Aim To determine how many severely injured mountain casualties handled at our department required input from tertiary services, and with what urgency.

Method Casualties who sustained major trauma (ISS>15) between 1 January 2004 and 30 September 2009 were identified from the Mountain Medicine Database (all casualties brought to our ED following contact with Mountain Rescue or RAF Search and Rescue). Patient notes were scrutinised for details of injuries and consultations with tertiary centres.

Results 26 major trauma casualties arrived at the ED (all by RAF helicopter). In addition, 31 were pronounced dead at scene.

• 10/26 (38%) required referral—not necessarily transfer—to tertiary specialities, mostly neurosurgery (8/26, 31%)

• The three most seriously brain-injured casualties had delays of 115, 70, and 45 min in obtaining neurosurgical management decisions.

• Only one patient required urgent transfer to tertiary care (neurosurgery—extradural haemorrhage)

Discussion/Conclusion Urgent transfer to tertiary specialities is rarely required in severely injured mountain casualties from Snowdonia: bypassing our DGH directly to a regional trauma centre is not required. Furthermore, it would be logistically difficult. In summer, with endurance typically 1 h 45 min, the RAF helicopter would likely need to re-fuel before continuing to NW England after picking up a casualty. This audit, although limited in number, supports the concept of a regional trauma system with pre-defined protocols and pathways for patient care. We also require a more timely service from neurosurgical colleagues.