Embedded Files
*Index:
Bivouac & Survival Skills
Factors Contributing to Crisis
If you want to help yourself
Bivouac Kit
Also see main left index for bleeding, shock, etc.
PAS: Patient Assessment System:
PAS: Patient Assessment System:
Primary Exam:
Stop, Survey the situation. Make sure your safe and everyone else is. Put on plastic gloves (BSI: barrier substance isolation) if you have these. Click on pink for videos.
Approach and access: What does the situation look like; how many injured. Call out to them and ask: "Are you all right?" "What happened?" Place your hand on their head and say: "Don't move." Tell them who you are and you're here to help. Quick status assessment: If you suspect a head or neck injury, have fellow rescuer or other individual hold "Cspine" (hold head and neck steady).
Tap on the victim and shout, looking for a response.
Look and listen for breathing for no more than 5 to 10 seconds.
Check for Pulse for no more than 5 or 10 seconds. If no pulse or breathing (and you have cell phone coverage) have someone Call 911. Start CPR (CAB: Circulation, Airway, Breathing). Be sure to do Head Tilt or if you suspect spinal injury, a Jaw Thrust or Alternate method when breathing for the victim. If suspect spinal injury and have to roll the patient on their back use Single Rescuer Roll
Note: If pulse but no breathing, start "rescue breathing."
If breathing, how well are they breathing:
Normal rate is 10 to 30 breaths a minute or 1-6 every 6 seconds
Less then 1 each 6 seconds, give full breath every 4-5 seconds
More then 1 each 2 seconds, give full breath every 4-5 seconds
If wheezing, or gurgling, place in Recovery position;
Unconscious, do not suspect spinal injury: Recovery Positions From Safety Training International.
Unconscious, possible spinal injury: Multiple Rescuers Premium Health. Hold head until help arrives or patient can be stabilized and evacuated.
Unconscious, possible spinal injury, but only one rescuer: One rescuer1
Are they bleeding? If so, find the source and apply pressure.
At this point you can check their AVPU score:
Alert: oriented ?x4 (who, when, where, how)
Verbal (responsive to verbal commands)
Pain (responsive to pain if rub with knuckles on chest)
Unresponsive
Deformity: Are there obvious deformities? Look, listen (where are they complaining about), feel ( do "chuck check") feeling for injuries or pain response.
Disability (danger): Is their neck or back at risk. Place hand on head to immobilize or ask others. Come back to this after completing PAS.
Environment: Where are they lying, complaining, feeling.
Every one else OK. Hunger, cold, emotional status. Is everyone dry and protected? Keep them busy.
Secondary Exam:
History: What happened (you may need to ask bystanders)
Vital Signs:
LOC: Are they Alert: oriented ?x4 (who, when, where, how)
HR: heart rate
RR: respiratory rate
Skin (i.e, pale, cold, clammy, sweating)
SAMPLE: If unconscious, ask bystanders or friends.
Symptoms: pain, headaches, dizziness, nausea
Pain measurement: OPQRST Onset,Provocation,Quality,Radiation,Severity,Time
Allergies: To what, what happens
Medications: Prescribed (did you take any today), over the counter, alcohol
Past history: Diabetes, seizures, head or back injuries
Last: intake, last output (is that normal for you), level of activity
Events leading up to crisis: Dizzy, lightheaded, nausea, just slip
Exam: Chunk Exam. Clear spine (below) before turning patient to check back.
SOAP
Subjective: MOI (mechanism of injury)
Objective:
Time
Vitals (above)
Assessment
Plan
Other Concerns:
Spinal Clearing: Can the patient be moved without endangering the spinal cord.:
Patient must be sober, conscious, alert and oriented x3.
No distracting injuries (fractured femur, compound fracture, burns).
No complaints of pain along back.
No radiating pain.
Full circulation, motion and sensation (CMS in extremities).
No tenderness of back on exam.
Concussion/Traumatic Brain Injury
Concussion: A concussion is a direct blow to the head or violent movement (like wipe lash) that may cause the brain to bump the inner portion of the skull. The word comes from the Latin "concutere," which means "to shake violently." The brain momentarily doesn't function properly. Usually there is no loss of consciousness or the loss is brief. The Mayo Clinic gives this definition: "A concussion is a traumatic brain injury that alters the way your brain functions. Effects are usually temporary but can include headaches and problems with concentration, memory, balance and coordination."
Symptoms:
Brief change in level of responsiveness
Short-term amnesia
Temporary blurred vision or seeing stars
Nausea and/or momentary vomiting
Headache
Dizziness or lethargy
Problems with balance and/or coordination
Grade 1 Mild: There is no loss of consciousness. but symptoms last for less than 15 minutes.
Grade 2 Moderate: There is no loss of consciousness but symptoms last for greater than 15 minutes.
Grade 3 Severe: The person loses consciousness, sometimes just for a few seconds.
Treatment: It is my personal feeling that all concussion patients should seek medical attention. A medical specialist can decide on the degree of severity and appropriate care. One should be monitored over the coming hours. The problem with even a mild concussion is that there is a risk of bleeding in the "subdural space" (between the brain and it's covering) with signs developing over several hours. This can be life threatening. The brain is enclosed in a tight compartment and bleeding can put pressure on the brain resulting in brain damage. A grade 3 should always be considered a medical emergency. Note: In the wilderness, immediate evacuation is required. A patient that quickly awakens with no other symptoms, can be walked out.
Traumatic Brain Injury: A contusion (bruising) of the brain and/or subdural bleeding. Symptoms of the above are more severe, prolonged and individual may be unconscious.
Symptoms:
Increasing prolonged symptoms noted above
More severe or prolonged changes in LOC (level of responsiveness), i.e., disoriented or remains unconscious
Increasing headache, vision disturbances
Combativeness
More severe symptoms:
Seizures
Hyperventilation and erratic respiration such as Cheyne-Stokes (also video)
Blood or spinal fluid leakage form the nose, ears or wound
On exam: Slowing pulse, increased blood pressure, irregular respiration
Treatment:
Follow the ABC's in approach and assessment.
Have someone call 911.
Hold neck stabilization (C-spine) assuming possible neck injury.
Question bystanders as to loss of responsiveness (immediate or delayed). Has the patient been confused or drowsy.
Notes:
If vomiting, perform a spinal roll.
Control scalp bleeding in necessary. Apply light pressure at the edges of the wound so as not to disturb any unstable bone. Use a bulky dressing. Do not clean as one may introduce infection.
Do not control internal bleeding or leakage of clear spinal fluid (to do so may increase intra cranial pressure and damage to the brain).
References:
Concussion From the Mayo Clinic
Concussion (Traumatic Brain Injury From WebMD
What is Traumatic Brain Injury? From TraumaticBrainInjury.com
NINDS Traumatic Brain Injury Information Page From the National Institute of Neurologic Disorders and Stroke
Injury Prevention & Control: Traumatic Brain Injury From the Center for Disease Control
Positioning the Crumpled Patient:
In an urban setting: The victim of a significant traumatic injury is best kept in the position found, as moving them before diagnosis and treatment (eg splints) may cause shock and further injury.
Only move the victim if:
The situation is dangerous to you or them.
Access to airway is needed (eg CPR).
Control of bleeding.
Their position is aggregating their injuries.
A limb that is uninjured can be moved to a more comfortable "neutral position."
An unconscious or semiconscious victim need to be turned to a "safe airway position" especially if there's a chance of vomiting or there's bleeding about the face.
Need for evacuation.
In a wilderness setting: Extend the limbs slowly, gently and try to keep the head in alignment with the spine. This typically makes the patient more comfortable and provides better immobilization. Attend to immediate problems and then perform spinal clearing once re-positioned.
If the victim does not need to be moved, perform a primary and secondary survey, apply necessary treatment (eg stop bleeding, splint broken limbs, etc.). If help is delayed due to location or wilderness concerns, perform "spinal clearing" before any movement. Any movement should be gently and slow as time allows. Use appropriate spinal stabilization techniques as required. Otherwise, leave the victim in the "position found" until help arrives.
1 person role: Single Rescuer Roll
2 Person roll2:
Kneel beside the patient. You and your partner must be far enough away so that the patient, when rolled toward you, does not come to rest in your lap.
First rescuer: Place both hand on shoulder, locking head between arms if you suspect spinal injury.
Second rescuer: On count of 3, Turn patient toward you by pulling on shoulder and hip. At the same time the first rescuer should control the head and neck so that they move a unit with the rest of the torso. This should be a single motion to minimize aggravation to the spine.
After patient is in supine position, with the legs straight and both arms at the sides.
3 or more rescuers. These videos concern sports but apply to all where spinal injury is a concern.
BokSmart - Acute on-field treatment of head, neck and spine Roll and continued management. Applies to non-sport injury also. Worth watching the entire video.
Management of C-Spine Injuries Roll and continued management. Applies to non-sport injury also. Worth watching the entire video.
Proceed with CPR and/or Spinal Clearing.
References:
First Aid, CPR, and AED advanced, 6th ed, American College of Emergency Physicians, Jones and Bartlett Learning, 2011, ISBN; 978-1-4496-0976-7
Emergency Care and Transportation of the Sick and Injured, American Academy of Orthopedic Surgeons (AAOS), Jones & Bartlett Learning, 2013, ISBN-13: 978-1284032840 ISBN-10: 1284032841
Red Flags:
AVPU: Not alert, not verbal, extreme pain, unresponsive
Airway
Breathing: No
Circulation: No pulse; Uncontrolled Bleeding
Spine or neck injury: From MOI (mechanism of injury) or exam (C: Lack of circulation or pulse; M: can't move; S: NO sensation (numbness)
TBI (traumatic brain injury)
Fracture or dislocation with C: Lack of circulation or pulse; M: can't move; S: NO sensation (numbness)
Shock
Bleeding/Wilderness Concerns
Follow concerns noted under menu item "Bleeding Acute and Severe."
Control Bleeding with direct pressure. Large lacerations may require packing with gauze and covering with moist dressing.
Elevation
Tourniquet as Last Resort
Clean Wound: Irrigate with sterile (or drinkable) water once bleeding is controlled.
Bandage: Lacerations less the 1/2 inch wide: can use "steri-strips"; greater then 1/2 inch: pack and dress wound. Also see Emergency Trauma Dressing from North American Rescue.
Wound Cleaning:
Abrasions: Scrub with disinfectant (provide iodine or soapy solution). Let air dry before covering for protection.
Punctures: Leave it open; bleeding will allow cleaning. Tetanus shot should be considered on return.
Open Wounds: Open wounds are serious in a survival situation, not only because of tissue damage and blood loss, but also because they may become infected. Bacteria on the object that made the wound, on the individual's skin and clothing, or on other foreign material or dirt that touches the wound may cause infection. Test for CMS beyond the would site.
By taking proper care of the wound you can reduce further contamination and promote healing.
Control bleeding.
Inspect wound: Look inside for dirt, particles or if you can see muscle or bone. Decide if the wound should remain open or can be closed with "steri-strips; " (see note).
Test for CSM beyond the wound site.
Clean the wound as soon as possible after it occurs.
Removing or cutting clothing away from the wound.
Always looking for an exit wound if a sharp object, gun shot, or projectile caused a wound.
If need be, cut away hair around wound but do not shave.
Thoroughly cleaning the skin around the wound with disinfectant or soapy water starting closest to the wound and moving outward. Make sure the injury is place such that the disinfectant or soapy water rinses away from the open wound, not into it.
If clean wound - rinsing (not scrubbing) the wound with large amounts of fresh drinkable water under pressure ("jet wash" using syringe or improvised device). Use clean water created from the tablets, filter pumps or boiled and cooled water used for drinking. You can use fresh urine if water is not available.
Large dirty wound and those that expose bone or ligament and should be left open (i.e. do not closed with steri-strips) after jet rinsing and bandaged. Extremely dirty wounds can be packed with moist gauze .
Animal bites should be scrubbed and irrigated for 2 minutes (or greater if there's a chance of rabies).
The "open treatment" method is the safest way to manage wounds in survival situations. Do not try to close any wound by suturing or similar procedures. Leave the wound open to allow the drainage of any pus resulting from infection. As long as the wound can drain, it generally will not become life-threatening, regardless of how unpleasant it looks or smells.
Cover the wound with a clean dressing. Place a bandage on the dressing to hold it in place. Elevate and split of necessary. Change the dressing daily to check for infection. Keep checking CMS.
Note: For small gaps (less then 1/2 inch) wounds on the face or scalp, you can bring the edges together with adhesive tape cut in the form of a "steri-strip" (butterfly).
Infection is characterized by:
Pain
Swelling
Heat
Pus
Fever
Treatment includes:
Remove any closures of present.
Jet wash 2 to 4 times.
Apply sterile dressing covered with thin coating of antibiotic ointment. Do not fill open wounds with ointment if available (if no ointment is available, plain white sugar or honey has been used by some).
Bandaging: Bandaging to hold dressing in place: Best Reference: First Aid, CPR, and AED Advanced
*Additional "How to" Bandaging Videos:
Usable Knee Brace - (after bandaging); Sprain
Also see: First aid Bandaging Recurrent Fold Bandage
Fractures: See "Fracture", "Sprains" and "Dislocations" on left menu for symptoms and diagnosis. Treatment by immobilizing the bones (through slings or splints) can reduce any pain and also prevent a closed fracture from becoming an open one. If it's not clear if it's a sprain or fracture, immobilize.
General Rules:
Initially, keep the victim still, in the "position found".
Clean and dress wounds before splinting (see "Wound Cleaning" above). Irrigate but do not scrub exposed bone with drinkable (clean) water.
Access circulation, sensation, movement (CSM) (movement of extremity may not be possible due to pain). Lack of CS signifies possible damage to surrounding vessel and/or nerves. Bone alignment may be necessary to relieve pressure on these structures and prevent further damage.
Remove jewelry, watches and tight clothing from the area.
Splint. Do not move unnecessarily.
Check CS again to make sure bandage and splint are not too tight or that re- alignment of bones are necessary. Repeat periodically.
Give adequate pain relief.
Assess other injuries and treat.
Treat for shock if needed (especially with multiple injuries and open fractures).
Closed Fracture
Primary Survey:
Initially, keep the victim still, in the "position found".
Immediately apply temporary splint to the injured limb/part as needed (one cab have victim or others hold limb in place) or other splint such as sand bags to ease pain and prevent shock. Do not move victim or injured part unnecessarily.
Give adequate pain relief and watch/treat for shock.
Secondary Survey:
May have to cut away superficial clothing over the area for examination if there is bleeding and/or the possibility of an open fracture.
Have a good look at the skin and joints above and below fracture and also feel the limb from end to end, especially the bone looking for additional injury.
Check CSM (circulation, sensation, movement - movement may not be possible due to injury and pain) in limb. Lack of CS signifies possible damage to surrounding vessel and/or nerves. Bone alignment may be necessary to relieve pressure on these structures and prevent further damage (see "Traction" below).
Carefully remove jewelry, watches and tight clothing from the area in case of swelling.
Apply a sling or more permanent splint is fashioned, depending on the limb and fracture location.
Recheck check CSM (circulation, sensation and movement) to make sure splint is not too tight and CS is maintained (loss of CS may require gentile traction is needed to re-align bones or immediate evacuation. Repeat periodically.
Complete secondary survey looking for injuries overlooked by distracting pain from fracture.
Evacuation will be needed but can become urgent if there is a loss of CS, the break is compound (open) or complicated by infection.
Additional Considerations:
Open ("compound") Fracture
Initially, keep the victim still, in the "position found".
Immediately apply temporary splint to the injured limb/part as needed (one cab have victim or others hold limb in place) or other splint such as sand bags to ease pain and prevent shock. Do not move victim or injured part unnecessarily.
Cut away superficial clothing over the area for examination to control bleeding and confirm open fracture.
Have a good look at the skin and joints above and below fracture, especially the bone looking for additional injury.
Check CS (circulation and sensation) in limb. Lack signifies possible damage to surrounding vessel and/or nerves. Movement may aggravate injury.
Carefully remove jewelry, watches and tight clothing from the area in case of swelling.
If medical help is more than 6 hours away, thoroughly clean the wound (jet wash) with disinfected water.
Leave the wound open and cover with sterile dressing.
Apply permanent split in a manner that leaves access to wound (you can try splint first on uninjured limb or someone else of similar size and then place on victim's limb.
Give antibiotics if available.
Watch for infection and shock.
Urgent Evacuation.
Angulated Fracture:
Proceed as in 1 thru 3 of primary survey above "closed fracture."
Return fracture to normal position only if the following criteria are met: The conscious victim gives consent AND:
The fracture does not appear to involve and joint, OR
There is loss of CS and you are more than 30 minutes from medical help, OR
The overlying skin is stretched to the point of splinting open if manipulated, OR
The shape of the fracture makes splinting and self-rescue evacuation impossible.
Traction involves:
Instruct helper to hold victims limb above fracture and be prepared to apply counter traction when you gently pull.
Take hold of the limb below fracture with both hands.
Slowly and gently apply traction in the direction the limb is pointing, gradually overcoming any muscle spasm. This may take several minutes. The pain should decrease. Stop if pain becomes unbearable.
Once straightened, check CSM. If CSM is lost, restore to where CSM is as normal as possible.
Maintain traction until permanent splint is in place, then slowly release.
Immediate evacuation should be planned if CS lacking.
If the conditions above for straighten angulated limb do not apply or cannot be done due to pain or muscle spasm, splint limb as is and evacuate urgently.
Reference: Cicerone Pocket First Aid and Wilderness Medicine, Drs Jim Duff and Peter Gormly, 11th ed, Cicerone, 2012, ISBN: 978 1 85284 715 9
Rib Fractures
Simple Fractures: A simple rib fracture usually associated with injury can be recognized by the fact the patient is holding they're hand over the are, sharp pain over the rib on breathing, as well as shallow breathing. Some relief can be given by:
Have victim in a comfortable position and hold soft object or rolled up clothing over area.
Ice if available (cold pack) then tape over soft object or rolled covering of the chest using a series of stirps of tape part way around and over the fracture. See Basic First Aid : How to Treat a Rib Fracture from eHow.
You can also tie a cravat arm sling (as you would do for wrist or arm injury) on the injured side and then tie a section cravat around the sling and opposite side of the chest. Do not tie the cravat to tight or you'll make breathing worse.
Complicated Rib Fracture: These include multiple rib fracture producing a flail chest, sucking wound (penetrating wounds), and pneumothorax (latter not covered here). With a flail chest, one side of the chest moving in the opposite direction then expected (moves in with inhaling, out with exhaling). Treatment includes:
Flail chest:
Apply pressure with bulky soft object or clothing (good for a short time).
Tape can be applied to the bulk dressing or cloth, but do not go all the way around the chest as this may inhibit breathing.
Rapid evacuation is necessary. Also see Treatment Flail Chest From drahciruohz. The cravats in this case should only hold the dressing or cloth and not be tight.
Sucking wound: Using a non-stick pad, tape on three side to allow a one way valve closure. See Treat a Sucking Chest Wound From Operational Medicine.
Penetrating wound: Do not try to remove. Secure with padding around wound and evacuate immediately.
Muscle Strain without fracture: Apply instant ice pack for 15 minutes (if you have one). Tape with adhesive tape in the manner shown in the video from KT tape.
Dislocation: Because of the pain involved, if you are close to a medical facility, this is best done with anesthetic. In the wilderness, reducing dislocations is recommended if prompt transportation is not available or circulation is impaired. Splint or sling may be required after relocation.
Dislocations can be dangerous to treat without medical help. If left untreated for more then a few day, it may become impossible to relocate later. Usually one will notice the limb is bent and the end of the limb is bulging out. Attempt to relocate only under the following conditions:
The conscious victim give consent AND
There is no suspicion of broken bones near the dislocation otherwise treat as fracture and splint.
If there is loss of circulation and medical help is more then 30 minutes away.
For dislocations of the shoulder, kneecap or fingers/toes: If you are more then 2 hours from medical help AND indirect force (falling and hitting with an outstretch hand, with low risk of fracture as oppose to direct force such as a rock hitting the hand.
For dislocations of the elbow, hip or knee: if you are 24 to 48 hours away from help AND the injury was cause by indirect force.
There is a short time where the dislocation is numb and will allow relocating. Apply traction as in angulated fractures with gentle pressure to pop the bone back in place. Splint and evacuate.
Specific joints:
Shoulder:
Have the victim lie face down with the arm positioned to hand vertically and freely.
The arm may relocate under it's own weight.
With time (up to 30 minutes) and some gentle assistance to swing the arm around, the arm may relocate.
Afterwards, always support the arm with sling and wide crepe bandages around the chest.
Another method involves a gentle arm rotation
Finger/toe:
If you decide to relocate, do it at once while finger is still numb.
Pull steadily in the direction the part is pointing while an assistance steadies the part above and provides counter-pull. Then apply gentle pressure to pop back in place. See Home Injury Treatments : Dislocated Finger Treatment Tips
Use two strips of adhesive tape to tape finger (toe) to the one next to it with padding in between.
Knee Cap (knee is locked in position and knee cap is seen out of place:
Have an assistant gentle pull the lower leg while you apply pressure at the edge of the knee cap to push it back into position.
Apply adhesive tape to pull the knee cap away from the direction of the dislocation. See Dislocated Kneecap
Pad and bandage knee from mid-thigh to mid-calf.
Ankle: If dislocated and skin is very tight over area, relocate as soon as possible as this is quite easy though painful to the victim.
Elbows, Hip and Knees: These are much more difficult because of the association with other injuries, i.e., fractures and tears to ligaments and cartilage. Your best off trying to reduce injury only if your are 24 to 48 hours away from help AND the injury was cause by indirect force. See videos on Elbow Relocation; Dislocated knee get put back in place; Hip Reduction Trauma, Kelly Barringer, MD. Also see reference for more information.
Reference: Cicerone Pocket First Aid and Wilderness Medicine, Drs Jim Duff and Peter Gormly, 11th ed, Cicerone, 2012, ISBN: 978 1 85284 715 9
Sprains
See Sprains and Strains on main left menu for diagnosis and differentiation from fractures. Sprains and strains are common injuries among atheletes and in hikers. Minor injuries should be iced and then can be wrapped to decrease swelling and give support. Gaurding, lack of movement, loss of CMS distal to the injury, deformity and numbness suggest fracture. When in doubt, treat as fracture.
Sprain Treatment
RICE: Rest, ice, compression, elevation. 10 to 15 minute intervals are all that the ice should be applied to prevent a cold or burn injury from the ice. Care with compression so as not to affect circulation or sensation in the extemity (check CMS after application).
Sprained Ankle?: How to wrap Ankle Sprains-correct From physical therapists Bob Schrupp and Brad Heineck
Wrapping & Taping Injuries : How to Wrap a Wrist With an Ace Bandage From ehowhealth
How to Apply an ACE Wrap to Your Knee From The San Antonio Orthopaedic Group
Shoulder Spica - Wrap From BethelATEP.
Splinting:
To be completely effective, the splint must completely stop movement above and below the area of fracture or sprain.
Remove rings, watches, cut tight clothing.
Dress any open wounds.
Can the injury be immobilized in the position found. Check circulation. If none, gently pull extremity into proper anatomical position to re-establish circulation.
Place limbs in position of function: hands slightly cupped, knee slightly bent, arm at 90 degrees.
Pad (towels, shirts, sweaters, etc.). Fill any natural gaps with padding.
Use hiking pole or stick as brace (away from any point tenderness).
Tie with what you have with knots away from wound or point tenderness. Do not make knot to tight such as to constrict circulation.
Elevate limb above heart (if not to painful for patient).
Leave an area open to check pulse (CMS) every 20 minutes.
Types of Slings and Splints:
Leg Bay Area Expeditions
Leg Sigma 3 Survival School
Pelvic Wrap and Improvised Pelvic Splint Use what ever you have including camping mats and paracord.
Arm Wrist and Forearm injuries. I also tie an additional cravat around the sling and other side of the chest to hold the arm close to the body so it doesn't move on this and the two below. From Training Aid Australia.
Shirt as a Sling: Wrist and forearm injuries. Pull bottom of shirt over shoulder as shown below.
Collar and Cuff Upper arm and elbow injuries. From Training Aid Australia.
Elevated Arm Shoulder and collar bone injuries. From Training Aid Australia.
How to Splint a Broken Arm From MonkeySee.
Shirt used as sling
Improvised Litter:
No spinal injury (after spinal clearing)
Wilderness Medic- Improvised Litter Part 2 From Sigma 3 Survival School
Wilderness Medicine: Rope litter MadiganHealthcare's channel
Improvised Litter From rspoley
Suspect spinal injury due to MOI, CMS (lack circulation, motion or sensation), or suggested by spinal clearing technique
Patient Transport | Cocoon Wrap From MedWild 2015
Patient Lift From MedWild 2015
Improvised Collar:
Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environmentt WILDERNESS & ENVIRONMENTAL MEDICINE, 2013, The Department of Orthopedic Surgery, University of Texas Health Sciences Center, San Antonio, TX
Spinal Injuries From the magazine of diver alert network
SAM C Collar Splintt From sammedical
Improvised c spine immobilization From Brickcorner
Lifting and Moving:
Lifting and Moving:
Lifting and Moving: In cases of suspected spinal and neck injury, it is vital to keep the neck, body and hips in alignment. Movement of all parts must be in unison without rotation. Someone should be devoid to holding the head and neck in place as shown.
One rescuer
Multiple rescuers
Management of C-Spine Injuries Roll and continued management
First Aid: Multi Person Log Roll and Eight Person Lift Roll and continued management
Keep patient head, neck and back straight:
Improved rope litter (do not recommend unless spine is clear).
Tarp with handles (do not recommend unless spine is clear).
Back Country Essentials:
Back Country Essentials:
Essentials:
Attitude: Think Positively.
Food: Fuel to burn. Carbs are a great source.
Water: Quench your thirst. Individuals require a minimum of 2 liters a day. More if active (sometimes up to 1 per hour). Have the ability to disinfect (chemical, filtration pump, boiling).
Clothing: Stay warm. Layer clothing. Use wool or wool blend. Bring spare socks, hat, rain gear.
Shelter: Get dry and stay dry. Bring plastic sheet or tarp.
Get warm: Bring ability to start fire (water proof matches, tinder, etc.). Tin cup to warm liquids.
Navigation: Know where your going and how to get there. Know orientering (map, compass, etc). It may save your life.
Weather:x Know the weather in your area and how to deal with it.
Signaling for help: Whistle, mirror, bright surveyor's tape, signal fire.
Experience: Practice before you need the skills. Make plans ahead of time and know you and your groups limitations.
Bivouac & Survival Skills: Crisis Intervention:
Be prepared to bivouac.
Keep everyone warm and dry,
Know how to get help
Send out two individual (if available).
Send out a SOAP (patient status) note: Include map with exact location.
Set up signaling as noted above.
Factors contributing to crisis:
Fatigue.
Pushing to hard.
Weather.
Equipment failure.
Lack of equipment.
Personality problems.
Poor judgment (often related to ego)
If you want to be found:
Stay Put
Make yourself obvious:
Build smoky fire
Lay out surveyor's tape
Mark with broken branches/clothing
Bivouac Kit:
Spare hat: balaclava.
Spare socks: can also act as mittens.
Space blanket or large garbage bag.
Metal cup.
Jello with real sugar.
Hard candles.
Plumbers candles: Short and thick.
Water proof matches.
Compass
Whistle or signal mirrors
Knife
Parachute cord: 100 feet
Bright color surveyor's tape.
Plastic tarp.
Paper & pencil.
Duct tape.
Bivouac Skills: What to do with what you have.
Knots:
Figure 8 Stopper Knot
How to Tie a Taught Line Hitch
Bushcraft Knots Tutorial Great slip knots and more!
Sheet Bend Knot Tie two ropes together securely
Knots by Grog Text with illustrations
Altitude Sickness
Altitude Sickness: Normally oxygen passes through the alveoli of the lungs to enter the blood stream supplying the body with its needs for normal metabolism. At altitude, diminished air pressure reduces the pressure needed to transfer that oxygen across the alveoli. Altitude sickness results from a lack of oxygen in the body at altitude. It is not know why some people are more prone to this then others, but it is known that most people who become ill do so within the first few days. Factors affected incidence and severity include:
Rate of ascent
Altitude attained
Length of exposure (how long your there)
Inherent susceptibility
We break down altitude illness into there areas: Acute Mountain Sickness (AMS), High Altitude Pulmonary Edema (HAPE) and High Altitude Cerebral Edema (HACE).
AMS: As your body makes normal adjustments to adapt to a high altitude, you may experience a few symptoms that are bothersome but are not cause for concern. One may have occasional shortness of breath, bur still comfortable, and increased urination. Assent may resume if symptoms abate. Symptoms often occurs within 6 to 12 hours, however, I have seen them occur earlier, especially on mountain ski slopes. Pharmacological prophylaxis at the time of travel to high altitudes is warranted for people with a history of AMS or when a graded ascent and acclimation are not possible—e.g., when rapid ascent is necessary for rescue purposes or when flight to a high-altitude location is required. Acetazolamide (125–250 mg twice a day), administered for 1 day before ascent and continued for 2 or 3 days, is effective. More serious signs include:
Symptoms:
Headache that is not relieved by over-the-counter pain medicine
Nausea or vomiting
Dizziness or lightheadedness
Difficulty sleeping
Loss of appetite
Treatment:
Hydrate
Rest
Use pain medication for headaches
Avoid sedation
Descend to altitude below which symptoms occurred
Continued descend if:
Signs of HAPE or HACE
Symptoms worsen
Use of low-flow oxygen if available
Treatment with Acetazolamide (250 mg q12h) and/or dexamethasone (4 mg q6h)
HACE: Cerebral edema is a swelling of the brain and is thought to occur do to hypoxic (lack of oxygen) damage. AMS and HACE are ends of a continuum. Pathophysiology involves both vascular, neurologic and hormonal factors Symptoms may not become immediately evident because it can occur during sleep. The individual may not recognize symptoms himself due to a change in mental status (confusion, loss of memory, and even unresponsiveness).
Symptoms:
Hallmarks include ataxia (loss of balance, staggering gait) and altered level of consciousnesss (LOC)
Slurred Speech
Worsening headache and vomiting
Exhaustion
Visual hallucinations (seeing things that are not real)
Coma (in advanced cases)
Treatment
Immediate descent or evacuation
Oxygen if available
Treatment with dexamethasone (8 mg PO/IM/IV; then 4 mg q6h) if available
HAPE: As altitude increases, more pressure is needed increase blood flow to the brain, resulting in patchy pulmonary vasoconstriction, increased pulmonary capillary pressure, capillary stress failure causing fluid from the capillaries to leak into the alveolar spaces of the lung. A number of hormonal and neurologic factors have been implicated. This rarely occurs below 8,000 feet. Symptoms usually occur 24 to 96 hours after ascent. Specific Medications such as sustained-release nifedipine (30 mg), given once or twice daily, prevents HAPE in people who must ascend rapidly or who have a history of HAPE.
Symptoms - Hall Marks include:
Fatigue and shortness of breath (dyspnea)at rest may be the only signs
Decreased exercise tolerance
Dry cough
Blood tinged sputum (anoxic damage leads to capillary breakdown)
Increase heart rate
"Rale's" (crackling noise) on osculation (listening with ear or stethoscope) of the lungs (usually upper middle lobes)
Treatment:
Immediate descend at least 2,000 to 3,000 feet or evacuation.
Oxygen if available
Adjunctive therapy with nifedipine (30 mg, extended-release, q12h)
For more information on symptoms, treatment, medications see:
Harrison's Principles of Internal Medicine (accompanying DVD), 18th edition, McGraw Hill, 2012, ISBN 978-0-07-1748889-6
Altitude Sickness From Drugs.com
Altitude Sickness From eMedicineHealth
Legal Issues:
A reminder, we should all be trained to do and we should treat patients with respect and politeness. The "scope of practice" is what a provider can provide and "standard of care" is used to describe the yardstick by which that care is measured. Most states have Good Samaritan Laws, including New Jersey and add a layer of protection as longer as the provider is not grossly negligent.
Consent: When treating a patient, it is good practice to identify yourself and ask permission to treat. Do this as part of our initial assessment and upon each set where we have hands on contact. Explain each step to the patient. "Informed Consent" is the process, ongoing thought our care, whee a reliable patient agrees to treatment and being informed of risks and benefits.
The law assumes that a patient who is not fully alert and oriented would want emergency care. This concept is called "Implied consent."
Confidentiality: Providers of care can turn over information to other providers but NOT to other colleagues or friends. This would be a breach of medical confidentiality under medical ethics and under state laws.
Abandonment: Abandonment happens when you stop care too soon or transfer the patient to someone who is not able to provide the care the patient need. One must consider the level of care needed and who they are to whom they are transferring control.
Reference:
Wilderness Medicine, National Outdoor Leadership School, Tod Schimelpfenig, 2006, Stackpole Books, ISbN-13: 978-0-8117-3306-9
First Aid, CPR, and AED Advanced, Emergency Care & Safety Institute, Sixth Edition, Jones and Bartlett Learning, ISBN: 978-1-4496-3505-3
Addendum:
Online Tutorials:
the Wilderness Medicine Training Center Individual cases studies from Wilderness Medicine Training Center, Winthrop, WA
SOAP Reports From the National Outdoor Leadership School (NOLS), Lander, Wyoming re: "SOAP Reports"
Test Yourself — Wilderness First Aid Scenario From True North Wilderness Survival School, Pittsburgh, PA, Case Senerios monthly newsletter
Additional First Aid Videos:
Basic First Aid Training HD Excellent lengthy review from American Safety EMT given by John Klatt. A Must Watch!
Intro to ProFirstAid Basic A multi-part review for the lay rescuer from ProFisrtAid
First Aid Lessons: Recovery Position, Bleeding, Bandaging and Burns From Yavapai College instructor Cathy Schiller with good video on the recovery position.
Patient Assessment Demonstration - Wilderness First Aid From The Center for Wilderness Safety (unconscious or semiconscious patient).
Patient Assessment from NOLS - National Outdoor Leadership School (conscious patient)
Focused Spinal Assessment from NOLS - National Outdoor Leadership School
Emergency Trauma Dressing Application Emergency Trauma Dressing 4" by North American Rescue
Severe Bleeding and Tourniquet Use from snareman, combat field training
NCCC Wilderness First Responder Spring 2007 Part 1 NCCC students participate in a wilderness medicine emergency simulation
NCCC Wilderness First Responder Spring 2007 Part 2 NCCC students participate in a wilderness medicine emergency simulation
Wilderness First Responder Field Scenario, Winter Lake Superior State University
Appalachian Mountain Training and Wilderness First Aid 5 From wildernessoutfitters
Wilderness First Aid Wilderness First Aid Kit from IA Woodsman
Leg Splint From Bay Expedition (also see section on "Fractures")
Reducing A Dislocated Shoulder US Navy Medical Video
References:
Pocket First Aid and Wilderness Medicine by Duff J. and Gormly P., 10th ed., Cicerone Press, 2007. ISBN: 13: 978-1-85284-500-1
Wilderness Medicine by William W. Forgey M.D. (Nov 6, 2012)
Backcountry First Aid , Tilton B., Falcon Press, 5th ed., 2007. ISBN: 978-0-7627-4357-5
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