Wilderness Protocols

Question 1

Describe the treatment for anaphylaxis.

Answer 1

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

Question 2

Diphenhydramine

Answer 2

An antihistamine used to relieve symptoms of allergies, hay fever, and the common cold.

Question 3

How can wound infection be prevented?

Answer 3

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.

Question 4

Compare/contrast the treatment guidelines for low-risk wounds, cosmetic/functional risk wounds, and high-risk wounds.

Answer 4

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.

Question 5

Describe the functions of the immune system.

Answer 5

Protect against infection and heal damaged tissue.

Question 6

Compare/contrast superficial, partial thickness, and full thickness burns.

Answer 6

Superficial – Intact sensation, red, inflamed, no blisters.

Partial Thickness – Intact sensation, red, inflamed, blisters.

Full Thickness – Reduced sensation, no blisters, black or leathery.

Question 7

Which medication is the definitive treatment for anaphylaxis (a.k.a. “the fix”)?

Answer 7

Epinephrine

Question 8

Describe the normal healing process following a soft tissue injury.

Answer 8

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.

Question 9

List the medications used to treat anaphylaxis including dosages, routes of administration, and some common side effects.

Answer 9

Question 10

When does a soft tissue injury become a high-risk problem requiring emergent evacuation?

Answer 10

When s/sx of systemic infection become evident.

Question 11

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).

Answer 11

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).

Question 12

Describe the treatment principles for wound infections.

Answer 12

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.

Question 13

Describe the treatment for a local immune reaction.

Answer 13

Topical steroids (i.e., Hydrocortisone…aka Anti-Itch Cream), dilute or remove the foreign substance, consider oral antihistamine.

Question 14

Epinephrine

Answer 14

The synthetic form of the hormone adrenalin. Used to constrict blood vessels and dilate airway tubes. The fix for anaphylaxis.

Question 15

What signs/symptoms should prompt a rescuer to initiate the Anaphylaxis protocol?

Answer 15

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).

Question 16

Anaphylaxis

Answer 16

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.

Question 17

Describe precautions one can take to prevent blisters (both self and group).

Answer 17

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.

Question 18

Describe the treatment for a mild allergic reaction.

Answer 18

Oral antihistamine (i.e., Diphenhydramine, cetirizine) and monitor for anaphylaxis.

Question 19

How should amputations be managed?

Answer 19

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.

Question 20

May the anaphylaxis protocol be used in a front country setting? If yes, what drugs are permitted to be administered?

Answer 20

Yes
0.3mg of Epinephrine via autoinjector.

Question 21

What is the problem with using wound closure strips/butterflies in the field?

Answer 21

It draws the surface of the skin together before the inside has healed forming a pocket that cannot drain debris and bacteria.

Question 22

Wilderness Protocol

Answer 22

An expanded scope of practice that can be used in the wilderness context.

Question 23

Compare/contrast a local reaction, mild allergic reaction, and anaphylaxis.

Answer 23

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).

Question 24

Cetirizine

Answer 24

An antihistamine used to relieve symptoms of allergies, hay fever, and the common cold.

Question 25

Describe the protocol for impaled objects/foreign bodies.

Answer 25

Remove impaled object unless…

• It’s in globe of eye.
• Will cause significant problems:
• Tissue destruction.
• Severe bleeding that cannot be controlled.
• Unmanageable pain.

Question 26

Describe the wound cleaning process.

Answer 26

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.

Question 27

Compare/contrast low risk, cosmetic/function risk, and high-risk wounds. Give an example for each.

Answer 27

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.

Question 28

Prednisone

Answer 28

A corticosteroid medication used to suppress the immune system and decrease inflammation in conditions such as asthma, autoimmune, and inflammatory diseases.

Question 29

When would you drain a blister? Why? Describe treatment principles for this process.

Answer 29

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 2^nd skin. Use the techniques above to prevent friction.

Question 30

Wilderness Context

Answer 30

A situation where access to definitive medical care is delayed by distance, logistics, or danger.

Question 31

What other generic treatment should be included in wound care? Hint: what promotes healing and compensation?

Answer 31

Maintain calorie and water intake, maintain body temperature, PROP.

Question 32

Describe the main functions of the skin.

Answer 32

Thermoregulation, Fluid Retention, & Protection.

Question 33

Describe how to differentiate between a shallow and deep wound. Hint: think color.

Answer 33

If you see white/shiny tissue it is deep.

Question 34

Describe the progression one might see for a local wound infection progressing into a system infection.

Answer 34

1. Redness expands, red streaks develop from the wound site and spread towards the heart.
2. Not feeling well.
3. Fever.
4. Vascular and Volume Shock.

Question 35

Describe the treatment principles for hot spots and blisters.

Answer 35

Stop the friction. Figure out and use what works for area (i.e., moleskin, a donut dressing, 2^nd skin, mole foam, smooth tape).

Unroof blisters that look infected.

Drain if the blister prevents travel.

Dress as you would a partial-thickness burn.

Question 36

How should amputations be managed?

Answer 36

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.

Question 37

When does anaphylaxis become a high-risk problem requiring emergent evacuation?

Answer 37

Persistent abnormal mental status, incomplete response to treatment, the patient is getting worse, a second injection is needed.

Question 38

Describe the treatment principles for burns.

Answer 38

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.

Question 39

List some of the complications associated with large body surface area burns.

Answer 39

Volume Shock, Hypothermia, Pain, & Infection.

Question 40

What are the signs/symptoms of a localized wound infection?

Answer 40

Increasing redness, pain, warmth, and swelling. Theses s/sx typically develop 2-4 days after injury
Presence of pus (draining or abscess).

Question 41

Describe how you would dress/bandage a wound after you have gone through the wound cleaning wilderness protocol.

Answer 41

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 2^nd 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).