeding from facial and lip abrasions, right periorbital ecchymosis, and obvious facial deformity and asymmetry. His pupils were both 4 mm in diameter, equal, round, and reactive to light; motor and sensory function was intact.
Bill received oxygen via non-rebreather mask, had a rigid cervical collar applied, and was logrolled onto a full backboard. Patrollers quickly transported him to the patrol's aid room in a toboggan. There, assessment revealed clear and equal breath sounds, BP 140/90 mm Hg, heart rate 90 beats/minute, respiratory rate 18 breaths/minute, and cool and dry skin. Although he was now alert, Bill's short-term memory remained impaired.
Paramedics transported Bill to a Level 1 trauma center where he was diagnosed with a closed head injury and facial fractures involving the zygoma, maxilla, and right orbit. The next day, he underwent an open reduction and internal fixation of his facial fractures.
The adverse effects of Bill's head injury, which persisted for more than a year, included diplopia, short-term memory impairment, headaches, and vertigo. Bill ultimately recovered, but his take-home lesson was to make a helmet an essential part of his ski wear.
Each year, millions of people like Bill take to the slopes seeking outdoor fun and excitement. Skiing and snowboarding are enjoyable winter snow sports that have well-known injury risks. This article provides an overview of ski- and snowboard-related trauma, describes injury management considerations in the field, and offers advice for snow sport injury prevention and safety.
Fortunately, for the people who made more than 57 million visits to U.S. ski areas in the 2008/2009 season, major injury and death are rare.1 Most recreational skiers and snowboarders who are hurt suffer only minor injuries, but life-threatening injuries can and do occur. Not surprisingly, head injuries account for the greatest number of fatalities.2
According to 2008 statistics, an average of 40 people die at U.S. ski resorts each year, which translates into a fatality rate of 0.88 deaths/million ski and snowboard participants.3 In comparison, the fatality rate for recreational swimming is 72.7 deaths/million participants; for bicycling, 29.4 deaths/million participants.3
Experience and ability levels of the snow sport participant are highly correlated with injury risk.4 Beginners and young males tend to have the highest injury rates due to either their lack of skills or their decision to engage in risky behaviors.4 The individual's physical condition, the quality of equipment, and snow conditions influence the risk as well. Some preexisting physical conditions such as knee instability and medications such as anticoagulants increase the injury risk.
Lack of physical fitness also may play a role.4 At any typical ski area, the "weekend warrior" syndrome abounds. Many adult skiers and snowboarders engage in these sports without appropriate conditioning. Weak muscles and overexertion greatly increase personal injury risk and even the threat of having a cardiovascular event.5
Inappropriate or inadequate equipment is another significant factor. For example, ski bindings, the apparatus that locks the boot onto the ski, are designed to release during twisting falls. Improperly adjusted or worn-out ski bindings may fail to release, leading to lower extremity injuries. Those who borrow another person's equipment or who rent poor quality gear have an increased injury risk.4
Before you trade in your skis for a snowboard, however, consider this: In comparison with skiers, snowboarders have more than double the injury rate.3,5 The reason most likely reflects the snowboarders' fondness for performing aerial maneuvers and stunts using both manmade and natural "features," such as logs and snow banks, to launch themselves down the slope.
The most characteristic injury is extremity trauma. Skiers are more likely to suffer lower extremity trauma, especially knee injuries, from rotational forces during a fall.5,6 In fact, the snowplow stance, a beginner technique in which skiers hold their legs in a pizza-wedge position to control speed, places particular stress on the medial collateral ligament. Functional failure of ski bindings leads to anterior cruciate ligament tears (see Anterior cruciate ligament tear for an illustration of this injury). High-speed impact can produce serious closed or open fractures involving the femur, tibia, fibula, and patella. Even the ankle, though somewhat protected in a ski boot, can be sprained or broken when the foot is held fixed in one position while the leg externally rotates. The resulting injury, termed a Maisonneuve fracture, is comprised of a spiral fracture of the proximal fibula just below the knee and either a medial malleolus fracture or a severe ankle sprain with ligament disruption.
Snowboarders are more likely to sustain upper extremity trauma by falling onto an outstretched hand or through direct impact.6 They're especially apt to suffer fractures of the distal radius (see Colles fracture of the wrist). Shoulder dislocations and clavicle, humerus, and elbow fractures can also result from falls and collisions.
Upper extremity injuries are less common in skiers, but occur in similar ways. Skier's thumb, or injury to the metacarpophalangeal (MCP) joint, commonly results from a fall while holding onto a ski pole. The forces are transmitted across the MCP joint and produce severe pain and loss of function. This injury may also result from a direct impact to the hand and can occur in snowboarders as well.
Both skiers and snowboarders risk all manner and severity of head, spine, and torso trauma from high-speed collisions with stationary objects or people, hard landings following jumping or other aerial maneuvers, and falls. For example, the spleen can be ruptured from a blow to the abdomen, even from the victim's own elbow during a bad fall. Direct impact to the back can cause vertebral fractures with or without spinal cord injury as well as blunt trauma to the kidneys. Ski poles, tree branches, and other sharp objects can penetrate the body. Even a well-tuned ski, characterized by very sharp edges that enable the ski to hold a turn in icy conditions, can cause a significant laceration if a skier lands on it. (For more about snow sport injuries, see Bone-crunching falls and collisions.)
If you come upon an injured person on the slopes (or are injured yourself and need assistance), wedge crossed skis or a snowboard upright in the snow above the incident. This signifies that assistance is needed and warns skiers and boarders uphill from the incident. To summon help, send a responsible person (or two) to report the incident to the ski patrol, lift personnel at the bottom of the nearest chairlift, or other nearby ski area personnel. Make sure the people you send for help know the correct trail location of the incident and can provide a brief description of the possible injury.
Many large ski areas have emergency telephones located at trail intersections. If your cell phone signal is strong, you may also be able to call an emergency phone number listed on the ski area trail map.
Quickly size up the situation to determine what immediate interventions are required. As in Bill's case, scene safety is the first priority. Ask bystanders to stand several yards above you and direct other skiers and boarders away from the incident.
Your overall approach to the victim will be the same in the field as it would be in an ED. If you have disposable gloves, wear them to protect yourself. Maintaining standard precautions can be challenging, but you can improvise using whatever clothing you have to avoid direct skin contact with the victim's blood or body fluids. For example, ski goggles and a face mask work well to prevent eye and mucous membrane contamination.
Perform a primary survey as part of your initial assessment, focusing on airway, breathing, circulation, disability, and exposure. If airway interventions are necessary, use a jaw-thrust maneuver while maintaining the victim's neck in a neutral, in-line position. An injured person who vomits or has blood or secretions blocking the airway needs to be quickly logrolled as a single unit to clear out debris and prevent aspiration.
Assess breathing and provide artificial respiration if needed. A pocket mask or other barrier device is useful if you carry one. Support circulation by controlling any external bleeding with firm, direct pressure.
Next, evaluate for disability by checking the victim's level of consciousness to establish a baseline for the ongoing monitoring of neurologic status. Prevent further injury by asking the victim not to move until spinal immobilization or extremity-splinting devices are in place.
Winter temperatures pose the risk of hypothermia, which can hinder resuscitation if the victim develops shock. Pile extra jackets or parkas over the victim and expose injuries only when absolutely necessary for emergency field interventions such as hemorrhage control. Provide calm reassurance and stay with the victim while awaiting the arrival of the ski patrol. (For more information, see Get to know the ski patrol.)
The patrollers will first address any threats to airway, breathing, and circulation. If they suspect a head or spine injury, they'll apply a rigid cervical collar and immobilize the victim on a backboard.
For isolated extremity injuries, long bones are splinted in anatomic alignment while joint injuries are splinted in the position found. If a commercial splint isn't available, various materials can be used to improvise a splint, including padded wooden boards, cardboard, blankets, and triangular dressings called cravats. Circulation, motor, and sensory function must be assessed before and after splint application.
After the injury is stabilized, the patient will be secured in a toboggan and transported to the ski patrol facility or medical clinic. From there, the patient can be transferred to a hospital or trauma center if necessary.
Staying safe in a winter environment requires constant situational awareness. Anticipating and recognizing common hazards found in the mountains are keys to proper preparation and injury prevention.
Hypothermia and frostbite stem from inadequate or wet clothing, lack of shelter from the elements, fatigue, and dehydration. Hypothermia hinders physical performance, and in severe cases, impairs cognitive function and is life-threatening. Frostbite ranges in severity from frost nip to deep tissue destruction. The prognosis depends on the extent of the injury; pain, tissue loss, and amputation of digits and extremities (including the nose and ears) are possible outcomes. Immediate first aid for hypothermia and frostbite involves recognition of the situation, limiting further heat loss, and arranging a prompt rescue from the cold environment. Do your best to protect the victim from the elements. Cover the victim with extra clothing. Keep in mind that a hat prevents significant radiant heat loss. If you can safely move the victim, place an insulating layer between the victim and the snow surface to prevent conductive heat loss. Remain with the victim until care can be transferred to rescue personnel.
Sunburn poses a significant risk to any exposed skin, especially at higher elevations where UV rays are stronger. Eye protection is important because sun exposure can damage the cornea and conjunctiva.
Snow blindness (also known as UV photokeratitis or solar keratitis) occurs when unprotected eyes are exposed to the sun's UV rays reflecting off the white snow or ice surface, particularly at high altitudes. The condition typically manifests about 8 to 10 hours after UV exposure and causes severe eye pain and impaired vision. Wind and dry air increase the damage.7 The treatment is to halt further UV exposure and cover the victim's eyes for several hours. Cool compresses and artificial tears are soothing first aid measures that will help relieve pain. Snow blindness is usually self-limited and generally resolves completely, but corneal erosion and infection can result from epithelial damage.7 Properly designed sunglasses or goggles with large lenses and side shields that block UV rays and most visible light are essential to prevent this condition.
In the United States, altitude illness occurs mainly at western ski areas where mountains rise 8,000 feet or higher. Hypoxia is the primary culprit: As altitude increases, the partial pressure of oxygen decreases. Typical complaints include headache, fatigue, shortness of breath, and sleep disturbances for the first few days. Although virtually everyone will succumb at very high altitudes (think Mt. Everest), some people are more prone than others. Physical fitness levels don't correlate with symptom development, but genetics might play a role.7
Acute mountain sickness manifests as a range of more severe effects, from flulike symptoms to life-threatening high-altitude pulmonary and cerebral edema. The priority emergency care plan is rapid evacuation to a lower altitude. The best prevention measure is acclimatization through slow ascent, taking care to maintain healthy nutrition and hydration, and avoiding overexertion, caffeine, and alcohol. Acetazolamide, a carbonic anhydrase inhibitor best known for its use in glaucoma management, may be prescribed for both prevention and treatment of altitude-related symptoms. It produces a mild metabolic acidosis that reduces periodic breathing or sleep apnea at night (common at high altitudes) and increases respiratory rate. Adverse reactions to low-dose acetazolamide include tingling or paresthesias in the fingertips, increased urination, and an alteration in the taste of carbonated beverages. Dexamethasone, a systemic corticosteroid, is also used to treat acute mountain sickness.
Two other significant winter sports hazards are avalanche and deep snow immersion asphyxiation. Fortunately, avalanches are rare in U.S. ski resorts due to the efforts of the ski patrol. However, skiers and snowboarders who venture outside the ski area boundaries (in the out of bounds areas commonly called the "backcountry") may face this danger.
Avalanches are triggered when snow sport participants move across terrain that has an unstable snow pack. The resulting slide crashes down the mountainside, taking victims on a violent ride that typically culminates in multiple trauma, suffocation, and death. The snow rapidly forms a concrete-like tomb around the victim.8 Having an air pocket and being found quickly after burial yields the best chances for survival.9
The best avalanche prevention strategy is to stay within ski area boundaries. Everyone who braves the winter backcountry should go in with an experienced partner who understands avalanche safety and rescue, and appropriate equipment, such as avalanche transceivers (rescue devices that enable members of the victim's party or other rescuers to pinpoint the buried victim's location by following an audible signal). Other standard survival gear includes a shovel and probe poles used to probe beneath the snow surface to feel for buried victims.
Relatively new in avalanche survival gear is the Avalung, a commercial device consisting of a mouthpiece and tube system that skiers can strap to their bodies to prevent suffocation in an avalanche burial. When properly worn, it allows for inhalation of fresh air and the exhalation of carbon dioxide to buy precious time while rescue operations are under way. Though a potential lifesaver, the Avalung offers no protection against an avalanche's violent forces on the body.
If you witness an avalanche, track the path of the victims (including their equipment and clothing, if possible) and inform rescuers. Knowing the last-seen point can narrow the search to the areas in which the victims are most likely buried.
Consider all avalanche survivors to be major trauma victims until proven otherwise. Emergency care priorities focus on management of their ABCs, spinal immobilization, and measures to prevent or treat hypothermia. A very thorough secondary survey is warranted to detect and address possible multisystem injuries.
Deep snow immersion asphyxiation can occur at ski areas in the absence of an avalanche. Coniferous forests with closely spaced trees, deep powder, and moderately steep terrain are most often associated with this hazard. The typical scenario involves a young skier or snowboarder who takes a head-first fall into deep snow. As the victim struggles to get free, the snow blocks air passages and causes suffocation.
If you come upon this scene, dig down to reach the victim's head and attempt to clear the airway of snow, taking care to avoid exacerbating potential spinal injury. Pay attention to scene safety and don't let the deep snow collapse on you. Perform a primary survey on the victim and manage immediate threats to life through rescue breathing and chest compressions as indicated. Send someone to alert the ski patrol.
To reduce the risk of deep snow immersion, advise winter sports enthusiasts to always ski with a partner in sight, choose terrain with more widely spaced trees, and remove pole straps from wrists to prevent arms from being trapped during a fall. Advise them to avoid the urge to panic or struggle if they become caught in a tree well. Instead, instruct them to create airspace with their hands and use a gentle rocking motion to free themselves. (For more tips on snow sport safety, see Playing it safe on the slopes.)
Skiing and snowboarding offer the chance for healthy fun, exercise, and recreation during cold winter months. Being well-prepared and knowledgeable about the potential hazards and how to manage them can help you and your patients stay safe.
The most frequent causes of injuries for skiers and snowboarders are falls and collisions. Although falls from a standing height are considered low risk in these sports, extremity injuries are common. Major falls occur when a skier or snowboarder falls from a great height, generally more than 20 feet. Examples include skiers or boarders who launch off large manmade or natural features, or fall out of a chair lift, down an embankment, or off a cliff.
Collisions occur due to impact with natural objects such as trees and rocks, manmade structures such as lift towers or fence posts, and other skiers and snowboarders.
Injury-producing forces related to falls and collisions include combinations of acceleration/deceleration, shearing, tearing, distraction, rotation, flexion, compression, and penetration. Depending on the circumstances, the victim may experience both blunt and penetrating trauma. The degree of trauma is associated with speed, the height of the fall, the body parts involved, the effectiveness of personal protective equipment (such as helmets, wrist guards, and padding), and the person's overall state of health.
A recreational skier or snowboarder typically travels at speeds between 11 mph to 30 mph but can achieve higher speeds. Helmets offer the greatest protection at speeds less than 15 mph. Laws mandating helmet use don't yet exist in the snow sport industry; requirements to wear a helmet are most often associated with children's ski programs, racing programs, and as a condition for obtaining rental equipment in some places.
The ski patrol provides emergency care and rescue at ski areas. These dedicated individuals are on the mountain before guests arrive and are the last off at the end of the day or night. Patrollers check the trails for obstacles and other hazards, educate snow sports enthusiasts in safe skiing and snowboarding, conduct avalanche control work, and act as ambassadors of the ski area.
Typically, ski patrollers wear a fanny pack, backpack, or utility vest that contains emergency care supplies and carry portable radios for communication. They use rescue toboggans that are strategically located around the ski area to safely transport injured patrons off the slopes. In addition to emergency care equipment, the patrol has gear for rescue operations, lift evacuation, climbing, and avalanche management (such as a shovel and avalanche probe pole). They may use snowmobiles to quickly move toboggans, equipment, and patrollers around the ski area.
If you love skiing and have an interest in ski patrol work, contact your local ski area to find out about volunteer or employment opportunities, as well as the training and duty requirements. The commitment entails much time and hard work, but the benefits are worth the effort if you're looking for a way to meld a recreational passion with your profession!!
Whether you're advising your patients or family about snow sport safety or thinking about your own upcoming trip to a ski resort, incorporate these common-sense safety strategies into your plan.
* Consider engaging in physical conditioning/training before the trip.
* Purchase or rent quality equipment and clothing, including a helmet.
* Dress appropriately in layers and anticipate changing environmental conditions; synthetic clothing is superior to cotton because it wicks moisture away from the skin. The old mountaineering adage that "cotton kills" is still true today.
* Carry identification, emergency contact names and numbers, a cell phone, and a health insurance card with you at all times.
* Whenever possible, ski or snowboard with a partner.
* Take appropriate snow sport lessons from an experienced instructor.
* Learn the mechanics of your sports equipment.
* Know and heed your own physical limits; consider any health issues you may have and prepare accordingly. For example, if you have asthma, have your rescue inhaler with you. If you have diabetes, maintain adequate nutrition to prevent hypoglycemia; carry glucose tablets in case hypoglycemia develops.
* Know the ski area-always carry a map.
* Follow the skier and snowboarder responsibility code:10
- Before using any lift, you must have the knowledge and ability to load, ride, and unload safely.
- Always stay in control and able to stop or avoid other people or objects.
- People ahead of you have the right of way. It's your responsibility to avoid them.
- Never stop where you obstruct a trail or aren't visible from above.
- Whenever starting downhill or merging into a trail, look uphill and yield to others.
- Always use prevention devices to help prevent runaway equipment.
- Observe all posted signs and warnings. Keep off closed trails and out of closed areas.
1. National Ski Areas Association. Press release: U.S. ski industry tallies 57.1 million skier visits (08/09 season). http://www.nsaa.org/nsaa/press/0809/nc-090515-kottke-prelim.asp. [Context Link]
2. Levy AS, Hawkes AP, Hemminger LM, Knight S. An analysis of head injuries among skiers and snowboarders. J Trauma. 2002; 53(4):695-704. [Context Link]
3. National Ski Areas Association. Facts about skiing and snowboard safety (updated 10/1/08). http://www.nsaa.org/nsaa/press/facts-ski-snbd-safety.asp. [Context Link]
4. Langran M, Selvaraj S. Increased injury risk among first-day skiers, snowboarders, and skiboarders. Am J Sports Med. 2004;32(1):96-103. [Context Link]
5. National Ski Patrol. Outdoor Emergency Care: Comprehensive Prehospital Care for Nonurban Settings. 4th ed. Boston, MA: Jones and Bartlett; 2003. [Context Link]
6. Moeller JL, Rifat SF. Winter Sports Medicine Handbook. New York, NY: McGraw-Hill; 2004. [Context Link]
7. Bledsoe GH, Manyak MJ, Townes DA. Expedition & Wilderness Medicine. New York, NY: Cambridge University Press; 2009. [Context Link]
8. Sharp B, Whiteside J. Mountain Rescue. Kirkby Stephen, UK: Hayloft; 2005. [Context Link]
9. McClung D, Schaerer P. The Avalanche Handbook. 3rd ed. Seattle, WA: The Mountaineers Books; 2006. [Context Link]
10. National Ski Areas Association. Skier responsibility code. http://www.thunderridgeski.com/Pages/skier-responsibility-code.html. [Context Link]
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