Wilderness Protocols

Question 1

Column Injury

Answer 1

Injury to the spinal column as evidenced by tenderness, wound, and/or deformity.

Question 2

Describe the best practice for administering a metered dose inhaler (MDI).

Answer 2

Use a spacer. Can improvise by rolling up a piece of paper approximately 6 inches long. Place MDI on end and other end in patient’s mouth. Depress canister on MDI and instruct patient to inhale and hold breath for 10 seconds if possible.

Question 3

How does a “low risk spine injury” differ from a “high risk spine injury”? Include treatment considerations.

Answer 3

A person with a low-risk spine injury may be able to walk out assisted. A person with a high-risk spine injury must be stabilized and requires an urgent evacuation if motor/sensory deficits are present.

Question 4

What conditions must be satisfied before the Asthma protocol can be initiated?

Answer 4

Hx of Asthma
Respiratory distress or failure not responding to MDI

Question 5

Spine Assessment

Answer 5

A specific assessment aimed at identifying if a spine injury exists and what type.

Question 6

Describe the treatment for anaphylaxis.

Answer 6

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 7

What is the purpose of the spine assessment?

Answer 7

To determine if there is a spine injury and the type of spine injury.

Question 8

List four MOI for spinal injuries.

Answer 8

• axial load
• whiplash
• blunt impact
• penetrating trauma

Question 9

Diphenhydramine

Answer 9

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

Question 10

How can a wound infection be prevented?

Answer 10

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 11

Which joints may be reduced?

Answer 11

Shoulder, Patella, Digits

Question 12

Albuterol

Answer 12

A medication used to treat or prevent bronchospasm in patients with asthma, bronchitis, emphysema, and other lung diseases.

Question 13

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

Answer 13

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 14

Describe the functions of the immune system.

Answer 14

Protect against infection and heal damaged tissue.

Question 15

What role does prednisone play in Asthma treatment?

Answer 15

Prednisone is a long-acting anti-inflammatory drug. It will lower inflammation in the lower airway and reduce the likelihood of another attack.

Question 16

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

Answer 16

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

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

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

Question 17

Cord Injury

Answer 17

Injury to the spinal cord as evidenced by abnormal motor and sensory function.

Question 18

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

Answer 18

Epinephrine

Question 19

List the steps of the spine assessment protocol.

Answer 19

1. Determine reliability.
2. Determine if patient has any new symptoms (ask the patient to do a mental scan of their body).
   - Any new numbness, tingling, weakness (strength, loss of blood/bowel control)?
   - Any new pain on spine?
3. Perform physical exam.
   - Check for motor and sensory deficits.
   - Motor Test = Finger Abduction or Finger or Wrist extension against resistance; Dorsiflexion and plantar flexion of foot or extension of big toe.
   - Sensory Test = Distinction between pain/sharp and light/dull stimulation on top/outside of hands and feet.

Question 20

Describe the normal healing process following a soft tissue injury.

Answer 20

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 21

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

Answer 21

Question 22

Asthma

Answer 22

A chronic inflammatory disease that can cause acute episodes of lower airway constriction and respiratory distress.

Question 23

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

Answer 23

When s/sx of systemic infection become evident.

Question 24

Define “low risk spine injury”.

Answer 24

Column Injury
Normal mental status, reliable patient that can tolerate pain/tenderness and able to move/bear weight easily. No new tingling, numbness, or muscle weakness. Normal motor/sensory exam.

Question 25

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 25

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 26

The ideal treatment for a patient with a spine injury is ________________.

Answer 26

The ideal treatment for a patient with a spine injury is spine stabilization.

Question 27

Describe the treatment principles for wound infections.

Answer 27

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 28

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

Answer 28

Persistent abnormal mental status

Incomplete response to treatment

MDI continues to not work.

Getting worse

Question 29

Which medication is the definitive treatment for an acute asthma attack (a.k.a. “the fix”)?

Answer 29

Albuterol MDI

Question 30

Describe the treatment for a local immune reaction.

Answer 30

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

Question 31

Epinephrine

Answer 31

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

Question 32

Describe what is meant by a reliable patient and an unreliable patient.

Answer 32

Reliable = no ASR, no distracting injury, intoxication, no TBI with persistent altered mental status

Unreliable = Patient is unable to cooperate or focus on the rescuer, instructions given, and exam.

Question 33

Dislocation

Answer 33

Displacement of a bone from its joint.

Question 34

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

Answer 34

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 35

Anaphylaxis

Answer 35

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 36

When does asthma not require evacuation?

Answer 36

When it was successfully treated using PROP and MDI.

Question 37

What criteria must be met to reduce these joints? Give an example for each type of joint.

Answer 37

Dislocation must be a result of an indirect force.

Shoulder – Fell and caught self by putting out hand.

Patella – Playing “Birdy on a Perch” and making a cutting move while running.

Digits – rock climbing, falling, and fingers stuck in a crack.

Question 38

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

Answer 38

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 39

Describe the treatment for a mild allergic reaction.

Answer 39

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

Question 40

How should amputations be managed?

Answer 40

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 41

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

Answer 41

Yes
0.3mg of Epinephrine via autoinjector.

Question 42

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

Answer 42

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

Question 43

Describe the treatment for a patient who is in respiratory distress or failure that is not responding to their MDI.

Answer 43

Administer 0.3mg of Epinephrine via autoinjector or syringe.

Follow up with 6-10 puffs of albuterol MDI up to 3x in the first hour.

Evac with extra EPI and albuterol MDI.

If evacuation is delayed consider admin of up to 60mg of Prednisone for 5 days.

Question 44

Wilderness Protocol

Answer 44

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

Question 45

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

Answer 45

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 46

Cetirizine

Answer 46

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

Question 47

Spine Injury

Answer 47

An injury to the spinal column, spinal cord, or both.

Question 48

Describe the protocol for impaled objects/foreign bodies.

Answer 48

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 49

Describe the wound cleaning process.

Answer 49

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 50

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

Answer 50

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 51

1. List the medications used in the asthma protocol including dosages, routes of administration, and common side effects.

Answer 51

Question 52

Prednisone

Answer 52

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

Question 53

At what point should the spine assessment be completed?

Answer 53

When there is an MOI for spine injury and after a full patient assessment and treatment of other more serious and distracting injuries/illnesses.

Question 54

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

Answer 54

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 55

What is the generic treatment for all patients who have a history of Asthma and are in respiratory distress or failure?

Answer 55

PROP
Administer albuterol metered dose inhaler.

Question 56

Describe how to reduce a patella dislocation.

Answer 56

Coach patient to relax quadricep muscle. Slowly extend leg keeping heel on ground. Manually manipulate the kneecap into position if needed.

Question 57

Wilderness Context

Answer 57

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

Question 58

Compare/contrast the spinal column and spinal cord?

Answer 58

The Spinal Column is the bony structure involved in protecting the cord. the Spinal Cord exists inside the spinal column and is the part of the nervous system involved in sending messages throughout the body.

Question 59

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

Answer 59

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

Question 60

Describe the main functions of the skin.

Answer 60

Thermoregulation, Fluid Retention, & Protection.

Question 61

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

Answer 61

If you see white/shiny tissue it is deep.

Question 62

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

Answer 62

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 63

Describe the treatment principles for hot spots and blisters.

Answer 63

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 64

How should amputations be managed?

Answer 64

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 65

What role does epinephrine play in treatment of an acute asthma attack?

Answer 65

Gateway drug – dilates the bronchioles (opens the airway) so the albuterol can get in and do its job.

Question 66

Describe three shoulder reduction techniques including when you would use them.

Answer 66

Cunningham – patient must be sitting up straight, shoulders back, lower arm supported, elbow next to side, relaxed. Coach to relax muscles. Massage muscles.=

External Rotation – patient should be sitting up straight/shoulders back or lying on back, rotate thumb outwards, pull gentle traction toward feet. Coach to relax muscles. Massage muscles.

Baseball Throw – Slowly abduct and rotate arm away from the body. Apply steady, firm traction once arm is near 90 degrees. Encourage patient to relax shoulder muscles. Toggle (baseball throw) first towards head and then toward feet.

Question 67

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

Answer 67

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

Question 68

Describe the treatment principles for burns.

Answer 68

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 69

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

Answer 69

Volume Shock, Hypothermia, Pain, & Infection.

Question 70

Bronchospasm

Answer 70

Action of the lower airways (bronchial tubes) that result in spasms and constrict.

Question 71

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

Answer 71

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

Question 72

Following an MOI for spine injury, which criteria must be fulfilled before a spine can be considered “clear”?

Answer 72

Patient must pass all three assessment criteria:

1) Patient is reliable.
2) Patient has no new symptoms.
3) Patient has no spine tenderness and has normal motor and sensory function.

Question 73

Describe how to reduce a digit dislocation.

Answer 73

Traction into position as you would an angulated long bone.

Question 74

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

Answer 74

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).

Question 75

List 5 Asthma attack triggers.

Answer 75

Answers will vary. Common triggers = dust, pollen, pet dander, smoke, cold air, exercise, smog, strong fragrances.