Chapter 12 First Aid and the Psychology of Survival

Immediate First Aid Steps for Survival Situations 425

Immediate First Aid Actions

Preventing and Treating Shock 427

Patient Assessment 427

Establishing Responsiveness

ABCDE

The Focused Exam and History

The Assessment

Injuries to the Head, Spine, Abdomen, and Chest 431

Brain and Spinal Cord Injuries 431

Chest Injuries 435

Rib Fractures

Flail Chest

Injuries to Lungs

Respiratory Distress

Fractures and Dislocations 436

Athletic Injuries 437

Common Causes of Athletic Injury on NOLS Courses

General Treatment for Athletic Injuries (RICE)

Tendinitis

Muscle Strains

Final Thoughts

Wound Care 438

Closed Wounds

Open Wounds

Treatment of Wounds and Skin Ailments 440

Open Wounds

Skin Diseases and Ailments

Care for Common Conditions 441

Burns

Foreign Bodies in the Eye

Wounds, Lacerations, and Infections

Blisters

Thorns, Splinters, and Spines

Sun Blindness

Bowel Disturbances

Treating Common Camping Injuries 441

Burns

Choking

Fish Hooks in Hand

Carbon Monoxide Poisoning

Fainting

Allergies and Anaphylaxis 442

Signs and Symptoms of Mild to Moderate Allergic Reactions

Signs and Symptoms of Severe Allergic Reactions

Use of the EpiPen

Respiratory and Cardiac Emergencies 442

Hyperventilation Syndrome

Pulmonary Embolism

Pneumonia

Asthma

Chest Pain and Heart Disease

Abdominal Illness 443

Kidney Stone

Appendicitis

Peritonitis

Hemorrhoids

Gastric and Duodenal Ulcer

Abdominal Trauma

Abdominal Assessment

Diabetes, Seizures, and Unresponsive States 445

Diabetes

Seizures

Unresponsive States

Bites and Stings 446

Snakebites

Lizard Bites

Animal Bites

Insects, Centipedes, Spiders, and Scorpions

Leeches 448

Human or Animal Bites 448

How to Extract Porcupine Quills 448

Poison Oak/Ivy/Sumac Rashes 448

Heat Injuries 449

Heat Rash

Sunburn

Muscle Cramps

Heat Exhaustion

Heat Stroke

Hyponatremin

High-Altitude Illnesses 449

Acclimatization

Acute Mountain Sickness

Chronic Mountain Sickness

Understanding High-Altitude Illnesses

Cold Injuries 451

Hypothermia

Frostbite

Trench Foot and Immersion Foot

Dehydration

Cold Diuresis

Sunburn

Snow Blindness

Constipation

Hypothermia 452

Frostbite and Nonfreezing Cold Injury 452

Medical Problems Associated with Sea Survival 453

Seasickness

Saltwater Sores

Immersion Foot, Frostbite, and Hypothermia

Blindness/Headache

Constipation

Difficult Urination

Sunburn

Injuries from Marine Animals 453

Maintaining Health in Survival Situations 453

Water

Food

Personal Hygiene

Survival Stress 455

Survival Stressors

Survival Tips

The Psychology of Survival 456

Survival Stressors

Natural Reactins

Preparing Yourself

Survival and Medical Kits 458

Survival Planning 458

Importance of Planning

Survival Kits

Three Steps to Wilderness Survival 459

Immediate First Aid Steps for Survival Situations

U.S. Army

Immediate First Aid Actions

Determine Responsiveness as Follows:

(1) If unconscious, arouse by shaking gently and shouting.

(2) If no response—

(a) Keep head and neck aligned with body.

(b) Roll victims onto their backs.

(c) Open the airway by lifting
the chin (figure V-1).

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Figure V-1. Chin Lift

(d) Look, listen, and feel for air exchange.

(3) If victim is not breathing—

(a) Check for a clear airway; remove any blockage.

(b) Cover victim’s mouth with your own.

(c) Pinch victim’s nostrils closed.

(d) Fill victim’s lungs with 2 slow breaths.

(e) If breaths are blocked, reposition airway; try again.

(f) If breaths still blocked, give 5 abdominal thrusts:

• Straddle the victim.

• Place a fist between breastbone and belly button.

• Thrust upward to expel air from stomach.

(g) Sweep with finger to clear mouth.

(h) Try 2 slow breaths again.

(i) If the airway is still blocked, continue (c) through (f) until successful or exhausted.

(j) With open airway, start mouth to mouth breathing:

• Give 1 breath every 5 seconds.

• Check for chest rise each time.

(4) If victim is unconscious, but breathing—

(a) Keep head and neck aligned with body.

(b) Roll victim on side (drains the mouth and prevents the tongue from blocking airway).

(5) If breathing difficulty is caused by chest trauma, treat chest injuries. [see below]

Control bleeding as follows:

(1) Apply a pressure dressing (figure V-2).

(2) If still bleeding—

(a) Use direct pressure over the wound.

(b) Elevate the wounded area above the heart.

(3) If still bleeding—

(a) Use a pressure point between the injury and the heart (figure V-3).

(b) Maintain pressure for 6 to 10 minutes before checking to see if bleeding has stopped.

(4) If a limb wound is still bleeding—

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Figure V-2. Application of a Pressure Dressing.

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Figure V-3. Pressure Points.

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Figure V-4. Application of a Tourniquet.

(a) Apply tourniquet (TK) band just above bleeding site on limb. A band at least 3 inches (7.5 cm) or wider is best.

(b) Follow steps illustrated in figure V-4.

(c) Use a stick at least 6 inches (15 cm) long.

(d) Tighten only enough to stop arterial bleeding.

(e) Mark a TK on the forehead with the time applied.

(f) Do not cover the tourniquet.

(g) If rescue or medical aid is not available for over 2 hours, an attempt to slowly loosen the tourniquet may be made 20 minutes after application. Before loosening—

• Ensure pressure dressing is in place.

• Ensure bleeding has stopped.

• Loosen tourniquet slowly to restore circulation.

• Leave loosened tourniquet in position in case bleeding resumes.

Treat Shock

(Shock is difficult to identify or treat under field conditions. It may be present with or without visible injury.)

(1) Identify by one or more of the following:

(a) Pale, cool, and sweaty skin.

(b) Fast breathing and a weak, fast pulse.

(c) Anxiety or mental confusion.

(d) Decreased urine output.

(2) Maintain circulation.

(3) Treat underlying injury.

(4) Maintain normal body temperature.

(a) Remove wet clothing.

(b) Give warm fluids.

Do not give fluids to an unconscious victim.

Do not give fluids if they cause victim to gag.

(c) Insulate from ground.

(d) Shelter from the elements.

(5) Place conscious victim on back.

(6) Place very weak or unconscious victim on side, this will—

(a) Allow mouth to drain.

(b) Prevent tongue from blocking airway.

Treat Chest Injuries

SUCKING CHEST WOUND

This occurs when chest wall is penetrated; may cause victim to gasp for breath; may cause sucking sound; may create bloody froth as air escapes the chest.

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Figure V-5. Sucking Chest Wound Dressing.

(a) Immediately seal wound with hand or airtight material.

(b) Tape airtight material over wound on 3 sides only (figure V-5) to allow air to escape from the wound but not to enter.

(c) Monitor breathing and check dressing.

(d) Lift untapped side of dressing as victim exhales to allow trapped air to escape, as necessary.

FLAIL CHEST

Results from blunt trauma when 3 or more ribs are broken in 2 or more places. The flail segment is the broken area that moves in a direction opposite to the rest of chest during breathing.

(a) Stabilize the flail segment as follows:

• Place rolled-up clothing or bulky pad over site.

• Tape pad to site.

Do not wrap tape around chest.

(b) Have victim keep segment still with hand pressure.

(c) Roll victim onto side of flail segment injury (as other injuries allow).

FRACTURED RIBS

(a) Encourage deep breathing (painful, but necessary to prevent the possible development of pneumonia).

(b) Do not constrict breathing by taping ribs.

Treat Fractures, Sprains, and Dislocations

(1) Control bleeding.

(2) Remove watches, jewelry, and constrictive clothing.

(3) If fracture penetrates the skin—

(a) Clean wound by gentle irrigation with water.

(b) Apply dressing over wound.

(4) Position limb as normally as possible.

(5) Splint in position found (if unable to straighten limb).

(6) Improvise a splint with available materials:

(a) Sticks or straight, stiff materials from equipment.

(b) Body parts (for example, opposite leg, arm-to-chest).

(7) Attach with strips of cloth, parachute cord, etc.

(8) Keep the fractured bones from moving by immobilizing the joints on both sides of the fracture. If fracture is in a joint, immobilize the bones on both sides of the joint.

(9) Use RICES treatment for 72 hours.

Rest.

Ice.

Compression.

Elevation.

Stabilization.

(10) Apply cold to acute injuries.

(11) Use 15 to 20 minute periods of cold application.

(a) Do not use continuous cold therapy.

(b) Repeat 3 to 4 times per day.

(c) Avoid cooling that can cause frostbite or hypothermia.

(12) Wrap with a compression bandage after cold therapy.

(13) Elevate injured area above heart level to reduce swelling.

(14) Check periodically for a pulse beyond the injury site.

(15) Loosen bandage or reapply splint if no pulse is felt or if swelling occurs because bandage is too tight.

—From Survival, Evasion, and Recovery (Field Manual 21–76–1)

Preventing and Treating Shock

U.S. Army

Anticipate shock in all injured personnel. Treat all injured persons as follows, regardless of what symptoms appear:

• If the victim is conscious, place him on a level surface with the lower extremities elevated 15 to 20 centimeters.

• If the victim is unconscious, place him on his side or abdomen with his head turned to one side to prevent choking on vomit, blood, or other fluids.

• If you are unsure of the best position, place the victim perfectly flat. Once the victim is in a shock position, do not move him.

• Maintain body heat by insulating the victim from the surroundings and, in some instances, applying external heat.

• If wet, remove all the victim’s wet clothing as soon as possible and replace with dry clothing.

• Improvise a shelter to insulate the victim from the weather.

• Use warm liquids or foods, a prewarmed sleeping bag, another person, warmed water in canteens, hot rocks wrapped in clothing, or fires on either side of the victim to provide external warmth.

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Treatment for shock.

• If the victim is conscious, slowly administer small doses of a warm salt or sugar solution, if available.

• If the victim is unconscious or has abdominal wounds, do not give fluids by mouth.

• Have the victim rest for at least 24 hours.

• If you are a lone survivor, lie in a depression in the ground, behind a tree, or any other place out of the weather, with your head lower than your feet.

• If you are with a buddy, reassess your patient constantly.

—From Survival (Field Manual 21–76)

Patient Assessment

Tod Schimelpfenig

The initial assessment is a ritual performed on every patient to find and treat life-threatening medical problems. Besides attending immediately to vital functions, it provides order during the first frantic minutes of an emergency. You check, stop, and fix problems in the vital respiratory and circulatory systems. You assume disability and protect the spine. You assess and treat for environmental hazards.

Establishing Responsiveness

As you approach the patient, introduce yourself and ask if you may help. You’re obtaining consent to treat, being polite, and finding out if the patient is responsive. If there is no response, attempt to arouse the patient by saying hello loudly—the person may just be asleep.

If this fails to arouse the patient, try a painful stimulus—pinch the shoulder or neck muscle or rub the breastbone.

At this point, if there is any mechanism of injury, control the cervical spine (neck). Place hands on the head to prevent unnecessary movement of the neck.

If the patient is awake and talking, the airway is not obstructed; the person is breathing and has a pulse. If the patient is quiet, you need to check the ABCs (airway, breathing, and circulation) immediately. In both responsive and unresponsive patients, you proceed through the entire initial assessment, and make a decision about possible disability, environmental threats, and hidden major injury.

ABCDE

The initial assessment checks the airway, breathing, and circulation, plus possible serious bleeding and shock. The airways are the mouth, nose and throat, and trachea. Oxygen is exchanged between the air and the blood in the lungs. Circulation is a function of the heart, the blood vessels, and the blood, which contains vital oxygen. We use ABCDE (airway, breathing, circulation, disability, environment, expose, examine) as a memory aid for the initial assessment sequence. ABC is familiar as the initial phase of cardiopulmonary resuscitation (CPR).

Airway. The airway is the path air travels from the atmosphere into the lungs. An obstructed airway is a medical emergency because oxygen cannot reach the lungs. If the patient is awake, ask the patient to open his or her mouth and check for anything, such as gum or broken teeth, that could become an airway obstruction. If the patient is unresponsive, assess the airway by opening it with the head-tilt-chin-lift method or the jaw thrust and look inside the mouth. If you see an obvious obstruction—a piece of food, perhaps—take it out.

If you can see, hear, or feel air moving from the lungs to the outside, the airway is open. A patient making sounds is able to move air from the lungs and past the vocal cords. This indicates that the airway is at least partially open.

Signs of an obstructed airway are lack of air movement, labored breathing, use of neck and upper chest muscles to breathe, and pale gray or bluish skin. If you discover an airway obstruction, attempt to clear the airway before proceeding to assess breathing. The appropriate techniques are those taught in CPR for treating a foreign body-obstructed airway.

Breathing. If the patient is awake, ask him or her to take a deep breath. If the patient’s breathing is labored or painful, expose the chest and look for life-threatening injuries. If the patient is unresponsive, assess breathing using the “look, listen, and feel” format taught in CPR classes. Look for the rise and fall of the chest as air enters and leaves the lungs. Listen for the sound of air passing through the upper airway. Feel the movement of air from the patient’s mouth and nose on your cheek. If the patient is not breathing, give two slow, even breaths, then proceed with a check for a pulse.

Circulation. Check for the presence or absence of a pulse. Place the tips of your middle and index fingers over the carotid artery for at least 10 seconds. The carotid is a large central artery, accessible at the neck. Other possible sites are the femoral artery in the groin and the radial artery in the wrist (preferable for a responsive patient).

It may be difficult to feel a pulse if the patient has a weak pulse from shock, is cold, or is wearing bulky clothing. Finding a pulse is not always easy. If you are unsure about the presence of the carotid pulse, try the femoral or the radial pulse.

If the patient is moving or moaning, he or she must have a pulse. If there is no pulse, start CPR. If there is a pulse but no breathing, start rescue breathing.

Look for bleeding. Severe bleeding can be fatal within minutes. Look for obvious bleeding or wet places on the patient’s clothing. Quickly run your hands over and under the patient’s clothing, especially bulky sweaters or parkas, to find moist areas that may be caused by serious bleeding. Look for blood that may be seeping into snow or the ground. Most external bleeding can be controlled with direct pressure and elevation of the wound. Chapter 7 [“Wound Care,” pages 431–435] addresses bleeding control in detail.

Disability. Initially assume a spinal injury in any accident victim. Since moving a spine-injured patient poorly can cause paralysis, move the patient only if necessary and as little as possible. An airway opening technique for an unresponsive victim or an accident victim is the jaw thrust. It does not require shifting the neck or spine. See pages 431–435 (“Brain and Spinal Cord Injuries”).

Environment/Expose/Examine. Without moving the patient, expose and examine for major injuries, which may be hidden in bulky outdoor clothing. Quickly unzip zippers, open cuffs, and look under parkas.

Assess and manage environmental hazards. It’s not uncommon in wilderness medicine to need to protect the patient from extreme environments. You may need to move your patient off snow and onto an insulating pad, or out of a river onto dry ground.

The Focused Exam and History

Now pause a moment to look over the scene. The initial assessment is complete. Immediate threats to life have been addressed. Take a deep breath and consider the patient’s and the rescuers’ needs. If the location of the incident is unstable—such as on or near loose boulders or a potential avalanche slope—move to a safer position. Provide insulation, adjust clothing, rig a shelter. Assign tasks: boil water for hot drinks, build a litter, set up camp, write down vital signs. Establishing clear delegation of tasks helps the rescuers by giving everyone something to do and helps the patient by creating an atmosphere of order and leadership.

The focused exam and history is done after life-threatening conditions have been stabilized. It consists of doing a complete head-to-toe physical exam, checking vital signs, and taking a thorough medical history.

Head-to-Toe Patient Examination

The head-to-toe exam is a comprehensive physical examination. Begin the head-to-toe examination by first making the patient comfortable. Except in cases of imminent danger, avoid moving an injured patient until after the exam. Your hands should be clean, warm, and gloved. Ideally, the examiner should be of the same gender as the patient; otherwise, an observer of the same gender should be present during all phases of the exam. Designate a notetaker to record the results of the focused exam and history.

As you examine the patient, explain what you are doing and why. Besides being a simple courtesy, this helps involve the patient in his or her care. This survey starts with the head and systematically checks the entire body down to the toes. One person should perform the survey in order to avoid confusion, provide consistent results, and minimize discomfort to the patient. Also, with a single examiner, the patient will be able to respond to one inquiry at a time.

The examination technique consists of looking, listening, feeling, smelling, and asking. If you are uncertain of what is abnormal, compare the injured extremity with the other side of the body or with a healthy person.

Head. Check the ears and nose for fluid and the mouth for injuries that may affect the airway. Check the face for symmetry; all features should be symmetrical down the midline from the forehead to the chin. The checkbones are usually accurate references for facial symmetry. Feel the entire skull for depressions, tenderness, and irregularity. Run your fingers along the scalp to detect bleeding or cuts. Check the eyes for injuries, pupil abnormalities, and vision disturbances.

Neck. The trachea, or windpipe, should be in the middle of the neck. Feel the entire cervical spine from the base of the skull to the top of the shoulders for pain, tenderness, muscle rigidity, and deformity.

Shoulders. Examine the shoulders and the collarbone for deformity, tenderness, and pain.

Arms. Feel the arms from the armpit to the wrist. Check the pulse in each wrist; it should be equal on both sides. Ask the patient to move his or her fingers, then check grip strength by having the patient squeeze your hands. Check for sensation by gently pinching the fingers or scratching the palm of the hand and fingers. If no injury is apparent, ask the patient to move each arm through its full range of motion.

Chest. Feel the entire chest for deformity or tenderness. Push down from the top and in from the sides. Ask the patient to breathe deeply as you compress the chest. Look for open chest wounds. Observe the rise and fall of the chest for symmetry.

Abdomen. Feel the abdomen for tenderness or muscle rigidity with light pressure. If there is tenderness, localize it into a quadrant. Look for distension, discoloration, and bruising.

Back. Feel the spine. Feel each vertebra from the shoulders to the pelvis. It may be difficult to accomplish this without moving the patient, but it is important to slide your hand as far as possible under the patient. There may be a hidden injury.

Pelvis. Press down on the front of the pelvis and in from the sides. Is there deformity or instability? Does the pressure cause pain?

Legs. Check the legs from the groin to the ankle. Check the pulse in each of the feet; they should be equal. Check for sensation and motor function in the feet by touching the patient’s feet and by asking the patient to move his or her toes and to push his or her feet against your hands.

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Vital Signs

Vital signs are objective indicators of respiration, circulation, heart and brain function, blood volume, and body temperature. Checking the vital signs helps further evaluate the ABCs. Airway and breathing are checked by noting skin color and respiratory rate and depth. Good color and easy and regular breathing are signs our airway and lungs are working well. Circulation is evaluated by pulse, skin color, skin temperature, and level of responsiveness. Effective circulation gives us warm, pink skin and enough oxygen to keep our brain alert.

As a general rule, measure and record vital signs every 15 to 20 minutes—more frequently if the patient is seriously ill or injured. The initial set of vitals—responsiveness, pulse, respiration, skin signs, pupils, temperature-provides baseline data on the patient’s condition. The changes that occur thereafter provide information on the progress of the patient.

Level of the Responsiveness. Brain function, also known as mental status and reflected in how responsive we are to our environment, may be affected by toxic chemicals such as drugs or alcohol, low blood sugar, abnormally high or low temperature, diseases of the brain such as stroke, circulatory or respiratory shock, or pressure from bleeding or swelling caused by a head injury.

I have chosen to use the term “responsiveness” rather than the more common “consciousness” to describe brain function. Consciousness is a vague term and difficult to measure. The more specific responsiveness is a criterion we can evaluate on every patient and then describe with clarity and specificity.

When you assess responsiveness, first determine the initial state. Begin by approaching the patient, introducing yourself, saying “Hello,” and asking if you can help. You’re being polite and finding out if the patient is awake, asleep, or possibly unresponsive.

Then describe the stimulus you used to arouse the patient. If the patient opened his or her eyes and responded after a simple “Hello,” the person may have been asleep or distracted. If you needed to shout loudly several times to arouse the patient, the person would be described as not awake but responsive to a verbal stimulus. If you needed to use pain to arouse the patient, the person would be described as not awake and responsive only to pain.

Alert. Normally, we are awake (or we wake quickly from sleep), are alert, and know who we are, where we are, the date or time, and recent events. This is described as A (awake/alert) and O (oriented) times 1, 2, 3, or 4, depending on whether the patient knows who he or she is, where he or she is, what date or time it is, and recent events:

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A patient who is awake but not oriented to person, place, time, or event is described as disoriented. The spoken response may be incoherent, confused, inappropriate, or incomprehensible.

Verbally Responsive. The patient is not awake but responds to a verbal stimulus, such as the rescuer saying, “Hello, how are you?” If the patient does not respond, repeat louder: “Hey! Sir (or Ma’am)! Wake up!” The patient’s response may be opening the eyes, grunting, or moving. Higher levels of brain function respond to verbal input, lower levels to pain. Test for responsiveness to verbal stimuli first, painful stimuli second.

Painfully Responsive. The patient is not awake, does not respond to verbal stimuli, but does respond to painful stimuli by moving, opening the eyes, or groaning. To stimulate for pain, pinch the muscle at the back of the shoulder or neck, or rub the sternum.

Unresponsive. The patient is not awake and does not respond to voice or painful stimuli.

Report the patient’s initial state, the stimulus you gave, and the response. For example: “This patient is awake, alert, and oriented times four.” Or, “This patient is not awake, but can be aroused with a verbal stimulus. When awake, the patient knows his name but is otherwise disoriented.”

Heart Rate. Every time the heart beats, a pressure wave is transmitted through the arteries. We feel this pressure wave as the pulse. The pulse rate indicates the number of heartbeats over a period of time. For an adult, the normal range is 60 to 100 beats per minute. A well-conditioned athlete may have a normal pulse rate of 50. Shock, exercise, altitude, illness, emotional stress, or fever can increase the heart rate.

The heart rate can be measured at the radial artery on the thumb side of the wrist or at the carotid artery in the neck. Place the tips of the middle and index fingers over the artery. Count the number of beats for 15 seconds and multiply by four.

In addition to rate, note the rhythm and strength of the pulse. The normal rhythm is regular. Irregular rhythms can be associated with heart disease and are frequently rapid. The strength of the pulse is the amount of pressure you feel against your fingertips. It may be weak or strong.

A standard pulse reading includes the rate, rhythm, and strength of the pulse. For example: “The pulse is 110, irregular, and weak.” Or, “The pulse is 60, regular, and strong.”

Skin Signs. Skin signs indicate the condition of the respiratory and cardiovascular systems. These include skin color, temperature, and moisture, often abbreviated SCTM.

Pinkness. In a light-colored person, normal skin color is pink. In darker-skinned individuals, skin color can be assessed at the nail beds, inside the mouth, palms of the hands, soles of the feet, or lips.

Redness. Redness indicates that the skin is unusually flushed with blood. It is a possible sign of recent exercise, heatstroke, carbon monoxide poisoning, fever, or allergic reaction.

Paleness. Pale skin indicates that blood has withdrawn from the skin. Paleness may be due to fright, shock, fainting, or cooling of the skin.

Cyanosis. Blue skin, or cyanosis, appears when circulation to the skin is reduced or the level of oxygen in the blood falls. Well-oxygenated blood is brighter red than poorly oxygenated blood. Cyanosis indicates that oxygen levels have fallen significantly, or that the patient may be cold.

Jaundice. Yellow skin combined with yellow whites of the eyes—jaundice—is a sign of liver or gallbladder disease. The condition results from excess bile pigments in the blood.

Temperature and Moisture. Quickly assess the temperature and moisture of the skin at several sites, including the forehead, hands, and trunk. In a healthy person, the skin is warm and relatively dry. Skin temperature rises when the body attempts to rid itself of excess heat, as in fever or environmental heat problems. Hot, dry skin can be a sign of fever or heatstroke. Hot, sweaty skin occurs when the body attempts to eliminate excess heat and can also be a sign of fever or heat illness.

Skin temperature falls when the body attempts to conserve heat by constricting blood flow to the skin; for example, during exposure to cold. Cool, moist (clammy) skin is an indicator of extreme stress and a sign of shock.

A report on skin condition should include color, temperature, and moisture. For example: “The patient’s skin is pale, cool, and clammy.”

Respiration. Respiratory rate is counted in the same manner as the pulse: Each rise of the chest is counted over 15 seconds and multiplied by four, or 30 seconds and multiplied by two. Watch the chest rise and fall, or observe the belly move with each breath. Normal respiration range is 12 to 20 breaths per minute.

The patient’s depth and effort of breathing enable you to gauge his or her need for air and the presence or absence of chest injury. In a healthy individual, breathing is relatively effortless.

A patient experiencing breathing difficulty may exhibit air hunger with deep, labored inhaling efforts. A patient with a chest injury may have shallow, rapid respirations accompanied by pain. Irregular respirations are a sign of a brain disorder. Noisy respirations indicate some type of airway obstruction. Assess and, if necessary, clear the airway.

Smell the breath. Fruity, acetone breath can be a sign of diabetic coma. Foul, fecal-smelling breath may indicate a bowel obstruction.

Report respirations by their rate, rhythm, effort, depth, noises, and odors. For example, a patient in diabetic ketoacidosis may have respirations described as “20 per minute, regular, labored, deep. There is a fruity breath odor.”

Temperature. Temperature measurement is an important component of a thorough patient assessment, but it is the vital sign that is least often recorded in the field. It can tell us of underlying infection or of abnormally high or low body temperatures. Although a normal temperature is 98.6°F (37°C), daily variation in body temperature is also normal, usually rising a degree during the day and decreasing through the night.

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Temperature can be measured orally or rectally. Axillary readings—taken under the armpit—are the least reliable. Rectal temperatures are the most accurate indication of the core temperature available to first responders. Rectal temperature is sometimes considered necessary for suspected hypothermia but is rarely measured due to patient embarrassment and cold exposure. Diagnosis of hypothermia in the outdoors, discussed in pages 451–452 (“Cold Injuries”), is often based on other factors, such as behavior, history, appearance, and mental status.

Before taking a temperature with a mercury thermometer, shake down the thermometer to push the mercury below the degree markings. This is essential for an accurate reading. Place the thermometer under the patient’s tongue for at least 3 minutes. The patient should refrain from talking or drinking during this time. A report on temperature should include the method, such as “100°F oral” or “37°C rectal.”

Pupils. Pupils are clues to brain function. They can indicate head injury, stroke, drug abuse, or lack of oxygen to the brain. Both pupils should be round and equal in size. They should contract symmetrically when exposed to light and dilate when the light dims. Evaluate pupils by noting size, equality, and reaction to light.

In the absence of a portable light source, such as a flashlight or headlamp, shield the patient’s eyes for 15 seconds, then expose them to ambient light. Both pupils should contract equally. When in doubt, compare the patient’s reactions with those of a healthy individual in the same light conditions.

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A patient whose brain cells are deficient of oxygen may have equal but slow-to-react pupils. A wide, nonreactive pupil on one side and a small, reactive pupil on the other side indicates brain damage or disease on the side with the larger pupil. Very small, equal pupils may indicate drug intoxication.

Blood Pressure. Although blood pressure is always measured when professional medical care is being administered, accurate measurement requires a stethoscope and a sphygmo-manometer—equipment rarely carried on wilderness trips. Because evacuation decisions can be made without measuring blood pressure, this vital sign is not presented.

Medical History

The patient’s medical history provides background that is often relevant to the present problem. Gathering the history is an ongoing process that you typically carry out while measuring vital signs and performing the head-to-toe exam. Obtaining an accurate history depends greatly on the quality of communication between you and the patient. This rapport begins as soon as you approach the scene. Communicating clearly, acting orderly, and appearing to be in control make it easier to obtain an accurate history.

Chief Complaint. Obtain the patient’s chief complaint—the problem that caused him or her to solicit help. Pain is a common complaint—for example, abdominal pain or pain in an arm or leg after a fall. In lieu of pain, a chief complaint may be nausea or dizziness. A memory aid for investigating the chief complaint is OPQRST.

Onset. Did the chief complaint appear suddenly or gradually?

Provokes. What provoked the injury? If the problem is an illness, under what circumstances did it occur? What makes the problem worse, and what makes it better?

Quality. What qualities describe the pain? Adjectives may include stabbing, cramping, burning, sharp, dull, or aching.

Radiates. Where is the pain? Does it move, or radiate? What causes it to move? Chest pain from a heart attack can radiate from the chest into the neck and jaw. Pain from a spleen injury can be felt in the left shoulder.

Severity. On a scale of 1 to 10 (with 1 being no pain or discomfort and 10 being the worst pain or discomfort the patient has ever experienced), how does the patient rate this pain? This question can reveal the level of discomfort the patient is experiencing.

Time. When did the pain start? How frequently does it occur? How long does it last? Correlate the patient’s complaints with the vital signs.

SAMPLE

This is a memory aid for a series of questions that completes the medical history.

Symptoms. What symptoms does the patient have? Nausea? Dizziness? Headache? Ask the patient how he or she is feeling, or if anything is causing discomfort. A symptom is something the patient perceives and must tell you about (e.g., pain). Tenderness, on the other hand, is a sign, something you can find when you touch an injury during a patient exam.

Allergies, Medications. Ask if the patient is currently taking any medications or has any allergies. If so, find out if he or she has been exposed to the allergen and what his or her usual response is. Ask about nonprescription, prescription, and herbal medications, as well as possible alcohol or drug use. Ask whether the patient is allergic to medications or has other environmental allergies to food, insects, or pollen.

Past History. The past history consists of a series of questions you ask the patient to discover any previous and relevant medical problems. (If the patient has a broken leg, for example, it’s unlikely we need to know about childhood illness.) First ask these general questions: Has the patient ever been in a hospital? Is the patient currently seeing a physician? Next, ask about specific body systems. Avoid medical jargon. For instance, asking the patient about any previous heart problems is less confusing than asking, “Do you have a cardiac history?”

Additional sources of information may include a medical alert tag or a medical information questionnaire. A medical alert tag is a necklace, bracelet, or wallet card that identifies the patient’s medical concerns. It reports a history of diabetes, hemophilia, epilepsy, or other disorders; allergies to medication; and other pertinent information. Medical forms are common to many outdoor schools, camps, and guide services. The NOLS student medical history form is filled out by the student prior to the trip and is available for review by field staff.

Last Intake and Output. Ask the patient when he or she last ate and drank. This information may tell you whether the patient is hydrated or give you important history if, for example, the patient is diabetic. Also find out when the patient last urinated and defecated. Clear, copious urine indicates good hydration; dark, smelly urine suggests dehydration. A patient with diarrhea or vomiting may be dehydrated.

Recent Events. Recent events are unusual circumstances that have occurred within the past few days that may be relevant to the patient’s present situation. Recent events might include symptoms of mountain sickness preceding pulmonary edema or changes in diet preceding stomach upset.

The Assessment

The assessment is a review of the information gathered during the initial assessment and the focused exam and history. Examine the records of the head-to-toe examination, the vital signs, and the medical history. Think through OPQRST and SAMPLE.

Rule out possibilities as you assess. Many diagnoses are made by physicians on the basis of what a condition isn’t rather than what it could be. Is chest pain a muscle pull or a heart attack? Does the patient have the flu, mountain sickness, or early cerebral edema?

The Plan

Next, prioritize the patient’s medical problems and develop a treatment plan for each.

The initial exam provides a baseline. Periodically repeat the exam to judge the patient’s response to treatment and any changes for better or worse. If there is any change or deterioration in the patient, return to the beginning and repeat the initial assessment.

—From NOLS Wildness Medicine

Injuries to the Head, Spine, Abdomen, and Chest

Greg Davenport

Injuries to the Head

Signs and symptoms of a head injury include bleeding, increasing headache, drowsiness, nausea, vomiting, unequal pupils, and unconsciousness. To treat a suspected head injury, first immobilize the neck if a neck injury is suspected. Then monitor the victim for any change in mental status, and if the victim is conscious, treat him or her for shock by slightly elevating the head and keeping him or her warm. If the victim is unconscious, treat him or her for shock by laying the victim on his or her side to avoid aspiration of vomit.

Injuries to the Spine

Signs and symptoms of a spinal injury include pain, numbness, tingling, decreased sensation or lack of feeling in extremities, and the inability to move the body below the injury site. Be sure to immobilize the neck and body on a firm flat surface, if a spinal injury is suspected, and treat for shock.

Injuries to the Abdomen

Signs and symptoms of an abdominal injury include bleeding, abdominal wall bruising, pain, drowsiness, nausea, and vomiting. An open wound where intestines are exposed should be covered, and care should be taken to prevent drying of the wound. To treat an open intestine wound, rinse away any dirt and debris with a mixture of sterile water and salt (1 quart of sterile water mixed with 1 teaspoon of salt). After cleaning the area, cover it with a clean dressing that is wetted with the above solution. It’s extremely important to prevent the intestines from drying out. Both open and closed abdominal injury should be treated for shock.

Injuries to the Chest

Signs and symptoms of a chest injury can vary tremendously, depending on the cause or problem. As a general rule, subject may have pain, coughing and shortness of breath, irregular breathing pattern (rapid or slow), anxiety, and cyanosis. An open chest wound should be covered with a piece of plastic or other airtight material. (While dressing may be used, it is not as effective.) Tape the covering on three sides to allow air to escape but not enter the opening. If the victim’s breathing pattern worsens, remove the patch. Both open and closed chest injuries should be treated for shock.

—From Surviving Coastal and Open Water

Brain and Spinal Cord Injuries

Tod Schimelpfenig

Brain Injuries

Head injuries include scalp, skull, and brain injuries. Scalp and skull injuries can be serious by themselves, but we’re more concerned with possible injury to the brain.

A large blood supply feeds the scalp, causing it to bleed profusely when cut. A bruised or lacerated scalp can mask underlying injury to the skull or brain. Examine scalp injuries carefully to see if bone or brain is exposed or if an indentation, which might be a depressed fracture, is present. Bleeding from the scalp can be controlled by applying gentle pressure on the edges of the wounds, being careful to avoid direct pressure on possibly unstable central areas.

The skull consists of 22 fused bones. The strongest are the bones forming the top and sides of the protective box encasing the brain. Fractures of the skull are not in themselves lifethreatening except when associated with underlying brain injury or spinal cord injury, or when the fracture causes bleeding by tearing the blood vessels between the brain and the skull. Many serious brain injuries occur without skull fractures.

Skull fractures can be open or closed. Open skull fractures expose the brain to infection.

Brain injury can be fatal when it disrupts heartbeat and breathing. In the long term, a severe brain injury may leave the patient physically immobile or mentally incompetent, with severely impaired judgment and problem-solving ability or an inability to process or communicate information properly.

The brain can be injured by a direct blow to the head or by twisting forces, which cause deformation and shearing against the inside of the skull. Some movement between brain and skull is possible. A blow to the head can make the brain “rattle” within the skull, tearing blood vessels in the meninges or within the brain itself, stretching and shearing brain cells and the connections between cells.

A mild brain injury (also known as a concussion) is temporary brain dysfunction or loss of responsiveness following a blow to the head. There may be no or only mild brain injury in this case. Contusions (bruising of brain tissue) and hemorrhages or hematomas (bleeding within the brain) are more serious injuries that can lead to increased pressure in the skull. Encased in this rigid box, a swelling or bleeding brain presses against the skull; the body has no mechanism to release such an increase in pressure. As pressure rises, blood supply is shut off by compression of swollen vessels, and brain tissue is deprived of oxygen. The brain stem can be squashed by the pressure, affecting heart and lung function.

Signs and Symptoms of Brain Injury

Signs and symptoms of brain injury depend on the degree and progression of injury. Some indications of brain injury appear immediately from the accident; others develop slowly.

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Changes in Level of Responsiveness. Loss of responsiveness may be short or may persist for hours or days. The patient may alternate between periods of responsiveness and unresponsiveness or be responsive but disoriented, confused, and incoherent—exhibiting changes in behavior and personality or verbal or physical combativeness.

Headache, Vision Disturbances, Loss of Balance, Nausea and Vomiting, Paralysis, Seizures. Headache, vision problems, loss of balance, nausea and vomiting, and paralysis may accompany brain injury. In serious cases, the patient may assume abnormal positions, with the legs and arms stiff and extended or the arms clutched across the chest. A brain-injured patient may have seizures.

Combativeness. A brain-injured patient may become combative, striking out randomly and with surprising strength at the nearest person. If the brain is oxygen-deprived, supplemental oxygen and airway maintenance may help alleviate such behavior. Restraint may be necessary to protect the patient and the rescuers.

Blood or CSF Leakage, Soft Tissue Injury to Skull, Obvious Skull Fracture, Raccoon Sign, Battle’s Sign. Blood or clear cerebrospinal fluid (CSF) leaking from the ears, mouth, or nose is a sign of a skull fracture, as are pain, tenderness, and swelling at the injury site or obvious penetrating wounds or depressed fractures. Two other signs of skull fracture—bruising around the eyes (called the raccoon sign) and bruising behind the ear (Battle’s sign)—usually appear hours after the injury.

Slow Pulse, Rising Blood Pressure, Irregular Respirations. Changes in vital signs that indicate a serious and late stage brain injury are a slow pulse, rising blood pressure, and irregular respiratory rate. These contrast with the rising pulse, falling blood pressure, and rapid, regular respirations seen with shock.

Assessment for Brain Injury

Initial assessment of brain injury can be difficult. The symptoms of a mild brain injury are similar to those seen in more serious injuries. The assessment may also be complicated when the patient’s mental status is affected by drugs, alcohol, or other traumatic injuries.

Assessment of brain injury begins by checking the airway, breathing, and circulation (ABC); bleeding; and cervical spine. A patient with a brain injury is at high risk for cervical spine injury. Avoid movement of the neck. If you suspect brain or neck injury, use the jaw thrust to open the airway.

After a thorough physical assessment, including vital signs, evaluate the nervous system. Note the level of responsiveness and the patient’s ability to feel and move extremities. Use the AVPU (awake and alert, not awake but responsive to a verbal stimulus, not awake but responsive to pain, or not awake and unresponsive) system to assess mental status. Question the patient or bystanders as to a loss of responsiveness. Was it immediate, or was there a delay before the patient became unresponsive? Has the patient been awake but drowsy, sleepy, confused, or disoriented? Has the patient been going in and out of responsiveness?

Watch any brain-injured patient carefully, even if the injury does not at first appear serious. Let the patient rest, but wake him or her up every couple of hours and assess responsiveness.

Treatment of Brain Injury

Evacuation is required for any patient who has become unresponsive, even for a minute or two, or who exhibits vision or balance disturbances, irritability, lethargy, or nausea and vomiting after a blow to the head. A patient who experiences momentary loss of responsiveness but who awakens without any other symptoms may be walked out of the wilderness with a support party capable of quickly evacuating the patient if his or her condition worsens.

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ABCs. An injured brain needs oxygen. Ensuring an open airway is the first step in treatment.

If Vomiting, Position Patient on Side. Brain-injured patients have a tendency to vomit. Logrolling the patient onto his or her side while maintaining cervical spine stabilization helps drain vomit while maintaining the airway. Use the jaw thrust to open the airway.

Control Scalp Bleeding. Cover open wounds with bulky sterile dressings as a barrier against infection. Although it is acceptable to clean scalp wounds, cleaning open skull injuries may introduce infection into the brain, so leave them as you find them. Stabilize impaled objects in place.

Do Not Control Internal Bleeding or Drainage. Do not attempt to prevent drainage of blood or clear CSF from the ears or nose. Blocking the flow could increase pressure within the skull.

Elevate head. Keep the patient in a horizontal or slightly head-elevated position. Do not elevate the legs, as this might increase pressure within the skull.

Record Neurological Assessment. Watch the patient closely for any changes in mental status. These observations will be valuable to the receiving physician. Record changes in your patient report.

Spinal Cord Injuries

As with head injuries, spinal cord injuries primarily involve young people, with most cases occurring in men between the ages of 15 and 35. An estimated 10,000 new spinal cord injuries occur each year in the United States, and because central nervous tissue does not regenerate, victims are left permanently disabled—half as paraplegics and half as quadriplegics. Motor vehicle accidents account for the majority of spinal injury cases, followed by falls and sporting injuries.

The spinal cord is the extension of the brain outside the skull. A component of the central nervous system, the spinal cord is the nervous connection between the brain and the rest of the body.

The spinal cord is protected within the vertebrae, 33 of which form the backbone, or spine. A force driving the spine out of its normal alignment can fracture or dislocate the vertebrae, thereby injuring the spinal cord. There can be vertebral fractures or ligament and muscle damage to the backbone, however, without damage to the spinal cord. Fractured or dislocated vertebrae can pinch, bruise, or cut the spinal cord, damaging the nervous connections.

The smallest vertebrae with the greatest range of motion are in the neck—the most vulnerable part of the spine. From there, the vertebrae become progressively larger as they support more weight. The location of damage to the spinal cord determines whether the patient may die or be left paralyzed from the neck down (quadriplegia) or the chest down (paraplegia).

Signs and Symptoms of Spinal Cord Injury

Signs and symptoms of spinal cord injury include weakness, loss of sensation or ability to move, numbness and tingling in the hands and feet, incontinence, soft tissue injury over or near the spine, and tenderness in the spine.

Assessment for Spinal Cord Injury

Check for strength, sensation, ability to move, and weakness or numbness in the hands and feet. Ask the patient to wiggle fingers or toes, push his or her feet against your hands, or squeeze your hands with his or hers. Ask the patient to identify which toe or finger you are touching. If the patient is unresponsive, check for sensation by applying a painful stimulus at the toes and fingers (a pinprick or pinch) and watching the patient’s face for a grimace.

Treatment of Spinal Cord Injury

Treatment for a spinal cord injury is to stabilize the spine to prevent further damage. Although it may be necessary to move a spine-injured patient, your first choice should be on-scene stabilization.

Stabilize the Spine. If spinal immobilization devices are not available, one person should always be at the head of the patient, controlling the head and maintaining stabilization of the neck. A clothing or blanket roll may be used as an improvised cervical or neck collar to aid in stabilization, freeing rescuers for other tasks. A strap of cloth or bandage across the forehead secured with wrapped clothing stabilizes the head and neck.

Move with Logroll or Lift. Assume that the patient may have to be moved at least twice during the rescue—once to place insulation underneath the body to prevent hypothermia, and a second time to place the patient on a litter or backboard. Two common techniques for moving the patient are the logroll and the lift. Practice these under the guidance of an emergency care instructor.

A patient can be assessed and immobilized while lying facedown or on his or her back or side. Unless airway, breathing, or bleeding problems are present, you should take the time required to carry out the logroll or lift and explain your actions to the patient.

How to Perform a Four-Person Logroll:

1. The rescuers take positions:

• Rescuer One maintains stabilization of the head throughout the procedure and gives the commands.

• Rescuer Two kneels beside the patient’s chest and reaches across to the patient’s shoulder and upper arm.

• Rescuer Three kneels beside the patient’s waist and reaches across to the lower back and pelvis.

• Rescuer Four kneels beside the patient’s thighs and reaches across to support the legs with one hand on the patient’s upper thigh, the other behind the knee.

2. The rescuers roll the patient onto his or her side:

• Rescuer One, at the head, gives the command, “Roll on 3; 1, 2, 3,” and the rescuers slowly roll the patient toward them, keeping the patient’s body in alignment. Rescuer One supports the head and maintains alignment with the spine. Once the patient is on his or her side, a backboard or foamlite pad can be placed where the patient will be lying when the logroll is complete.

3. The rescuers roll the patient onto his or her back:

• When Rescuer One gives the command, “Lower on 3; 1, 2, 3,” the procedure is reversed, and the patient is slowly lowered onto the backboard or foamlite pad while the rescuers keep the spine in alignment.

Lifting Technique. The patient can be lifted by four people, enabling a fifth person to slide a backboard, foamlite pad, or litter underneath. The rescuer at the head again maintains stabilization during the entire procedure and gives commands. The other three rescuers position themselves at the patient’s sides, one kneeling at chest level and another at pelvis level on the same side, while the third rescuer kneels at waist level on the opposite side. Before lifting, the rescuers place their hands over the patient to visualize their hands in position under the chest, lower back, pelvis, and thighs. They then slide their hands under the patient as far as they can without jostling the patient. On the command, “Lift on 3; 1, 2, 3,” rescuers lift the patient to a standing position, then lower him or her onto the pad or litter.

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Immobilize the Spine. Ideally, the patient should be moved as few times as possible, and preferably after immobilization on a backboard, Kendrick Extrication Device, SKED litter, or other spine-splinting device, and with a cervical collar and head immobilization. Until such equipment arrives, insulate and shelter the patient.

Wilderness treatment may require caring for a patient during prolonged immobilization. It’s uncomfortable to lie still on a hard surface for hours. Current advanced trauma life support (ATLS) curriculum recommends that patients on backboards be logrolled off the backboard approximately every 2 hours to prevent pressure sores on the back. Padding is important. A little bit under the lower back and behind the knees goes a long way to make the patient comfortable. Strapping over bony areas helps tie the patient down, but the straps should be padded and can be loosened when the patient is not being carried.

The Focused Spine Assessment. If a mechanism for a spinal cord injury has occurred, for example, from a fall from a height, a high-velocity skiing fall, a diving accident, or a blow to the head, initially assume the worst and control the head. If the mechanism is severe, or the patient has signs of a spinal cord injury, immobilize the spine. If the mechanism seems trivial and the patient has no signs of spine injury, you may consider performing a focused spine assessment to gather information to help you decide if immobilizing the spine is necessary.

After a thorough assessment, it is acceptable to consider “clearing” the spine of injury by using a method approved by the Wilderness Medical Society to rule out spine injury. Without this protocol, we would unnecessarily immobilize all patients with insignificant mechanisms for injury. As with all wilderness protocols, support from a physician advisor is recommended.

Making a decision to not immobilize begins with a thorough patient assessment. Then proceed sequentially through this series of steps:

1. Is the patient A+O 3/4 and sober?

—If no, immobilize the spine. If yes, proceed to the next step.

2. Is the patient free from distractions (injuries, emotional distress)?

—If no, immobilize the spine. If yes, proceed to the next step.

3. Is the patient free of pain, tenderness, tingling, or numbness on the spine?

—If no, immobilize the spine. If yes, proceed to the next step.

4. Is the patient free of unusual or abnormal sensations in the extremities, such as numbness or tingling? Do extremities have normal circulation and movement?

—If no, immobilize the spine. If yes, you can make a decision to not immobilize the spine.

If the patient fails any step in this process, or you’re uncertain about the results of your exam, immobilize the spine. If at any time you’re uncomfortable with this process, you can choose a conservative plan and immobilize the patient.

–From NOLS Wilderness Medicine

Chest Injuries

Tod Schimelpfenig

Rib Fractures

The most commonly fractured ribs are ribs five through ten. Ribs one through four are protected by the shoulder girdle and are rarely fractured. The floating ribs—ribs eleven and twelve—are more flexible and will give before breaking.

Signs and Symptoms. Rib fractures cause deformity and/or discoloration over the injured area. The patient complains of tenderness over the fracture (point tenderness) when touched. Breathing or coughing causes sharp, stabbing pain at the site of the fracture. Respiratory rate increases as the patient breathes shallowly in an attempt to decrease the pain. The patient may clutch the chest on the fractured side in an attempt to splint it. Carefully observe rib fracture victims for other injuries.

Treatment. A single fractured rib that is not displaced (simple rib fracture) does not require splinting. Non-narcotic pain medication (acetaminophen or ibuprofen) may be all the treatment necessary.

Tape the Fracture Site on One Side of Chest. If the pain is severe, tape the fractured side from sternum to spine with four or five pieces of 1- to 2-inch adhesive tape. This decreases movement at the fracture site and diminishes pain. Tape should never be wrapped completely around the chest, as this can restrict breathing. You may also find that a simple sling and swathe on the arm on the injured side limits movement and provides comfort. If the patient is not in respiratory distress, he or she may be able to walk out.

Flail Chest

A flail chest occurs when 3 or more adjacent ribs are broken in two or more places, loosening a segment of the chest wall. When the patient breathes in, the increased negative pressure pulls the flail segment inward, and the lung does not fill with air as it should. When the patient breathes out, the opposite occurs, and the flail segment may be pushed outward. The flail segment moves in a direction opposite of normal breathing, thus the term “paradoxical respirations.”

Signs and Symptoms. A flail chest develops only with a significant chest injury, such as a heavy fall against a rock. The patient may be in respiratory distress. Put your hands under the patient’s shirt, and you may feel a part of the chest moving in while the opposite part of the chest is moving out. This may also be visible upon inspection.

Treatment. Stabilize the flail chest:

• Position the patient on the injured side with a rolled-up piece of clothing underneath the flailed segment.

• Apply pressure with your hand to the flailed area. This works only as a temporary measure, as it is difficult to hold pressure while transporting the patient.

• Tape a large pad firmly over the flail segment (without circling the chest).

Treat the patient for shock and evacuate.

Injuries to Lungs

In addition to injuries to the ribs, the underlying lungs may be damaged. Blood vessels can be ruptured and torn, causing bleeding into the chest, and lungs can be punctured, causing air to leak into the chest.

Pneumothorax. This occurs when air leaks into the pleural space, creating negative pressure that collapses the lung. Pneumothorax can be caused by a fractured rib that lacerates the lung (traumatic pneumothorax), a weak spot on the lung wall that gives way (spontaneous pneumothorax), or an open chest wound.

Hemothorax. This occurs when lacerated blood vessels cause blood to collect in the pleural space. The source can be a fractured rib or lacerated lung. If more than 1 liter of blood leaks into the pleural space, a hemothorax may compress the lung and compromise breathing. The loss of blood may also cause shock.

Spontaneous Pneumothorax. A congenital weak area of the lung may rupture, creating a spontaneous pneumothorax. The highest incidence occurs in tall, thin, healthy men between the ages of 20 and 30. Eighty percent of spontaneous penumothoraxes occur while the person is at rest. The patient complains of a sudden, sharp pain in the chest and increasing shortness of breath.

Tension Pneumothorax. If a hole opening into the pleural space serves as a one-way valve—allowing air to enter but not to escape—a tension pneumothorax develops. With each breath, air enters the pleural space, but it cannot escape with expiration. As pressure in the pleural space increases, the lung collapses. Pressure in the pleural space eventually causes the mediastinum to shift to the unaffected side, putting pressure on the heart and good lung. If the pressure in the pleural space exceeds that in the veins, blood cannot return to the heart, and death occurs.

As pressure builds, you may see the trachea deviate toward the unaffected side, tissue between the ribs bulge, and the neck veins distend. Respirations become increasingly rapid. The pulse is weak and rapid. The pulse is weak and rapid; cyanosis occurs.

Open Chest Wounds

If a wound through the chest wall breaks into the pleural space, air enters, creating a pneumothorax. If the wound remains open, air moves in and out of the pleura, causing a sucking noise.

The goal of treatment is to limit the size of the pneumothorax. Quickly seal the hole with any nonporous material—a plastic bag or petroleum jelly–impregnated gauze, for example. Tape the dressing down on three sides to seal the hole, yet allow excess air pressure in the chest to escape.

Respiratory Distress

Respiratory distress is an overall term that covers any situation in which a patient is having difficulty breathing. Respiratory distress can occur after an injury, during an illness such as pneumonia, during a heart attack or an asthma attack, or after inhalation of a poisonous gas.

Signs and symptoms of respiratory distress are anxiety and restlessness; shortness of breath; rapid respirations and pulse; signs of shock, including pale, cool, and clammy skin and cyanosis of the skin, lips, and fingernail beds; and labored breathing using accessory muscles of the neck, shoulder, and abdomen to achieve maximum effort. The patient is usually more comfortable sitting than lying.

Respiratory distress is a frightening experience for both the patient and the rescuer. If the underlying cause is emotional, as in hyperventilation syndrome (see page 442), reassurance may be all that’s needed to alleviate the problem. If a chest injury with underlying lung damage or an illness such as pneumonia or a pulmonary embolus occurs, treatment in the field is difficult. Evacuation is the course of action. The airway can be maintained, the patient placed in the most comfortable position for breathing, the injury splinted or taped, wounds dressed, and the patient treated for shock.

–From NOLS Wilderness Medicine

Fractures and Dislocations

U.S. Army

Fractures

There are basically two types of fractures: open and closed. With an open (or compound) fracture, the bone protrudes through the skin and complicates the actual fracture with an open wound. After setting the fracture, treat the wound as any other open wound.

The closed fracture has no open wounds. Follow the guidelines for immobilization, and set and splint the fracture.

The signs and symptoms of a fracture are pain, tenderness, discoloration, swelling deformity, loss of function, and grating (a sound or feeling that occurs when broken bone ends rub together).

The dangers with a fracture are the severing or the compression of a nerve or blood vessel at the site of fracture. For this reason minimum manipulation should be done, and only very cautiously. If you notice the area below the break becoming numb, swollen, cool to the touch, or turning pale, and the victim shows signs of shock, a major vessel may have been severed. You must control this internal bleeding. Treat the victim for shock, and replace lost fluids.

Often you must maintain traction during the splinting and healing process. You can effectively pull smaller bones such as the arm or lower leg by hand. You can create traction by wedging a hand or foot in the V-notch of a tree and pushing against the tree with the other extremity. You can then splint the break.

Very strong muscles hold a broken thighbone (femur) in place making it difficult to maintain traction during healing. You can make an improvised traction splint using natural material as follows:

• Get two forked branches or saplings at least 5 centimeters in diameter. Measure one from the patient’s armpit to 20 to 30 centimeters past his unbroken leg. Measure the other from the groin to 20 to 30 centimeters past the unbroken leg. Ensure that both extend an equal distance beyond the end of the leg.

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Improvised traction splint.

• Pad the two splints. Notch the ends without forks and lash a 20- to 30-centimeter cross member made from a 5-centimeter diameter branch between them.

• Using available material (vines, cloth, rawhide), tie the splint around the upper portion of the body and down the length of the broken leg. Follow the splinting guidelines.

• With available material, fashion a wrap that will extend around the ankle, with the two free ends tied to the cross member.

• Place a 10- by 2.5-centimeter stick in the middle of the free ends of the ankle wrap between the cross member and the foot. Using the stick, twist the material to make the traction easier.

• Continue twisting until the broken leg is as long or slightly longer than the unbroken leg.

• Lash the stick to maintain traction.

Note: Over time you may lose traction because the material weakened. Check the traction periodically. If you must change or repair the splint, maintain the traction manually for a short time.

Dislocations

Dislocations are the separations of bone joints causing the bones to go out of proper alignment. These misalignments can be extremely painful and can cause an impairment of nerve or circulatory function below the area affected. You must place these joints back into alignment as quickly as possible.

Signs and symptoms of dislocations are joint pain, tenderness, swelling, discoloration, limited range of motion, and deformity of the joint. You treat dislocations by reduction, immobilization, and rehabilitation.

Reduction or “setting” is placing the bones back into their proper alignment. You can use several methods, but manual traction or the use of weights to pull the bones are the safest and easiest. Once performed, reduction decreases the victim’s pain and allows for normal function and circulation. Without an X-ray, you can judge proper alignment by the look and feel of the joint and by comparing it to the joint on the opposite side.

Immobilization is nothing more than splinting the dislocation after reduction. You can use any field-expedient material for a splint or you can splint an extremity to the body. The basic guidelines for splinting are—

• Splint above and below the fracture site.

• Pad splints to reduce discomfort.

• Check circulation below the fracture after making each tie on the splint.

To rehabilitate the dislocation, remove the splints after 7 to 14 days. Gradually use the injured joint until fully healed.

—From Survival (Field Manual 21–76)

Athletic Injuries

Tod Schimelpfenig

Living and traveling in the wilderness, carrying a pack, hiking long distances, climbing, and paddling can all cause sprains, strains, and tendinitis. Athletic injuries account for 50 percent of injuries on NOLS courses and are a frequent cause of evacuations.

Sprains, or injuries to ligaments, are categorized as grades one, two, or three. With a grade one injury, ligament fibers are stretched but not torn. A partly torn or badly stretched ligament is a grade two injury. Completely torn ligaments are grade three injuries. Strains are injuries to muscles and tendons. A muscle stretched too far is commonly referred to as a “pull.” A muscle or tendon with torn fibers is a “tear.” A tendon irritated from overuse can become tendinitis.

When faced with an athletic injury, the first responder in the wilderness has to choose between treating the injury in the field—possibly altering the expedition route and timetable to accommodate the patient’s loss of mobility—or evacuation.

We don’t try to diagnose the injury or grade the sprain or the strain. We decide if an injury is usable or not. If usable, we use RICE therapy and may tape for support. If unusable, we immobilize and evacuate.

The most common athletic injuries on NOLS courses are ankle and knee sprains, Achilles tendinitis, and forearm tendinitis. Most of the athletic injuries we experience are minor, but even a moderate ankle sprain can take a week to heal. It is difficult to rest for 7 days without affecting a wilderness trip.

Common Causes of Athletic Injury on NOLS Courses

• Playing games such as hug tag and hacky sack.

• Tripping while walking in camp.

• Stepping over logs.

• Crossing streams, including shallow rock hops.

• Putting on a backpack.

• Lifting a kayak or raft.

• Falling or misstepping while hiking with a pack (on any terrain).

• Falling while skiing with a pack.

• Shoveling snow.

• Bending over to pick up firewood.

General Treatment for Athletic Injuries (RICE)

Athletic injuries are generally treated with RICE: rest, ice, compression, and elevation. Allowing these injuries to heal until they are free of pain, tenderness, and swelling prevents aggravation of the condition. Gently rub the injured area with ice, wrapped in fabric to prevent frostbite, for 20 to 40 minutes every 2 to 4 hours for the first 24 to 48 hours, then allow it to passively warm. Cooling decreases nerve conduction and pain, constricts blood vessels, limits the inflammatory process, and reduces cellular demand for oxygen.

Compression with an Ace bandage helps reduce swelling. Care must be taken when applying the wrap not to exert pressure on an injury that swells dramatically or to cut off blood flow to the fingers or toes.

Elevating the injury above the level of the heart reduces swelling. Nonprescription pain medications such as acetaminophen and ibuprofen may help as well.

Assessment of Athletic Injuries

A thorough assessment includes an evaluation of the mechanism of injury, as well as the signs and symptoms. Knowing the mechanism helps you determine whether the occurrence was sudden and traumatic, indicating a sprain, or whether it was progressive, suggesting an overuse injury.

Signs and symptoms of a sprain include swelling, pain, and discoloration. Point tenderness and obvious deformity suggest a fracture. Ask the patient to try to move the joint through its full range of motion. Painless movement is a good sign. If the patient is able to use or bear weight on the affected limb, and pain and swelling are not severe, he or she can be treated in the field.

Severe pain, the sound of a pop at the time of injury, immediate swelling, and inability to use the joint are signs of a serious sprain, possibly a fracture. This injury should be immobilized and the patient evacuated from the field.

Ankle Sprains

Uneven ground, whether boulder fields in the backcountry or broken pavement in the city, contributes to the likelihood of ankle sprains. Of all ankle sprains, 85 percent are inversion injuries—those in which the foot turns in to the midline of the body and the ankle turns outward. Inversion injuries usually sprain one or more of the ligaments on the outside of the ankle.

Ankle Anatomy. The bones, ligaments, and tendons of the ankle and foot absorb stress and pressure generated by both body weight and activity. They also allow for flexibility and accommodate surface irregularities so that we don’t lose our balance.

Bones. The lower leg bones are the tibia and the fibula. The large bumps on either side of the ankle are the lower ends of these bones—the fibula on the outside, and the tibia on the inside. Immediately under the tibia and fibula lies the talus bone, which sits atop the calcaneus (heel bone). The talus and calcaneus act as a rocker for front-to-back flexibility of the ankle. Without them, we would walk stiff-legged.

In front of the calcaneus lie two smaller bones, the navicular (inside) and the cuboid (outside). They attach to three small bones called the cuneiforms. Anterior to the cuneiforms are five metatarsals, which in turn articulate with the phalanges (toe bones).

Ligaments. Due to the number of bones in the foot, ligaments are many and complex. For simplicity, think of there being a ligament on every exterior surface of every bone, attaching to the adjacent articulating bone.

There are four ligaments commonly associated with ankle sprains. On the inside of the ankle is the large, fan-shaped deltoid ligament jointing the talus, calcaneus, and several of the smaller foot bones to the tibia. Rolling the ankle inward, an eversion sprain, stresses the deltoid ligament. Spraining the deltoid requires considerable force, and due to its size and strength, it is seldom injured. In fact, this ligament is so strong that if a bad twist occurs, it frequently pulls fragments of bone off at its attachment points, causing an avulsion fracture.

On the outside, usually the weaker aspect, three ligaments attach from the fibula to the talus and the calcaneus. Together these three ligaments protect the ankle from turning to the outside.

Muscles and Tendons. Muscles in the lower leg use long tendons to act on the ankle and foot. The calf muscles—the gastrocnemius and soleus—shorten to point the toes. These muscles taper into the largest tendon, the Achilles, which attaches to the back of the calcaneus. The peroneal muscles in the lower leg contract and pull the foot laterally and roll the ankle outward. Muscles in the front of the lower leg turn the foot inward and extend the toes.

Treatment of Ankle Sprains. Sprains should have the standard treatment of rest, ice, compression, and elevation to limit swelling and allow healing. If a severe sprain or a fracture is suspected, immobilize the ankle. Aggressively treating a mild sprain with RICE for the first 24 to 48 hours and letting it rest for a few days may allow a patient to stay in the mountains rather than cut the trip short. A simple method for providing ankle support is to tape the ankle using the basket weave.

Knee Pain

Pain in the knee from overuse can be treated by ceasing the activity causing the discomfort and controlling pain and inflammation with RICE. In the event of a traumatic injury resulting in an unstable knee, splint and evacuate. If the injury is stable and the patient can bear weight, use RICE to control pain and inflammation. If the patient can walk without undue pain, wrap the knee with foamlite for support.

Tendinitis

A tendon is the fibrous cord by which a muscle is attached to a bone. Its construction is similar to that of kernmantle rope, with an outer sheath of tissue enclosing a core of fibers. Some tendons, such as those to the fingers, are long. The activating muscles are in the forearm, but the tendons stretch from the forearm across the wrist to each finger. These tendons are surrounded by a lubricating sheath to assist their movement.

Tendinitis is inflammation of a tendon. When the sheath and the tendon become inflamed, the sheath becomes rough, movement is restricted and painful, and the patient feels a grating of the tendon inside the sheath. Fibers can be torn or, more commonly, irritation from overuse or infection can inflame the sheath, causing pain when the tendon moves. There may be little pain when the tendon is at rest.

Tendons are poorly supplied with blood, so they heal slowly. Tendons are well supplied with nerves, however, which means that an injury will be painful. Tendons can be injured by sudden overloading, but are more frequently injured through overuse. Factors contributing to tendinitis include poor technique, poor equipment, unhealed prior injury, and cool and tight muscles.

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Assessment for Tendinitis

Tendinitis, in contrast to ankle sprains, is a progressive overuse injury, not a traumatic injury. Common sites for tendinitis are the Achilles tendon and the tendons of the forearm. The Achilles, the largest tendon in the body, may fatigue and become inflamed during or following lengthy hikes, especially with significant elevation gain. Boots that break down and place pressure on the tendon can provide enough irritation in one day to initiate inflammation.

Forearm tendinitis is common among canoeists and kayakers. Poor technique and inadequate strength and flexibility contribute to the injury. Similar tendinitis comes with repetitive use of ski poles, ice axes, and ice climbing tools.

Tendinitis may also occur on the front of the foot, usually caused by tightly laced boots or stiff mountaineering boots. The tendons extending the toes become irritated and inflamed. Tendinitis causes swelling, redness, warmth, pain to the touch (or pinch), painful movement, and sounds of friction or grinding (crepitus).

Treatment of Tendinitis

Treat tendinitis with RICE: rest, ice, compression, and elevation. It may be necessary to cease the aggravating activity until the inflammation subsides. Prevent or ease tendinitis of anterior muscles by varying boot lacing. Lace boots more loosely when hiking and more tightly when climbing.

Achilles Tendinitis. To relieve stretch on the Achilles tendon, provide a heel lift. To relieve direct pressure from the boot, place a 6-inch by 1-inch strip of foamlite padding on either side of the Achilles tendon. The placement should take the pressure off without touching the Achilles.

Forearm Tendinitis. Forearm tendinitis is primarily associated with the repetitive motion of paddling. Pay close attention to proper paddling technique. Keep a relaxed, open grip on the paddle. On the forward stroke, keep the wrist in line with the forearm during the pull and push, and avoid crossing the upper arm over the midline of the body.

Other paddling techniques that may help prevent forearm tendinitis include keeping the thumb on the same side of the paddle as the fingers and switching a feathered paddle for an unfeathered paddle. The feathered paddle requires a wrist movement that can sometimes aggravate tendinitis.

Tendinitis of the forearm is treated with RICE. Also, the wrist can be taped to limit movement that aggravates the condition.

Muscle Strains

Muscles can be stretched and torn from overuse or overexertion. Initial treatment is RICE, followed by heat, massage, and gentle stretching. Radiating muscle pain, strong pain at rest, pain secondary to an illness, or pain from a severe trauma mechanism is a reason to evacuate the patient for evaluation by a physician.

Final Thoughts

Errors in technique and inadequate muscular conditioning or warm-up produce injury. Overuse of muscles and joints (when there is no single traumatic event as the cause of injury) generates many of the sprains and strains on NOLS courses.

Jerky movements, excessive force, or an unnecessarily tight grip on the paddle while kayaking contribute to forearm tendinitis. Performing the athletic movements required for difficult rock climbs without warming up or paying attention to balance and form can cause injury. Even the seemingly simple actions of lifting a backpack or boat, stepping over logs, and wading in cold mountain streams can be dangerous.

Steep terrain and wet conditions contribute to injuries. Slippery conditions make it harder to balance and can cause falls. Falls that occur in camp and while hiking are the cause of many athletic injuries. Surprisingly, injuries are just as likely to occur when backcountry travelers are wearing packs as when they are not. Possibly this is because people are more attentive to technique when hiking or skiing with a pack.

You are more likely to be injured when you are tired, cold, dehydrated, rushed, or ill. You’re not thinking as clearly, and your muscles are less flexible and responsive. Injuries happen more frequently in late morning and late afternoon, when dehydration and fatigue reduce awareness and increase clumsiness. Shifting from a three-meal-a-day schedule to breakfast and dinner plus three or four light snacks during the day helps keep your food supply constant.

Haste, often the result of unrealistic timetables, is frequently implicated in accidents. Try to negotiate the more difficult terrain in the morning, when you are fresh. Take rest breaks before difficult sections of a hike or paddle. Stop at the base of the pass, the near side of the river, or the beginning of the boulder field. Drink, eat, and stretch tight muscles. Check equipment for loose gaiters that may trip you and for poorly balanced backpacks.

The sustained activity of life in the wilderness and the need for sudden bursts of power when paddling, skiing, or climbing necessitate physical conditioning prior to a wilderness expedition. A regimen of endurance, flexibility, and muscle strength training will help prevent injuries and promote safety and enjoyment of wilderness activity.

–From NOLS Wilderness Medicine

Wound Care

Tod Schimelpfenig

Closed Wounds

Closed injuries include contusions (bruises) and hematomas. With both, the tissue and blood vessels beneath the epidermis are damaged. Swelling and discoloration occur because blood and plasma leak out of the damaged blood vessels. With contusions, blood is dispersed within the tissues. Hematomas contain a pool of blood—as much as a pint surrounding a major bone fracture. Depending on the amount of blood dispersed, reabsorption can take from 12 hours to several days. In some cases, the blood may have to be drained by a physician to enhance healing.

Treatment for Closed Wounds

A memory aid for treating closed injuries is RICE: rest, ice, compression, and elevation.

Rest. Rest decreases bleeding by allowing clots to form. In the event of a large or deep bruise, extremities can be splinted to decrease motion that may cause newly-formed clots to break away and bleeding to continue.

Ice. Ice causes the blood vessels to constrict, decreasing bleeding. Never apply ice directly to bare skin, as this can cause frostbite. Instead, wrap the ice in fabric of a towel-like thickness before applying to the skin. Ice the wound for 20 to 40 minutes every 2 to 4 hours for the first 24 to 48 hours, then allow the area to passively warm.

Compression. Apply manual pressure or a pressure dressing. When applying a pressure dressing, wrap it snugly enough to stop bleeding but not so tightly that the blood supply is shut off. Check by feeling for a pulse distal to the injured site.

Elevation. Elevate the injury above the level of the heart. Elevation reduces bleeding and swelling by decreasing the blood flow to the injury.

Open Wounds

Open injuries include abrasions, lacerations, puncture wounds, and major traumatic injuries—avulsions, amputations, and crushing wounds.

Abrasions. Abrasions occur when the epidermis and part of the dermis are rubbed off. These injuries are commonly called “road rash” or “rug burns.” They usually bleed very little but are painful and may be contaminated with debris.

Abrasions heal more quickly if treated with ointment and covered with a semiocclusive or occlusive dressing.

Lacerations. Lacerations are cuts produced by sharp objects. The cut may penetrate all the layers of the skin, and the edges may be straight or jagged. If long and deep enough to cause the skin to gap more than ½ inch (1 cm), lacerations may require sutures. Sutures, a task for a physician, are also indicated if the cut is on the face or hands or over a joint, or if it severs a tendon, ligament, or blood vessel. Tendons and ligaments must be sutured together to heal properly. Lacerations on the hands or over a joint may be sutured to prevent the wound from being continually pulled apart by movement. Lacerations on the face are usually sutured to decrease scarring.

Puncture Wounds. Puncture wounds are caused by pointed objects. Although the skin around a puncture wound remains closed and there is little external bleeding, the object may have penetrated an artery or organ, causing internal bleeding.

If an impaled object is through the cheek and causing an airway obstruction, it must be removed to allow the patient to breathe. Otherwise, leave impalement in place. Removing the object may cause more soft tissue injury and increase bleeding by releasing pressure on compressed blood vessels. Stabilize and prevent movement of impaled objects with protective padding. Some people argue for removal of impaled objects in situations of long or difficult transportation. This advice usually applies to objects in the extremities, not those in the chest, head, abdomen, or eye. Check with your physician advisor for guidance on this question.

Tetanus is a rare but serious complication. Although tetanus may be more likely to occur in a farm or ranch environment than on a “clean” mountainside, it is a good idea to make sure your tetanus booster is up-to-date before you take off into the backcountry. Tetanus boosters should be given at least every 10 years.

Treatment for Open Wounds

The principles for treating open wounds are to control bleeding, clean and dress the wound, and monitor for infection.

Control Bleeding. Controlling bleeding is the first priority when treating open wounds. Death can come quickly to a patient with a tear in a major blood vessel. There are four methods for controlling bleeding. The most effective—direct pressure and elevation—will stop most bleeding when used in combination. Pressure points and tourniquets are also used.

Direct Pressure. The best method for controlling bleeding is to apply pressure over the wound site. Using your hand and a piece of wadded fabric—preferably sterile gauze—apply direct pressure to the wound. Be sure to wear rubber or latex gloves or place your hand in a plastic bag. If the wound is large, you may need to pack the open area with gauze before applying pressure. Maintain pressure for 5 minutes, then slowly release. If the bleeding resumes, apply pressure for 15 minutes.

Elevation. As with closed injuries, the combination of splinting, a pressure dressing, and elevation will help decrease the bleeding. Direct pressure and elevation control almost all bleeding. In fact, it is unusual for a wound to require the first responder to utilize pressure points or a tourniquet.

Pressure Points. Pressure points are areas on the body where arteries lie close to the skin and over bones. Pressure applied to the artery at one of these points can slow or stop the flow of blood in that artery, thereby reducing bleeding at the site of the injury. Pressure on these points is rarely effective by itself and is usually applied in conjunction with other techniques.

Tourniquets. Apply a tourniquet only as a last resort, when no other method will stop the bleeding. Tourniquets completely stop the blood flow, and if the tourniquet is left on for more than a few hours, there is a chance that the tissue distal to the tourniquet will die and the extremity may require amputation.

Clean the Wound. Consider any wound, even a minor finger cut or a blister, as potentially infected. On wilderness expeditions wound cleaning is a priority. When you clean a wound, eliminate as much potentially infectious bacteria and debris as possible without further damaging the skin.

Wash Your Hands and Put on Gloves.

Wash your hands. Use soap and water to prevent contamination of the wound. Put on rubber or latex gloves.

Scrub and Irrigate the Wound. Scrub the skin around the wound, being careful not to flush debris into the wound. Clip long hair, but don’t shave the skin. Then scrub or irrigate an open wound for at least 3 minutes with water that has been disinfected with chlorination or iodination, filtering, or water that has been boiled and cooled. Many wounds can be cleaned simply by irrigating with clean water. If the wound is obviously dirty or contaminated, a 1 percent povidoneiodine (usually one part 10 percent povidone-iodine diluted with 10 parts water to approximate the color of dark tea) is a suitable irrigation solution. Medical science tells us that the volume of water is the most important factor in cleaning the wound. At NOLS, we carry 35cc syringes in the first aid kit for pressure-irrigating wounds. Plastic bags or water bottles with pinholes can work as improvised irrigation syringes. Try to remove all debris even if this requires some painful scrubbing. Remove large pieces of debris with tweezers that have been boiled or cleaned with povidone-iodine.

Rinse with Disinfected Water. After cleaning the wound, rinse off the solution with liberal amounts of disinfected water. Check for further bleeding—you may need to apply direct pressure again if blood clots were broken loose during the cleaning process.

Dress and Bandage the Wound. Dressings are sterile gauze placed directly over the wound; bandages hold the dressing in place. Both come in many shapes and sizes. Semiocclusive (Telfa) or occlusive (Second Skin, Opsite, Tegaderm) dressings promote healing by keeping the area moist. Ointments (such as Polysporin or Bacitracin) serve the same purpose. Dry dressings that adhere to the wound impede the healing process.

Next, apply an antibiotic ointment. The ointment should be applied to the dressing rather than directly to the wound. This avoids contaminating the remaining antibiotic in the tube or bottle. Apply the bandage neatly and in such a way that blood flow distal to the injured area is not impaired. After applying the bandage, check the pulse distal to the injury.

Do not close wound edges until the wound has been thoroughly cleaned. Generally, the edges of a small wound will come together on their own. If the skin is stretched apart, butterfly bandages or Steri-strips can hold the edges together. If the injury is over a joint, the extremity may require splinting to prevent the edges from pulling apart. Highly contaminated wounds should be packed open.

Physicians don’t agree on how long a wound can be kept open until it is stitched. A wound that will not close on its own or with a bandage can usually be stitched even a day or two later. The need to use sutures to close a wound does not, by itself, create an emergency. Reasons to expedite an evacuation for an open wound include obvious dirt or contamination; animal bites; wounds that open joint spaces; established infection; wounds from a crushing mechanism; any laceration to a cosmetic area, especially the face; wounds with a lot of dead tissue on the edges or in the wound itself; and wounds that obviously need surgical care, such as open fractures and very deep, gaping lacerations.

Animal bites are a concern for infection because of the bacterial flora in animal mouths and the crushing, penetrating, and tearing mechanism of the wounds. In North America, wild animal attacks, while dramatic and often highlighted in the press, are unusual. Worldwide they are believed to be more common, but the evidence is anecdotal, not scientific.

After the Bandage Is Applied. Check circulation, sensation, and movement of the body part distal to the injury. Can the patient tell you where you are touching? Can he or she flex and extend the extremity? Is the area distal to the injury pink and warm, indicating good blood perfusion? Any negative answers to these questions may indicate nerve, artery, or tendon damage that will require evacuating the patient.

If a dressing becomes soaked with blood, leave it in place and apply additional dressings. Removing the dressing disturbs the blood clots that are forming. After bleeding has been controlled, dressings should be changed daily and the injured area checked for signs of infection.

Infection

The newspapers and television media occasionally tell dramatic tales of aggressive and resistant wound infections and “flesh-eating bacteria.” But on a daily basis outside the wilderness, we give little thought to the potential for wounds to be contaminated and colonized by bacteria. Before modern medicine understood infection and practiced clean wound care, infections were common and dangerous. In some environments, such as the tropics, they remain quite common and serious. In the wilderness we have less than ideal circumstances for cleaning wounds, but our efforts are essential in preventing wound infection.

Assessment for Infection. Redness, swelling, pus, heat, and pain at the site; faint red streaks radiating from the site; fever; chills; and swollen lymph nodes are all signs of infection.

It may be difficult to decide if local swelling, without an obvious wound, is due to a muscle strain, bug bite, or infection. The possibility of a deep infection is a concern. History may help rule out the muscle strain.

The four cardinal signs of a soft tissue infection are: redness, swelling, warmth, and local pain. The progression in a wound to increased pain, warmth, increased soft tissue swelling, and expansion of redness over 18 to 24 hours suggests infection. Drawing a circle around the swollen area with a pen will help you determine if the infection is spreading or resolving.

Treatment of Infection. An infection that is localized to the site of the injury can be treated in the field. If the edges of the wound are closed, pull them apart and soak the area in warm antiseptic solution or warm water for 20 to 30 minutes three to four times a day. If the infection starts to spread—as evidenced by fever, chills, swollen lymph nodes, or faint red streaks radiating from the site—or if the wound cannot be opened to drain, evacuate the patient. If you have oral antibiotics and a protocol for their use, start them early in suspected wound infections.

–From NOLS Wilderness Medicine

Treatment of Wounds and Skin Ailments

U.S. Army

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.

By taking proper care of the wound you can reduce further contamination and promote healing. Clean the wound as soon as possible after it occurs by—

• 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.

• Thoroughly cleaning the skin around the wound.

• Rinsing (not scrubbing) the wound with large amounts of water under pressure. You can use fresh urine if water is not available.

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. Change the dressing daily to check for infection.

If a wound is gaping, you can bring the edges together with adhesive tape cut in the form of a “butterfly” or “dumbbell.”

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Butterfly closure.

In a survival situation, some degree of wound infection is almost inevitable. Pain, swelling, and redness around the wound, increased temperature, and pus in the wound or on the dressing indicate infection is present.

To treat an infected wound—

• Place a warm, moist compress directly on the infected wound. Change the compress when it cools, keeping a warm compress on the wound for a total of 30 minutes. Apply the compresses three or four times daily.

• Drain the wound. Open and gently probe the infected wound with a sterile instrument.

• Dress and bandage the wound.

• Drink a lot of water.

Continue this treatment daily until all signs of infection have disappeared.

If you do not have antibiotics and the wound has become severely infected, does not heal, and ordinary debridement is impossible, consider maggot therapy, despite its hazards:

• Expose the wound to flies for one day and then cover it.

• Check daily for maggots.

• Once maggots develop, keep wound covered but check daily.

• Remove all maggots when they have cleaned out all dead tissue and before they start on healthy tissue. Increased pain and bright red blood in the wound indicate that the maggots have reached healthy tissue.

• Flush the wound repeatedly with sterile water or fresh urine to remove the maggots.

• Check the wound every four hours for several days to ensure all maggots have been removed.

• Bandage the wound and treat it as any other wound. It should heal normally.

Skin Diseases and Ailments

Although boils, fungal infections, and rashes rarely develop into a serious health problem, they cause discomfort and you should treat them.

Boils

Apply warm compresses to bring the boil to a head. Then open the boil using a sterile knife, wire, needle, or similar item. Thoroughly clean out the pus using soap and water. Cover the boil site, checking it periodically to ensure no further infection develops.

Fungal Infections

Keep the skin clean and dry, and expose the infected area to as much sunlight as possible. Do not scratch the affected area. During the Southeast Asian conflict, soldiers used anti-fungal powders, lye soap, chlorine bleach, alcohol, vinegar, concentrated salt water, and iodine to treat fungal infections with varying degrees of success. As with any “unorthodox” method of treatment, use it with caution.

Rashes

To treat a skin rash effectively, first determine what is causing it. This determination may be difficult even in the best of situations. Observe the following rules to treat rashes:

• If it is moist, keep it dry.

• If it is dry, keep it moist.

• Do not scratch it.

Use a compress of vinegar or tannic acid derived from tea or from boiling acorns or the bark of a hardwood tree to dry weeping rashes. Keep dry rashes moist by rubbing a small amount of rendered animal fat or grease on the affected area.

Remember, treat rashes as open wounds and clean and dress them daily. There are many substances available to survivors in the wild or in captivity for use as antiseptics to treat wounds:

Iodine tablets. Use 5 to 15 tablets in a liter of water to produce a good rinse for wounds during healing.

Garlic. Rub it on a wound or boil it to extract the oils and use the water to rinse the affected area.

Salt water. Use 2 to 3 tablespoons per liter of water to kill bacteria.

Bee honey. Use it straight or dissolved in water.

Sphagnum moss. Found in boggy areas worldwide, it is a natural source of iodine. Use as a dressing.

Again, use noncommercially prepared materials with caution.

—From Survival (Field Manual 21–76)