Accident analyses, such as those we review, tell us that long bone injuries, pelvic and spinal fractures, and internal bleeding are the most common serious consequences of extreme sports accidents.
Because these accidents often occur in remote locations, it is usually fellow practitioners rather than the emergency services who are first on scene. Limited equipment, skills and communications, in combination with the weather, can make dealing with time-critical injuries more challenging than in an urban environment. We would highly recommend running incident simulations with your friends, on in your club, on bad weather days. A good incident simulation brings people together, while revealing the challenges of accident management in the local area in a safe and controlled environment. We have put together a simulation pack to help you run your own.
The following are some key skills that may help you manage an extreme sports incident. Please remember, these are guidelines, not rules: please use your own judgment, be mindful of your own safety and that of the rest of the group, act in proportion to your skills and in the casualty’s best interest.
All of these skills are best learned from an experienced person on a certified first aid course. We run our own two-day courses, especially designed for extreme sports practitioners but attending any outdoor first aid course is a great start.
Spinal Injury Management
Any high-energy fall, collision or impact that produces significant force through the head, neck or back should make you suspect a spinal injury until proven otherwise. In an extreme sports setting, common mechanisms include falling from height while climbing or mountain biking, being thrown while skiing or snowboarding, diving into shallow water, and being struck by a falling rock or piece of equipment. If the casualty is conscious and complains of neck or back pain, numbness, tingling, or weakness in the limbs, treat them as having a spinal injury. If they are unconscious, assume a spinal injury is present. Your goal is to prevent any movement of the spine that could worsen an unstable fracture and damage the spinal cord.
Start by keeping the casualty still. If they are already lying in a safe position and are breathing adequately, do not move them unless absolutely necessary for scene safety or airway management. Ask them not to move their head or neck, and assign one person to hold manual in-line stabilisation: kneel behind the casualty’s head, place your hands on either side of their head over the ears, and hold it firmly but gently in a neutral alignment. Do not pull or apply traction. If the head is not in line with the body, do not force it into a neutral position if this causes pain, resistance or muscle spasm; maintain the position found and note it for rescuers. In a remote setting where a proper cervical collar is unavailable, an improvised collar can be made from a rolled towel, clothing or a foam sleeping mat, but this must never replace manual stabilisation. The person holding the head is the cervical collar.
If the casualty must be moved because of danger such as rockfall, avalanche risk, rising water or fire, use a coordinated log roll or drag that keeps the head, torso and pelvis moving as one unit. With at least three people, one takes the head, one the shoulders and chest, and one the pelvis and legs. The leader counts aloud and everyone moves together, turning the casualty as a single block. For a short emergency drag, grasp the casualty’s clothing at the shoulders and pull along the long axis of the body, keeping the head supported by the forearms. Once on a firm surface, continue to protect the airway using a jaw thrust rather than a head tilt, and continue manual stabilisation until advanced help arrives or you are confident from a focused assessment that spinal injury is highly unlikely.
Improvised Splinting of Fractures
In a remote environment you rarely have purpose-made splints, but a great deal can be achieved with the equipment you already carry or find around you. The main aims of splinting are to immobilise the broken bone, reduce pain, prevent further damage to soft tissues, nerves and blood vessels, and make evacuation easier. Walking poles, tent poles, ski poles, ice axes, rolled sleeping mats, padded clothing, rucksack frames, and even pieces of wood or plastic found on site can all be turned into effective splints. Before applying a splint, remove or cut away clothing over the injury so you can see the skin, and check for an open wound. Cover any open fracture site with a sterile or clean dressing, but do not try to push exposed bone back under the skin.
The basic rule is to immobilise the joint above and the joint below the fracture. For a suspected forearm fracture, this means immobilising the elbow and the wrist; for a lower leg fracture, the knee and the ankle. Pad any bony prominences and the hollows of the body with soft material such as gloves, socks or spare clothing to prevent pressure sores. Firmly pad the rigid splint material itself, especially if it is hard like a ski pole or ice axe shaft, then secure it in place with tubular bandages, triangular bandages, strips of clothing, webbing straps or cord. Tie the securing knots over the splint, not directly over the injury, and check that they are snug but not so tight that they cut off circulation. After the splint is applied, check the fingers or toes beyond the injury every fifteen minutes for colour, warmth, sensation and movement. If they become pale, cold, numb or difficult to move, loosen the splint and re-check.
Avoid straightening a severely angulated or deformed fracture unless the limb beyond the injury has no pulse, is turning blue, or you are certain that the angulation will prevent evacuation. If you must realign the limb, do so with gentle, steady traction along the line of the bone while supporting the joint above and below, stopping if the casualty reports a sudden increase in pain or you feel resistance. Once the limb is in a more normal position, splint it as found. For lower limb fractures, a splint can be made by binding the injured leg to the uninjured leg with padding between them, using the healthy leg as a natural splint. For upper limb injuries, a sling made from a jacket, shirt or triangular bandage supports the weight of the arm, and a broad-fold bandage or second strap around the torso holds the arm against the chest to reduce movement.
Managing Hypothermia in the Trauma Patient
Trauma and hypothermia are a dangerous combination. Blood loss, shock, exposure to wind and cold, and lying on frozen ground all accelerate heat loss, while hypothermia impairs the body’s ability to form blood clots and increases the risk of bleeding to death from injuries that might otherwise be survivable. In extreme sports accidents, a casualty who is also hypothermic is at much greater risk of the so-called lethal triad of hypothermia, acidosis and coagulopathy. This means that preventing further heat loss and beginning rewarming is not a comfort measure but a critical part of trauma care. Even in relatively mild weather, a casualty who is injured, immobile and lying on the ground can become hypothermic surprisingly quickly, especially if their clothing is wet or if there is wind.
The first priority is to move the casualty onto an insulating layer that separates them from the cold ground. A closed-cell foam sleeping mat, a rucksack, a pile of branches, a dry bag filled with clothing or even a folded foil blanket can all serve this purpose. If the casualty is wearing wet clothing, cut or remove the outer wet layers as quickly as possible and replace them with dry clothing, a sleeping bag, a bivvy bag, or an emergency shelter. Cover the head with a hat or hood, as a large proportion of heat is lost from the head and neck. Use a foil blanket or plastic bag over the casualty to reduce convective and evaporative heat loss, but remember that these are not a substitute for dry insulation.
Handle a hypothermic casualty gently. Sudden movement or rough handling can trigger a fatal heart rhythm in a severely hypothermic patient. Avoid giving the casualty alcohol, caffeine or any fluids if they are not fully alert and able to swallow safely. If they are conscious and shivering, you can give warm, sweet drinks and provide active warming by placing warm water bottles, heat packs or warm stones wrapped in clothing next to the chest, armpits and groin, never directly against bare skin. A rescuer can also share body heat by getting into a sleeping bag or group shelter with the casualty. The goal is to stop the temperature from falling further and to begin slow, safe rewarming, while remembering that a hypothermic casualty with a serious injury needs urgent evacuation just as much as a warm casualty does.
Communication and Evacuation Planning
Getting help to a remote accident site and arranging a safe evacuation depends almost entirely on good communication and clear planning. Before you set out, always agree on a communication plan: who carries a satellite messenger or personal locator beacon, who has a mobile phone with offline maps and local emergency numbers, and what the procedure is if one of these devices fails. In many mountainous or coastal areas there is no reliable mobile signal, so a two-way satellite communicator such as an inReach or SPOT device is the most dependable way to send a distress message with your exact location. If you have no signal and no satellite device, send two fit party members to the nearest known point of contact with a written message containing the essential information, and make sure they know the route and carry a map, compass, torch and warm clothing for the journey.
When you do make contact with emergency services, give them a concise and structured casualty report. The key details to communicate are:
- Your exact location, ideally a grid reference, latitude and longitude, or a clear description of the terrain and nearest named feature.
- The number of casualties and the number of uninjured people in the party.
- The main injuries or medical problems, and whether the casualty is conscious and breathing.
- The time of the accident and any changes since then.
- What first aid has already been given.
- The local weather, visibility, wind and any hazards such as avalanche risk or falling rock.
- What equipment you have, including shelter, warm clothing, food, water and means of signalling.
While waiting for help, prepare for the evacuation. If a helicopter is likely, choose and mark a landing zone if it is safe to do so: a flat area free of loose objects, with any skis, poles or bags secured, and use a bright item of clothing or a foil blanket to indicate wind direction. Keep the casualty and the rest of the group well clear of the landing zone when the helicopter approaches. If evacuation will be by ground party or stretcher, clear a route where possible, and assign one person to stay with the casualty while another prepares the party’s equipment for a long carry. Do not let the desire to evacuate quickly override scene safety and ongoing casualty care: a well-managed, slow evacuation is far better than a rushed one that causes further injury or leaves someone behind.