Wilderness Protocols Flashcards
Treatment guidelines for situations where a delay in treatment will result in unacceptable risk to the patient and rescuers.
Describe the treatment for anaphylaxis.
PROP
Administer 0.3mg of Epinephrine
Follow up with 25-50mg Diphenhydramine every 6 hours
Evacuation
Consider 40-60mg Prednisone up to 5 days for prolonged evacuation
Diphenhydramine
An antihistamine used to relieve symptoms of allergies, hay fever, and the common cold.
How can wound infection be prevented?
Coach good self-care.
Apply hand balm daily to lower likelihood of skin drying and cracking on hands.
Daily self-body checks.
Daily checks of hands and feet by guide/leader/instructor.
Compare/contrast the treatment guidelines for low-risk wounds, cosmetic/functional risk wounds, and high-risk wounds.
All Wounds –
Clean surrounding skin thoroughly.
Irrigate with copious amounts of clean water or 1% povidone iodine solution.
Explore wound and remove foreign bodies.
Cut away dead tissue.
Remove impaled object after surface debris is removed.
Cosmetic/Functional Risk – early evacuation is ideal if it is safe to perform. The desire for plastic surgeon does not warrant a high-risk evacuation.
High Risk Wound – early evacuation, consider antibiotics, contact health department if the wound is an animal bite.
Describe the functions of the immune system.
Protect against infection and heal damaged tissue.
Compare/contrast superficial, partial thickness, and full thickness burns.
Superficial – Intact sensation, red, inflamed, no blisters.
Partial Thickness – Intact sensation, red, inflamed, blisters.
Full Thickness – Reduced sensation, no blisters, black or leathery.
Which medication is the definitive treatment for anaphylaxis (a.k.a. “the fix”)?
Epinephrine
Describe the normal healing process following a soft tissue injury.
Within Minutes – bleeding and clotting.
0-2 Days – clots dry and form a scab at surface, inflammation forms a protective barrier underneath.
2-7 Days – wounds drain flushing out debris/bacteria; edges draw closer.
7+ Days – protective barrier gets absorbed.
List the medications used to treat anaphylaxis including dosages, routes of administration, and some common side effects.
When does a soft tissue injury become a high-risk problem requiring emergent evacuation?
When s/sx of systemic infection become evident.
Sun exposure and hot water burns are the main cause of burns in the field. Describe precautions one can take to prevent these types of burns (both self and group).
Create a welcoming atmosphere and self-care expectation.
Remind each other to put sunscreen on, cover areas with clothing (hats, buffs, gloves, etc.).
Coach heavily in the kitchen regarding proper camp stove practices (i.e., dynamic position, pouring hot water into bottles, and establishing safety zones in the kitchen).
Describe the treatment principles for wound infections.
Treat what you see and keep it from progressing!
Get rid of pus – incise and drain the wound.
Hot soaks 3-4 x day.
Irrigate and dress multiple times a day allowing for drainage.
Oral Antibiotics.
Evac if not field manageable.
Describe the treatment for a local immune reaction.
Topical steroids (i.e., Hydrocortisone…aka Anti-Itch Cream), dilute or remove the foreign substance, consider oral antihistamine.
Epinephrine
The synthetic form of the hormone adrenalin. Used to constrict blood vessels and dilate airway tubes. The fix for anaphylaxis.
What signs/symptoms should prompt a rescuer to initiate the Anaphylaxis protocol?
Any s/sx of a critical system problem (respiratory distress, facial swelling, tight/scratchy throat, nausea, vomiting, diarrhea, vascular shock/volume shock, altered mental status).
Anaphylaxis
Severe systemic allergic reaction capable of causing generalized edema (swelling), vascular and volume shock, and respiratory distress secondary to upper airway swelling and lower airway constriction.
Describe precautions one can take to prevent blisters (both self and group).
Create an atmosphere of checking feet as soon as something feels uncomfortable- addressing hot spots early. Stop the friction as soon as hot spot is detected. Try different methods and stick with one that works the best for that hot spot. Daily foot checks to monitor condition of feet.
Describe the treatment for a mild allergic reaction.
Oral antihistamine (i.e., Diphenhydramine, cetirizine) and monitor for anaphylaxis.
How should amputations be managed?
Wrap the amputated part in sterile, moist dressings. Transport the amputated part with the patient and keep it cool. Control bleeding with direct pressure or tourniquet. Do not complete partial amputations.
Splint the extremity. Perform an emergency evacuation.
May the anaphylaxis protocol be used in a front country setting? If yes, what drugs are permitted to be administered?
Yes
0.3mg of Epinephrine via autoinjector.
What is the problem with using wound closure strips/butterflies in the field?
It draws the surface of the skin together before the inside has healed forming a pocket that cannot drain debris and bacteria.
Wilderness Protocol
An expanded scope of practice that can be used in the wilderness context.
Compare/contrast a local reaction, mild allergic reaction, and anaphylaxis.
Local Reaction = normal immune response. May see rash, swelling, itching at site of exposure.
Mild Allergic Reaction = Slight over reaction of the immune system. S/Sx may include the above plus generalized hives/itching. Normal mental status. No facial swelling. No tight/scratchy throat. No respiratory distress. No signs of shock.
Anaphylaxis = Life threatening (critical system problem) over reaction of the immune system. S/Sx may include that of local and mild reaction plus S/Sx of a critical system problem (altered mental status, facial swelling, tight/scratchy throat, vascular/volume shock, respiratory distress, nausea, vomiting, diarrhea).
Cetirizine
An antihistamine used to relieve symptoms of allergies, hay fever, and the common cold.
Describe the protocol for impaled objects/foreign bodies.
Remove impaled object unless…
- It’s in globe of eye.
- Will cause significant problems:
- Tissue destruction.
- Severe bleeding that cannot be controlled.
- Unmanageable pain.
Describe the wound cleaning process.
Clean surrounding skin thoroughly.
Irrigate with copious amounts of clean water or 1% povidone iodine solution.
Explore wound and remove foreign bodies.
Cut away dead tissue.
Remove impaled object after surface debris is removed.
Compare/contrast low risk, cosmetic/function risk, and high-risk wounds. Give an example for each.
Low Risk = Shallow wound (don’t see white/shiny), clean, straight, no devitalized (weakened) tissue. Example = shallow kitchen knife laceration.
High Risk = deep wound (see white/shiny), involves critical system, contaminated, crushed, devitalized tissue, open fractures, deep punctures, bite wounds. Example: dog bite, stick impalement.
Cosmetic or Functional Risk = Low risk wound, BUT anticipated problem = unacceptable scar formation and/or functional impairment. Example: laceration on face.
Prednisone
A corticosteroid medication used to suppress the immune system and decrease inflammation in conditions such as asthma, autoimmune, and inflammatory diseases.
When would you drain a blister? Why? Describe treatment principles for this process.
If it appears to be infected or is impacting travel. Unroof the blister, drain, remove the dead skin, and dress with a thin layer of antibiotic ointment or 2nd skin. Use the techniques above to prevent friction.
Wilderness Context
A situation where access to definitive medical care is delayed by distance, logistics, or danger.
What other generic treatment should be included in wound care? Hint: what promotes healing and compensation?
Maintain calorie and water intake, maintain body temperature, PROP.
Describe the main functions of the skin.
Thermoregulation, Fluid Retention, & Protection.
Describe how to differentiate between a shallow and deep wound. Hint: think color.
If you see white/shiny tissue it is deep.
Describe the progression one might see for a local wound infection progressing into a system infection.
- Redness expands, red streaks develop from the wound site and spread towards the heart.
- Not feeling well.
- Fever.
- Vascular and Volume Shock.
Describe the treatment principles for hot spots and blisters.
Stop the friction. Figure out and use what works for area (i.e., moleskin, a donut dressing, 2nd skin, mole foam, smooth tape).
Unroof blisters that look infected.
Drain if the blister prevents travel.
Dress as you would a partial-thickness burn.
How should amputations be managed?
Wrap the amputated part in sterile, moist dressings. Transport the amputated part with the patient and keep it cool. Control bleeding with direct pressure or tourniquet. Do not complete partial amputations.
Splint the extremity. Perform an emergency evacuation.
When does anaphylaxis become a high-risk problem requiring emergent evacuation?
Persistent abnormal mental status, incomplete response to treatment, the patient is getting worse, a second injection is needed.
Describe the treatment principles for burns.
Cool immediately and continue for several minutes. Limit to what is necessary if burn >10% BSA (Body Surface Area).
Irrigate with water or 1% PI solution.
Remove dead skin.
Decompress (open) blisters only if necessary.
Dress to prevent contamination and evaporative cooling; moist dressing with vapor barrier on top (i.e., plastic bag). Limit moist dressings if burn >10% BSA.
Monitor for infection.
List some of the complications associated with large body surface area burns.
Volume Shock, Hypothermia, Pain, & Infection.
What are the signs/symptoms of a localized wound infection?
Increasing redness, pain, warmth, and swelling. Theses s/sx typically develop 2-4 days after injury
Presence of pus (draining or abscess).
Describe how you would dress/bandage a wound after you have gone through the wound cleaning wilderness protocol.
Use the following techniques to prevent contamination.
For abrasions, ruptured blisters, and very shallow lacerations:
- Option 1: apply moist gauze pad over the site with an occlusive dressing (i.e., Tagaderm, plastic bag) to prevent contamination.
- Option 2: Apply thin layer of petroleum or beeswax-based product (i.e., hand salve) and cover (Bandaid, gauze/tape, gauze/Coban, etc.). Option 3: Apply 2nd skin over area and cover with clean dressing.
For deep Lacerations – pack moist and cover with clean dressing. Keep warm. Monitor. Clean and Re dress frequently (multiple times a day if needed; at least twice a day).
