Blow to head with loss of consciousness neurological
abnormalities, including confusion, memory lapses, partial paralysis.
Rescuers should treat hypothermia in the setting of head injury no
different from other cases of hypothermia: add as much heat as possible.
Rescuers should not withhold fluid from a head-injured patient with
shock or dehydration. Shock or dehydration are likely to cause a worse
outcome in head injury. However, rescuer should not fluid overload
such a patient. Just provide fluids until signs of dehydration or shock are gone.
Rescuers should position the patient flat in the litter unless they must place the patient on the side to protect the airway. Regardless, the patient's head should be in neutral position with respect to the rest of the body (not twisted). Package the patient so that there is nothing even slightly constricting the jugular veins across the neck. Just slight twisting of the neck, or slight obstruction of the neck veins, may cause increased intracranial pressure.
Evacuate the patient with the head slightly up.
Do not hyperventilate unless the patient is definitely becoming
progressively worse. Hyperventilation may cause damage to ischemic
parts the brain after injury. However, hyperventilation will decrease
intracranial pressure and thus may buy some time in a patient with
massive brain swelling.
Rescuers should care for chest injuries as taught by their standard prehospital emergency medical or first aid training. Particular points to observe during evacuation include two items for those with serious chest injury, and one for isolated rib fractures:
First, check to make sure the mechanism of injury is appropriate for you to evaluate as a likely back strain. For instance, don't use this protocol for someone who fell 35' onto his back and has severe back pain; he or she needs to be treated as a multiple trauma patient. This protocol is only for back pain after twisting or heavy lifting.
Ask: "Have you had any trouble passing your urine?" (If the injury just happened, the person doesn't know. But, if the injury happened several hours ago, and the person tried to go and couldn't, or is dribbling all the time, you want to know about it right away.)
Ask: "Do you have any pain, numbness, tingling, or weakness going down your legs?" If answer to either is yes, or back pain is so severe as to prevent walking, carry team member out of field.
WEMSI Wilderness EMTs only: perform exam as follows: Check
sensation to pinprick between the first and second toes, and in both
medial and lateral aspects of foot, ankle, lower leg, and thigh. Do this
on both sides. Check motor strength in the lower leg (this can easily be
done by having the person walk first on toes, and then on heels, with the
toes up). Check motor strength in the thigh; this can be done by having
the person try to flex and extend the knee against the resistance of your
hand. Check deep tendon reflexes in the knee and ankle. They should
be about the same on both sides. Do a straight-leg-raising test.
With the patient lying on his or her back, or sitting on a chair or equivalent,
hold the thigh and knee both bent at 90ř. Gently, without moving the back
at all, straighten the knee. Markedly increased back pain, or increasing
pain down the leg, is a positive straight leg raise test. What you are trying
to do is to pull on the sciatic nerve. If it is tightly squeezed by a herniated
disk or other problem, pulling on the nerve will irritate it and cause a positive
test. If exam suggests herniated disk, carry team member out.
Use standard rice treatment for first 24-48 hours: rest, ice, compression
(elastic bandage) and elevation. Do not let people sleep with elastic
bandages; swelling may turn them into tourniquets overnight. After
36-48 hours, apply heat, to bring more blood to area and speed healing.
Clean the nail with soap and water, alcohol, or povadone-iodine
(e.g., BetadineŽ) and then trephine the nail (make a hole in it). The
preferred method is to heat tip of a safety pin in a flame to sterilize
and make red-hot, then apply firmly to nail. An alternative is to use
a #11 scalpel blade to drill a hole in the nail.
Examine the wound and classify it as either low risk or high risk for complications.
High risk wounds include: open fracture, bone or tendons exposed, human or other bites, deep punctures, grossly contaminated wound, or severe crushing.
Never put alcohol, merthiolate, mercurochrome, or peroxide into
an open wound. Povadone-iodine may be used around but not in
wounds; the only exception is diluted povadone-iodine for high-risk
wounds as described below.
If a team member has a wound that requires surgical repair or medical
attention, and has not had a tetanus immunization within the past 10 (ten)
years, have the team member return to Base to obtain tetanus immunization.
When removing an impaled object, you should generally remove it
slowly, and gently but firmly, pulling out along the line the object entered.
You should stop your attempt if you encounter any significant resistance
or cause a significant increase in pain.
Minor injuries that appear to be sprains, and do not interfere significantly with use of the part, should be treated with RICE treatment for the first 24-48 hours: Rest, Ice, Compression (elastic bandage) and Elevation.
Do not let people sleep with elastic bandages; swelling may turn them into tourniquets overnight.
After 36-48 hours, apply heat, to bring more blood to the area and speed healing.
For more significant sprains (or possibly minor fractures) management depends on the medic's level of training:
There are two indications for your realigning a deformed long bone fracture (including open fractures). They are (1) to correct or at least improve a sensory or vascular deficit secondary to the fracture (if numbness, tingling, weakness, or lack of pulse beyond fracture), and (2) to align severely deformed long bone fractures to allow splinting with adequate immobilization.
Don't try to reduce (set) the fracture or force all the bone fragments back into anatomic alignment. This is a physician's responsibility.
Pull longitudinally, that is, along the normal axis of the injured extremity. Grasp the extremity distal to the fracture firmly. Once you apply traction, you will not release it until the limb is fully splinted. Have an assistant stabilize by countertraction, holding the extremity proximal to the fracture. Use the least amount of force needed to align the extremity. Having a person support the injured extremity under the site of the fracture. This will make the patient more comfortable. Your initial pull will usually cause slight discomfort as the fragments move, but it quickly subsides. Then, you can apply further gentle but firm traction to align the fracture. If the patient strongly resists traction, or if it causes markedly increasing pain that continues, stop, and splint in the deformed position.
Attempt realignment of a long bone fracture only twice, unless there is
a sensory or vascular deficit. If you are unsuccessful after two attempts,
or if you encounter resistance during realignment, splint the extremity as is.
In these circumstances there is a greater risk of making the injury worse
than the potential benefit of the realignment.
For the initial management of a femur fracture, use a traction splint. Even with the best-padded ankle hitches, traction splints tend to cause pressure necrosis when used for a long period of time. You must monitor carefully for signs of pressure necrosis, and readjust or take off the traction splint if the ankle shows signs of skin breakdown. If the evacuation will be more than three or four hours, use skin traction instead of an ankle hitch: apply tincture of benzoin to the calf on both sides, then run a piece of duct tape in a "U" shape under the instep and up along both sides of the calf; fold the section under the instep over on itself so it does not stick to the skin. Attach the traction to the duct tape under the instep.
Many orthopedic surgeons doubt the usefulness of traction splinting for extended evacuations. Instead, they recommend a Jones' dressing: bulky padding surrounded by plaster, fiberglass, or flexible SamSplints, and held together with elastic bandages. If no traction splint is available, apply a Jones' dressing.
If none of these splints are available, transport the patient supine on a
well-padded backboard with the legs strapped together or with a tree limb
or another reasonable substitute secured between them.
Realign open fractures for the same reasons as for long bone fractures as described above.
Open fractures deserve special consideration. You must arrange immediate evacuation for any patient with an open fracture. These fractures require irrigation, debridement, and open surgical reduction in the operating room. You must assume that any fracture (or suspected fracture) with a nearby laceration or wound is an open fracture. Care of open fractures in the wilderness environment depends upon evacuation time.
If you estimate that you can complete evacuation within six hours, limit cleansing to just brushing off dirt and other contaminants with clean gauze or a cloth and apply a dry, sterile dressing. Control hemorrhage by a carefully applying a pressure dressing and immobilize the extremity by splinting.
If evacuation time will exceed six hours, you should clean the wound,
perform limited debridement (trim away any obviously dead tissue), and
irrigate as described for wounds, above, before applying a sterile dressing.
Control hemorrhage with a pressure dressing, and immobilize. If you find
evidence of any nerve or vascular, and the extremity is deformed, realign
the fracture and reevaluate before splinting and evacuating.
First Aid/First Responder level: attempt reduction only if numbness, or if no pulse beyond dislocation.
Wilderness EMT level: attempt reduction of all dislocations if numbness,
or if no pulse beyond dislocation. Attempt reduction of the following
dislocations: jaw, finger or toe, elbow, shoulder, patella, knee, ankle.
Attempt hip dislocation reduction only if needed to evacuate patient.
Control hemorrhage by direct pressure. Clean the amputated part
with water or saline, wrap it in a moistened sterile gauze or towel, place
it in a plastic bag, and transport it as cool as possible without freezing it.
Never place an amputated part in direct contact with ice or icy water.
Keep the amputated part with the victim throughout the evacuation process.
Syncope may be a sign of serious medical problems, such as a seizure disorder, a heart valve problem or arrhythmia, or a stroke. On the other hand, fainting may be due to minor problems, such as dehydration, a sudden psychological shock, prolonged standing, or forgetting to eat breakfast.
If you are on a wilderness SAR task and find yourself confronted with a team member who has had a syncopal or near-syncopal episode (passing out or nearly passing out), evaluation depends on level of training.
You should use the above protocol with caution; anything about the episode that makes you suspicious that it was not heat syncope, even if the team member meets all the above criteria, should be cause to terminate the task and head back to base.
Any team member with syncope should be examined by a physician when the team returns to base, even if you have cleared the team member to continue with the task.
For all levels of training: You should carefully check the team member
for orthostatic changes in blood pressure (or pulse, if you do not have a blood pressure cuff), and should continue rehydration and sugar replenishment until the person is no longer orthostatic.
Treat heat cramps with gentle stretching and
If you suspect dehydration in a team member (common symptoms are: lightheadedness, weakness, nausea, redness of vision or tunnel vision):
If a patient or team member has a temperature more than about 101 degrees F, with neurological symptoms (e.g., confusion, decreased level of consciousness, weakness or numbness or tingling of one leg or one arm), in a proper setting for heat illness, and without history or physical exam evidence to suggest fever, treat for heat illness:
Rehydrate if any suspicion of dehydration, place in cool area, dampen the patient's clothes with water (preferably tepid, not cold), and fan to cause evaporation heat loss. You may place cold packs at sides of the neck, in armpits, and in groin.
Use cooling to bring temperature down to 102 degrees F, then stop.
Monitor temperature for decreases or increases. Evacuate. If you have
no thermometer, and patient feels hot and seems to have heat illness,
treat for heat illness.
(Burns the size of five palms, which is about 5%, or less): Gently clean the burn of loose blister fragments, and any foreign material, clean the burn with soapy water, and apply silver sulfadiazine (SilvadeneŽ) cream or bacitracin ointment twice a day. (If you don't have silver sulfadiazine (SilvadeneŽ) or bacitracin, canned non-mentholated shaving cream makes an acceptable substitute.)
Leave complete blisters intact, unless they are where they are sure to
rupture (e.g., the soles of the feet), or are very large and tightly filled with
bloody fluid. In such cases, prep the blister with povadone-iodine
(e.g., BetadineŽ), then drain by a small incision at the edge of the blister
with a sterile scalpel blade or needle. Press the blister flat, in the hope that
it will stick to the underlying skin and continue to serve as a burn dressing.
Apply a dry dressing.
Treat the burnt area as described for small burns, above.
Evaluate carefully for shock, and be prepared to give large amounts of fluid by mouth if tolerated. Use urine output to gauge adequacy of fluid replacement.
Evaluate for airway burns and toxic inhalation.
A particularly important point about lightning strikes is that the patient may have respiratory paralysis, unconsciousness, and vasospasm with undetectable pulses; despite which, prolonged artificial respiration may allow the patient to recover with no neurological deficit. (Vasospasm is a "cramp" of blood vessel muscles that may make a pulse impossible to feel.) Coma may last for days or weeks, but some patients will still make a full recovery. Each lightning strike victim needs immediate ABC's, with careful attention to protecting the C-spine. Almost all trauma patients and many cardiac patients with cardiac arrest will die even if you apply CPR. Lightning strike victims, on the other hand, offer you an excellent chance to save a life through basic life support.
If you find a patient in or near a thunderstorm, with coma, dendritic burns, or ruptured eardrums, you should start vigorous resuscitation, for the patient may be a lightning victim.
Anyone you find confused near a lightning strike might be a victim of the strike. You should check for pulses (remember the possibility of vasospasm) and check the BP. Perform a regular trauma exam; if you have an otoscope, check for tympanic (eardrum) perforations. Although such patients are generally stable, and recover without incident, evacuation is in order, with cardiac monitoring if available.
Check the patient's urine for signs of myoglobinuria (see below) and treat it if found.
If you must triage a group of people who have been hit by lightning, the rule
should be "resuscitate the dead," because those showing some signs
of life are likely on the way to recovery.
Hypothermia is divided into deep and mild by the temperature 90 degrees F
(32 degrees C). Those with mild hypothermia and no medical problems can be
rewarmed by any method and will do well. Team members with mild hypothermia
may return to duty after rewarming and adequate food and drink.
When caring for a hypothermic patient in the field, add as much heat as
you can, using any and every method available. Try to rewarm the core first.
Acceptable methods include warm IVs, warm fluids by mouth if the patient can
take them, hot packs at lateral neck, armpits, and groins, warm humidified air
or oxygen, and rewarming devices such as a charcoal vest. However, don't
delay evacuation to rewarm the patient. Also provide fluids and food calories
if you can.
Cold water submersion (near-drowning) is not the same as acute
(immersion) hypothermia; the treatment for the two is very different. Do not
rewarm victims of cold water submersion; keep them cold.
Wrap the frostbitten extremities in towels or thick pieces of clothing soaked with warm (40-42 degree C = 104-110 degree F) water. Next, wrap waterproof plastic and pieces of closed-cell foam around the towel-wrapped extremity, then place the patient in the litter. A liter of water can be quickly heated on a stove while the patient is prepared for evacuation. The water will cool during evacuation; this is acceptable. There is no benefit to providing continued warmth once the frostbitten part has rapidly thawed. If the evacuation will be very long, you may want to take the wet towels off several hours later to allow the skin to dry.
Heat packs and heating pads are well-known for the burns they cause during rewarming, sometimes even to extremities that were not truly frostbitten. If it is so cold that you must use heat packs to prevent the wet towels from cooling too fast, even when insulated, make sure the hot packs aren't in direct contact with the skin.
Some might argue against thus treating frostbite in a patient who is
also hypothermic. True, rewarming of the periphery should be avoided in
hypothermia, but the hands and feet (not the arms and legs) have direct
venous connections to the core, so rewarming of the hands and feet is
quite acceptable, even if the patient is hypothermic.
At altitudes above 4000 feet, may suspect acute mountain sickness, especially if rapid ascent to altitude, and symptoms of headache and nausea, and many symptoms of alcohol hangover, or a migraine headache:
Severe acute mountain sickness recognized by increasing neurological symptoms, including confusion, ataxia (an abnormal walking gait), and grades into high altitude cerebral edema.
Treatment of acute mountain sickness: Stop ascending or go down.
Mild AMS may be a harbinger of worsening AMS to come if the rate of ascent
stays the same. After the symptoms have gone, ascend at a slower rate.
For more severe AMS, a descent of 500-1000 meters (1500-3000 feet) is
adequate. If the patient recovers completely, he or she may safely
reascend (gradually), but with the understanding that he or she is predisposed
to altitude illness.
The most reliable sign of developing high altitude cerebral edema is ataxia. Ask the patient to walk a straight line, placing the heel of one foot directly in front of the toes of the other foot. At altitude, anyone who is not otherwise intoxicated, and who cannot walk the line, must descend as soon as possible.
Later stages of HACE usually show increasing somnolence and coma,
followed by death.
For patients with altitude illness and significant neurological symptoms, the
only accepted treatment is to go back down.
Early high altitude pulmonary edema (HAPE) is characterized by a dry cough, decreased exercise tolerance, and intermittent slight shortness of breath and chest tightness, usually at night. Onset is usually slower than acute mountain sickness, usually occurring from the second to the fourth day after starting the ascent, or arriving at elevation.
Hypoxia from HAPE may cause confusion, neurological symptoms, or even coma, all without shortness of breath. Patients with more severe HAPE often develop frothy sputum. Once a patient becomes unconscious from HAPE, death usually ensues in 6-12 hours.
For patients with altitude illness and severe pulmonary symptoms, as for
those with severe neurological symptoms, the only accepted treatment is to
go back down
Do not use electric shock, pack in ice, or use any other snakebite treatments
except for those given here.
In Australia, highly-toxic bites are more common than in the U.S. The venom of Australian snakes is deadly but causes little local tissue damage. For such snakebites, an arterial tourniquet might be lifesaving. However, because of the pain and damage caused by an arterial tourniquet, Australians searched for better first aid treatments. These ``Australian'' techniques use less-painful methods to immobilize venom at the site of the snakebite. The ``CSL'' technique, named after Commonwealth Serum Laboratories, where the principal researchers work, is simple: use an elastic bandage or roller gauze, wrapping firmly but not tightly (pressure of 55 mmHg) proximally most of the way up the arm or leg, then immobilize the limb in a splint. This decreases the blood flow in the area around the bite, theoretically limiting both the spread and absorption of the venom. This might then permit the victim to survive until you can get antivenin. Another group of Australians argue that using a firm pressure dressing over the bite (pressure of 70 mmHg) works better than an elastic bandage, and have done experiments in humans that support this. One animal experiment seemed to show that the CSL treatment worked for North American rattlesnake bites, but Dr. Findlay Russell of the University of Arizona says he has seen a number of patients whose rattlesnake bites were made much worse by this treatment. Therefore, the best evidence is that for North American pit vipers, this method causes severe local tissue damage and you should not use it unless willing to sacrifice the limb to save a life.
If you are on a disaster response to a country with very poisonous snakes,
you might use the CSL treatment for envenomated bites.
Apply ice to sting to reduce pain. See also anaphylactic reactions
under Allergic Reactions, below.
If person is bitten by mammal (other than rodents, squirrels, or rabbits) , that might potentially be rabid, or contaminated by its saliva:
For a team member complaining of a significant headache:
Examine the eye, starting with checking visual acuity, then evert the
eyelid if trained to do so, and gently remove any foreign bodies seen on
the eyelid or conjunctiva (white part of the eye) with a cotton applicator
(Q-Tip) or improvised equivalent. Use irrigation with clean water to
attempt to remove foreign bodies from the cornea (clear part of eye). If
foreign body sensation persists, place firm pressure patch on injured
eye (enough pressure to keep eyelid closed). Do not patch the uninjured
eye. Evacuate at a pace determined by the patient's discomfort level.
Use direct pressure to pinch the nostrils together firmly, as close to the face as possible. Use uninterrupted pressure for 10 minutes then recheck. Hold for another 10 minutes if still bleeding. Have the patient sit forward during pressure.
If bleeding persists, pack the nose with gauze. Roll up a
small gauze pad (not a tissue or paper towel that will partially
dissolve) and place it in the bleeding side of the nose to aid in direct
pressure. It will also serve as a pressure dressing once pressure is
released. If you have double-compressed nasal tampons, you may
use these instead of gauze. To avoid infections, leave gauze pads
in place for no more than 1-2 days.
If the tooth is completely out of the socket (a complete avulsion), you may rinse dirt off it. But, don't scrub it, even with a gauze pad, as this will destroy the delicate layer of cells that will allow it to reattach. Further treatment depends on the time until you can reach a dentist or oral surgeon.
If you are within an hour or two of a dentist or oral surgeon, and a tooth is completely out, keep it moist so that an oral surgeon can reimplant it. Keeping the tooth in the patient's cheek is ideal, since the patient's own saliva is the best protection.
If you are distant from a dentist or oral surgeon, replace the tooth in its
socket as soon as possible. Apply some dental splinting material to
keep the tooth in place if you have some. A large wad of chewing gum
often works fairly well as a dental splint.
No matter the distance to the dentist or oral surgeon, you must assure
that the patient doesn't aspirate the tooth. If the route out involves some
difficult climbing, or if the patient is only semiconscious, don't put the
tooth in the mouth. Instead, place it in a gauze pad dampened with the
patient's saliva and a bit of clean water or saline, then put it in a plastic
bag. Evacuate the patient immediately but not urgently, unless there are
other severe injuries.
If a team member has an asthma exacerbation, first ask if the patient has
his or her own medicine to take. Several cups of coffee, tea, or
caffeine-containing soft drink will help asthma, though side effects are
prominent (sweating, tachycardia, tremor, irritability). If the team
member shows signs of severe respiratory distress, and an Epi-PenŽ
is available, show the team member how to use it, and assist if necessary.
Treat suspected pneumonia or bronchitis the same:
A classic deep venous thrombosis (clot) in the leg is characterized by swelling in one (and only one) leg and ankle, with mild redness and warmth. The calf is swollen compared with the unaffected calf and is tender to deep palpation (compare with the unaffected calf). If the foot is forcibly dorsiflexed (pushed up), the resulting traction on the calf may cause pain. Sometimes, you can feel the tense, clotted veins behind the knee or in the upper calf or posterior thigh ("cords"). If there is any suggestion the patient might have a deep venous thrombosis, don't let the patient walk out. Walking on the leg could make a piece of clot break off and go to the lung, causing a pulmonary embolism, possibly killing the patient. Evacuate with the leg elevated and keep it warm with heat packs. (We think heat will help the body reabsorb the clot.)
There are several things you can do to prevent deep venous
thrombosis in litter patients, who are often at high risk for multiple reasons:
trauma, immobilization, or dehydration. If the patient is conscious, you
can prompt the patient to alternately tighten and relax the legs. If you
have a long wait because some of the rigging isn't ready, and the patient
doesn't have a suspected spine injury, untie the patient and let him or
her move around a little. Try to hydrate the patient as best you can.
There is one final thing that you can do. Be careful of your leg tie-in.
Anything tight around the leg or ankle will decrease venous flow and
promote clotting. If you can leave room for the patient to wiggle his or
her legs, that's even better.
Always start CPR in a pulseless victim well away from a road unless one of the following contraindications is present:
In the backcountry, discontinue CPR if, after 30 minutes of effort, you can detect no evidence of spontaneous pulse or respirations, and if CPR cannot be continued throughout the evacuation. For certain situations, the possibility of resuscitation with Basic Cardiac Life Support is high, so continue CPR for more than half an hour:
Anyone with severe abdominal pain, spasm of the abdomi~nal wall
muscles (guarding), and exquisite tenderness of the abdomen has an
Evacuate anyone with an acute abdomen as quickly as possible, because
the patient might need surgery.
Give nothing to eat or drink. The patient with an acute abdomen will
probably not absorb anything you give. He or she is likely to vomit
during the evacuation, or regurgitate and aspirate during anaesthesia
once the patient reaches the operating room.
For pain control, trans~port with the hips and knees bent to relieve some
pain from abdominal wall muscle spasm.
Instruct person to fix vision on the horizon or on a distant object.
Gastroenteritis is a general term for irritation of the stomach or intestines, which may result in cramps, diarrhea, or vomiting.
The most serious consequence of diarrhea is dehydration, which may even progress to shock. Therefore, the most important treatment for diarrhea is oral rehydration fluid replacement.
After infectious diarrhea, adopting an appropriate diet may prevent the diarrhea from lingering. Clear fluids are the first place to start, because they are almost totally absorbed, leaving no residue to form stool and prompt an unwanted bowel movement.
If clear liquids are tolerated, the victim may start eating as soon as possible. Food will stimulate regeneration of intestinal enzymes, and will increase water absorption. Easy-to-digest starches will actually decrease the diarrhea. Bread, toast, crackers, rice, potatoes, and cooked vegetables are good to start with. For young children and infants, the BRAT diet is commonly recommended: Bananas, Rice cereal or noodles, Applesauce, and Toast.
Avoid greasy foods, as diarrhea washes out the digestive chemicals
needed to absorb fat. Avoid spicy foods that tend to cause loose bowel
movements at the best of times (e.g., barbecue sauce or Thai food).
Diarrhea washes certain enzymes out of the gut, and it takes three or
four days for these to regenerate. Eating foods that require these
enzymes will cause diarrhea, even if the infection is gone. The enzymes
are those responsible for absorbing fruit and milk sugars, so
avoid these sugars. Avoid milk, milk shakes, ice cream, or fresh fruit
or fruit juices for three to four days. The victim may eat and drink items
containing table sugar, as found in sherbet, gelatin desserts, and
soda drinks, and dextrose, as found in GatoradeŽ and similar drinks.
The classic symptoms of cystitis include:
Other symptoms may be associated with cystitis:
Instruct any person with suspected cystitis to drink lots of fluids and to urinate frequently in an attempt to wash out the infection. Evacuation is not necessary unless the patient's discomfort requires it.
If a person with suspected cystitis develops fever or significant back
pain, evacuate immediately.
Men may develop pain in the testicles without direct trauma. All such
cases should be evacuated, except that WEMSI Wilderness EMTs may
try to determine if there is testicular torsion, and attempt to untwist the
If a team member has (a) small amounts of unexpected menstrual bleeding,
or (b) during expected menses has more than normal menstrual flow but less
than a pad an hour and no pain worse than usual menstrual cramps, check
orthostatic vital signs. If she has normal orthostatic vital signs, she may
continue with the task. If the flow is enough to soak a pad every hour or
so, or if the pain is more than the team member's usual menstrual period
cramps (dysmenorrhea), send her back to base. If the flow is more
than a pad an hour, or if she is orthostatic, evacuate immediately.
If you suspect a team member has a kidney stone, arrange for immediate
evacuation; if unable to give pain medications yourself, consider asking for
a more advanced provider to respond into the field to provide pain relief
so the team member will then be able to exit without being carried out.
Have the person strain the urine to try to collect the stone, and have the
patient take the stone to his or her family doctor.
Standard first aid training teaches that any sick diabetic should be given sugar, because it will make insulin shock better and will not harm someone who is hyperosmolar or in ketoacidosis.
If a diabetic does not improve with sugar, start
oral rehydration, preferably
with WHO Oral Rehydration Solution.
Some allergic reactions, especially to bee and wasp stings, may cause a severe allergic reaction, sometimes severe enough to kill in seconds.
Some people may have a generalized allergic reaction to things such as certain medications, stings, plants, foods, or other materials in the environment. This reaction is not limited to the area of contact with the allergen. Its most prominent sign is a rash. With some allergies, especially those to medications, the rash may be made up of many flat, itchy, red macules (tiny patches). In other cases, a wheal-like rash (like mosquito bites without the bite), which may occur over the entire body.
Anaphylactic reactions are characterized by wheal (hive) formation that is very severe. As with milder urticaria, the primary problem is leaking of fluid from capillaries. In anaphylaxis, though, the leakage is so massive that volume depletion and shock may result. Not only that, but the leakage in the lungs may cause wheezing, and leakage in the mucous membranes of the airway may cause airway obstruction.
Danger signs for progression toward anaphylaxis include:
All PA-ASRC/ER-NCRC personnel should see their personal physician
and obtain a prescription for an Epi-PenŽ. This device allows injection of
epinephrine without special training. If providers of any level have an
Epi-PenŽ and are confronted by a patient with the above signs of a severe
allergic reaction progressing toward anaphylaxis, they should offer the
Epi-PenŽ to the person and assist the person in using it.
den death. Though the person has survived days of entrapment, the sudden release from entrapment allows "evil humors" (various poisonous waste products, including potassium and lactic acid) to escape into the blood. The entrapped limb may also act like a sponge, soaking up precious intravascular fluid, causing sudden shock. This "crush syndrome" is well-recognized, and can be prevented.
The stress of release from entrapment may also contribute to renal failure (kidney failure). Renal failure can occur even if the patient is still producing urine. Renal failure causes death over the course of several days, as waste products build up in the blood.
You can help prevent hyperkalemia, acidosis, shock, and renal failure by preventing dehydration. If a patient is already dehydrated from long entrapment, rehydration prior to release is essential. Intravenous fluids are ideal but you won't always have them; give oral fluids if the patient meets the requirements described above.
Myoglobinuria with crush injuries to muscle and other soft tissues, and with severe burns, large amounts of myoglobin are released into the circulation. Myoglobin is an oxygen carrying molecule found in muscles. It is similar to the hemoglobin molecule found in red blood cells. Myoglobin and hemoglobin are toxic to the kidney. (Hemoglobin in red blood cells and myoglobin in muscle cells are necessary, but hemoglobin and myoglobin are toxic when free in the blood. After lightning strikes or severe burns, hemoglobin may be released from thousands of damaged red blood cells. The loose hemoglobin can cause problems similar to myoglobin.) When dehydration causes concentration of urine in the kidney, the high levels of myoglobin or hemoglobin in the urine are known as myoglobinuria and hemoglobinura. Myoglobin is dark brown, and with myoglobinuria, the urine looks very much like tea. Hemoglobin is a bit more red, but still dark.
If you are caring for or transporting a patient, and based on the mechanism of injury you suspect myoglobinuria or hemoglobinuria, check the patient's urine. If it is brown or tea-colored, start treating for possible myoglobinuria:
Increase oral (or intravenous, if using an IV) fluids as necessary to maintain a urine output of 100 cc/hr (4 cc/kg/hr in children) unless there are definite signs of fluid overload.
When giving oral rehydration
to a victim of crush syndrome, give fluids with salt but without potassium for
the first several liters: drinks salted with table salt are best. After this, you
may switch to other types or rehydration fluids. (Crush injury releases
much potassium into the blood, and high levels may make the heart stop.)
Compartment syndrome is caused by blunt trauma to a muscle compartment. Muscle compartments are groups of muscles bounded by walls of tough fibrous tissue. The most common compartment to develop compartment syndrome is in the anterior compartment of the lower leg.
Swelling from trauma causes pressure in the compartment to build up. The pressure finally gets to be more than the pressure inside the veins; the veins collapse, and blood can no longer leave the compartment. This sets up a vicious cycle where increasing pressure holds the veins more tightly closed, causing increased pressure, which holds the veins even more tightly closed, and so forth.
When pressure in the compartment exceeds the pressure in the capillaries, muscle perfusion stops; this will cause severe muscle pain and tenderness over the compartment. The increasing pressure damages sensory nerves traveling through the compartment, so you will find numbness over the compartment and distal to it (e.g., in the web space of big toe for the calf compartment). Finally, arteries traversing the compartment collapse from the pressure. (E.g., the patient may lose the dorsalis pedis pulse.)
Diagnose compartment syndrome by looking for the following:
If you think a patient has compartment syndrome, and you face a long evacuation, try to have a surgeon brought in to operate on the leg.
Other first aid treatments have been suggested for compartment
syndrome: elevation and cold. There is little or no evidence that either
is effective, and at least some reason to suspect that each might
actually be harmful.
Use the MAST garment only temporarily, i.e., about 1.5 hours, otherwise,
it might cause irreversible ischemic damage to legs. (The MAST garment
is not designed for use longer than an hour or so.) You may find the MAST
garment helpful in patients with only mild dehydration or mild shock when
they must be raised vertically (head-up) out of a pit or lowered vertically
(head-up) down a vertical cleft. Inflate the MAST prior to raising, and
slowly deflate the MAST right after leveling the stretcher again, monitoring
the blood pressure carefully. This may help prevent seizures from lack of
blood to the brain; it is using the MAST garment as a "G suit" and not for
it usual medical purpose, and thus should not be construed as going against
standard EMT training for using MAST garments.
Pain, even that from major trauma, has a large psychological component. Part of this is perception: the more one concentrates on pain and the consequences of the injury, the more it hurts. Part of this is related to endorphins, narcotic-like chemicals that may be produced in the brain or spinal cord to block pain. These pain control systems are amenable to control in a variety of ways.
Apprehension may accentuate pain, and if the person is worried about the extent and implications of his injuries, a clear statement of the patient's injuries may dispel unwarranted fears and thus reduce apprehension and pain.
Distraction can greatly diminish the perception of pain: you may give an absorbing task to a patient or engage his interest in a discussion.
You may invoke imagination to distance a patient from his pain: ask the patient to imagine his favorite place or event as vividly as possible and describe it to you in detail. Imagery in this way can provide powerful pain relief.
If you have the training and the patient has the ability, an extension of this to
a light state of hypnosis may serve as outstanding pain control.
Many patients are anxious, and rightfully so. Some may even be so anxious as to appear unreasonable, or partially or completely psychotic.
Managing such a patient, or for that matter any patient, includes:
You must understand that, even though the patient appears confused and may answer inappropriately, the patient may still have excellent understanding. Therefore, you must continue to talk as if the patient understands, even though the patient's replies seem nonsensical. Sometimes, the patient's body language is a better answer than the words coming out of the patient's mouth. (E.g., nodding the head "yes" despite saying something bizarre.) Communicating with many psychotic patients can be effective as long as you don't give up easily. And, as with the unconscious patient, you always explain what's happening, even if you aren't sure the patient is hearing or understanding.
Some wilderness patients are experienced outdoorspeople. These people are used to being in situations where they are totally responsible for their own survival and well-being. The change to being strapped into a litter and being dependent on a loud, smelly, scraggly-looking search and rescue team, is likely to provoke anxiety if not downright hostility. Doing whatever you can to respect the patient's dignity will do much to assure cooperation. "talking down" to such a patient is a sure way to lose your credibility in the patient's mind.
You will do well to treat such a patient as an equal in intellectual and outdoor terms. For instance, you might explain some details of the search and rescue technique, just as you might teach an experienced outdoorsman who just joined the team. This can be a great confidence-builder for the patient, and can serve as excellent distraction, especially for patients who tend to intellectualize. Intellectualization is a very high level defense mechanism against psychological stress. It might even result, eventually, in a new recruit for the search and rescue team.
"Laying on of hands" in wilderness search and rescue, or any phase of prehospital emergency medicine, is a touchy subject (pun intended). Palpation is an integral part of the physical exam, as is exposure of the body, and is necessary for the patient's well-being.
Male rescuers worry about homophobia (fear of unwanted homosexual advances by heterosexual men) and female patients' fear of sexual assault (especially with a female being undressed by a group of smelly, unkempt, mostly male rescuers). Female rescuers, too, may worry about their laying on of hands being misinterpreted, whether by male or female patients, but women in American society have less of a tabu about touching others.
In the Emergency Department, patients expect to get undressed and have doctors and nurses poke and prod at various parts of their body, including, for women, pelvic exams, and for men, rectal exams. Doctors and nurses work so much with naked patients and are so used to using their hands in their work that it is no problem for them.
For the rescuer on the side of a mountain or in a cave, however, the social situation is not nearly so easy. The problem, however, is usually more for you than for the patient. Most wilderness patients are so far removed from their normal environment that concerns of the "real" world seem far away. Having one's clothes cut off and a rectal temperature probe inserted seem inconsequential, at least when compared with the prospect of another night in the wilderness. You should keep this in mind, so that any of your own embarrassment does not become obvious to the patient. However, you should exercise as much discretion as is possible.
Wilderness patients have told, in retrospect, of the most reassuring
part of a harrowing rescue: a warm hand on the shoulder. Although, as
with everything a rescuer does, common sense and careful observation
of the patient is imperative, a good general rule about touching patients
is: don't keep your hands off. No one likes to be taken care of by someone
who has a "hands off" approach. If the patient finds it objectionable, a person
with any powers of observation at all should be able to tell.
You may encounter search and rescue team members having immediate stress reactions, and may be the person best qualified to deal with the situation. Rescuers are quite capable of performing on-scene psychotherapeutic "first aid," following the guidelines presented here.
A critical incident is any situation faced by an emergency services worker that generates unusually strong emotional impact. These include:
The immediate stress reaction may include physical, emotional, cognitive, and behavioral components. Any of these signs and symptoms may be present. It generally occurs at the time of the incident or within 24 hours. A most important point: an immediate stress reaction is the response of a normal person to an abnormal situation, and not a sign of any psychological weakness or chronic psychiatric problems.
Physical symptoms include:
Emotional symptoms include:
Cognitive symptoms include:
Behavioral symptoms are relative to the person's normal behavior patterns, which may vary widely between individuals. They include:
Look for those who are showing some signs of stress (even if not a full-blown immediate stress reaction) and try to arrange rest breaks for them. Look for those with immediate stress reactions: a person walking about aimlessly, a person sitting and staring blankly (unless simply exhausted), or a person behaving irrationally.
The first step in managing an immediate stress reaction is to isolate the person from the sights, sounds, and smells of the incident. Having the person face away from the incident, or get on the other side of a vehicle, may be effective. If smells are prominent, move the person upwind. If you determine that the person should not be moved, place an object to block the person's view.
When engaged in on-scene psychological first aid, peers (e.g., other rescuers) can ask "Hey, are you OK?" However, this is not an acceptable question coming from a mental health worker at the scene. For this kind of psychological first aid, you just need to lend a sympathetic ear. If you need to prompt the person to start talking, start asking about facts first, and only after some rapport is established, start asking about feelings.
When an emergency services worker "breaks down" in the course of
psychological first aid, it is important to validate the person's
feelings ("hey, this is pretty hard for all of us to take.") and
back off, going to another person or another topic. Do not
abandon the person; monitor him or her, and arrange extra help if it
seems necessary. Group interventions are never appropriate
at a scene where hazards are still a problem. All on-scene psychological
first aid should be one-on-one.When engaged in on-scene psychological
first aid, peers (e.g., other rescuers) can ask "Hey, are you OK?" However,
this is not an acceptable question coming from a mental health
worker at the scene. For this kind of psychological first aid, you just need
to lend a sympathetic ear. If you need to prompt the person to start talking,
start asking about facts first, and only after some rapport is established, start
asking about feelings.
Return to Wilderness EMS Protocols.
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Date Last Revised: February 10, 1997