Wilderness Medicine -- Backcountry First Aid (excellent article!)

[Take-a-knee]

It is not easy to tape and ankle so that it will do any good if you've never done it or have experience with it.

True, but a "U" or two of duct tape down each side of a boot and under the heel, with a few wraps around the top of the boot to secure it will do along way towards stabilizing a weak ankle. Done it many, many times for guys with a bad ankle before a jump. Don't recall it ever going bad.

 

[5MilesBack]

I played college football and they wouldn't tape our ankles with pre-wrap. Had to shave, unless you wanted to pull the hair with tape, and tape right to the skin. Required to tape them to practice. Pre-wrap just slips and doesn't allow you to get a good tape job.

You should have just learned to do your own. If done right, the tape job won't slip with pre-wrap. I taped both my ankles before every single practice and every game for over 10 years without any issues. Still used to shave them regardless because the hair would also get into the prewrap. Can't imagine having to unpeel all that tape every time, and the tape itself was pretty harsh on the skin.

 

[Backpack Hunter]

I played college basketball, and a short stint professionally. They never taped my ankles without prewrap, weird.

 

[Ironman8]

College baseball here and always used prewrap (wrists).

 

[KH_bowfly]

College hockey here. Not too many ankle injuries, but a couple bad sprains and they were wrapped with pre-wrap. Also took an athletic training class and they taught us with pre-wrap, but didn't say anything about it really being a good or bad idea that I remember.

 

[Darktimber]

I really liked the article and some of this information could be critical. Unfortunately, when you are in the wilderness, this information is not readily available. So, I copied the article, placed a few definitions in brackets, like hemostasis for example, took out side comments, and pasted it in the Notes App on my iPhone. It could be posted into other apps, like Evernote, etc. I have been in cases where people had infected wounds or altitude sickness and I wasn't sure the correct way to handle the situation. It may be too long of a post here and I apologize if so. However, I thought others may want to copy and paste it to their mobile device, or print it, so they will have it in the field.


Head and spine injuries
A patient with a spinal injury should be stabilized but probably not moved until a search-and-rescue team with proper training and equipment has arrived. A patient with head injuries with loss of consciousness may need to be evacuated.

Closed extremity injuries
Any constricting bands (rings) should be removed. Injuries of the shoulder and arm usually can be treated with a sling or by pinning the sleeve of a long sleeve to the shirt in the chest area. Immobilizing the arm against the chest wall makes a very good splint. Lower-extremity fractures obviously make self-evacuation difficult. These can be splinted with a sleeping pad wrapped around the leg and then blown up, if this type of pad is available. Splints of any type should be well padded. All extremity injuries should be repeatedly assessed for proper circulation, sensation, and movement.

Open wounds
Wound hemostasis [stopping flow of blood] can be achieved by direct pressure in most situations. Pressure points are no longer recommended. Tourniquets are recommended as the primary intervention to control life-threatening arterial bleeding. A tourniquet should be at least 4 cm wide, and should be used with a windless device of some sort (otherwise sufficient pressure cannot be achieved to overcome arterial pressure). A standard belt cannot be pulled tight enough to overcome arterial flow. Most limbs can tolerate up to 6 hours of ischemia [inadequate blood supply]. Hemostatic material can be carried in a first-aid kit to achieve hemostasis in areas not amenable to direct pressure or tourniquets, such as the neck. Impregnated gauze is the most widely used substance.

An open wound should be cleaned as soon as possible to reduce the risk of infection. Wounds should be cleaned by irrigation under pressure [spray]. Potable water is adequate for irrigation; sterile water is not necessary. Clean and even dirty wounds can probably be safely closed in the field after thorough irrigation. Large or contaminated wounds (a wound impregnated with organic material, or a wound already infected) should be left open, packed with wet-to-dry dressings, and allowed to close by secondary intention or with delayed primary closure. Of course, sterile techniques are impossible in a wilderness setting, but primary closure with sutures, staples, wound closure strips, or cyanoacrylate tissue adhesive [medical super glue] is usually feasible after the wound has been thoroughly irrigated. Large and deep wounds should be irrigated and packed open with a sterile dressing, to be closed later in the ED. Weight and size of suture or staple kits are a problem, so wound closure strips and tissue adhesive may be more practical to carry in a first-aid kit.

Burns
The burning process should be stopped by immediately cooling the burn site with water and continuing for at least 30 minutes. Clothing and constricting bands should be removed. Rings should be removed, even if the hands are not injured, because subsequent edema [watery fluid collecting in tissues of the body] may cause problems. If the face is burned, the airway has to be assessed. Size of the burn should be estimated using the “rule of nines” or using the patient’s palm and fingers as an estimate of approximately 1% of total body surface area. The burn should be washed and it may be covered with a gel dressing, a topical antibiotic, or honey. Covering wounds reduces pain and evaporative fluid losses.

Hydrating the patient is critical. Elevate, and have the patient gently and regularly move burned areas to reduce edema. Emergency evacuation is important for burns of more than 10% of body surface area; deep facial burns; if there are signs of airway injury; deep burns to hands or genitals; or circumferential burns.

Acute Chest Pain
The Wilderness Medical Society’s recommendation is to give 4 tablets (81 mg chewable) aspirin immediately and then once daily until the patient is evacuated to an ED. Nitroglycerin 0.4 mg tablets may be given sublingually [beneath the tongue] every 10 minutes if the radial pulse is palpable [able to be felt] in a standing position and there are no signs of hypotension [abnormally low blood pressure]. Nitroglycerin reduces pain and relieves pulmonary edema. Clopidogrel, a platelet inhibitor, is given as an initial loading dose of 300 mg, followed by 75 mg daily until evacuation to the ED. The beta-blockers metoprolol or atenolol (25 mg) are given every 6 hours, beginning 30 minutes after onset of chest pain and repeated every 6 hours even if pain improves. Beta-blockers should not be given if heart rate is less than 60 beats per minute; the pulse is not palpable in a standing position; or if the patient is short of breath or wheezing. When preparing a first-aid kit, however, weight and size and expiration dates of multiple medicines must be considered carefully.

Patients should be instructed in the first minutes of chest pain to cough if they feel like they are about to faint. Coughing repeatedly and deeply may prevent loss of consciousness during episodes of bradycardia [slow heart action] or ventricular tachycardia [fast heart rate]. Resting the patient is ideal, but rapid evacuation to an ED is important. If care from emergency medical services is not practical because of location and remoteness, the patient may need to self-evacuate by walking slowly.

Altitude Illness
Travel to elevations above 8200 feet is associated with risk of 1 or more forms of acute altitude illness: acute mountain sickness (AMS), high-altitude pulmonary edema (HAPE), and high-altitude cerebral edema (HACE). Symptoms of AMS are nonspecific and may be difficult to differentiate from viral illness, but include headache plus 1 or more of the following symptoms: nausea/vomiting, fatigue, lassitude, dizziness, and difficulty sleeping. If symptoms are mild, patients may remain at their current altitude and use nonopiate analgesics for headache and antiemetics [drug effective against vomiting and nausea - typically used to treat motion sickness] for gastrointestinal symptoms.

Descent to lower altitudes (900 to 3000 feet), however, remains the most effective treatment. If symptoms are moderate in severity or progressing, or neurologic symptoms develop (ataxia [loss of full control of bodily movements], altered mental status, or severe lassitude [physical or mental weariness]), the patient may have HACE and should descend in elevation immediately. Dexamethasone should be administered (intravenous, intramuscular, or by mouth) as 8 mg loading dose followed by 4 mg every 6 hours until symptoms resolve. The pediatric dose is 0.15 mg/kg/dose every 6 hours.

Cold injury and illness
Hypothermia should be treated by removing the patient from wind and, if possible, removing wet clothes. The patient should be given as much insulation as possible with such items as double sleeping bags, coats, and insulating pads under them, and, if possible, wrapped in a foil emergency blanket, tarp, tent, or other waterproof covering to prevent convective and conductive heat loss. Hot water bottles may be placed inside the wrap to provide added heat, but generally having another person inside the wrap is not helpful. More rapid warming may induce ventricular fibrillation [a heart rhythm problem that occurs when the heart beats with rapid, erratic electrical impulses causing chambers in your heart to quiver uselessly, instead of pumping blood].

Frostbite should be treated with skin-to-skin warming if it appears superficial; that is, if the skin is pale but the underlying tissue is still soft and pliable. If deep frostbite is suspected because the skin is white and hard, the patient should be evacuated immediately. Patients with frostbitten feet may self-evacuate. All patients with deep or superficial frostbite should be given ibuprofen to inhibit thromboxane production and care should be taken not to allow thawing and then refreezing because this causes much more severe tissue damage.

Heat illness
Heat illness ranges from mild symptoms such as heat cramps (widespread muscle cramps) and heat syncope (transient loss of consciousness with rapid spontaneous return to consciousness) to heat exhaustion (with sensation of intense thirst, weakness, anxiety, and dizziness), and then to heat stroke (severe heat illness associated with core temperature greater than 104°F, altered mental status, seizures, and coma). Children with a decreased thirst mechanism and less active sweat glands are more prone to heat illness.

Obviously, high environmental temperature and humidity are predisposing environmental factors that increase the risk of developing heat illness. Heat illness is more easily prevented than treated in the field. Wetting the patient, removing to shade, fanning, and giving cold drinks are helpful. If the patient has mental status changes, immediate evacuation is indicated. Continued hydration should be done awaiting evacuation.

Animal bites
Rattlesnake bites may not involve envenomation [venom is injected] in as many as 20% to 30% of bites. Because rattlesnake venom is basically made up of digestive enzymes, when a patient is envenomated, rapid pain and swelling ensues. Any restrictive clothing or rings should be removed; the extremity should be immobilized and maintained at the level of the heart as possible; and the patient should be evacuated to an ED. Commercially available “rattlesnake bite kits” are dangerous and should never be used.

Bat bites should always be treated as a rabies exposure. Bats have extremely small teeth, and a wound may not be easily visible. The wound should be washed thoroughly to reduce viral inoculum, and the patient should be immediately evacuated to an ED for administration of rabies immune globulin and rabies vaccine.

Plant dermatitis
Poison ivy and poison oak are common plant-induced dermatoses in North America caused by exposure to the plant resin urushiol. This resin is rapidly absorbed and binds to subcutaneous fat. Therefore, washing must be done in the first 10 minutes to be effective. Topical steroids applied in the first few hours after exposure may have some efficacy, but once the dermatitis has appeared, oral prednisone is indicated at a dose of 1 mg/kg/day (maximum dose, 60 mg/day) for 14 days and then tapered by 10 mg every other day.7

Foot blisters
Foot blisters are the most common injury faced in outdoor settings. Friction between the feet, socks, and shoes causes shearing between the stratum spinosum and overlying layers of skin. Hydrostatic forces cause the space to fill with plasma-like fluid. Pain can then cause abnormal gait patterns, which can lead to secondary overuse injuries. Foot blisters often can be prevented by wearing properly fitting shoes or boots, which are “broken in,” as well as wearing polyester or acrylic socks (that wick moisture away from the feet) under wool socks, and aggressively treating “hot spots” by taping with duct tape, moleskin, and hydrocolloid or hydrogel adhesive bandages. Blisters larger than 5 mm should be drained with sterile technique, by puncturing at the base and leaving the roof intact. This improves pain control and also reduces complications and risk of secondary infection. An antibiotic ointment may be applied and then the wound covered with a hydrocolloid or hydrogel patch or moleskin.

Ankle sprains
Ankle sprains are among the more common injuries in the wilderness. They can be difficult to deal with when one is far from a paved road. An ankle sprain may be taped to give enough support to allow a patient to self-evacuate. A durable tape is best. Duct tape can be used but it is difficult to remove and wrinkles in the tape can cause blisters. Cloth tape is the usual tape used, but it sticks poorly to skin, so the foot and ankle may be wrapped with “prewrap.” This allows the tape to stick well and be removed easily.


First-aid kits
A kit for a day hike, an extended backpacking trip, or a trip to a foreign country will obviously vary in content, size, and weight. The following supplies are recommended for any basic kit, based on data from what is actually used in the field:

· Equipment. Disposable nonlatex gloves; irrigating syringe; small scissors; tweezers; several safety pins; optional small bottle of sterile eyewash (for irrigating wounds); alcohol swabs (for cleaning equipment); small notebook and pencil; foil emergency blanket; and aluminum foam splint.

· Dressings and wound care. Twelve adhesive bandages; roll of 2-inch cloth tape and prewrap for ankle sprains; roll of 2-inch paper tape; duct tape; roll of 3-inch gauze; 3-inch elastic bandage; moleskin; second skin dressings; transparent skin dressings; sterile 4-inch by 4-inch pads; wound closure strips; and tissue adhesive.

· Medications. Ibuprofen; aspirin; acetaminophen; antibiotic ointment; antihistamine; steroid cream; tincture of benzoin (to assist with taping); optional sublingual nitroglycerine tablets; epinephrine auto-injector; albuterol metered-dose inhaler.