Wilderness first aid

Wilderness first aid is the specific discipline of First aid which relates to care in remote areas, where emergency medical services will be difficult to obtain or will take a long time to arrive. Nursing care though not part of normal first aid is part of wilderness first aid.

Training in wilderness first aid is available in the the US, UK, and Canada. Any group of persons traveling in wilderness should have at least one person trained in wilderness first aid and carry a first aid kit designed for the area they are traveling in.

See medical emergency for a list of medical emergencies and specific guidance directed towards first-aiders, Outdoor Emergency Care technicians and EMTs, often including evacuation criteria.

Leaving or staying with an injured person
A classic problem is whether to leave an injured person or stay if only one person is ambulatory. Barring special circumstances, the injured one should be stabilized, placed in shelter, and marked in a way visible from the air (usually a single, long line of cut brush or trampled snow). Then the injured one should be left alone, while the other goes for help.

If there are three or more, the healthy group should be split into halves by speed, with the fastest going for help, and the others remaining to make the preparations. (In a party of four, it would be a rare hiker who would be better sent for help alone, rather than sent in a sub-party of two.)

Ensuring the rescuers can find the injured person is crucial. If a personal locator beacon is available, it should be triggered and placed with the injured person. If enough help is available, air-visible markings may be worthwhile. Where surveyor's tape is available within the party (and assuming clear trails are available), it should be used by the sub-party going for help, to back up memory and notes with tape-flagging of the toward-the-injury-location choices of trail at intersections. (When an injury location is off clear trails, by distances that make it impractical to keep blazes of tape within sight of each other, forks in watercourses should be treated as substitutes for trail intersections.)

Exposure
Exposure, sometimes called hypothermia, is a normal hazard of temperate wilderness. It occurs when a person's core body temperature falls below 33.7C (92.6F). If a person is wet, in a mild wind, it can occur in less than an hour at temperatures as high as 15°C (59°F).

The basic early symptoms are uncontrollable shivering, stiffness and confusion. The conclusive evidence is a cool or cold stomach. If the hypothermia has not yet advanced to a critical stage, basic treatment is to warm the person in a sleeping bag. People with hypothermia may have such depressed metabolisms that they can no longer heat themselves. However, if the hypothermia has become severe - the victim is confused or unconscious - it is critical not to warm them suddenly. Evacuation would be the preferred option, with warming undertaken in a controlled medical environment. Sudden warming of a severely hypothermic person can send the heart into a fatal, irregular beating pattern or arrhythmia.

Heat syncope: heat exhaustion or sunstroke
Both maladies tend to occur during heavy exercise in high humidity, or with inadequate water. Some chronically ill persons enter this state normally.

The basic symptom of heat syncope is a body temperature above 40°C (104°F) with fainting, or weakness but without mental confusion. If unconsciousness, confusion or convulsions are present, it is sunstroke which is rarer, but far more severe condition, a true medical emergency.

Note that some authorities do not distinguish heat syncope from sunstroke, and treat heat syncope as sunstroke in order to be safe. All authorities recognize that these are stages in the same process.

Heat syncope is caused by mild overheating with inadequate water or salt. In young people, it is far more common than true sunstroke. Blood pressure is lowered when the body dilates (widens) capillaries (small blood vessels) in the skin to radiate heat. Also, water is evaporated from the blood, reducing the blood's volume and therefore lowering blood pressure further. The result is less blood to the brain, causing light-headedness and fainting.

The basic treatment for heat syncope is to treat it like fainting: Have the victim sit, if sitting lay down, if laying down, raise legs. Then, administer water, and oral rehydration salt, slowly, and move the victim to a cooler area.

With sunstroke, cool the victim. Remove their clothing, shade them, fan them and sponge with cool water. Massage limbs vigorously to move cooled blood into the body cavity. Ice or alcohol can cause damage. Get help immediately. Sunstroke, especially when the victim has been unconscious, often causes major damage to body systems such as brain, kidney, liver, gastric tract. Unconsciousness for more than two hours usually leads to permanent disability.

Cramps
There are two basic causes of cramping. One is inadequate oxygenation of muscle, and the other is lack of water or salt. Cramps from poor oxygenation can be improved by rapid deep breathing, and stretching the muscle. Cramps from lack of salt and water can be treated by stretching the muscle, drinking water and eating salt. Pounding on the muscle can increase soreness.

What happens in a cramp is that lactic acid builds up because of normal anaerobic muscle metabolism. When the muscle burns sugar without enough oxygen, it makes lactic acid. The lactic acid finally becomes concentrated enough to trigger the contraction of the muscle. When the muscle lacks salt, the nerves firing the muscle are unable to recharge properly, causing a similar effect.

Insect and animal bites
Most animal bites should be considered as possible sources of infection, including rabies. Wash the wound, ideally with povidone iodine soap. Loosely bandage it, and do not suture it. Know the venomous animals in your area.

Animal bites by carnivores other than rodents should be considered possible cases of Rabies. If you are bitten, try to capture alive or kill the animal and preserve its head. Look for signs of Rabies (foaming mouth, self-mutilation, growling, jerky behavior, red eyes). If the animal lives for ten days and does not develop rabies, then no infection has probably occurred. The head can later be analyzed to detect the disease.

If the animal is gone, prophylactic Rabies treatment is recommended in most places. Certain places, such as Hawaii, are known not to have native Rabies. Treatment is generally available in North America, Britain and the Northern European states. Away from these areas, try to get to the nearest embassy of one of these states and indicate an acute medical emergency. The embassy doctor is usually willing and able to help.

Many snake-bites, even by venomous snakes, are not envenomed, and these can be treated as animal bites. Croatilid (rattlesnake and pit-viper) venoms cause the bitten area to turn green or purple. Elapsid (coral and monay other non-U.S. snakes) venoms cause swollen lymph nodes. If symptoms appear, they should be treated by compressing and cooling the bite(many say the bite should not be cooled, http://www.fda.gov/fdac/features/995_snakes.html) and evacuating the victim, on a litter if possible. If a victim is unable to reach medical care within 30 minutes, a bandage, wrapped two to four inches above the bite, may help slow venom. The bandage should not cut off blood flow from a vein or artery. A good rule of thumb is to make the band loose enough that a finger can slip under it(American Red Cross, FDA/Office of Public Affairs:http://www.fda.gov/fdac/features/995_snakes.html). If available, antivenin should be administered. See below for phone numbers to locate antivenins.

The black widow spider, and some scorpions are dangerous mostly to small children and elderly adults. Only the Sydney funnel-web spider of Australia is frequently dangerous to adults, and it resides only within 100 miles of Sydney Australia. Treat as snake-bite. Antivenins are available in the U.S. for black widow spiders and the dangerous scorpions native to the U.S.

To locate antivenins, the Anti-venin index in Oklahoma City, Oklahoma, USA (1-405-271-5454) maintains a 24-hour hotline to help locate rare antivenins. Another possible number is the Poisondex central office in Denver, Colorado, USA (1-800-332-3073). In Australia, contact Commonwealth Serum Laboratories, Parkville, Victoria. In Asia try Haffkine Biopharmaceutical Corporation, Parel, Bombay, India. In Africa try the South African Institute for Medical Research, Johannesburg, Republic of South Africa. In most moderately developed countries, the national hospital can treat local venomous bites.

Anaphylactic shock
Main article: Anaphylactic shock

Insect bites as well as exposure to allergens can trigger anaphylaxis in some people. Anaphylaxis is a life-threatening medical emergency because of rapid constriction of the airway, often within minutes of onset. Call for help immediately. First aid for anaphylaxis consists of obtaining advanced medical care at once; rescue breathing (a skill that is part of CPR) is likely to be ineffective but should be attempted if the victim stops breathing. Look to see if a device such as an Epi-pen is available for administration of epinephrine by a layperson.

Altitude sickness
Main article: Altitude sickness

Altitude sickness can begin in susceptible people as low as 8,000ft. The early symptoms are drowsiness, feeling unwell, and weakness, especially during exercise. More severe symptoms are headache, poor sleep, persistent rapid pulse, nausea and sometimes vomiting, especially in children. More severe symptoms include pulmonary edema (fluid in the lungs- persistent coughing), confusion, psychosis, hallucination and death.

Victims can sometimes control mild altitude sickness by consciously taking ten to twelve rapid large breaths every five minutes. If overdone, this can blowoff too much carbon dioxide and cause tingling in the extremities of the body. The quickest cure is to reduce the victim's altitude if possible. Some mountain rescue groups carry acetazolamide (a prescription drug) to treat mountain sickness, injectable steroids to reduce pulmonary edema, and inflatable pressure vessels to relieve and evacuate severe mountain-sick persons.

Altitude acclimatization has two stages. Overnight, the body can adjust its carbonic acid balance, and substantially improve its performance. Over four to six weeks, the body can grow more blood cells, strengthen the heart and make other tissue changes. Above 18,000ft, further altitude exposure weakens one, rather than strengthening one's acclimation.

Wounds
The care of significant wounds in the wilderness presents a great challenge. Lack of access to sterile supplies and hospital care renders useless many aspects of routine wound care. The care of wounds can be broken down into acute care (immediate) and chronic (long term – day to day care).

For acute wounds, the most important aspect of care is to control bleeding. If not immediately addressed, there are two types of acute wounds you might encounter in the wilderness that could become life threatening; scalp lacerations and wounds with arterial bleeding (spurting blood). Direct pressure will control bleeding for most wounds. If there is arterial bleeding, put the pressure either right on the bleeding point or on the undamaged skin right adjacent to the bleeding point. Accurately applied pressure will control the bleeding in almost every wound. The only artery in your body that is bigger than your thumb is the aorta and if you have hit that, you will not be alive long enough to worry about the wound. For scalp wounds, there can be significant bleeding all along the edge of the wound, so your direct pressure will have to be applied along a broader surface. The pressure will have to be applied until the bleeding has stopped. Start by applying the pressure for 15 minutes without checking to see if it is still active. Ultimately, you may have apply pressure until you can seek professional help.

Two common mistakes are made with bleeding wounds. The first is to wrap an extremity wound with a dressing but not apply enough direct pressure to actually stop the bleeding. In this scenario, the wound continues to bleed under the dressing and becomes life threatening. Take the dressing off and apply direct pressure. The other mistake is the incorrect use of a tourniquet. Proper use of tourniquet is beyond the scope of this article, but tourniquets should only be use when all of the above recommendations have failed. If left in place too long or applied incorrectly loss of limb will result. If a tourniquet is deemed necessary as a result of lack of access to professional help and uncontrolled bleeding, the tourniquet should be applied between the wound and the heart as close to the wound edge as possible. If possible, the tourniquet should be released every 1-2 hours for 10 minutes while direct pressure is used to stop most of the bleeding during interval. The tourniquet should only be applied with just enough force to stop the bleeding. Sleeping bag straps make a convenient tourniquet, but any item of clothing can be tied around the extremity and then a stick fitted under the item and twisted until bleeding stops. Stay well hydrated.

The chronic care of wounds is directed at preventing wound infection. The key to prevention is keeping the wound clean. If bleeding is controlled, the wound should be thoroughly washed. Although sterile saline is best for irrigating wounds (rinsing them out), it will not be available in the wilderness. The next best solution is to clean the wound from a fresh water source (preferably running clean water) and "camp soap". The more water you use, the better (surgeons routinely use 3 gallons of saline under pressure to clean open wounds). Remove as much of the visible dirt as possible. When you have cleaned the wound to the best of your abilities with what you have available, dressing the wound will keep further contamination from entering the wound. Sterile gauze is best, but a good substitute is any absorbent material that has been placed in boiling in water for at least 3 minutes. Such a dressing can even be safely reused if cleaned and boiled again. Change the dressing at least once a day and every time the area is heavily contaminated. If available, antibiotic ointment is useful and can be applied directly to the wound. Use of antibiotic pills should be reserved for treatment of actual wound infections – not for the prevention of infection. If evacuation is not possible in a timely fashion, some WFA courses provide instruction on the proper administering of antibiotic drugs to help treat serious infections.

The final treatment for significant wounds should be the most obvious; return to civilization as quickly and safely as possible and seek professional help.

Sucking chest wounds
See open pneumothorax. A person with a penetrating chest wound is experiencing a life-threatening medical emergency and needs immediate access to advanced medical care and equipment to save their life. One standard first-aid treatment is to cover the wound with a pressure bandage made air-tight with petroleum jelly or clean plastic sheeting. It is important not to completely close off the opening. Leave a flap or corner open so that air does not build up around the lungs yet the patient can still breathe.

Fractures
Stabilize the break with splints, and move the injured party as little as possible unless they are certain to die from lack of shelter or care. The object is to prevent the bone from causing more injuries. If the skin is broken, treat it as a major wound.

Broken ribs are stabilized with tape. A person with a broken arm, collarbone or ribs can often be stabilized enough to walk out, however large amounts of pain indicate this is a bad idea. Waxed cardboard splints are inexpensive, very lightweight, quite waterproof and quite strong.

Toothache
The basic treatment is oil of cloves on packing in the sore tooth to reduce the pain. Systemic antibiotics and analgesic such as acetaminophen (paracetamol) or NSAIDs may also help if available. Although teeth may hurt terribly, most severe tooth infections simply result either in a dead tooth, or a tooth that falls out and are rarely life-threatening.

CPR (Cardio-Pulmonary Resuscitation)
CPR is often portrayed in movies and television as being highly effective in rususcitating a person who is not breathing and has no circulation. A 1996 study by the New England Journal of Medicine showed that CPR success rates in television shows was 75%. The reality is that CPR administered outside hospitals has a 2-15% success rate on its own, and is most importantly used to sustain oxygen supply to the brain until specialized medical equipment and personnel can reach the scene (see defibrillator).

If you are performing CPR, you can only stop:
 * 1) when a competent health professional takes responsibility for the patient; or
 * 2) when the rescuers are in danger; or
 * 3) when you are physically unable to continue.