Abstract
To the Editor:
We read with great interest the article by Martínez-Caballero et al regarding the epidemiology of cardiovascular events during mountain rescue missions conducted in Aragón, Spain. 1 The authors describe prehospital and in-hospital invasive procedures, diagnoses, and outcomes of 34 patients with cardiovascular events rescued by prehospital emergency medical services (EMS) in collaboration with mountain rescuers and the Spanish Air National Guard. Twelve of 34 patients were diagnosed with an acute coronary syndrome (ACS).
Although the authors state that treatment for patients with ACS has been optimized through Aragón’s current infarction code protocols within the end of the study period, 2 only 58% of the 12 patients with ACS were transferred to the hospital in an advanced life support (ALS) staffed vehicle; it is not discussed why the other 42% were not. Risk assessment and prehospital triage of these patients should be done as soon as possible with an electrocardiogram (ECG), as recommended by European Society of Cardiology guidelines. 3 It could be foreseen to implement new technology such as point-of-care ultrasound (POCUS) and telemedicine to optimize care; POCUS can, in fact, allow an accurate diagnoses and thus enhance prehospital and telemedicine consultation with ECG transfer.
We should emphasize that all patients with moderate and high risk of ACS should be transported, if possible, within the professional ALS-staffed EMS to provide an ideal chain of survival. This will also optimize the application of national and international guidelines wherein the initial evaluation of the patient should include the initial diagnosis process, estimation of the probability of experiencing ACS, assessment of the patient’s vital risk, need for transfer to a hospital, and urgent care measures.3,4 In mountain and remote areas, the average transport is longer compared to urban areas, 5 which puts the patient at higher risk of fatal coronary events. 6 An early ACS diagnosis with an ECG and/or treatment by an ALS provider onsite can improve the rescue chain. Furthermore, automated external defibrillator (AED)-equipped rescue teams and automated external defibrillators located in ski resorts and mountain huts could optimize outcome. In addition, the introduction of standard operation procedures for refractory cardiac arrest and use of mechanical chest compression devices in selected cases could be beneficial, allowing early transport to a hospital with ongoing cardiopulmonary resuscitation. 7 We suggest that in mountain and remote areas, onsite medical diagnostics and treatment according to guidelines 4 should be provided by integrating mountain rescue service and ALS-staffed EMS and helicopter EMS.