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- Dr Mike Langran |
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Introduction
Incidence of head
injuries on the slopes
Mechanisms of head injuries whilst skiing or snowboarding
Minor head Injuries
Serious head
injuries
Treatment of head injuries
Deaths from head
Injuries on the slopes
Who needs to see a
ski patroller and/or doctor after a head injury?
Head injury instructions
Helmets
An injury to the head, wherever and however it occurs, always causes anxiety one way or another - to the casualty, their relatives/friends and also those of us who have to provide medical assistance.
| Fortunately, most look worse than they actually
are, but if you asked me about some of the most challenging injuries I have had
to deal with over the years, many of them have involved injury to the head. When
the injury is severe, the casualty is usually rendered unconscious.
As a result, not only can they not tell you anything about their
accident or where they are hurt, but they can also struggle to
protect their own airway. Additional complications can include
respiratory depression, seizures (fits) and associated spinal
injury. If the brain has been badly damaged, bleeding both in and
around the brain can occur and the brain itself can swell. This is a
real problem, because the brain is encased in a solid case (the
skull) which has no vent for this increased pressure, which damages
the brain still further. All in all, not good.Serious injuries to the head,
even with appropriate management, can therefore lead to death or permanent and significant disabilities.
From a snow sports prospective, it was really the
high profile deaths of Sonny Bono and Michael Kennedy in 1998 that first heightened public
awareness of the risks of head injury and lead to the controversial CPSC report
on helmets in snow sports. Certainly the wearing of a helmet seems to have gone
from "geek" to "cool" in recent years. Helmet sales in the USA have risen from 290,000 in
1998/99 to 629,000 in 2000/01. Latest data from Switzerland indicate that 30% of
skiers and boarders there now wear a helmet. So what are the true facts about head injuries
from skiing and snowboarding? What are the statistical risks? Are they high
enough to warrant mandatory helmets for everyone? Or should we just concentrate on
putting lids on kids? This topic has become so big that I have now split it into
two separate pages on this website - this one covers head injuries per se,
whilst the second page looks specifically at the issues regarding helmets and
the evidence for their use. As ever, I greatly appreciate any feedback that you
may wish to pass on to me - use the
contact page.
Incidence of head
injuries on the slopes |
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Mechanisms of
head injuries whilst skiing or snowboarding
There are three main
mechanisms of head injury on the slopes. These are (in descending order of
severity)
Collisions - either
with another person or an object (tree, rock, ski fence, pylon, grooming machine
etc)
Collisions cause the majority of PSHI. Given that skiers and boarders
regularly reach 30-40mph even on intermediate slopes, you can see that the
impact speeds can be quite high. If you do hit another person, at least their
body has a bit of "give" in it, unlike a static object like a tree. Hitting a
tree or a pylon full on at 30-40mph is not much fun. Most traumatic deaths on
the slopes occur as a result of a collision with a tree. So while it is
undoubtedly a beautiful experience winding your way in and out between those
trees, just take care. One wrong move and you could end up with more than a bad
headache (that's if a tree well doesn't get you first!). Even padding around
pylon bases can only do so much. The take home message is one that is repeated
throughout this website and its quite simple, if in doubt SLOW DOWN!
Impacts with snow
surface (e.g falls onto a hard icy surface
Whilst this particular kind of fall can affect anyone on the slopes, they
tend to be most common amongst beginner snowboarders who, losing their balance
quickly, are unable
to recover or compensate in time. Usually this results in a backwards fall with
a quite heavy impact to the back of the head. A good time in your life to be
wearing a helmet!
Lift accidents (e.g
hits on the head from swinging T-bars, chairs or pomas)
This is quite a common accident scenario in Scotland as we have a large
percentage of T-bar lifts and not enough room on many slopes to allow enough
space for the T-bar, once dropped, to travel a safe distance to the turn wheel.
This means that the T-bar is still recoiling when it goes around the turn wheel
and, if swinging wildly, can pose a danger to anyone near by. I speak from
personal experience when I say that a helmet is also invaluable here.
Fortunately, the worst injuries to date have been a few really nasty
lacerations, but the weight and inertia of a T-bar is certainly enough to knock
someone out cold. See the contrasting pictures below.
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.JPG) |
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T-bar in Scotland - minimal distance between the get-off point at the turn wheel. A returning T-bar can swing round the turn wheel and hit someone who is standing around the dismount area. |
T-bar lift in St.Moritz. Note the ample and safe distance from the turn wheel. In addition, there is room for a wooden "funnel" system to safely guide the discarded T-bar away from the dismount area and up to the turn wheel. |
Minor head Injuries
Minor head injuries include superficial abrasions, lacerations (cuts) and
low impact bumps to the head. As I have already mentioned, thankfully the vast
majority of head injuries seen on the slopes fall into this category. Abrasions
usually result from a sliding contact between the skin of the head and the snow
surface. They can be fairly painful but thankfully require very little medical
attention apart from perhaps a clean up and a supply of pain killers. Generally,
they are best left open to the air so that they can dry out and scab over.
They'll get soggy if you leave a dressing on for too long. Because the scalp has
a good blood supply, secondary infection is fairly rare and shows itself with
increasing redness, pain and perhaps pus around the site of the abrasion. Minor
lacerations tend to bleed impressively initially (thanks to that good blood
supply) but once this has stopped (by applying a pressure dressing) can often be
treated in the ski patrol room and the skier/boarder can often continue on. Very
small cuts can be steri-stripped with adhesive strips, larger cuts we now tend
to seal with medical superglue, which is great stuff and saves many a casualty
from the pain and inconvenience of stitches. Low impact bumps may produce a
relatively impressive
bump/bruise (known in the trade as a haematoma) but otherwise no major harm is
done. We run through a general check list when examining such patients (see
below) and if all is well, nothing more need to be done. Although strictly
speaking there's no reason why not, most casualties decide to call it a day at
this point and head home or to the bar.
Serious head
injuries
PSHI include all episodes of unconsciousness, suspected skull fractures,
large wounds to the scalp and penetrating injuries to the head. There is often
associated multi-trauma to other parts of the body and the medical response
needs to be coordinated, skilled and rapid. It goes without saying that all
patients in this category need emergency transfer to a trauma centre, often by
helicopter ambulance once stabilised. Depending on circumstances a direct
transfer to a neurosurgical centre may be the most appropriate course of action.
In all cases, the possibility of associated injury to the spine has to be
carefully considered and the patient appropriately packaged - see below.
Treatment of head
injuries
Treatment of all PSHI (like all serious injuries on the slopes) should follow
the established "Safety, A.B.C.D.E." system for major trauma.
Safety - of the scene, rescuer and casualty
Airway - with cervical spine control
Breathing - with assessment and control of ventilation
Circulation - with control of haemorrhage
Disability - neurological assessment
Exposure - for associated conditions (may not be appropriate in all situations)
Its beyond the scope of this website to go into the precise medical details of this system which can be found in any standard trauma management textbook or online resource. One such resource is the NICE guidance - click here for the pdf file.
Deaths from head injuries on the slopes
The most complete data on deaths on the slopes comes from the USA. During the
2006/07 season there were 22 deaths from 55.1 million skier/snowboarder
days. This gives a death rate of one for every 2.5 million skier days.
(Source - NSAA, USA).
This is a reduction from the 37
skiers and snowboarders who died accidentally on U.S. slopes in 2002/03. With
57.6 million visits in 2002/2003, the death rate translates to 0.64 deaths
per million visits (or one death every 1.6 million skier visits). In 2001/02
there were 45 deaths.
In a published research study of the death rates from skiing and snowboarding in US resorts from 1991/2 to 1998/9 Shealy, Ettlinger and Johnson reported 285 deaths from a total of 426.2 million participant visits (MPVs). This equates to an overall rate of 0.67 deaths per MPVs - put another way, statistically a death can be expected for every 1.49 million visits to a ski area. Interestingly, the death rate for snowboarding (0.46 per MPV) was 34% lower than that for alpine skiing (0.70 per MPV). The causes of death and the fatality rate associated with them are given in the table below (adapted from Shealy et al) :-
| Modality of death | Fatality rate per PMV | Ratio of skiing to snowboarding death rates | |
| Snowboarding | Skiing | ||
| Overall | 0.455 | 0.702 | 1.54 to1 |
| Impact -object or person | 0.195 | 0.563 | 2.89 to 1 |
| NARSID* | 0.081 | 0.016 | 0.19 to 1 |
| Impact with snow | 0.081 | 0.085 | 1.05 to 1 |
| Jump | 0.065 | 0.022 | 0.34 to 1 |
| Other | 0.033 | 0.016 | 0.48 to 1 |
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(* NARSID = Non-Avalanche Related Snow Immersion Death - see intro page for more details) So the leading mechanism of death in both sports is a collision with either a static object (tree, for example) or another person. This is particularly so for skiers. This aside, snowboarders are most likely to die from a NARSID or as the result of a jump. In the 1998/99 part of the study, Shealy and colleagues followed the deaths as they happened and found that, where the information was available, 35% of individuals who died were wearing a helmet. This is much higher than the rate of helmet use amongst the general population on the piste. Two of the deaths amongst snowboarders resulted from them being struck by young skiers wearing helmets who had jumped without being able to see where they would land. Shealy et al conclude "...the findings are not particularly supportive of the notion that wearing helmets will significantly reduce the number of fatalities in winter snow sports". This was supported by a presentation at the last ISSS meeting by the Chief Medical Examiner for the state of Vermont, USA - Dr Paul L. Morrow. Dr Morrow was of the opinion that of 54 deaths at commercial ski areas in Vermont from 1979/80 to 1997/98, helmets would not have been of any particular value in saving any of the lives lost - as the degree of trauma simply overwhelmed any benefits that the helmet might convey in an impact. To quote Shealy et al again - a team of highly respected ski injury researchers - "On the basis of results to date, there is no clear evidence that helmets have been shown to be an effective means of reducing fatalities in alpine sports".
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Who needs to see a
ski patroller and/or doctor after a head injury?
This can be tricky one and will often depend on exact circumstances. We
certainly don't need to see every tiny bump and scrape but the golden rule is
"if in doubt, see". Obviously, all PSHI need to be seen. The following
characteristics also indicate that a medical assessment would be sensible (this
list is not exhaustive and I'm bound to forget a few) :
Any episode where the casualty may have lost consciousness, even if they seem to be ok now
Any episode where the casualty cannot remember what has happened, is confused, has a severe headache or vomits more than once
Any episode where the casualty is complaining of or demonstrating problems with walking, talking, coordination or responding normally
Children - personally, I have a very low threshold for seeing children in any aspect of my medical practice if concern exists, and a bang on the head is no different.
Any cut that is gaping or won't stop bleeding after 5 mins of pressure bandaging
Bleeding from either ear
Clear or yellow-coloured fluid loss from the nose and/or either ear - may indicate a leak of cerebrospinal fluid from around the brain
Head injury
instructions
If and when you decide to allow someone home after a head injury, it is
sensible clinical practice to provide a head injury advice sheet. Two examples
used in the UK are shown below - the one on the left for adults and the one on
the right for the parents of children with a head injury. Click on the thumbnail
to see the advice. The take home message
is always "if you're worried, get in touch".
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Helmets
Although I have mentioned helmets
several times on this page, the topic itself requires its own page which you can
access by clicking here.
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© Copyright Dr Mike Langran 1999-2008 This website is registered and protected under International Copyright Law. All international rights reserved. No part of this web page may be reproduced in any form, or by any electronic, mechanical or other means, without permission in writing from Dr Langran.
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