High-speed falls in ski touring, freeride skiing, snowboard mountaineering and steep alpine descents produce injury patterns that are categorically different from the low-energy falls that dominate summer hiking medicine. The forces involved — speed, hard snow or ice surface, contact with obstacles — generate trauma that standard trail first aid training does not fully prepare responders for. Understanding what high-speed winter trauma produces and how to assess it correctly in the field is the competence gap most winter mountain users have and most need.

The Physics of a High-Speed Snow Fall

A ski tourer descending at 40km/h who falls and slides on firm spring snow travels approximately 200 metres before stopping — assuming no obstacle contact. The deceleration forces are significant. If contact with a tree, rock, cliff edge or mogul occurs at speed, the impact forces can exceed those of a road traffic accident. The specific injury patterns that result differ from summer falls in three ways:

• Deceleration injuries: internal organ injury from rapid deceleration — spleen, liver, aorta — can occur without external visible trauma. A person who slid 100m and stopped abruptly against a tree may have internal bleeding with no external wound.
• Rotation and tumbling: high-speed tumbling falls expose the head, neck and spine to repeated impacts from multiple directions simultaneously. Spinal injury risk is significantly higher than in a simple trip-and-fall.
• Equipment-related injury: ski bindings, poles, crampons and ice tools become injury factors in a fall — binding release failure, pole impalement risk, crampon lacerations from tumbling with crampons attached.

Primary Survey: The XABCDE Approach for Trauma

Standard ABCDE primary survey is modified for trauma to XABCDE — the X representing catastrophic external haemorrhage control, which takes priority over airway management when present:

X — Catastrophic haemorrhage

Look immediately for life-threatening external bleeding — arterial bleeding (spurting, bright red), large-volume venous bleeding from major lacerations, or amputation-type injuries from crampon or ski contact. Apply direct pressure or tourniquet (see below) before addressing airway if catastrophic bleeding is present. Junctional bleeding (groin, axilla, neck) that cannot be compressed with a tourniquet requires wound packing with haemostatic gauze and sustained direct pressure.

A — Airway with cervical spine control

In any high-speed fall, assume cervical spine injury until excluded. Open the airway using jaw thrust (push the jaw forward from both sides without tilting the head) rather than head-tilt-chin-lift. If alone and airway management requires head tilt, prioritise the airway — a living patient with a cervical injury is better than a dead one with a protected neck.

B — Breathing

Assess breathing rate, depth and symmetry of chest movement. Unequal chest rise with significant trauma suggests pneumothorax (collapsed lung) — the injured side moves less. A tension pneumothorax (progressive deterioration, trachea deviated to one side, absent breath sounds on one side, plummeting blood pressure) is a life-threatening emergency requiring needle decompression if trained to perform it, and immediate evacuation regardless.

C — Circulation and haemorrhage

Assess pulse rate and quality; skin colour and temperature; capillary refill (under 2 seconds is normal); level of consciousness as a proxy for blood pressure. Rapid, weak pulse + pale, cold skin + confusion = shock. Lay flat, conserve warmth, call emergency services immediately, do not give oral fluids to a shocked patient.

D — Disability (neurological)

AVPU consciousness level; pupil equality and reactivity (unequal pupils after head trauma indicate intracranial pressure event); gross limb movement — can the person move all four limbs on command? Inability to move lower limbs after a spinal mechanism injury indicates potential spinal cord involvement.

E — Exposure and environment

In a winter fall, hypothermia begins immediately — wet, still, in cold air. Remove only what is necessary to assess injuries; insulate aggressively otherwise. A trauma patient in shock becomes hypothermic within minutes in alpine conditions, and hypothermia worsens coagulopathy (the ability to clot blood), accelerating haemorrhage.

Tourniquet Application for Limb Haemorrhage

Commercial tourniquets (CAT — Combat Application Tourniquet, SOFTT-W) are increasingly carried by ski patrollers, guides and prepared backcountry skiers. Improvised tourniquets from webbing, gaiters or clothing can be effective but must be applied correctly:

• Apply 5–8cm above the wound on a single bone (upper arm or thigh) — not on a joint, not below the knee or below the elbow where two bones prevent effective compression
• Tighten until bleeding stops — not until it hurts; the endpoint is cessation of bleeding, not patient pain threshold
• Note the time of application on the patient’s forehead, arm or a visible piece of clothing — tourniquets cannot safely remain in place beyond 2 hours
• Do not remove in the field once applied — removal is a medical facility decision
• An effective tourniquet eliminates the pulse in the limb below it — check for this as confirmation of adequate compression

Spinal Injury: When to Move, When Not To

The traditional wilderness medicine approach of “never move a potential spinal injury” has been substantially revised. Current evidence supports movement when:

• The scene is not safe and remaining in place creates greater injury risk than movement (avalanche zone, cliff edge, rapidly deteriorating weather)
• Airway management requires repositioning
• The person has no signs of spinal injury (no neck/back pain, no neurological symptoms, mechanism of injury was low-energy)

If you move a potential spinal injury casualty: use the log roll technique (3–4 people; one controls head and provides commands; body rolled as a single unit, maintaining alignment; onto improvised backboard or ski, sleeping mat, or hard surface for transport). Never drag a potential spinal injury along the ground from below.

Evacuating a Winter Trauma Casualty

Most high-speed winter falls occur in terrain where ground evacuation is slow and difficult. The decision framework for evacuation method:

• Walking evacuation: only if the person is conscious, fully oriented, has no suspicion of spinal injury, has adequate perfusion and can walk with assistance; appropriate for relatively minor falls
• Improvised sled evacuation: skis strapped together with poles as runners, sleeping mat as base; for a stable (non-deteriorating) casualty where helicopter is delayed
• Helicopter: required for any unconscious casualty, any suspected spinal injury, any shocked patient, any suspected internal injury, and any patient who cannot safely walk — call early, before conditions deteriorate further