Curriculum Updates

Narcan Administration

February 15, 2021

As of recent, the epidemic of opioid overdoses should be familiar to most people. Reports of incidents in wilderness are rare, not entirely zero. Narcan, like the AED, is a valuable skill for both wilderness and emergency medical providers to have. Commonly administered via intranasal spray (2.0 – 4.0 mg per spray), Narcan is a narcotic-antagonist which blocks the narcotic effects of an opiod by occupying, without activating, narcotic receptor sites. The duration of action is roughly 30 to 90 minutes. It is used for the reversal of narcotic effects such as unresponsiveness/altered mental status; especially respiratory depression, due to known or suspected overdose of narcotic opioid drugs.

 

In the U.S., every state has passed laws to increase access to Narcan (naloxone) and to legally protect people such as first responders, family and friends, police officers and others who administer it. Narcan remains a prescription medication in the United States; however, most pharmacies may be able to provide Narcan without a prescription, upon request.

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Treatment for Drowning

February 15, 2021

Drowning is a hypoxic brain issue (requiring supplemental oxygenation administration on scene). The focus on treatment is to reverse hypoxia with A-B-C CPR (not C-A-B). Use rescue breathing and if available, supplemental oxygen. Remove any likely water and vomit from the airway as needed (likely from the stomach). Do not spend time removing white foam from the upper airway, which is likely from the lungs. Instead, ventilate the patient, essentially ignoring the foam.

 

Consider protecting the spine only if there is a clear MOI for spine injury. Treat for hypothermia as appropriate (expected). Monitor patients of non-fatal drowning, as the onset of signs of respiratory distress usually begin to appear within six hours. Continually assess for ‘wet’ lung sounds, productive cough, rapid shallow ventilations, cyanosis, any substernal burning sensations, the inability to take a deep breath, an irregular and/or depressed heart rate, or any decrease in the patients level of responsiveness.

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Thrombolytics in Frostbite Treatment

February 15, 2021

Thrombolytics (clot-dissolving medications) have a role in the treatment of severe frostbite in restoring circulation after the injury has been thawed. This hospital based treatment is time sensitive, and the sooner the treatment is started, the better. Patients exhibiting thawed severe frostbite should be evacuated to definitive care as soon as possible; preferably within several hours if possible.

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Albuterol for HAPE

February 15, 2021

We no longer suggest the use of albuterol in the treatment of High Altitude Pulmonary Edema (HAPE). Although there are reports of beta-agonist use in HAPE treatment and the risks of use are low, no data support a benefit from albuterol in patients experiencing HAPE.

 

Read the WMS Journal publication for more information.

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Cooling for Heat Stroke

February 15, 2021

Cold water immersion is the gold standard treatment for heat stroke. How much should we worry about inducing hypothermia when we cool heat stroke patients with cold water immersion?

 

This is a classic example of benefit versus risk. The benefit of rapidly cooling heat stroke is clear: it’s life-saving, while the risk of inducing severe hypothermia is fairly low. To manage this risk, many studies recommend stopping cooling at 100°F (38°C), but they can measure temperature accurately. Guidance for real-world situations when we can’t measure core temperature as accurately is hard to find. Cool the patient down first, then worry about hypothermia later. There is some science that in 50°F (10°C) water, it takes about 15-20 minutes to lower a core temperature just 4°F. Evaporative cooling (tepid water and fanning) takes at least twice as long.

 

For heat stroke, immersing someone in cold water is strongly recommended if possible. The idea that this is bad due to causing shivering and vasoconstriction which limits heat loss is not true — the conduction of cold water overwhelms these effects, even if they occur.

 

If applying cold compresses or snow, apply to the whole body. If you don’t have enough, don’t apply to the traditional neck, armpit, chest and groin; instead, apply to the palms of the hand, soles of the feet and cheeks. This technique has been shown to be more than twice as effective.

 

Don’t give Tylenol (acetaminophen, paracetamol), Ibuprofen (e.g., Motrin, Advil) or Naproxen (Aleve) as they don’t help with heat stroke. Heat stroke is not a fever (your body heating up to kill a virus or bacteria). Your body is overheated due to external forces (overexertion, the sun, etc.).

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Use of Rigid C-Collars

February 15, 2021

The Journal of Wilderness and Environmental Medicine (WEMJ 2019; 30(4): 412e6) has a study on improvised cervical collars that was conducted by a group at the University of Utah. They used a model soft improvised C-Collar of a rolled up fleece, similar to a common model we use in the classroom. They found that there was no difference in stability when compared to a hard C-Collar, and actually improved patient comfort.

 

The following takeaway points should be implemented into patient care:

    • Voluntary spinal movement within the patient’s normal range of motion is safe.
    • Avoid adding energy to the patient’s vertebral system through external movement or poor handling. Encourage awake patients to extricate themselves from difficult positions, with or without assistance.
    • Rigid cervical collars, commercial or improvised, are unnecessary, potentially harmful, and should be avoided if possible. A soft cervical collar may be used if it increases patient comfort and does not restrict access to the patient’s airway.
    • Patients who pass the focused spine assessment (for WAFA/WFR/WEMT trained providers) do not need to be evacuated for a potential spine or spinal cord injury.
    • Patients who fail the focused spine assessment may have a spine injury and must be evacuated for physician assessment and potential imaging; those who have motor or sensory impairment may also have a spinal cord injury. Gentle handling and voluntary patient movement during their evacuation will not exacerbate the injury. Consider self-evacuation with awake, ambulatory patients.

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Syncope (Fainting)

February 15, 2021

Syncope (fainting) is a brief loss of postural tone followed by a spontaneous and complete recovery. It is often caused by a decreased blood flow to the brain, usually from low blood pressure. It may be due to severe pain, strong emotion, urination, defecation, vomiting, swallowing, or carotid sinus stimulation. Syncope may also be a sign of underlying disease, especially if symptoms do not resolve.

 

The patient may report prodromal symptoms such as dizziness, vision changes, warmth, lightheadedness. A fainting episode may be accompanied by twitching or seizure-like activity, which is not a seizure.

 

Treatment is to lay the patient flat, elevate the legs, make the patient comfortable (shade, out of the cold, etc.) and to complete a PAS. Assess for residual signs and symptoms.

 

Most syncope is benign and resolves promptly without further symptoms. Sometimes syncope suggests an underlying medical problem and in these cases this patient should be evacuated. We want to evac syncope that occurs during exertion; that occurs without the presence of prodromal symptoms such as dizziness, lightheadedness, pallor, diaphoresis, vision changes; and where there are residual signs and symptoms. Rapidly evacuate all events of syncope that are accompanied by chest pain, headache, SOB, abdominal pain, known pregnancy, or with signs and symptoms of shock.

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Changes in Orthopedic Injury Management

February 14, 2021

For decades, orthopedic injuries have been treated using the “RICE” mnemonic; rest, ice, compress, elevate. As there have been many studies done on best practices; many of which from both professional and collegiate athletic programs, new science shows that a drastic change may show significantly greater results.

 

Rest is no longer advised unless absolutely necessary. Rather, continued (gentle) use of the injured extremity may benefit the patient more in the long run.

 

Cooling the injury for long periods of time is no longer recommended; however, applying ice for 20-40 minutes may help to manage pain. Ice can decrease skin temperature to the point where nerve conduction is inhibited and pain decreases and can be an effective non-pharmacological pain intervention.

 

Elevating an orthopedic injury above the patient’s heart may reduce throbbing in addition to possibly alleviating a bit of swelling and discomfort.

 

The *NEW* mnemonic used to remember the steps to treating an orthopedic injury is now: HELP Stabilize.

    • Hydrate
    • ELevate
    • Pain management
    • Stabilize (splint) the injury

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

OTC Pain Medication

February 14, 2021

The combination of a non-steroidal anti-inflammatory (NSAID) medication such as Ibuprofen (eg. Advil), when taken together with Acetaminophen (eg. Tylenol), has been demonstrated in a number of studies to provide superior pain control to either drug alone or in combination with an oral narcotic. We concur with the sequence that NOLS uses, which was chosen because it’s easy to remember and avoids exceeding maximum daily doses:

 

    • 1000 mg Acetaminophen (every 8 hours) taken along with
    • 800 mg Ibuprofen (every 8 hours).

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

Curriculum Updates

Epinephrine Administration for Anaphylaxis

February 14, 2021

OVERVIEW OF ANAPHYLAXIS

Anaphylaxis is an allergic reaction that has life-endangering effects on the circulatory and respiratory systems. Anaphylaxis is an almost immediate, rapidly progressive multi-system allergic reaction to a foreign protein injected into the body by stinging and biting insects, snakes, and sea creatures or ingestion or inhalation of food, chemicals, and medications. Early recognition and prompt treatment, particularly in a wilderness setting, is essential to preserve life. The onset of symptoms usually follows quickly after an exposure (minutes after a sting or bite, within 30-60 minutes following ingestion). Rebound or recurrent reactions can occur within 24 to 72 hours of the original episode.

 

In addition to shortness of breath, weakness and dizziness, victims also frequently complain of a sense of impending doom, cough, chest tightness, trouble swallowing, abdominal cramps, or generalized itching. Physical findings include rapid heart rate, low blood pressure, and other evidence of shock, upper airway obstruction (stridor) and lower airway obstructions (wheezes) with labored breathing, generalized skin redness, hives, and swelling of the mouth, face, and neck. Epinephrine should only administered to patients having symptoms suggestive of an acute systemic reaction (i.e. generalized skin rash, difficulty breathing, fainting, or facial swelling).

Visit www.wildsafe.org/protocols for the complete wilderness medical field protocol for anaphylaxis and other wilderness medical protocols.

 

 

ROUTES OF ADMINISTRATION

The subcutaneous is the preferred route of administration of epinephrine by vial or ampule. If given intramuscularly (as with an epinephrine auto-injector such as an Epipen), injection into the buttocks should be avoided as it has been proven nearly ineffective compared to administration to the lateral thigh ONLY. If administering epinephrine by vial or ampule, it is also recommended to do so ONLY subcutaneously on the lateral thigh, and NOT the arm if possible.

 

 

INJECTION LOCATION

It has been shown that intramuscular (IM) injection of epinephrine into the lateral thigh (using a 1 or 1½ inch needle such as an Epipen) results in the fastest and most effective reduction of swelling in the airway. The rate at which epinephrine levels in the blood peak when administered via IM injection to the upper arm is significantly slower than when administered to the thigh, and should be only used as an alternative injection site. Subcutaneous (SC) injection (regardless of injection site) has been shown to have significantly delayed absorption rates of epinephrine into the bloodstream as compared to IM injection into the thigh. Avoid any injections to the buttocks, as this method has been rendered ineffective in a life-threatening situation.

 

 

CONTRAINDICATIONS

Although there are no contraindications stated for the use of epinephrine for anaphylaxis, epinephrine is not recommended for patients who are in labor or suffer from coronary insufficiency (angina).

 

 

ADMINISTRATION OF EPINEPHRINE BY SYRINGE

    1. Take proper scene safety & body substance isolation precautions such as donning non-latex gloves.
    2. Inspect the medication vial to ensure that it is not discolored or cloudy. Epinephrine should be clear like water.
    3. Check the label and expiration date of the medication. Do NOT use expired or discolored epinephrine.
    4. Select a sterile syringe with a proper gauge needle. A 25 gauge needle is recommended for adults.

 

 

AMPULES

    1. If using a glass ampule, carefully break off the tip and hold the ampule upside down at a 45° angle.
    2. Insert the syringe carefully into the liquid and slowly pull back on the plunger, pulling out slightly more epinephrine than required (.3 – .5 ml).
    3. Remove needle from ampule and expel any air from the syringe.

 

 

VIALS

    1. If using a vial, wipe the top of the bottle (the rubber) with an alcohol swab.
    2. Draw air into the syringe, equal to or slightly greater than the volume of epinephrine required.
    3. Turn the vial upside down and insert the syringe into the rubber top.
    4. Insert the air of the syringe into the vial by pushing the plunger until it is completely empty.
    5. Slowly pull the plunger back to the same level that it was filled with air moments ago.
    6. Remove needle from bottle and expel any air from the syringe.
    7. Clean the injection site (the patient’s lateral thigh) with an alcohol wipe.
    8. Using a “darting action”, insert the needle directly into the subcutaneous tissue of the skin and slowly push the plunger all the way down until the syringe is empty. Remove the needle and dispose properly. If bleeding should occur, apply triple-antibiotic ointment and place a Band-Aid over the site.
    9. Record the event (date, time, & location of injection) in your patient documentation or incident report.

 

 

ADMINISTRATION OF EPINEPHRINE BY AUTO-INJECTOR

    1. Take proper scene safety & body substance isolation precautions such as donning non-latex gloves.
    2. Inspect the auto-injector to ensure that it is not discolored or cloudy. Epinephrine should be clear like water.
    3. Check the label and expiration date of the auto-injector. Do NOT use expired or discolored epinephrine.
    4. Ensure that the auto-injector is the correct dose (adult or pediatric).
    5. Prepare the auto-injector for use and administer as soon as possible.
    6. Record the event (date, time, & location of injection) in your patient documentation or incident report.

ADULT auto-injectors: contain 0.3 mg of epinephrine, and are intended for patients weighing 55 lbs. or greater.Adult epinephrine auto-injectors and cases are typically YELLOW, BLUE, GREY and/or BLACK.

Pediatric auto-injectors: contain 0.15 mg of epinephrine, and are intended for patients weighing up to 55 lbs. Pediatric auto-injectors and cases are typically GREEN.

 

Beware of generic epinephrine auto-injectors may not be color-coded. Always check the dose!

 

 

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

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