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PHTLS_ Prehospital Trauma Life Support 8TH

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PHTLS_ Prehospital Trauma Life Support 8TH

PHTLS_ Prehospital Trauma Life Support 8TH

618 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Figure 22-26 Signs/Symptoms Treatment

Condition

Skin bends Intense itching (pruritus); red rash patches over Self-limiting; resolves on its own; observe for
Limb-pain DCS shoulders and upper chest; skin marbling may delayed signs of limb-pain DCS.
precede burning sensation and itching over
shoulders and torso; localized cyanosis and Mild pain only often resolves on its own; observe
pitting edema. 24 hours; moderate to severe pain. Start
with 100% oxygen, 12 to 15 liters/minute
Large joint tenderness; mild to severe joint or nonrebreathing mask; transport all patients in
extremity pain; pain is usually steady but supine position; glucose-free IV fluid therapy
may throb and present in 75% of cases; (1 to 2 ml/kg/hr); early consult DAN (919-684-
grating sensation on joint motion; worse with 8111) for closest recompression chamber for
movement. DCS Type I may progress to DCS definitive treatment.
Type II.

Cardiopulmonary Substernal pain, mild cough, dyspnea, ABCs; 100% oxygen, 12 to 15 liters/minute
"chokes" nonproductive cough, cyanosis, nonrebreathing mask; BLS or ALS as needed;
tachypnea, tachycardia, shock and cardiac glucose-free IV fluid therapy (1 to 2 ml/kg/
Neurologic arrest hr); transport all patients in supine position;
Brain early consult DAN (919-684-8111 ) for
Many visual changes, headache, confusion, closest recompression chamber for definitive
disorientation, nausea and vomiting treatment.

Spinal cord Back pain, heaviness or weakness, numbness,
paralysis, urine retention, fecal incontinence

Inner ear Vertigo, ataxia

ABCs, airway, breathing, circulation; ALS, advanced life support; BLS, basic life support; DAN, Divers Alert Network; IV, intravenous.
Source: From Barratt DM, Harch PG, Van Meter K: Decompression illness in divers: A review of the literature. Neurologist 8:186, 2002; and Van
Hoesen KB, Bird NH: Diving medicine. In Auerbach PS: Wilderness medicine, ed 6, St. Louis, 2012, Mosby Elsevier.

training. Five general medical screening recommendations for diver's life because of the condition itself, because it
identifying individuals who are at an increased risk for a div- occurs in the water, or because inadequate medical
ing-related problem are listed below. These recommendations help is available.
are based on consensus of medical diving specialists.7o,95 Also
refer to Figure 22-27 for the severe risk (absolute contraindica- • Impaired tissue perfusion or diffusion of inert gases
tions), relative risk, and temporary risk conditions of concern increases the risk of DCS.
for scuba diving.70 Recommendations include the following:
• Poor physical condition increases the risk of DCS or
• Inability to equalize pressure in one or more of the exertion-related medical problems. The factors com-
body's air spaces increases the risk for barotrauma. promising physical condition may be physiologic or
pharmacologic.
• Medical or psychiatric conditions may manifest under-
water or at a remote diving site and can endanger the • In women who are pregnant, the fetus may be at
increased risk of dysbaric injury.

CHAPTER 22 Environmental Trauma II: Lightning, Drowning, Diving, and Altitude 619

Figure 22-27 •• •I • • I • .. • •

System Severe Risk Conditions Relative Risk Conditions Temporary Risk
Neurologic Conditions

Cardiovascular Seizures Complicated migraine Arterial gas embolism
Transient ischemic attack Head injury with sequelae without resid ual, in
Pulmonary Herniated disc which pulmonary air
or cerebrovascular Peripheral neuropathy trapping has been
Gastrointesti nal accident Multiple sclerosis excluded and probability
Serious decompression Spinal cord or brain injury of recurrence is low
Metabolic and sickness with residual lntracranial tumor or aneurysm
endocrine deficits

Otolaryngologic lntracardiac right-to-left Coronary artery bypass grafting Pacemaker: if problem
shunt (atrial septal Percutaneous transluminal coronary necessitating pacing
Orthopedic defect) does not preclude diving;
angioplasty or coronary artery disease pacemakers must be
Hypertrophic History of myocardial infarction certified by manufacturer
cardiomyopathy Congestive heart failure to withstand pressure
Hypertension
Valvular st enosis Dysrhythmias
Valvular regurgitation

Spontaneous Asthma or reactive airway disease
pneumothorax Exercise-induced bronchospasm
Solid, cystic, or cavitating lesions
Impaired exercise Pneumothorax caused by surgery,
performance due to
respiratory disease trauma, previous overinflation
Immersion pulmonary edema
Interstitial lung disease

Gastric outlet obstruction Inflammatory bowel disease Unrepaired hernias of the
Chronic or recurrent small Functional bowel disorders abdominal wall Peptic
ulcer disease associated
bowel obstruction with obstruction or
Severe gastroesophageal severe reflux

reflux
Paraesophageal hernia

Pregnancy Insulin- or noninsulin-dependent
diabetes mellitus

Open tympanic membrane Recurrent otitis externa, otitis media or Acute upper respiratory
perforation sinusitis infection Acute sinusitis
Acute otitis media
Tube myringotomy Eustachian tube dysfunction
Middle ear or inner ear History of tympanic membrane

surgery perforation, tympanoplasty, or
Tracheostomy mastoidectomy
Significant conductive or sensorineural
hearing loss
History of round or oval window rupture

Amputation Back pain
Scoliosis with impact on respiratory

performance
Aseptic necrosis

(Continues on next page)

6 2 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Hematologic Sickle cell disease
Leu kemia
Hemophilia
Polycythemia vera

Behavioral health Inappropriate motivation Use of psychotropic medications
to dive Previous psychotic episodes

Claustrophobia
Acute psychosis
Untreated panic disorder

Source: *From Van Hoesen KB, Bird NH: Diving medicine. In Auerbach PS: Wilderness medicine. ed 6, St. Louis, 2012, Mosby Elsevier.

For many years, diabetics have questioned the diving use medication (oral hypoglycemic agents or insulin) to
medical experts about scuba diving waivers for individu- treat diabetes, but who are otherwise qualified to dive may
als who have control of their blood sugar. In June 2005, an undertake recreational scuba diving. However, they stated
international workshop was held in the United States that that strict criteria need to be met before diving. The panel
was jointly sponsored by the Undersea and Hyperbaric agreed that those diabetics using dietary control will eas-
Medical Society (UHMS) and DAN. They brought together ily meet t he new guidelines. The consensus guidelines
over 50 medical and research experts from around the (Figure 22-28) consist of 19 points, under the categories of
world to develop guidelines for recreational divers with selection and surveillance, scope of diving, and glucose man-
diabetes.00 The panel indicated that dive candidates who agement on the day of diving.

Figure 22-28

Selection and Surveillance • There must be no significant secondary complications
• Individual must be at least 18 years of age (16 years if from diabetes.
in special training program).
• Diving will be delayed after starting/changing • A physician/diabetologist should carry out an annual
medication, as follows: review and determine that the diver has a good
• Three months with oral hypoglycemic agents understanding of the disease and the effect of exercise in
• One year after initiation of insulin therapy consultation with an expert in diving medicine, as required.
• There must be no episodes of hypoglycemia or
hyperglycemia requiring intervention from a third party • An evaluation for silent cardiac ischemia for
within at least 1 year. candidates older than 40 years of age must be
• There must be no history of hypoglycemia performed.
unawareness. • After initial evaluation, periodic surveillance for
• A glycated hemoglobin (HbA1c) test result of s; 9% silent cardiac ischemia can be in accordance with
must be recorded no more than 1 month prior to initial accepted local/national guidelines for the evaluation
assessment and at each annual review. of diabetics
• Values> 9% indicate the need for further evaluation
and possible modification of therapy. • Candidate must document intent to follow protocol
for divers with diabetes and to cease diving and seek
medical review for any adverse events during diving
possibly related to diabetes.

(Continues on next page)

CHAPTER 22 Environmental Trauma II: Lightning, Drowning, Diving, and Altitude 621

Figure 22-28

Scope of Diving • Complete a minimum of three predive blood glucose
• Diving should be planned to avoid: tests to evaluate trends at 60 minutes, 30 minutes,
• Depths > 100 feet (30 m) seawater and immediately prior to diving.
• Durations > 60 minutes
• Compulsory decompression stops • Alterations in dosage of oral hypoglycemic agent or
• Overhead environments (e.g., cave, wreck insulin on evening prior or day of diving may help.
penetration)
• Situations that may exacerbate hypoglycemia (e.g., • Delay dive if blood glucose is:
prolonged cold and arduous dives) • < 150 mg·dl-1 (8.3 mmol·l-1)
• Individuals must have a dive buddy/leader informed of • > 300 mg·dt-1 (16.7 mmol·l-1)
diver's condition and steps to follow in case of problem.
• Dive buddy should not have diabetes. • Rescue medication considerations include:
• Carry readily accessible oral glucose during all dives.
Glucose Management on the Day of Diving • Have parenteral glucagon available at the surface.
• Individuals should perform a general self-assessment
of fitness to dive. • If hypoglycemia is noticed underwater, the diver should
• Blood glucose must be ~ 150 mg·dl-1 (8.3 mmol·l-1), surface (with buddy), establish positive buoyancy,
stable or rising, before entering the water. ingest glucose, and leave the water.

Source: Data courtesy of Divers Alert Network" (DAN") • Check blood sugar frequently for 12 to 15 hours after diving.
• Ensure adequate hydration on days of diving.
• Log all dives, including blood glucose test results and

all information pertinent to diabetes management.

Figure 22-29

The following guidelines are the consensus of attendees at • For multiple dives per day or multiple days of diving,
the 2002 Flying After Diving Workshop. They apply to dives a minimum preflight surface interval of 18 hours is
followed by flights at cabin altitudes of 2,000 to 8,000 feet suggested.
(61Oto 2438 m) for divers who do not have symptoms of
decompression sickness (DCS). The recommended preflight For dives requiring decompression stops, there is little
surface intervals do not guarantee avoidance of DCS. evidence on which to base a recommendation, and a
Longer surface intervals will reduce DCS risk further. preflight surface interval substantially longer than 18 hours
appears prudent.
• For a single no-decompression dive, a minimum
preflight surface interval of 12 hours is suggested.

Source: Data courtesy of Divers Alert Network" (DAN")

Flying After Diving DCS during flight or after arriving at the destination because of
the reduced atmospheric pressure in either a pressurized or a
Because diving is conducted at many popular dive locations in nonpressurized commercial aircraft. Figure 22-29 lists the cur-
the United States and at remote locations outside the United rent guidelines recommended by DAN for flying safely after
States, persons may dive the day before flying. Because of Boyle's diving.70
principle, flying too soon after a dive can increase the risk of

622 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

High Altitude Illness AMS develops in 20% to 25% of cases above 8,200 feet (2,500 m)
and in 40% to 500Ai of cases at 14,000 feet (4,267 m). The incidence
In the United States, more than 40 million people each year travel of AMS is greater than 900Ai when the rate of ascent to approx-
above 8,202 feet (2,500 m) without acclimatization to participate imately 14,000 feet (4,267 m) occurs over hours versus days.102
in activities that include snowboarding, alpine skiing, hilting, Furthermore, a small number of AMS cases (5% to 1OOAi) progress
camping, concerts, and festivals. Thus, many people are at risk from mild symptoms to become high-altitude cerebral edema, a
for altitude-related illness, which can develop within hours to severe form of AMS.99 High-altitude cerebral edema (HACE) is
days after they arrive at altitude.97 Prehospital careproviders and a severe neurologic form of high-altitude illness and has a low
ED staff need to become familiar with the predisposing factors, incidence rate of 0.01% in the general population at an altitude
signs and symptoms, medical management, and education and above 8,200 feet (2,500 m); this rate increases to 1%to 2%in more
prevention techniques to reduce the morbidity and mortality of physically active individuals.97
high-altitude illness. See Figure 22-30 for a wide range of acute
medical problems experienced by visitors and residents at high High-altitude pulmonary edema (HAPE) is rare but
altitudes. accounts for the most deaths from high-altitude illness and
is easily reversed if recognized early and managed correctly.
This section presents three medical conditions directly HAPE typically presents within 2 to 5 days after arrival at alti-
caused by high-altitude environments and highlights specific tude.99 The incidence rate for HAPE is 0.01% to 0.1% at 8,200
underlying medical conditions that worsen as a result of high- feet (2,500 m) in the general population and increases to 2%
altitude-induced hypoxia (altitude-exacerbated pre-existing to 6% in climbers at an altitude of 13,120 feet (4,000 m). The
medical conditions). overall mortality for HAPE is 11% and increases to 44% when no
treatment interventions are made.103 Forty-seven cases of HAPE
Epidemiology were reported in Vail, Colorado, from 1975 to 1982. These were
young, healthy males who skied at an average altitude of 7,644
High-altitude illness is a term that encompasses two cerebral feet (2,330 m).104
and one pulmonary syndrome: (1) acute mountain sickness,
(2) high-altitude cerebral edema, and (3) high-altitude pulmo- Hypobaric Hypoxia
nary edema. Even though the risks of acquiring high-altitude ill-
ness are low, once it develops, progression can be fatal.98•99 There are three defined levels of altitude. High altitude is
defined as an elevation of 5,000 to 11,480 feet (1,500 to 3,500 m).
Acute mountain sickness (AMS) is a mild form of high- This is a common altitude in the western mountain ranges of the
altitude illness, rarely experienced at altitudes below 6,540 United States, where high-altitude illness is reported with greater
feet (2,000 m), but the incidence increases to 1.4% to 25% with frequency than in other regions. 104 Very high altitude is defined
increasing altitudes of 6,754 to 8,000 feet (2,060 to 2,440 m). 100•101

Figure 22-30

Lowlanders on Ascent to Altitude • Disordered sleep
• Acute hypoxia • Periodic breathing disturbances during sleep
• High-altitude headache • High-altitude pharyngitis, bronchitis, and cough
• Acute mountain sickness • Ultraviolet keratitis (snow blindness)
• High-altitude cerebral edema • Exacerbation of pre-existing conditions
• Cerebrovascular syndromes
• High-altitude pulmonary edema Lifelong or Long-Term Residents of Altitude
• Symptomatic pulmonary hypertension • Chronic mountain sickness (chronic mountain
• High-altitude deterioration polycythemia)
• Organic brain syndrome (extreme altitude) • Symptomatic high-altitude pulmonary hypertension
• Peripheral edema with or without right heart failure
• Retinopathy (engorgement of retinal veins; may be • Problems of pregnancy: preeclampsia, hypertension,
associated with vitreous hemorrhage and swelling of and low-birth weight infants
the optic disc, leading to vision impairment) • Exacerbation of lung disease and congenital heart disease

Source: Modified from Hackett PH, Roach RC: High-altitude medicine. In Auerbach PS: Wilderness medicine, ed 6, St. Louis, 2012, Mosby
Elsevier.

CHAPTER 22 Environmental Trauma II: Lightning, Drowning, Diving, and Altitude 6 2 3

as an elevation of 11,480 to 18,045 feet (3,500 to 5,500 m) and Factors Related to High-Altitude
Illness
is the more common altitude for serious forms of high-altitude
The major development of high-altitude illness depends on
illness.105 Extreme altitude is defined as elevations higher than many factors specific to each high-altitude exposure, but key
factors include rapid ascent, poor acclimatization, physical exer-
18,045 feet (5,500 m).99 With a progressive increase in altitude, tion at altitude, young age, and history of prior altitude illness
(Figure 22-32). Additional factors include:
the environment becomes very hostile to an individual not accli-
• Increased altitude and ascent rate. The incidence and
matized to the decreased availability of oxygen, causing a condi- severity of high-altitude illness are primarily related to
the speed ofascent, altitude reached, and length ofstay,
tion known as hypobaric hypoxia. because these three factors increase the hypoxic stress
in the body.98•106
High altitude is a unique environment because there is a
• Previous history of high-altitude illness. A docu-
decreased availability of oxygen for respiration, which results mented history of high-altitude illness is a valuable
predicator of who is susceptible for subsequent high-
in cellular hypoxia. Even though the concentration of oxygen altitude illness when returning to the same altitude
at the same ascent rate.107 Incidence rates for HAPE
remains at 21% at all altitudes, decreased atmospheric pres- increase from 100;6 to 60% for those with a previous
history of HAPE who abruptly ascend to an altitude of
sure at higher altitude results in a decreased partial pressure 14,960 feet (4,560 m).108

of oxygen (P02). For example, P02 is 160 mm Hg at sea level • Preacclimatization. Having a permanent residence
(1 atm) and 80 mm Hg at 18,045 feet (0.5 atm at 5,500 m), result- above 2,950 feet (900 m) provides some preacclimatiza-
tion and is associated with a lower rate of and severity
ing in less oxygen available during respiration. Figure 22-31 of high-altitude illness when ascending to higher alti-
tudes. However, this protection is limited if the ascent
shows that as altitude increases from sea level to extreme alti- rate is rapid or reaches an extreme altitude.106•107

tude, there is a proportional decrease in barometric pressure, • Age and gender. Age, but not gender, is a factor in
developing AMS; the incidence is lower in those older
arterial blood gases, and arterial oxygen saturation (Sa02). It than 50 years. HAPE occurs more frequently and with

is worth noting that Sa0 remains, on average, above 91% in
2

healthy, acclimatizing adults until reaching an altitude above

9,200 feet (2,810 m). Prehospital care providers are trained to

provide aggressive ventilatory support with 100% oxygen for

all patients who are symptomatic with a pulse oximetry read-

ing of 91% Sa02, because this is indicative of moderate hypoxia
(86% to 91%).

This relationship between increasing altitude and progres-

sive hypoxia forms the basis for the acute physiologic adjust-

ments in ventilatory rate and cardiac output and biochemical

changes.106 Consequently, it is the hypobaric hypoxia and hypox-

emia that set up nonacclimatized individuals for high-altitude

illness.98

Figure 22-31

Altitude (meters) Altitude (feet) Pb (mm Hg) Pa02 (mm Hg) Sa02 (%) PaC02 (mm Hg)
760 100 98.0 40.0
Sea level Sea level

1646 5400 630 73.0 95.1 35.6

2810 9200 543 60.0 91.0 33.9

3660 12,020 489 47.6 84.5 29.5

4700 15,440 429 44.6 78.0 27.1

5340 17,500 401 43.1 76.2 25.7

6140 20, 140 356 35.0 65.6 22.0

*Data are mean values for subj ects age 20 to 40 years.
Pao,. Arterial oxygen partial pressure; Sao,, arterial oxygen saturation; Paco,, arterial carbon dioxide partial pressure.
Source: Modified from Hackett PH, Roach RC: High-altitude medicine. In Auerbach PS: Wilderness medicine, ed 6, St. Louis, 20 12, Mosby
Elsevier.

6 2 4 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Figure 22-32

Probably No Extra Risk Caution Contraindicated

Young and old Moderate COPD Sickle cell anemia (with history of
Fit and unfit Compensated congestive heart failure crises)
Obesity
Diabetes (C HF) Severe COPD
After coronary artery bypass grafting Sleep apnea syndromes Pulmonary hypertension
Troublesome arrhythmias Uncompensated CHF
(without angina) Stable angina/coronary artery disease
Mild chronic obstructive pulmonary High-risk pregnancy
Sickle cell trait
disease (COPD) Cerebrovascular diseases
Asthma Any cause for restricted pulmonary
Low-risk pregnancy
Controlled hypertension circulation
Controlled seizure disorder Seizure disorder (not receiving
Psychiatric disorders
Neoplastic diseases medication)
Inflammatory conditions Radial keratotomy (surgery of the cornea

to improve near-sightedness)

Source: From Hackett PH, Roach RC: High-altitude medicine. In Auerbach PS: Wilderness medicine, ed 6, St. Louis, 2012, Mosby Elsevier.

greater severity in children and young adults and is interactions and for those patients with renal and/or hepatic
reported in equal proportions of males and females in insufficiencies. A discussion of these issues can be found in a
these age groups.98•109 review article of the medications for the prevention and treat-
ment ofaltitude illness (i.e., AMS, HAPE, and HACE) for healthy
• Physical fitness and exertion. The onset and severity individuals and the drug selection and dosing for patients with
of high-altitude illness is independent of physical underlying medical conditions.112
fitness; fitness does not accelerate altitude acclimatiza-
tion. A high level of fitness does allow individuals to Figure 22-33 lists conditions that increase the likelihood of
exert themselves more, but vigorous exertion on arrival developing high altitude illness. Additionally, specific medical
at high altitude further exacerbates hypoxemia and conditions lmown to increase susceptibility to high-altitude ill-
hastens the onset of high-altitude illness. tM,llo ness include:

• Medications and intoxicants. Any substance that • Cardiopulmonary congenital abnormalities: absent pul-
depresses ventilation and disrupts sleep patterns at alti- monary artery, primary pulmonary hypertension, con-
tude should be avoided because this will further exac- genital heart defects
erbate altitude-induced hypoxemia. These substances
include alcohol, barbiturates, and opiates.99·[[1 • Carotid artery surgery: irradiation or abolishing carotid
• Cold. Exposure to cold ambient temperatures increases bodies

the risk for HAPE because cold increases the pulmo- High-Altitude Illness
nary arterial pressure.m
Acute Mountain Sickness
Pre-existing medical conditions are another factor related
to high-altitude illness. It is important to note that when clinical AMS is a self-limited, nonspecific syndrome that is easily mis-
studies are used to determine effective dose of medication for taken for a number of other conditions because of common
altitude illness, they generally include only healthy individuals symptoms, including influenza, hangover, exhaustion, and dehy-
without underlying medical problems. However, today many dration. A consensus panel defined AMS as the presence of head-
more high-altitude travelers and those who move their residence ache in an unacclimatized person who has recently arrived at an
to higher altitudes have underlying diseases such as diabetes, altitude above 8,202 feet (2,500 m) and has one or more symp-
hypertension, heart disease, or depression. The current medi- toms ofAMS. 114 However, AMS can occur at levels as low as 6,562
cation recommendations for managing altitude illness may not feet (2,000 m). AMS has been viewed as a mild form of cerebral
be appropriate for these patients due to the potential for drug

CHAPTER 22 Environmental Trauma II: Lightning, Drowning, Diving, and Altitude 6 2 5

Figure 22-33 .. •.. ... ..

Risk Category Description

Low • Individuals with no prior history of altitude illness and ascending < 9,200 ft (2,800 m)
• Individuals taking~ 2 day to arrive at 8,200 to 10,000 ft (2,500 to 3,000 m) with subsequent
increases in sleeping elevation of less than 1,600 ft (500 m) per day

Moderate • Individuals with prior history of AMS and ascending to 8,200 to 9,100 ft (2, 500 to 2,800 m) in 1 day
• No history of AMS, but ascending > 9, 100 ft (2,800 m) in 1 day
• All individuals ascending > 1,600 ft (500 m) per day at alt itudes above 10,000 ft (3, 000 m)

High • History of AMS and ascending to ~ 9, 100 ft (2,800 m) in 1 day
• All individuals with prior history of HAPE or HACE
• All individuals ascending to > 11,500 ft (3, 500 m) in 1 day
• All individuals ascending> 1,600 ft (500 m) per day at alt itudes above 11,500 ft (3, 500 m)
• Very rapid ascents

AMS, acute mountain sickness; HACE, high-altitude cerebral edema; HAPE, high-alt itude pulmonary edema.

Source: Modified from Luk AM, M cintosh SE, Grissom et al. Wilderness Medical Society consensus guidelines for t he prevention and treatment of
acute altitude illness. Wilderness Environ Med 21 :146-55;2010.

edema, often preceding both RACE and HAPE. At the other end Because a headache is the most common finding with AMS,
of the spectrum, RACE is viewed as a severe form of AMS. 115•116 assess for location and quality. Cheyne-Stokes respirations are
The majority of AMS cases do not progress to more severe forms a common finding in individuals who have ascended above
of high-altitude illness unless there is continued exposure to 10,000 feet (3,000 m). Findings ofa dry cough and dyspnea on exer-
higher altitude. tion are common at altitude and may not always be specific for
AMS. Auscultate all lung fields because crackles are common with
The hallmark symptom of AMS is a mild to severe, pro- AMS. Assess neurologic function, and assess specificallyfor ataxia
tracted headache believed to be caused by hypoxia-induced and excessive lethargy, as these symptoms are indicative of RACE.
cerebral vasodilation.117 Patients describe their headache as
throbbing, as located in the occipital or temporal regions, and Management
as worsening at night or on awakening. Other symptoms include
nausea, vomiting, insomnia, dizziness, lassitude (weariness), Descending 1,640 to 3,280 feet (500 to 1,000 m) will provide the
fatigue, and difficulty sleeping. Malaise and lack of appetite may quickest resolution of symptoms. Mild AMS will resolve on its
be present along with a decrease in urine output. It is important own, but patients should avoid further ascent and any exer-
to recognize early symptoms of AMS so that continued ascent tion until symptoms resolve. Provide analgesics for headache
does not cause a preventable condition to progress into a severe and anti.emetics for nausea per local protocols. For moderate
form of RACE. symptoms, descend to lower altitude and provide oxygen at
2 to 4 liters/minute by nasal cannula initially. Assess pulse oxirn-
The onset ofsymptoms in AMS can occur as early as 1 hour etry for Sa02 greater than 90%. If lower than 90%, titrate oxygen
after arriving at high altitude but typically occurs after 6 to 10 by 1 to 2 liters/minute and reassess. For patients with neurologic
hours of exposure. Symptoms usually peak in 24 to 72 hours and symptoms, see management of RACE. Patients with underlying
subside in 3 to 7 days. Ifthe onset of symptoms occurs beyond 3 medical problems exacerbated by altitude should be transported
days after arriving at altitude and does not include headache, and on oxygen for medical evaluation of their primary illness and the
if oxygen therapy provides no benefit, the condition is probably secondary development of high-altitude illness.
notAMS.98
See Figure 22-34 for a summary of the signs and symptoms,
Assessment management, and prevention of AMS. See Figure 22-35 for dos-
ing recommendations for children with AMS.
If patients are alert, the key is to obtain a good medical history,
including the onset and severity of symptoms, rate of ascent, High-Altitude Cerebral Edema
duration of exposure, use of medications that may cause dehy-
dration, use of alcohol, and level of physical exertion. Obtain RACE is a very serious neurologic syndrome that can develop
vital signs, including pulse oxirnetry. Also, assess the status of in individuals with AMS or HAPE. At altitudes above 8,000 feet
any underlying medical condition, as determined by the medical (2,438 m), cerebral blood fl.ow increases as a result of
history.

6 2 6 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Figure 22-34

Signs/Symptoms Treatment Prevention

Mild: Headache, nausea, Oxygen 1 to 2 liters/minute by nasal cannula, Ascend at slow rate; spend night
dizziness, and fatigue in and/or descend 1700 to 3300 feet (500 to at intermediate alt itude; avoid
first 12 hours 1000 m); avoid further ascent until symptoms overexertion; avoid direct t ransport to
resolve; consider acetazolamide (125 mg PO bid) 9000 feet (2750 m)
to speed acclimatization; give analgesics and
antiemetics as needed Consider acetazolamide 125 mg PO
bid, starting day before ascent and
continued for 2 days at maximum
altitude

Treat AMS early

Moderate: Moderate to Descend, consider dexamethasone (4 mg PO/IM Same as listed above. Dexamethasone
severe headache, marked every 6 hours) and/or acetazolamide (2 50 mg PO 2 mg q 6 hours, or 4 mg q 12 hours
nausea, vomiting, bid); if unable to descend, vigilant observation PO, starting day of ascent and
decreased appetite, for deterioration; oxygen (1 to 2 liters/minute) discontinued cautiously after 2 days
dizziness, insomnia, fluid and/or portable hyperbaric therapy (2 to 4 psi) at maximum altitude
retention for~ 12 hours for a few hours if available

AMS for~ 24 hours, Immediately descend or evacuate ~ 3300 foot As listed above for AMS
ataxia, confusion, bizarre
behavior, severe lassitude (1000 m); give oxygen 2 to 4 liters/minute; titrate
to maintain Sa0 ~ 90% w ith pulse oximetry;

2

dexamethasone (8 mg IV/IM/PO initially, then
4 mg q 6 hours); hyperbaric therapy if cannot

descend

Dyspnea at rest, moist Start oxygen 4 to 6 liters/minute, then titrate to Ascend at a slow rate; avoid
cough, rales, severe maintain Sa02 ~ 90% with pulse oximetry; overexertion; consider nifedipine
exercise limitation, minimize exertion; keep warm; descend or (30-mg sustained-release dose every
cyanosis, drowsiness, evacuate 1700 to 3300 feet (500 to 1000 m); 12 hours bid PO or 20 mg sustained-
tachycardia, tachypnea, consider nifedipine (30 mg sustained-release release every 8 hours) in person w ith
desaturation PO q 12 hours or 20 mg of sustained-release repeated episodes of HAPE; start
every 8 hours) if no HACE; consider inhaled 1 day prior to ascent and continue for
beta-agonists (salmeterol, 125 mcg inhaled q 2 days at maximum altitude
12 hours, or albuterol); consider EPAP mask;

dexamethasone only if HACE develops

bid, twice daily; EPAP, expiratory posit ive airway pressure; IM, intramuscular; IV, intravascular; m, met er; mcg, microgram; mg, milligram; PO, by

mouth; psi, pounds per square inch; q, every; Sa02, arterial oxygen saturation.
Source: Modified from Luk AM, Mcintosh SE, Grissom et al. Wilderness M edical Society consensus guidelines for the prevention and t reatment of
acute altitude illness. Wilderness Environ Med 21:146-55;2010.

hypoxia-induced vasodilation. The mechanism of iajury appears RACE can occur within 3 to 5 days after arrival at
to be related to a combination ofsustained cerebral vasodilation, 9,022 feet (2,750 m), but generally it occurs at altitudes above
increased capillary permeability across the blood- brain barrier, 12,000 feet (3,600 m), with an onset of symptoms within
and the inability to compensate sufficiently for the excess cere- hours. Some mild to moderate symptoms of AMS may be pres-
bral edema.118 ent, but the hallmark features of RACE are altered level of

CHAPTER 22 Environmental Trauma II: Lightning, Drowning, Diving, and Altitude 627

Figure 22-35

In 2001, the International Society for Mountain Medicine published a consensus statement recommending that adult
treatment algorithms (for AMS, HACE, and HAPE) be followed with adjustments for pediatric drug dosages.

AMS Acetazolamide 2.5 mg/kg/dose PO q 12 hours (maximum 125 mg per dose)
Dexamethasone 0.15 mg/kg/dose PO q 6 hours up to 4 mg

HACE Acetazolamide 2.5 mg/kg/dose PO q 12 hours (maximum 125 mg per dose)

HAPE Dexamethasone 0.15 mg/kg/dose PO q 6 hours up to 4 mg

kg, kilogram; mg, milligram; PO, by mouth; q, every.

Source: From Pollard AJ, Niermeyer S, Barry PB, Bartsch P. Berghold F, Bishop RA, et al: Children at high altitude: An international consensus

statement by an ad hoc committee of the International Society for Mountain Medicine. High Alt Med Biol 2001 :2:389-401.); Luk AM, Mcintosh SE,
Grissom et al. Wilderness Medical Society consensus guidelines for t he prevention and treatment of acute altitude illness. Wilderness Environ Med
21:1146-55;2010

consciousness and ataxia, along with drowsiness, stupor, and of 1 to 3 days) and rarely occur 4 days after arriving at a given
irrational behavior progressing to coma. Death results from altitude.121 The development of HAPE and the rate ofprogression
brain herniation. u9 are hastened by cold exposure, vigorous exertion, and contin-
ued ascent. Compared with the other two high-altitude illnesses,
Assessment HAPE accounts for the greatest number offatalities.

Ifpatients are alert, as with AMS, the key in patients with HAGE Assessment
is to obtain a good medical history, including the onset and sever-
ity of symptoms, rate of ascent, duration of exposure, and level Patient assessment, including vital signs, lung sounds, and med-
of physical exertion. Obtain the patient's vital signs, including ical history, are vital in the determination of HAPE, which is
pulse oximetry. Also, assess the status of any underlying medical defined by at least two or more symptoms (e.g., dyspnea at rest,
condition, as determined by the patient's medical history. It is cough, weakness, or decreased exertion performance; chest
important to assess the patient's lung sounds because a strong tightness or congestion) and at least two signs (e.g., crackles or
association exists between HAGE and HAPE. wheezing, central cyanosis, tachypnea, or tachycardia).122 Rales
are generally present in the lung fields, starting in the right axilla
Management and eventually becoming bilateral. Assess the patient for fever,
which is a common sign with HAPE. Late findings as HAPE pro-
Do not delay planning for treatment and evacuation at the first gresses are resting tachycardia, tachypnea, and blood-tinged
signs or symptoms of HAGE. The highest priority for any patient sputum. If treatment interventions are not provided, symptoms
with HAGE is inunediate descent, along with initiation of high- will progress over hours to days to include audible gurgling,
:fiow oxygen (15 liters/minute) by nonrebreathing mask and mon- respiratory distress, and eventually death.
itoring of SaO2 until 900Ai or greater. Unconscious patients should
be managed as a patient with head injury (see the Airway and Management
Ventilation and the Head Trauma chapters), including intubation
and other ALS procedures.m Descending to a lower altitude by at least 1,640 to 3,280 feet (500
to 1,000 m) provides the fastest recovery, but initially patients
See Figure 22-34 for a summary of the signs and symptoms, show good improvement with rest and oxygen. Keep patients
management, and prevention of HACE. See Figure 22-35 for dos- warm, and prevent any exertion. These patients need to improve
ing recommendations for children with HAGE. their arterial oxygenation, so start oxygen at 4 to 6 liters/min-
ute or titrate oxygen flow until Sa02 is 900Ai or greater. Reassess
High-Altitude Pulmonary Edema the patient's vital signs after starting oxygen because improved
arterial oxygenation decreases the tachycardia and tachypnea.
The onset of HAPE follows a pattern similar to that seen with As HAPE is a form of noncardiogenic pulmonary edema, diuret-
AMS and HAGE, occurring in unacclimatized individuals after ics have not been shown to be helpful. Anecdotal case reports
a rapid ascent to high altitude. This high-altitude illness has a have suggested favorable results with the use of continuous pos-
different mechanism of injury than AMS and HAGE, however, itive airway pressure (GPAP) for serious cases of HAPE; how-
because HAPE is induced by hypobaric hypoxia. HAPE is a form ever, specific research is lacking and such equipment is often not
of noncardiogenic pulmonary edema associated with pulmonary available in the environment most likely to be associated with
hypertension and elevated capillary pressure.107 More than 50% of HAPE. 123,124
patients with HAPE have AMS, and 14% have HAGE.120 The signs
and symptoms generally appear during the second night (onset

6 2 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

See Figure 22-34 for a surrunary of the signs and symptoms, Figure 22-36
management, and prevention of HAPE. See Figure 22-35 for dos-
ing recommendations for children with HAPE.

Prevention The following are key points for acclimatizing to high
altitude:
Acute high-altitude illness in unacclimatized individuals is pre-
ventable. The common factor for the onset of AMS, RACE, and • Ascend high enough to induce adaptions, but not so
HAPE is the rate of ascent to higher altitude. Altitude illness high as to develop altitude illness.
may be experienced by skiers who travel by commercial airlines
and take an early morning flight from cities at sea level, arrive at • Unacclimatized individuals should not ascend above
high altitude around noon, and begin skiing by early afternoon 7,800 feet (2,400 m).
at about 7,000 to 14,000 feet (2,100 to 4,500 m). Another scenario
with risk of high-altitude illness is a call for mutual aid to var- • Stage for 7 to 14 days between 4,600 and 6,500
ious public safety personnel living below 3,300 feet (1,000 m). feet (1,400 to 2,000 m).
They assemble quickly and then arrive at 9,000 feet (2,750 m)
or higher to assist local volunteer search-and-rescue teams trek- • Stage for 4 to 6 days between heights of 6,500 and
king to higher altitudes in search ofa missing backcountry hiker. 7,800 feet (2,000 to 2,400 m).
Prehospital care personnel, whether ground crew or flight crew,
who have responsibilities at high altitude for patient transfer to • Staging reduces AMS incidence for altitudes 3,300
another hospital or for medical evacuation from the backcoun- to 6,500 feet (1,000 to 2,000 m) above the staging
try need to possess the knowledge to minimize the risk of high- altitude.
altitude illness for their own safety and the safety of coworkers
(Figures 22-36 and 22-37). • Graded ascents above 7,800 feet (2,400 m) should
not exceed 1,000 feeVday (300 m/day).
Medications as Prophylaxis for High-Altitude
Illness • Graded ascents greater than 1,000 feeVday (300 ml
day) should include a rest day at each higher altitude.
For the prevention of AMS and RACE, individuals traveling from
sea level to over 9,850 feet (3,000 m) as their sleeping altitude • Avoid heavy exertion for the first 3 days.
in 1 day or individuals who have a history of AMS should con- • Keep well hydrated with water.
sider prophylactic treatment. The drug of choice is oral acet- • Avoid alcohol, sleeping pills, and other sedatives.
azolamide (Diamox), 125 to 250 mg twice daily, beginning 1 day • Eat a high-carbohydrate diet.
before ascent and continuing for 2 days at maximum altitude. • Avoid overexertion.
The alternative drug is dexamethasone (Decadron), 2 mg orally • Avoid smoking.
or intramuscularly (IM) every 6 hours and continuing for 2 days • Physical training is not preventive for high-altitude
at maximum altitude. The combination of both drugs has been
shown to be more effective than either drug alone. 111•112 Aspirin illness.
(325 mg) taken every 4 hours for three doses reduced the inci-
dence of headache from 50% to 7%.115 Figure 22-37

Recent research clearly demonstrated the advances of pro- The "golden rules" of high-altitude illness are as
phylactic use of ibuprofen 600 mg three times per day beginning follows:
6 hours before ascending from 4,100 feet (1,250 m) up to 12,570
feet (3,800 m) as compared to a placebo treatment. The study 1. If you are ill at altitude, your symptoms are caused
reported that 43% of the participants in the ibuprofen group by the altitude until proved otherwise.
reported the development of AMS compared with 69% in the pla-
cebo group. Also, the placebo group reported that the severity of 2. If you have altitude symptoms, do not go any
AMS was worse than reported in the ibuprofen group.125 The ben- higher.
efit for using ibuprofen is that it provides a second-choice med-
ication and can be taken the same day of ascent with no or low 3. If you are feeling ill or are getting worse, or if you
side effects when compared to the traditional use of acetazol- cannot walk heel to toe in a straight line, descend
amide for the prevention of AMS.125 immediately.

For the prevention of HAPE in individuals with a history of 4. A person ill with altitude illness must always be
repeated episodes, prophylaxis with oral nifedipine, 20 to 30 mg accompanied by a responsible companion who
can accomplish or arrange for descent should it
become necessary.11 1

CHAPTER 22 Environmental Trauma II: Lightning, Drowning, Diving, and Altitude 6 2 9

(extended-release formulation) every 12 hours, is recommended. cerebral edema and increased ICP (manage per recommenda-
Currently, prophylactic treatment should be avoided as a method tion for cerebral edema; see the Head Trauma chapter).
to prevent altitude illness in children because ofinsufficient clin-
ical studies. 126

Prolonged Transport Recreational Scuba-Related Diving
Injuries

Drowning The standard treatment protocol for scuba-related injuries caus-
ing pulmonary overpressurization syndrome (e.g., AGE, DCS) is
Asymptomatic patients can become symptomatic in an to provide high-flow oxygen (15 liters/minute via nonrebreathing
extended-care situation with a delay of 4 hours before pulmo- mask) atthe scene and continue oxygen therapy during transport
nary symptoms. Initiate CPR for a drowning victim with :five of the patient to the closest recompression chamber for hyper-
continuous breaths using the traditional ABC approach, not baric oxygen (HBO) therapy. Conduct an extensive neurologic
CAB, to begin correcting hypoxia. Obtain a pulse oximetry read- evaluation, and reassess the patient frequently for progression
ing before and after administration of oxygen. Provide high-flow ofsigns and symptoms. Use analgesics for pain control per local
oxygen via a nonrebreathing mask at 15 liters/minute. protocols. Also consider giving aspirin (325 or 650 mg) for its
antiplatelet activity.70
Any patient with pulse oximetry values less than 900Ai,
altered mental status, apnea, or coma may require early active Use Divers Alert Network (DAN, telephone 919-684-9111)
airway management to protect from aspiration. Any patient and local medical control for the closest location of a functional
who continues to be hypoxic with pulse oximetry readings less recompression chamber. Before transporting a patient for HBO
than 85% after administration of high-flow oxygen is a candidate therapy, contact the chamber directly because the status of
for CPAP or rapid-sequence intubation protocol. Liberal use of chamber readiness can change without notification. When trans-
suction through the endotracheal tube is necessary to remove porting by air, use aircraft that can preferably maintain sea-level
pulmonary secretions and water aspirated during submersion. atmosphere during flight. Any nonpressurized aircraft should
Consult with medical control, if available, to sedate and paralyze maintain an altitude below 1,000 feet (300 m) en route to the
the patient (if permitted by protocols) to ensure successful intu- chamber site.
bation, oxygenation, and effective ventilation.
High-Altitude Illness
Another effective method to ensure effective oxygenation
and ventilation is the use of positive end-expiratory pressure Mild to moderate AMS can be managed with low-volume oxygen
(PEEP) in apneic submersion patients.34•39 PEEP increases the at 2 to 4 liters/minute by nasal cannula, titrated by 1 to 2 liters/
diameter of small and large airways and improves the ventila- minute (greater than 90% Sa02), with a combination of anal-
tory-perfusion ratio and arterial oxygenation. gesics (e.g., aspirin, 650 mg; acetaminophen, 650 to 1,000 mg;
ibuprofen, 600 mg) for headache and prochlorperazine (5 to
Determine the patient's GCS score and assess routinely for 10 mg IM) for nausea. Other medications used for treating mild
trends because it is predictive of patient outcome. Monitor for to moderate AMS include oral acetazolamide (250 mg twice
hypothermia and hypoglycemia Any comatose patient should daily) and dexamethasone (4 mg orally [PO] or IM every 6 hours)
have his or her blood glucose measured or, if unable, receive IV until symptoms resolve.
dextrose. The placement of a nasogastric tube may be needed to
reduce gastric content and water swallowed during submersion. Treat RACE with descent to a lower level, oxygen at 2 to
4 liters/minute by nasal cannula, to maintain greater than 900;6
Lightning Injury SaOv and with dexamethasone (8 mg PO, IV, or IM initially, then
4 mg every 6 hours). Consider using oral acetazolamide (250 mg
Victims of lightning maybe in respiratory arrest, cardiac arrest, twice daily) with prolonged delays to descent.
or both. Following CAB assessment, initiate CPR rapidly. When
in an extended-care situation with multiple victims, use reverse If a severe form of RACE develops and the patient is coma-
triage and resuscitate those who appear dead :first. However, tose, manage according to recommendations for cerebral edema
prolonged (multiple hours) CPR on these victims has a poor (see the Shock chapter). Prolonged management of HAPE pri-
patient outcome, and there is little benefit from CPR or ACLS marily consists of administering oxygen at 4 to 6 liters/minute
procedures lasting longer than 20 to 30 minutes. All measures to by nasal cannula (greater than 90% Sa02) until improvement
stabilize the patient to correct for hypoxia, hypovolemia, hypo- of symptoms, then 2 to 4 liters/minute for conserving oxygen.
thermia, and acidosis should be attempted before terminating If oxygen is not available, give oral nifedipine (10 mg initially,
resuscitative efforts.2 then 30 mg extended-release dose every 12 to 24 hours). If the
patient acquires RACE, add dexamethasone (8 mg PO or IM
Assess the patientfor cerebral edemaand increasedintracra- every 6 hours).
nial pressure (ICP). Establish a baseline GCS score, and reassess
the patient every 10 minutes as an indicator of progressive

6 3 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Use of portable hyperbaric chambers, such as the Gamow dexamethasone, nifedipine). They inflate with manual pumps up
bag (Altitude Technologies), has been successful for treating to 2 psi, which is equivalent to descending 5,250 feet (1,600 m),
high-altitude illness.99 These lightweight, fabric pressure bags depending on the initial altitude. The use of these chambers for
simulate descending to a lower altitude with or without the use 2 to 3 hours can effectively improve symptoms. Thisis an ideal use
of supplemental oxygen or medication (e.g., acetazolamide, of technology while waiting for transportation to definitive care.

• Prehospital care providers will inevitably be faced with unpredictable environmental encounters, such as
those described in this chapter.

• Basic lmowledge of common environmental emergencies is necessary s o that rapid assessment and treat-
ment in the prehospital setting can be provided.

• It is not easy to remember this type of information because these problems are not frequently encountered.
Therefore, remember the general principles involved, as follows:
• Drowning. Assume all drowning patients have pulmonary distress until proved otherwise; correct
hypoxia, acidosis, and hypothermia as indicated.
• Lightning. Patients with severe lightning injury need rapid assessment of cardiopulmonary status. Use
the reverse triage principle for multiple victims. Initiating CPR early is the key to survival.
• Recreational scuba-related diving injuries. Patients with sever e decompression siclmess and arterial
gas embolism n eed high-flow oxygen and rapid treatment in a recompression chamber for the best out-
come. Consult early with m edical control and Divers Alert Network (919-684-9111).
• High-altitu de illness. Key interventions for acute mountain siclmess and high-altitude cerebral or pul-
monary edema are to descend at least 1,640 to 3,280 feet in altitude (500 to 1,000 m) and provide rest
and oxygen.

• In every case, remember that personal safety must be maintained. There are too many cases in which prehos-
pital care providers and other emergency responders have lost their lives as a result of attempting a rescue.

In a coastal town, a family of four was strolling on the beach w ith their dog during a ch illy winter day. The son tossed a rubber ball
tow ard the w ater's edge, and the dog gave chase. In an instant, a large shore-breaking w ave sw allow ed up the dog in t he rough surf.
The 17-year-old son w as first into the water to attempt to save the dog, only to be overtaken by the water. He w as seen struggling in
the rough surging surf by his parents and sister.

The boy's father and mother both followed him into the surf in an effort to help. Their 19-year-old daughter remained on shore and
called for help on her cell phone. The dog eventually made it back to the shore. The parents were able to pull their son out of the cold
water after finding him submerged and unresponsive. Your paramedic unit arrives to the scene within 7 minutes of the daughter's call.

As you exit the ambulance, you observe an unconscious teenage boy lying partially facedow n in sand with surging w ater close
by. He is still in the surf zone and could be submersed by a wave. You team up with arriving fire department emergency responders to
approach the victim.

• How should you approach the patient in this setting?
• If the patient has no pulse or respirations, what is the next immediate intervention?
• What other concerns do you have for the patient that need to be addressed on scene?

CHAPTER 22 Environmental Trauma II: Lightning, Drowning, Diving, and Altitude 631

Your plan is to have one fire fighter serve as a lookout for a threat of oncoming surf and for you, your partner, and two other fire f ighters
t o approach the victim to pick him up by all four extremities and quickly carry him away from t he surging waves.

As the lead prehospital care provider, you d irect the team to place the victim supine, parallel to t he shore, so that the head and trunk
are at the same level and then immediately check for responsiveness. The other emergency responders begin staging t he emergency
medical gear near the victim as you check t he ABCs. The patient may be apneic and need only rescue breathing or may need f ull CPR.
In either sit uation, you know that the recommendation for drowning is now to provide five rescue breaths initia lly followed by 30 chest
compressions and then to cont inue two breaths and 30 compressions until signs of life appear.

The initial approach to t he ABCs in drowning victims is essential to address the hypoxia. High-flow oxygen is provided using a bag-
mask device. You start an IV wit h crystalloids. In this case, spinal immobilization is not needed since t here was no mechanism of inj ury to
suspect spinal trauma . Early intubation or mechanical ventilation (e.g., CPAP) may be indicated if t he victim shows signs of deterioration
with Sp02 less t han 90%. You transport the patient and his parents t o the hospit al for continued treatment and evaluation.

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76. Divers Alert Network. Annual Diving Report. Durham, NC: Divers 102. Gertsch JH, Seto TB, Mor J, Onopa J. Ginkgo biloba for the pre-
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77. Divers Alert Network (DAN). Report on D iving Fatalities: 2008
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104. Honigman B, Theis MK, Koziol-McLain J, et al. Acute mountain
78. Hardy KR. Diving-related emergencies. Emerg M ed Clin North Am.
1997;15(1):223. sickness in a general tourist population at moderate altitudes. Ann
I ntern Med. 1993;118(8):587.
79. Green SM. Incidence and severity of middle-ear barotraumas in rec- 105. Zaphren K, Honigman B. High-altitude medicine. Emerg Clin North
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106. Hultgren HN. H igh-Altitude Medicine. Stanford, CA: Hultgren
80. Kizer KW. Dysbaric cerebral air embolism in Hawaii. Ann Emerg Publications; 1997.
Med. 1987;16:535. 107. Schneider M, Bemasch D, Weymann J, et al. Acute mountain
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81. Cales RH,Humphreys N, PilmanisAA, Heilig RW. Cardiac arrestfrom Med Sci Sports Exerc. 2002;34(12):1886.
gas embolism in scuba diving. Ann Emerg Med. 1981;10(11):589. 108. Bartsch P. High-altitude pulmonary edema. M ed Sci Sports Exerc.
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82. Butler BD, Laine GA, Leiman BC, et al. Effect of Trendelenburg 109. Roach RC, Houston CS, Honigman B. How well do older persons
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mountain sickness at simulated high altitude. J Appl Physiol.
83. Moon RE. Treatment of diving emergencies. Grit Gare Clin. 2000;88(2):581.
1999; 15:429. 111. Roeggla G, Roeggla H, Roeggla M, et al. Effect of alcohol on acute
ventilation adaptation to mild hypoxia at moderate altitude. Ann
84. Van Meter K. Medical field management of the iitjured diver. Respir I ntern Med. 1995;122:925.
Gare GlinNorth Am . 1997;5(1):137. 112. Luks AM, Swenson ER. Medication and dosage considerations
in the prophylaxis and treatment of high-altitude illness. Chest.
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clothes? Undersea H yperb Med. 1997;24:2. 114. Roach RC, Bartcsh P, Oelz 0, Hackett PH, Lake Louise Scoring
Committee. The Lake Louise Acute Mountain Sickness Scoring
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88. Spira A. Diving and marine medicine review. Part II. Diving dis- brain volume and development of acute mountain sickness (AMS).
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Millennium: Advances in Experimental Medicine and Biology.
89. Clenney TL, Lassen LF. Recreational scuba diving iitjuries. Am Fam Vol 474. New York, NY: Kluwer Academic/Plenum; 1999.
Physician. 1996;53(5):1761. 116. Hacket PH. High-altitude cerebral edema and acute moun-
tain sickness: a pathological update. In: Roach RC, Wagner PD,
90. Kizer KW. Women and diving. Physician Sportsmed. 1981;9(2):84. Hackett PH, eds. H ypoxia: Into the Next Millennium: Advances
91. Francis TJ, Dutka AJ, Hallenbeck JM. Pathophysiology of decom- in Experimental Medicine and Biology. Vol 474. New York, NY:
Kluwer Academic/Plenum; 1999.
pression sic kness. In: Bove AA, Davis JC, eds. Diving Medicine. 117. Sanchez de! Rio M, Moskkowitz MA. High-altitude headache: lessons
2nd ed. Philadelphia, PA: Saunders; 1990. from aches at sea level. In: Roach RC, Wagner PD, Hackett PH, eds.
92. Greer HD, Massey EW. Neurologic iitjury from undersea diving. H ypoxia: I nto the Next Millennium: Advances in Experimental
Neural Glin. 1992;10(4):1031. Medicine and Biology. Vol 474. New York, NY: Kluwer Academic/
93. Kizer KW. Management of dysbaric diving casualties. Emerg Med Plenum; 1999.
Glin North Am. 1983;1:659. 118. Hackett PH. The cerebral etiology of high-altitude cerebral
94. Department of the Navy. U.S. Navy Diving Manual. Vol 1, Rev 4. edema and acute mountain sickness. Wilderness Environ M ed.
Washington, DC: U.S. Government Printing Office; 1999. 1999;10(2):97.
95. Davis JC. Hyperbaric medicine: critical care aspects. In: Shoemaker
WC, ed. Oritical Care: State of the Art. Aliso Viejo, CA:. Society of
Critical Care Medicine; 1984.
96. Pollock NW, Uguccioni DM, Dear GdeL, eds. Diabetes and
recreational diving: guidelines for the future. Proceedings of
the Undersea and Hyperbaric Medical Society/Divers Alert
Network. June 19, 2005, Workshop. Durham, NC: Divers Alert
Network; 2005.
97. Gallagher SA, Hackett PH. High-altitude illness. Emerg Med Clin
North Am. 2004;22:329.
98. Hackett PH, Roach RC. High-altitude illness. N Engl J Med.
2001;345(2):107.

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119. Yarnell PR, Heit J, Hackett PH. High-altitude cerebral edema 125. Lipman G. Ibuprofen prevents altitude illness: randomized
(HACE): the Denver/Front Range experience. Semin Neurol. controlled trial for prevention of altitude illness with nonsteroidal
2000;20(2):209. anti-infiammatories. Ann Emerg Med. 2012;59(6):484-490.

120. Hultgren HN, Honigman B, Theis K, Nicholas D. High-altitude pul- 126. Pollard AJ, Niermeyer S, Barry PB, et al. Children at high altitude:
monary edema at ski resort. West J Med. 1996;164:222. an international consensus statement by an ad hoc committee of
the International Society for Mountain Medicine. H igh Alt Med
121. Stenmark KR, Frid M, Nemenoff R, et al. Hypoxia induces cell- Biol. 2001;2:389.
specific changes in gene expression in vascular wall cells: impli-
cations for pulmonary hypertension. ln: Roach RC, Wagner PD, Suggested Reading
Hackett PH, eds. Hypoxia: Into the Next Millennium: Advances
in EX']Jeriment;al Medicine and B iology. Vol 474. New York, NY: Auerbach PS, ed. Wilderness M edicine. 6th ed. St. Louis, MO: Mosby
Kluwer Academic/Plenum; 1999. Elsevier; 2012.

122. The Lake Louise Consensus on the Definition and Quantification of Bennett P, Elliott D. The Physiology and Medicine of Diving. 4th ed.
Altitude Illness. In: Sutton JR, Coates G, Houston C, eds. Hypoxia Philadelphia, PA: Saunders; 1993.
and Mountain Medicine. Burlington, VT: Queen City Press; 1992.
Bove AA. Bove and Davis' Diving Medicine. 5th ed. Philadelphia, PA:
123. Luks AM. Do we have a "best practice" for treating high-altitude Saunders; 2003.
pulmonary edema? High Alt Med Biol. 2008;9:111-114.
Sutton JR, Coates G, Remmers JE, eds. Hypoxia: The Adaptations.
124. Koch RO, Burtscher M. Do we have a "best practice" for treating Philadelphia, PA: BC Dekker; 1990.
high-altitude pulmonary edema? Letter to the Editor. H i gh Alt Med
Biol. 2008;9:343-,'344.

At the completion of this chapter, the reader will be able to do the following:

• Explain four factors that distinguish the • Describe updated ways to manage bleeding
wounds in the wilderness.
wilderness and street emergency medical services
• Discuss the symptoms and signs of common
(EMS) contexts. bites and stings and medical management in the
wilderness.
• List the five critical selection criteria for clearing a
spine in the wilderness. • Describe when, in the wilderness context, an
attempt at cardiopulmonary resuscitation (CPR) is
• Discuss the reasons for the dictum, "Every appropriate and when it is not appropriate.
wilderness patient is hypothermic, hypoglycemic,
and hypovolemic until proven otherwise."

636 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Your search and rescue (SAR) team is called out at 2130 hours to support t he county's volunteer f ire fighters in the technical rescue of
a trauma vict im in a remote location. Early reports indicat e that one member of a t hree-person rock climbing group, a 31 -year-old man,
fell at around 2030 hours from the cliff edge to the rocky floor 80 f eet (24 meters) below, sustaining multiple long-bone fractures. One
member of the group ran back to his t ruck, grabbed a sleeping bag to keep t he patient w arm, and instructed t he other climber to go
get help.

The vol unt eer t echnical rescue team includes a paramed ic and an emergency department (ED) nurse. They arrive at the incident
command post at about 2230 hours. Follow ing an incident briefing, t he initial rescue t eam comprised of six personnel drive several miles
on a t rail using all-terrain vehicles and then hike for 60 minutes up a creek bed w ith gear to arrive at t he scene. When you arrive after
midnight, it is rain ing lightly and t he ambient temperature is 50°F (10°C). You and t he initial rescue team fi nd the patient at the bottom
of t he cliff sitting up w ith his back against a rock.

• How would you begin managing this pat ient in this wilderness setting wit h limited resources?
• What are the major concerns when treating this patient 's injuries?
• What w ill be the best way to evacuate this patient?

Proper Care Depends Figure 23-1 Wilderness terrain.
Source: Courtesy of Rick Brady.
on Context

Although our medical lmowledge, understanding, and technol-
ogy change from month to month, the principles of medical care
change little over the years and independent ofthe patient's loca-
tion. PHTLS has long advocated that the critically injured patient
be transported as quickly as possible to an appropriate destina-
tion, without detailed physical examination and treatment of
noncritical conditions.1

However, proper care is still somewhat context dependent.
The definition of detailed p hysical examination and noncritical
conditions may be different on an urban street than when deep
in the wilderness (Figure 23-1). This concept is introduced in the
chapter titled The Science, Art, and Ethics of Prehospital Care:
Principles, Preferences, and Critical Thinking, showing how sit-
uation, lmowledge level, skill, scene conditions, and equipment
available may alter management of the trauma patient.1

Consider a patient with a complex fracture-dislocation of
the shoulder. What is the proper care in the operating room
(OR)? In many cases it involves an open reduction and inter-
nal fixation (ORIF). However, proper care in t he OR may not
be proper care in the emergency department (ED), where it
would not be p roper to attempt an open reduction. In the ED,
the patient needs to have x-ray films taken to evaluate the frac-
ture-dislocation, a short-acting pain medication is given, and
a closed reduction of the dislocation is performed to reduce
pain and swelling, to realign the bones grossly, and t o decrease
pressure on nerves and blood vessels. The definitive ORIF will
occur later, in t he OR.

Likewise, proper care in the ED may not be proper care
in the field. The prehospital care providers may not have the
advantage of a large, warm, dry area to perform an assessment

CHAPTER 23 Wilderness Trauma Care 6 3 7

and provide treatment. They may be working in the rain, where For a small but significant number ofsituations, great differ-
the patient is hanging upside down inside a crushed vehicle ences exist between proper street emergency medical services
while a rescue crew uses power tools to cut and remove metal (EMS) care and proper wilderness EMS care. Such situations
to reach the patient. Once the patient is free, the prehos- bring up the following important questions:
pital care provider will assess the patient for other injuries,
check the distal neurovascular status in the arm, immobi- • Is street EMS care always optimal in the wilderness?
lize the patient's shoulder, provide some pain medication, • If street EMS care is not optimal, how does the prehos-
and transport t he patient rapidly to the ED. Similarly, on the
street, it would not be proper care to attempt a closed or open pital care provider know what the optimal care is? Is
reduction to re duce the fracture-dislocation. Finally, proper this written down as a set ofprotocols?
care on the street may not be proper care in the wilderness • How does the prehospital care provider deal with sit-
(Figure 23-2). What if a patient falls off a rope a half-mile into uations in the field when unsure precisely what the
a limestone cave, requiring a multihour evacuation through patient's injury might be? For example, in the previous
cave passages, followed by a several-hour drive to the nearest case, how does the wilderness medicine provider deter-
hospital? mine that a fracture-dislocation is present when exam-
ining a patient who is hanging upside down from a rope
For most conditions, however, proper care is proper care deep within a cave?
whether it is performed in the OR, in the ED, on the street, or • How does the prehospital care provider decide, for
in the wilderness. Given a good fund of knowledge, critical- a particular patient in a particular situation, which is
thinking skills, and understanding of key principles, prehos- more proper, street or wilderness care?
pital care providers can make reasoned decisions regarding • What makes a situation wilderness or street? What
patient care in all of the various situations in which they will about all the in-between cases?
encounter patie nts.
Definitive answers to all the questions cannot be pro-
vided. Often the answer is "it depends." But at least good
background information can be provided so that prehospital
care providers may, as needed in a particular patient care sit-
uation, answer the questions. The Prehospital Trauma Life
Support (PHTLS) philosophy has always been that, given a
good fund of knowledge and key principles, prehospital care
providers are capable of making reasoned decisions regarding
patient care.

Several wilderness issues are critical for optimal wilder-
ness patient care and are common wilderness problems for
which management is different than on the street. This chapter
provides an overview of the many issues involved in wilder-
ness-related medical emergencies. Prehospital care providers
who will be functioning in a formal capacity in the wilderness
setting as wilderness medicine providers should obtain spe-
cific training in managing these patients (Figure 23-3). In addi-
tion, medical direction by a knowledgeable physician should
be an integral component of wilderness medicine activities.2
However, in many regions of the United States there is no
medical direction for wilderness medicine providers on many
search and r escue teams.3•4

Figure 23-2 Trauma care in the wilderness is often hampered by Figure 23-3
adverse environmental conditions, mud, underbrush, and confined
spaces. Those prehospital care providers who may provide EMS in
the wilderness as wilderness medicine providers or who
Source: Courtesy of Tom Pendley/Desert Rescue Research. regularly travel in the backcountry are advised to take a
specialized course.

6 3 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

The Wilderness EMS We often talk of wilderness EMS, but in reality, all of EMS
Context lies on a spectrum. At one end ofthe spectrum is an incident half
a block from a level I trauma center, and at the other end of the
Many terms are used to describe areas far from civilization, spectrum is an incident in the deepest part of the Mammoth-
including wilderness, remote, backcountry, isolated, and austere. Flint Ridge cave system in Kentucky. In the final analysis, where
EMS personnel tend to lump these together under the rubric does the street end and the wilderness begin? The answer is, "It
wilderness and to speak of wilderness EMS. According to the depends.n It depends on the distance from the ambulance and
dictionary, the following definitions apply to wildemess5: the ED. It depends on the weather. It depends on the terrain.
Even more importantly, it depends on the nature of the injury
• A tract or region uncultivated and uninhabited by and the capabilities of the EMS and rescue personnel on scene.
human beings
Wilderness Injury Patterns
• An area essentially undisturbed by human activity
together with its naturally developed life community As mentioned in the PHTLS: Past, Present, and Future chapter,
death from trauma has a trimodal (three-peaked) distribution.
• An empty or pathless area or region The first peak of death is within seconds to minutes of injury.
Deaths occurring during this period are usually caused by lacer-
Because EMS is focused on patient care, the EMS definition ations of the brain, brain stem, high spinal cord, heart, aorta, or
of wilderness differs from the preceding definitions. The EMS other large vessels and can best be managed by preventive mea-
definition is really the answer to a question: "When should we sures such as helmets and seat belts. Only a few of the patients
think about wilderness EMS?" That is, "When should we think can be saved, and then only in large urban areas where rapid
and work differently from what we do on the street?" emergency transport is available.

The answer to this question goes beyond simple geography The second death peak occurs within minutes to a few
and involves the following considerations: hours after injury. Rapid assessment and resuscitation are
carried out to reduce this second peak of trauma deaths. Deaths
• Access to the scene occurring during this period are usually caused by subdural and
• Weather epidural hematomas, hemopneumothoraces, a ruptured spleen,
• Daylight lacerations of the liver, pelvic fractures, or multiple injuries asso-
• Terrain ciated with significant blood loss. The fundamental principles of
• Special transport and handling needs trauma care (hemorrhage control, airway management, balanced
• Access and transport times fluid resuscitation, and transport to an appropriate facility) can
• Available personnel best be applied to these patients. The third death peak occurs
• Communications several days or weeks after the initial injury and is almost always
• Hazards present caused by sepsis and organ failure.
• Medical and rescue equipment available
• Injury patterns for the specific environment Prehospital care providers focus mostly on saving patients
from the second death peak. In the wilderness, most of those
Numerous potential examples exist besides the traditional who survive to be rescued have already weathered the first peak
view ofwilderness. For example: of death and usually most of the second. However, the presence
of medically trained individuals on a search and rescue (SAR)
1. In a city after an earthquake, it may be very difficult to rescue team may also prevent deaths related to the second death
access those who are injured or trapped, there may be peak.6•7 Often, this wilderness care focuses on, "What can we do
no road for transport, and local EMS systems may be now that will keep the patient from dying or having major com-
out of commission. In this situation, patients are likely plications later?" Wilderness medicine providers need to make
to remain in their location for a considerable amount sure the patient does not develop problems such as kidney fail-
of time. They will have the same care requirements as ure from dehydration, overwhelming infection from poor resis-
a hiker who has fallen in the mountains and is hours or tance due to starvation, pulmonary embolism from deep venous
days away from a hospital. thrombosis (blood clots in the legs breaking off and going to the
lungs), and infections from decubiti (bedsores).
2. A person who has fallen into a suburban landfill site
late in the evening during an ice storm is at risk from Safety
the same factors as a patient suffering the same type
of fall in the wilderness. The patient may need a rescue In the wilderness, even more so than on the street, scene safety
team with ropes, ice axes, and crampons, and prehos- is paramount.8 An injured or dead wilderness medicine provider
pital care providers who can anticipate and cope with distracts from the care ofthe patient and limits the possibility of
issues such as hypothermia, toileting needs, prevention a successful rescue mission. Street scene safety considerations
of pressure sores, wound management, and food and
fluid requirements.

CHAPTER 23 Wilderness Trauma Care 639

still apply evenin the wilderness. In the wilderness, scene dangers EMS Decision Making:
are usually much less obvious than on the street; they tend to Balancing Risks and
slowly "sneak up" on unwary wilderness medicine providers. Benefits

The wilderness medicine provider and patient will be Experienced physicians, nurses, and prehospital care providers
exposed to the weather, and changes in weather, such as an know that procedures such as airway management and wound
incoming cold front with freezing rain, which may complicate management are the easy part of medicine. The difficult part
the operation or even iajure or kill the wilderness medicine pro- is in knowing when to do what: critical thinking. Even more
vider and patient. Ifa rescue lasts for hours, the lack of food and often than on the street, in the wilderness one risk needs to be
water may cause debilitation. The wilderness terrain is often rug- weighed carefully against another and against the potential ben-
ged, and poisonous plants and wildlife may complicate patient efits. For this particular patient, in this particular setting, and
care (Figure 23-4). Wilderness medicine providers need to be with these particular resources, and with this particular likeli-
aware of dangers specific to the environment, such as rockfall, hood of this particular help arriving at this particular time in
avalanche risk, rising waters, high altitudes or altitude exposure, the future, what are the potential risks? What are the potential
and recirculating eddies at the base of waterfalls. benefits? Wilderness EMS is largely the art of compromise: bal-
ancing the particular risks and benefits for each patient. To illus-
Itis essential that appropriate preparations and precautions trate the wilderness EMS decision-making process, consider the
are taken to ensure the safety, health, and well-being of the SAR following example:
team. All members of the SAR team must be educated about the
hazards and dangers of t he specific environment in which they A healthy 22-year-old woman was rock climbing along a river
will be working. Each member of the SAR team must know their gorge when she fell 65 feet (20 meters [ml). All her chocks
limitations and not exceed their capabilities trying to rescue an (anchors placed in cracks in the cliff) came out one by one,
iajured patient. Each member of the SAR team must be appro- so she fell all the way to the ground, but was slowed by each
priately prepared with the necessary clothing and equipment for anchor as it failed. She was wearing a helmet but struck her
the environmental conditions and rescue at hand. Lastly, ensur- head and experienced a brief loss of consciousness. After an
ing that the medical needs of the SAR team are met must be an hour-long hike up the river gorge from where they parked the
integral component ofthe response effort. Appropriate supplies ambulance at the end of the road, a wilderness medicine pro-
to address potential illness or iajury of an SAR team member vider and partner find the patient conscious and alert, com-
as well as enforcement of work-rest cycles will help maintain a plaining of only a mild headache, with a normal neurologic
well-functioning SAR team. examination and a normal physical examination. It is late fall,
it is getting dark, the nearest helicopter landing zone is back
The Wilderness Is Everywhere at the road an hour away, and the forecast is for a blizzard to
start tonight. Does the patient need to undergo spinal immo-
In the rest of this chapter, wilderness EMS, in the wilderness, bilization? Does the wilderness medicine provider need to call
and wilderness patients will be discussed. However, remember for an SAR team with a Stokes litter and a long backboard, or
that the wilderness might be a short distance from the road if it can the patient be walked out to the ambulance?
is dark and the weather is bad, or even on the road if a disaster
has made roads impassable or made nearby hospitals unable to
accept patients.

Figure 23-4 Steep slopes and uneven footing are a danger in Street Cervical Spine Management History
wilderness rescue.
Spinal immobilization for severely iajured trauma patients
Source: © Danny Warren/iStock/Thinkstock. became the standard of care decades ago. Even if unstable cer-
vical spine fractures were rare in alert trauma patients, and even
ifno evidence indicated that spinal immobilization was effective
at preventing paralysis in alert patients, strapping a patient to a
board seemed unlikely to hurt anyone. Over the ensuing years,
prehospital care providers used spinal immobilization for more
and more patients. It has since been recognized that patients
experience gradually increasing pain from the long backboard.
Studies show moderate pain at 30 minutes and severe pain after
about 45 minutes.9

As EMS training became more widely used by wilderness
SAR teams, the practice ofstrapping every patient to a long back-
board after an accident did not seem to make sense, especially
ifthe patient was on the side of a mountain in a snowstorm and

6 4 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

the nearest long backboard was 10 miles away and 10,000 feet In each of these situations, wilderness medicine providers
(3,000 m) down. So SAR teams in cooperation with the physi- at the scene are faced with the following two options:
cians working with them developed guidelines, based on the
available literature, for when not to immobilize trauma patients • Stay and wait for the spinal-immobilization equipment
in the wilderness. rn-12 Recently the Wilderness Medical Society to arrive.
published a practice guideline for managing spine iajuries in the
wilderness.13 That guideline is available on their website. • Start an improvised evacuation without spinal
immobilization.

Implications of the NEXUS Study Neither option is ideal; however, wilderness medicine pro-
viders need to choose. To make this choice intelligently, the fol-
A large and important multicenter study called NEXUS (short for lowing questions must be asked and answered:
National Emergency X-radiography Utilization Study) showed
that, in the hospital, many trauma patients can have their spinal • What are the risks of an improvised evacuation without
column cleared without the need for x-ray films, ifthe following spinal immobilization, and what are the risks of waiting
selection criteria are used14: for spinal-immobilization equipment to arrive, for this
particularpatient in this particular situation?
• Absence of tenderness at the posterior midline of the
cervical spine • What are the benefits of moving without waiting
for spinal immobilization versus waiting for spinal-
• Absence of a focal neurologic deficit immobilization equipment to arrive,for this particular
• Normal level of alertness patient in this particular situation?
• No evidence ofintoxication
• Absence of clinically apparent pain that might distract The benefits of spinal immobilization depend on the likeli-
hood that this particular patient has an unstable spinal iajury.
the patient from the pain of a cervical spine iajury In the NEXUS study, even those who did not meet the NEXUS
criteria, and who could not be "cleared," still had a very low risk
Although the NEXUS study was not a prehospital study, vari- of unstable spinal fracture, as follows14:
ants of these criteria have been used by many EMS systems to
guide the need for spinal immobilization. A few studies suggest • 2% of those who failed the NEXUS "clearing" protocol
some problems with using these criteria in the field. The wording had "clinically significant" fractures.
ofsome EMS selective spinal-immobilization protocols deviates
significantly from the previous wording, raising concerns about • Of that 2%, only a small fraction likely required specific
whether they really reflect the NEXUS criteria. However, it is gen- treatment.
erally accepted that the NEXUS criteria, when properly applied,
are a reasonable guide for the selection of patients who do not • Of that small fraction, only a small fraction likely had
need to be strapped to a long backboard, whether on the street or iajuries that might endanger the spinal cord if not
in the wilderness. Although NEXUS may be useful for inference immobilized, and most of those were in patients with
in the EMS setting, one should remember that the study was not multiple major fractures and multiple life-threatening
designed as a prehospital spinal-immobilization trial, but rather iajuries.
an evaluation of the need for cervical spine x-rays in-hospital.
Therefore, it seems likely that, for wilderness trauma
The problem in the wilderness, however, is not as simple. patients who have survived long enough to be rescued, the inci-
What if a patient does not quite meet these criteria? Does that dence of unstable spinal iajury will be less than 1%.
mean that the patient has to be immobilized? As discussed ear-
lier, wilderness EMS is the art of compromise, and nowhere In the end, wilderness medicine providers at the scene need
is this more apparent than in making decisions about spinal to assess these potential risks and benefits to make an informed
immobilization. decision for their patient.

What if the patient has a potential spine iajury and it is a Improvised Evacuations
2-hour walk from the nearest road, and no spinal-immobilization
equipment is at hand? Is it necessary to send someone on the When discussing spinal iajury in the wilderness context, con-
4-hour round-trip hike back to the ambulance for it? What if the sider the idea of starting an improvised evacuation rather than
patient is in a cave, with the water level rising? Could the patient waiting for a litter and spinal-immobilization equipment.15
and rescuers be cut off from an escape route and drown if the
SAR team delays? What if the patient is in the mountains, far Carrying patients in the wilderness is an extremely diffi-
from the ambulance, and a storm is moving in? What are the risks cult, time-consuming, and potentially dangerous activity for
to the patient and rescuers if they are forced to spend the night both the patient and those doing the carrying. Those with no
on the mountain? SAR experience generally underestimate the time and difficulty
of a wilderness evacuation by at least half, or sometimes up to

CHAPTER 23 Wilderness Trauma Care 641

Figure 23-5 Because of uneven terrain, creativity and technical (Figure 23-6). It is possible for men and women to urinate even
rescue skills may be needed to evacuate patients safely out of the while immobilized in a Stokes litter (Figure 23-7) with a full-body
wilderness. vacuum splint, if packaging is planned carefully and the litter is
tipped up on the foot end. For women, a small funnel device,
Source: Courtesy of Tom Pendley/Desert Rescue Research. often carried by women when backpacking, will be needed to
assist in elimination.

Patients who are lying on their backs for a long time tend to
develop decubiti (bedsores). These sores may end up requiring
surgery or debridement, resulting in a longer hospital admission.
Some patients will die from infection and other complications
of the decubiti. Lying in one's own urine and feces for a long
time Gust hours, not even days) may make decubiti more likely.
Ifpatient care occurs for only a few minutes during a short trans-
port, urine and feces are not a major issue. However, if a wil-
derness medicine provider has been taking care of a patient for
several hours and then delivers the patient to the ED lying in his
or her own feces, the likelihood of decubiti and resulting sepsis
is much greater.

a factor of five for more difficult evacuations, especially cave Figure 23-6 Elimination supplies.
rescues.

Ifsomeone without SAR experience says, "It'll take us about
2 hours to get the patient out of here," the time should be tripled.
Wilderness medicine providers should expect it to take 6 hours
or longer if the patient is in a cave, if the SAR team is short on
people, if the terrain is particularly difficult, or if the weather
is bad. This is especially important to remember if darkness is
approaching or the weather is deteriorating.

Walking a patient out, even with a couple of people helping,
is almost always much faster. If the patient is able to and starts
moving now, rather than waiting for a litter or spinal immobili-
zation, the evacuation will be much, much faster and completed
much earlier. If the patient cannot walk (e.g., because ofan ankle
fracture), it may be possible to do a piggyback carry or to make
an improvised stretcher out ofsticks and rope (Figure 23-5).

Patient Care in the
Wilderness

Elimination Needs

The truth described in a popular children's book Everyone Figure 23-7 Stokes litter.
Poops 16 applies to wilderness patients as well. Given the rela-
tively short transport times in an urban setting, most patients Source: Courtesy of Rick Brady.
do not have an elimination need. Trauma patients almost never
defecate during their prehospital and ED care. However, if you
are caring for a patient who has been in the wilderness for a day
or more and it takes you several hours to get to the patient, it is
much more likely that the patient will need to urinate or defecate.

Having patient care supplies that include blue pads (Chux)
for placing under the patient, having some toilet paper, improvis-
ing a large trash bag as an outer layer diaper, or even stopping
to let the patient urinate or defecate are all reasonable measures

6 4 2 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Long Backboard Use hypoglycemic. Dehydration is more than just hypovolemia,
which refers only to intravascular volume within the blood vas-
Other important preventive measures for wilderness patients, cular system. Patients who are dehydrated have also lost water
especially those who face prolonged evacuation, include preven- from their cells and the interstitial spaces between the cells.
tion of decubiti as follows15•17:
On the street, water and food are generally rwt given to
• Allow (and assist) the patient to turn from side to side patients. There are many reasons not to feed patients on the
in the litter. street. Ifthe patient needs to go to the OR, having food or fluid in
the stomach is harmful; it increases the likelihood ofvomiting or,
• Keep t he patient's sacrum (buttocks) clean and dry. more likely, passive regurgitation leading to possible aspiration
• Provide adequate padding. when under anesthesia. Also a patient will not starve or dehy-
drate in the time it takes to get to the hospital.
If the patient truly needs spinal immobilization, prevention
of decubiti is even more important, although correspondingly In the wilderness, if a rescued patient needs to go to the
more difficult. Techniques to avoid decubiti during spinal immo- OR, it will take time to transport the patient to the hospital, to
bilization include the following: be evaluated in the ED, and to be prepared for the OR. With
wilderness patients, the focus is to ensure that the patient
• Put the patient in a full-body vacuum splint rather than does not die right after admission to the hospital. Starving
on a long backboard. Vacuum mattresses provide excel- patients is seldom good for injured bodies. Feeding the patient
lent spinal immobilization and are much less likely to today will make the patient better tomorrow. Since the stom-
cause decubiti. •s.21 ach needs to be empty for only a few hours before anesthesia,
the wilderness medical provider may provide food and water
• If no full-body vacuum splint is available, pad the long to any reasonably alert wilderness patient who can safely
backboard well and add support under the lumbar swallow. 26,21
spine, knees, and neck. Studies show that immobiliza-
tion on an unpadded long backboard causes even unin- Vomiting and aspiration are always a danger, and careful
jured people to experience excruciating pain in about attention to the patient's airway is always important (e.g., posi-
45 minutes and skin necrosis (cell death) in about tioning on the side for long transports, even if the patient needs
90 minutes.9• 22-25 spinal immobilization). Wilderness medicine providers may still
attempt to provide food and water for wilderness patients, even
• Carry the litter first on one side, then the other, so that though they have vomited once or twice, as long as their airway
pressure alternates between the two hips rather than is protected.
always on the sacrum.

To prevent deep venous thrombosis and pulmonary embo- Sun Protection
lism, do the following:
The ultraviolet (UV) rays of the sun can damage the skin-
• Package patients so that they can move their legs; do acutely, sometimes severely, and in a delayed fashion. Acute
not tie them down tight. injury can include partial-thickness and full-thickness sun-
burns seen in some victims of exposure, and such severe sun-
• Consider rest stops to allow patients to get out of the burn can cause shock or death. Delayed injury is manifested
litter to stretch their legs. as increased risk for skin cancer. Avoiding exposure to direct
sunlight, especially from 10 a.m. to 3 p.m. when UV radiation
If there is mild suspicion of a cervical spine injury but not from the sun is strongest, decreases but does not eliminate the
a lumbar spine injury, it might be appropriate to allow an alert risk ofsunburn.
patient to get out of the litter, still wearing a cervical collar, and,
with many trained hands to help, allow the patient to stretch his Topical sunscreens usually contain combinations of organic
or herlegs and take care ofany elimination needs. Speaking with chemicals that absorb various wavelengths of UV light. UV light
a physician knowledgeable with wilderness EMS first might be comes in two frequencies, A and B (UVA and UVB). UVA was
reassuring ifthis is contemplated. once thought to be harmless, but now we know that it works
synergistically with UVB to cause sunburn. UVB is responsible
Food and Water Needs for most of the erythema (redness) of sunburn. UVA has been
implicated in the development of phototoxicity and photo-
Every wilderness patient should be considered to be cold, aging.28 Thus, sun-blocking materials or creams must block both
hungry, and thirsty; that is, he or she should be considered UVA and UVB to be effective. Seek the term board-spectrum sun
hypothermic, starved, and dehydrated-or at a slight expense protection factor (SPF) on the product label to ensure coverage
of accuracy, hypothermic, hypoglycemic, and hypovolemic. for both UVA and UVB.

Starvation is much more than just hypoglycemia (low Sun protection is measured by SPF (Figure 23-8). The SPF is
blood sugar), and not all starving patients are significantly a numeric measure ofhow much the clothing or cream increases

CHAPTER 23 Wilderness Trauma Care 6 4 3

the minimum dose ofUV light to make the skin red. For example, Figure 23-9
a sunscreen lotion with a rating of SPF 45 provides protection
from sunburn for about 45 times longer than without the sun- Wind, heat, humidity, and altitude can all decrease the
screen. An SPF of 10 blocks 90% of UVB radiation, an SPF of effective sun protection factor (SPF) of a sunscreen.
15 blocks 93%, an SPF of 30 blocks 97%, and an SPF of 50 blocks Also, it is now known that the combined application of
98%. Consequently, the Food and Drug Administration does not insect repellents that contain DEET (N,N-diethyl-meta-
allow sunscreen products to have an SPF label greater than toluamide) also decreases SPF effectiveness.28
50 due to the limited benefit added for protection. The degree of
protection against UVA is hard to quantify and is usually much Figure 23-10
less than protection against UVB.29
Some patients may have an acute allergic reaction if
It is advisable to wear protective clothing, such as wide- the lotion contains para-amino benzoic acid (PABA);
brimmed hats, pants, and long-sleeved shirts, and to apply sun- therefore PABA-free products are recommended.
screen to exposed skin. To check clothing for SPF, hold a piece
of clothing up against a light bulb. If an image of the light bulb Pain Control
is seen through it, the SPF is slightly below 15. If light is seen Acetylsalicylic acid
through it but not the image of the light bulb, the SPF is in the Nonsteroidal anti-inflammatory drugs
range of 15 to 60 SPF.
Skin Care
Protective lotions with a minimum SPF of 15 should be Cool soaks and compresses
applied to exposed skin to minimize the potential injury from Nonmedicated moisturizers
sun exposure. For prolonged evacuations, lotion with an SPF Topical anesthetics
of 30 should be used, but little benefit can be claimed with an Pramoxine (Prax) lotion
SPF 30 alone unless it is reapplied every 90 minutes. Ideally, Menthol plus camphor (Sarna) anti-itch lotion
sunscreens should be applied 15 to 30 minutes before going Anti-itch concentrated lotion (Pramoxine) plus
out into the sun. Most people do not apply a thick enough layer camphor plus calamine (Aveeno)
to achieve the claimed SPF. A minimum of 1 ounce (about a Lidocaine plus camphor (Neutrogena Norwegian
shot glass full) should be used on all exposed areas. With pro- Formula) soothing relief moisturizer
fuse sweating or water immersion, sunscreen should be reap-
plied frequently depending on the product label. Generally, Steroids
water-resistant SPF will be effective up to either 40 or 80 min- Topical (e.g., triamcinolone 0.1 % cream applied twice
utes per product directions. Further considerations regard- daily when erythema first appears)
ing the application of sunscreen are included in Figures 23-9 Systemic
and 23-10.
Source: From Krakowski AC and Kaplan LA. Exposure to Radiation from
Sunburn is treated as any other burn, and the care the Sun. Auerbach PS, editor: Wilderness medicine, ed 6, Philadelphia, 2012,
is essentially the same in the wilderness as on the street Elsevier Mosby.

Ill

-.

Figure 23-8 Sunscreen. (Figure 23-11).30 The only major difference is that in the wil-
derness, the prehospital care provider needs to be aware of
Source: Jones & Bartlett Learning. Photographed by Darren Stahlman. and treat the potential fluid loss, dehydration, or sometimes

6 4 4 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

even shock, and to recognize that patients with sunburn are at Training programs for those venturing into wilderness

higher risk for hypothermia. situations should address these lifesaving skills:

Specifics of Wilderness • Direct digital pressure should be applied for 10 to
EMS 15 minutes directly on the bleeding site followed by a
pressure bandage.
This section reviews a few of the most important situations in
which proper wilderness trauma care differs from care on the • Hemostatic agents may be useful in wilderness care
street. Issues covered include wound management, joint disloca- in the control of severe bleeding. Wilderness medi-
tions, cardiopulmonary arrest, and bites and stings. cine providers may encounter injured patients who
have had hemostatic agents already applied by others
Wound Management in their group. Many of these agents are available for
sale to the general public; however, training on how
Wound management encompasses the following: to effectively apply them is still recommended. It is
important to remember that even if hemostatic agents
• Hemostasis (stopping bleeding) are used, direct pressure on the wound remains part of
• Antisepsis (preventing infection) the treatment process.
• Restoration offunction (returning the skin to its protec-
• Tourniquets may be used when all other methods to
tive function, and restoring a limb or other body part to control the hemorrhage have failed and the priority
normal function) is life preservation over limb preservation. The tour-
• Cosmesis (ensuring pleasant appearance) niquet should be applied above the wound as close
to the wound as possible (Figure 23-13). (For more
In the wilderness, prevention ofinfection and restoration of about hemostatic agents, tourniquets, and other hem-
function assume great importance. orrhage control principles and preferences, see the
Shock chapter.)

Hemostasis Prevention of Infection

Control of bleeding is part of the primary assessment. On the After injury in the wilderness, it may be a long time before
street, arterial bleeding can kill. In the wilderness, even venous the wound receives definitive treatment in an ED. Routine
bleeding can kill if it continues for a sufficient amount of time. wound care in the ED includes appropriate cleaning to pre-
Remember, every red blood cell counts. Bleeding control, includ- vent infection. Wounds contaminated by dirt or caused by
ing standard measures such as direct pressure, is as important or
more important in the wilderness. Unless medical personnel are Figure 23-13
part of the actual injured party's group, severe bleeding that is
not stopped will probably result in the patient's demise prior to
the SAR team's arrival (Figure 23-12).

Figure 23-12 • Not using one when the injury indicates its use
• Using a tourniquet for minimal bleeding
Recently, an international consensus panel, convened • Applying it too proximally
by the American Heart Association, updated first aid • Not taking it off when indicated
skills, including hemorrhage control principles.31 It • Taking it off when the patient is in shock or has only a
is now recommended to control severe bleeding by
manual direct pressure, gauze and a pressure dressing, short transport time to the hospital
hemostatic agents, and a tourniquet. The traditional • Not making it tight enough (The tourniquet should
methods of using pressure points and extremity elevation
are no longer recommended due to the lack of any eliminate the distal pulse.)
evidence supporting their effectiveness. • Not using a second tourniquet if needed
• Waiting too long to apply the tourniquet
• Periodically loosening the tourniquet to allow blood

flow to the injured extremity

Source: Adapted from the Department Def ense Lessons Learned from t he
Committee on Tactical Combat Casualty Care. See Chapter 27 in t he eighth
edition of PHTLS: Prehospital Trauma Life Support, Military Edition.

CHAPTER 23 Wilderness Trauma Care 6 4 5

penetration from a dirty object are cleaned with high-pressure is complete, dress and bandage the wound. Reapply a clean
irrigation. Uncontaminated wounds are cleaned with low- dressing at least daily or sooner if the bandage gets wet.
pressure irrigation.
Ifthe wound is gaping open, a wet dressing will prevent tis-
High-pressure irrigation may cause swelling ofwounds, but sue damage as a result of drying out; change or at least rewet the
in the case of contaminated wounds full of dirt and bacteria, the dressing with clean water several times a day. However, because
benefit of removing bacteria outweighs the risks from wound the wound will be mostly closed by bandaging, a dry dressing
swelling.32•33 Infection may set in quickly. After a wound has can be used in most cases.
been open for about 8 hours, bacteria have spread from the skin
deep into the wound, and suturing a wound is likely to create a Early antibiotic administration is commonly used
deep wound infection. Deep wound infections develop pressure, upon arrival at the ED for patients with significant trauma.
which keeps out white blood cells, the body's normal defense Antibiotics are not given in most civilian prehospital emer-
mechanism against infection. gency medical systems because of the very short transport
times encountered in the urban environment. However, defin-
Routine wound care on the street does not include cleansing itive care may be significantly delayed in wilderness settings
due to the longer distances to be covered and rescue consider-
the wound because it makes sense to delay wound cleansing for ations in rugged terrain.
a few minutes until the patient reaches the ED, which is better
Antibiotics must be given as soon as possible after injury to
suited for wound cleansing and evaluating the patient's wound. maximizetheirabilitytopreventwoundinfections. Intramuscular
The ED can determine ifthe patient has a tendon or nerve lacer- benzylpenicillin begun within 1 hour of injury was found to be
ation, an associated fracture, a spleen laceration, or a subdural effective in preventing streptococcal infections in a swine model
of wound infection. If administration was delayed until 6 hours
hematoma in the head. after injury, the medication was not effective.46
Delaying wound care does not make sense in the wilder-
A recent military review of antibiotic use on the battlefield
ness. If it will take hours to get to the ED, the wound should recommended that antibiotics be used if arrival at a medical
be cleaned. In extremely remote areas, the wound could even treatment facility was anticipated to be 3 hours or longer.47 The
become infected before the patient arrives at the ED several U.S. Department of Defense's Tactical Combat Casualty Care
days later. Course (TCCC) advocates for the early administration of anti-
biotics for any open wounds at the point of wounding. TCCC
Studies have shown that early irrigation is essential to cites multiple case studies where no wound infections devel-
removing bacteria and reducing wound infections.3<h'l6 It is not oped when service men and women received battlefield antibi-
necessary or practical to carry sterile solutions for wound irriga- otics. TCCC further recommends that oral antibiotics be given to
tion. There is no need to add an antiseptic to the water.37 Water casualties once a day if the casualty has the ability to swallow.
that is good enough to drink is good enough to irrigate a wound. Although no comparable studies have been done in the civilian
Water from streams or melted snow can be treated with any stan- setting, these recommendations make sense for application in
dard wilderness drinking water treatment and used to cleanse a the wilderness environment if the physician medical director
wound.32, 38-42 agrees.

When cleaning an uncontaminated wound, for example, Restoration of Function and Cosmesis: Closing
a laceration sustained from a football player banging his fore- Wilderness Wounds

head against a teammate's helmet, it is only necessary to wash Because of the lack of good lighting, x-ray films, and a warm,
the laceration out with water poured through the wound. A bulb dry place to work, it does not make sense to perform definitive
wound closure in the wilderness. It is recommended to simply
syringe, usually available in the ED, is commonly used, but squirt- cleanse the wound, dress and bandage, ensure good wound
ing some clean available water from a drinking-water bottle or a care for 4 days, and then have a delayed primary closure per-
hydration bladder-backpack system, for example, will do as well. formed in the ED. As long as the wound is not infected, it is
safe to suture the wound 4 days later as if it had just occurred.
If the wound is contaminated, it must be irrigated with Although bacteria move into the wound soon after injury, even-
enough pressure to clean out the bacteria. The original studies tually enough of the body's defenses (e.g., white blood cells)
showed that a 35-rnilliliter (ml) syringe with an 18-gauge needle have entered the wound and make it safe to close. If a physi-
provided an appropriate amount of pressure (5 to 15 pounds per cian or someone else experienced at wound closure is pres-
square [psi]).43-45 Squirt the water, at high pressure, throughout ent, the wound may be closed at the scene. However, it is still
reasonable to only cleanse, dress, and bandage the wound and
the wound. This procedure, however, is a major bloodborne allow closure to occur later.
pathogen risk; protection from the spray of blood with a gown
or a clean trash bag or rain poncho when irrigating is necessary. Closing a wilderness wound may be important in one sit-
Eye protection and gloves are essential. uation: when bleeding cannot be controlled in any other way.

Sometimes it is necessary to use a gauze pad or clean cloth
with gloved fingers to clean out some gross dirt or foreign mate-

rial. The patient's pain may need to be treated before the wound
can be cleaned. Lidocaine applied topically to the wound or
injected subcutaneously for local anesthesia can provide reliefin
most cases. Narcotic analgesics may impair the patient's ability
to ambulate and thus delay the evacuation. Once the irrigation

6 4 6 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

These situations are uncommon and usually involve a scalp recognized in many EMS protocols. For traumatic cardiac arrest,
laceration. For this reason, some wilderness medicine pro- initiate CPR with cervical spine stabilization if:
viders are trained to use disposable surgical staplers to
repair scalp wounds. However, wound repair is complex 1. Cardiac arrest occurs in the presence ofEMS personnel.
and s hould not be attempted without sufficient training and 2. A victim of penetrating trauma had signs of life within
experience.
15 minutes of the arrival of EMS personnel.

Dislocations Wilderness Traumatic Arrest

A healthy 20-year-old man was kayaking along a white-water A few signs can be uniformly equated with nonsurvivability:
stream when the top of his kayak paddle hit a low-hanging tree
branch. Now his right shoulder is swollen, deformed, and pain- • Decapitation
ful. He cannot bring his right arm across his chest. Distal pulses, • Transection ofthe torso
capillary refill, sensation, and movement are intact. From the • Patient is frozen so hard that the patient's chest cannot
ambulance, the wilderness medicine provider and partner hike a
mile through the woods to get to the stream. Should they "splint be compressed
it as it lies" or try to reduce what looks like an anterior shoulder • Patient's rectal temperature is very cold and the same
dislocation?
as the environment
The common practice for fractures and dislocations on the • Well-progressed decomposition
street is to "splint it as it lies" and transport for definitive treat-
ment. The only exception is the patient whose distal pulse is not The following presumptive signs of death may be of use to
palpable, in which case the extremity is realigned anatomically wilderness medicine providers, although no one sign by itself is
in an effort to restore circulation. reliable:

Although "splint it as it lies" is a good general rule for the • Rigor mortis. Postmortem rigidity is well known
street, "make it look normal" is a better general rule for the wil- but not always present, and similar rigidity is often
derness patient. It is certainly appropriate for both fractures and observed in hypothermic patients.
dislocations when transport is delayed.
• Dependent lividity. This finding is common in corpses
There are many types of dislocations-finger, toe, shoul- but can also be found, along with pressure necrosis and
der, patella, knee, elbow, hip, ankle, and jaw-and all have been frostbite, in some patients exposed to the elements for
successfully reduced in the wilderness, some more easily than a longtime.
others. It is usually very easy to reduce dislocations of the ankle
(which are almost always fracture-dislocations), patella, toe, • Decomposition. This finding is usually self-evident.
or finger, except the proximal interphalangeal joint of the index • Lack of presumptive signs of life. Hypothermia can
finger in some cases. Elbow, knee, and hip dislocations are usu-
ally quite difficult. All are much easier with training and practice; mimic death, in that pulses may not be palpable, res-
in particular, it takes training or experience to know, without pirations may be undetectable, and pupils may be
a radiograph, when a joint is likely dislocated and to attempt dilated and unreactive with no signs of consciousness.
reduction. However, some such severely hypothermic patients
have occasionally been resuscitated, with full neuro-
EMS training courses seldom provide training in disloca- logic recovery.
tion reduction. However, because wilderness dislocations are
so common, dislocation reduction is covered in almost all wil- Therefore, in the wilderness context, CPR is inappropriate
derness emergency responder and wilderness EMS training or for traumatic arrest. It is appropriate for wilderness medicine
at orthopedic workshops at wilderness medicine conferences. providers and the SAR team members to examine the patient,
Those who might provide EMS in the wilderness or who regu- then gently but firmly tell the companions that the victim is dead
larly travel in the backcountry are advised to take one of these and there is no reason to initiate resuscitation. Although it is
courses. oftentimes difficult to use the word "dead," euphemisms often
lead to misunderstanding and misinterpretation of what is actu-
ally being said.

Cardiopulmonary Resuscitation Wilderness Medical Arrest
in the Wilderness
The term medical cardiac arrest applies to a patient who has a
Traumatic cardiac arrest on the street has a poor prognosis, contributing, underlying medical condition or suffers an acute
even if the scene is within minutes of a level I trauma center. medical condition (chest pain, shortness of breath, diabetes,
No person survives more than a few minutes of cardiopulmo- etc.) and then sustains a cardiac arrest. Again, in the wilder-
nary resuscitation (CPR) after traumatic arrest.48-51 This reality is ness context, the chances of survival are poor or nonexistent

CHAPTER 23 Wilderness Trauma Care 647

when the patient is more than a few minutes from CPR or Bites and Stings
de:fibrillation.52--0S It is possible that an SAR team might be car-
rying out a patient when the patient sustains a cardiac arrest. Bites and stings are common wilderness problems. The exact
Although some lightweight defibrillators are now being manu- type of bite or sting likely in a wilderness area depends on the
factured, the weight-to-need-for-use ratio of defibrillators is so specific locale.
poor that they are seldom carried by SAR teams.
Bee Stings
Recently a position statement was released on the
Termination of Resuscitation of Nontraumatic Cardiopulmonary The most widespread, common, and deadly sting is that of the
Arrest by the National Association of EMS Physicians common honeybee, at least to those who are allergic. Most reac-
(NAEMSP).57 This statement, which is available on the NAEMSP tions to bee stings are severe (although brief) local pain, and in
website, can provide some guidance on when to consider some cases local swelling and redness persist for 1 or 2 days;
termination ofa cardiac arrest resuscitation effort. these latter reactions are likely directly related to irtjected toxins
and are not an indication of allergy.
There are a variety of other causes of cardiac arrest in the
wilderness, such as ventricular :fibrillation (VF) cardiac arrest Some individuals who are stung will progress within a
secondary to hypothermia or cardiac arrest secondary to pul- few minutes to a generalized allergic reaction. This may range
monary embolism. For such cardiac arrests, survival is even from urticarial (hives) to a full-blown anaphylactic reaction.
less likely than with a cardiac arrest secondary to a myocardial Although the exact spectrum of generalized allergic reaction
infarction. depends on the contents of the injected toxin (which varies
among the many species of bees and wasps) and the aller-
However, "nontraumatic" wilderness cardiac arrest might gic history of the patient, one or more of the following are
be survivable in the following situations: usually seen:

• Hypothermia58 • Urticaria (hives) (Figure 23-14)
• Cold-water submersion5!J.62 • Lip swelling
• Lightning strike63 • Hoarseness or stridor
• Electrocution • Wheezing and/or shortness of breath
• Drug overdose • Abdominal cramping, vomiting, or diarrhea
• Avalanche burial64 • Tachycardia or bradycardia
• Hypotension
In all these cases, a patient may appear to be in cardiac • Syncope
arrest but still might be resuscitated by basic CPR. For hypo- • Shock
thermia in particular, there is a saying that "Nobody is dead
until they are warm and dead" (see the Environmental Trauma Those individuals with a history of a generalized allergic
I: Heat and Cold chapter). A significant minority of those who reaction to a sting are more likely to have another generalized
appear dead from the mechanisms listed can be resuscitated. reaction to the next sting. However, venom among different
There are special considerations for each of these situations-
for example, scene safety for those who have been electrocuted
and are still attached to a power line, or the fact that external
cardiac compression can actually induce a VF cardiac arrest in a
hypothermic patient whose heart is beating just enough to keep
the patient alive.ru;-08 Although appropriate in a wilderness EMS
course, detailed discussion of these topics is beyond the scope
of this chapter (see the Environmental Trauma I: Heat and Cold
and the Environmental Trauma II: Drowning, Lightning, Diving,
and Altitude chapters).

1\vo simple and standard wilderness CPR rules are:

• If the patient appears to be in cardiac arrest from

causes other than trauma, attempt CPR for 15 to 30

minutes; if, at the end of this period of time, the patient

has not been resuscitated, stop CPR and consider the

patient dead.

• Do not start CPR if it will put rescuers at risk and

decrease their chances of retreating from the scene

safely, given concerns about daylight, terrain, weather, Figure 23-14 Allergic urticaria.

and available nearby shelter. Source:© Chuck Stewart, MD.

6 4 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

species varies enough that, despite a history of generalized Figure 23-15
allergy in the past, a patient might have no generalized reaction
to the next sting. Warning: There is another autoinjector medication on the
market that has the appearance of an EpiPen autoinjector.
A patient with mild urticaria after a sting will probably The drug is Alsuma, a sumatriptan autoinjector prescribed
do well. If a p atient with hives after a sting progresses to to treat migraines. This autoinjector could be used by
real anaphylaxis, however, the best early sign is hoarseness. mistake on an anaphylactic patient since there is no
The major cause of death after bee sting allergic reaction is warning that it is not epinephrine and has the identical
airway obstruction from hives in the airway, and hoarse- size, color, and cap appearance as the EpiPen released
ness is usually the first sign of airway swelling. Any patient in 2010.70
with a generalized reaction to a bee sting needs treatment
immediately.

Basic life support interventions generally involve keeping
the patient fiat or in a position of comfort, performing standard
airway management, and providing oxygen.

Honey bee stingers usually remain in the skin when the
insect leaves b ecause t he stinger is barbed. Venom from the
stinger and venom sac will continue to enter t he skin for 45
t o 60 seconds if the stinger is not removed; thus it is import-
ant to remove the stinger quickly. There has been a great deal
of discussion a bout the proper way t o remove a bee stinger,
but recent information indicates it really does not matter
how it gets out as long as it is removed as soon as possible.
Fingernails, a knife blade edge, or a credit card edge are all
effective tools for removing an embedded stinger. If a stinger
is removed within 15 seconds of the sting, the severity of the
sting is reduced.

The main medications used to treat allergic reactions to bee
stings include the following:

1. Epinephrine (adrenalin). Although epinephrine acts Figure 23-16 Coral snake.
only for a few minutes, it can be lifesaving.
Source:© Jason Ondreickaffhinkstock.
2. Antihistamines (e.g., diphenhydramine [Benadryl]).
Anyon e who requires epinephrine for a bee sting allergy Snakebite
should receive an antihistamine.
There are approximately 3,000 species of snakes, of which some
3. Steroids (e.g., prednisone). Most people who require 600 are poisonous but only 200 are considered to be medically
epinephrine also require steroids. significant venomous types.71•72 Few are found in northern lat-
itudes. Most reside naturally in tropical areas, and many are
Some wilderness SAR teams carry drugs for bee sting deadly. Although many snakes have venom glands, there are only
allergic reactions in their medical kits; the SAR team's wil- two types ofsnakes in North America with venom strong enough
derness medicine providers have special training in their to cause more than minor irritation to humans.
use. Oftentimes, some people with a history of bee sting
allergy will carry these medications in t heir personal Coral snakes are small snakes found in the southern parts of
first-aid kits. North America. They have venom that is neurotoxic and causes
paralysis (Figure 23-16). These snakes are small, have small
The most important drug is epinephrine, which acts fangs, cannot open their mouths very far compared to larger
rapidly to reve rse the acute reaction. Epinephrine is avail- snakes, and have to chew to allow the venom to penetrate; there-
able as a pen-sized autoinjector (e.g., EpiPen), which is often fore, serious envenomations are not common.
prescribed to any patient wh o has had a generalized allergy
to bee stings (Figure 23-15). These autoinjectors are found in Pit vipers are found throughout large portions of
many wilderness first-aid kits. The Wilderness Medical Society North America and include rattlesnakes of various types
has recently published a practice guideline on t he use of epi- (Figure 23-17), copperheads (Figure 23-18), and water mocca-
nephrine in the wilderness.69 This guideline recommends sins, or cottonmouths (Figure 23-19). The majority of pit viper
the administration of epinephrine by wilderness instructors bites do not occur in the wilderness, but rather in rural, subur-
who are traine d to recognize acute anaphylaxis and t o give ban, or even urban areas. A classic example is the intoxicated
epinephrine. man who was kissing his pet rattlesnake when he was bitten

on the lips or tongue. * poiss

Figure 23-17 Rattlesnake. CHAPTER 23 Wilderness Trauma Care 649

Source:© Patrica Vargas/Photos.comlfhinkstock. Snakebites are not as rare as one might think. In the
United St.ates, almost 10,000 patients are treated each year for
Figure 23-18 Copperhead snake. snakebites, and 5 die.73 It is estimated that worldwide there
are approximately 421,000 envenomations annually, resulting
Source: © Matt Jeppson/ShutterStock, Inc. in 20,000 deaths, although this number could be much higher
because of poor death records in many countries.72
Figure 23-19 Water moccasin (cottonmouth) snake.
Historically, there have been a variety of prehospital treat-
Source: ©James DeBoer/ShutterStock, Inc. ments attempted by patients, bystanders, or sometimes EMS
personnel. The only treatment shown to be effective for enven-
omated pit viper bites is antivenin (anti.venom), which is very
expensive (thousands of U.S. dollars for a single treatment) and,
thus, not routinely carried in first-aid kits. The only street care
proven to be helpful is transport to the hospital.74

The first step in treating snakebite is to watch for signs of
envenomation (i.e., determine that venom was injected). Only
a fraction of bites by pit vipers actually result in envenomation
(200Ai to 25% are dry bites), and the signs of envenomation are
fairly distinct. Although signs and symptoms of envenomation
usually develop in a few minutes, sometimes they are delayed by
6 to 8 hours or perhaps even longer, so starting to the hospital
after a suspected poisonous snakebite is appropriate. Signs of
envenomation include the following:

• Severe local redness, swelling, bruising, and pain
• Continued nonsignificant bleeding from the bite
• Paresthesias in the fingers and toes (Paresthesia is

unusual sensation, usually caused by damage to nerves
or biochemical abnormalities; a feeling of "pins and
needles" is a common paresthesia.)
• Met.a.Ilic taste in the mouth
• Feeling of severe anxiety ("impending doom")
• Nausea, vomiting, and abdominal pain

Prehospital Treatment of Suspected Pit
Viper Envenomation73·74

When managing a patient with a suspected envenomation, the
initial care is similar to any other seriously ill or injured patient:
Support the ABCs (airway, breathing, circulation), provide oxy-
gen to maintain an adequate oxygen saturation, apply a cardiac
monitor, st.a.rt intravenous therapy (to keep vein open), and t.a.ke
the patient's vital signs.

Assess the bite site for signs ofenvenomation, including ery-
thema, swelling, ecchymoses, tenderness, and the development
of blisters or soft-tissue necrosis. Any jewelry or tight clothing
on the involved extremity should be removed.

The leading edge of the swelling should be marked with
a black pen every 15 minutes to determine the severity of the
swelling and rate of progression. The involved extremity should
also be immobilized and elevated to help minimize any swelling.
Major joints such as the elbow should be maintained in relative
extension (less than 45 degrees offiexion).

If the patient requires pain relief, opiates are preferred for
pain relief over nonsteroidal anti-inflammatory drugs because of
the risk of bleeding associated with some envenomations and
with nonsteroidal use.

6 5 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Do not attempt to kill the snake. A killed or decapitated snake It should be noted that this recommendation is controversial, in
still offers a risk of envenomation to EMS personnel. If circum- that some experts believe that localizing venom in a single area
stances permit, take a photo of the snake from a safe distance. might lead to an increased chance for local tissue damage.

While a litter rescue is preferred, if necessary the patient The following are treatments that have been recommended
can be slowly w alked for evacuation, with frequent rest stops over the years but are not supported by the literature and should
and reassurance to help keep the patient calm. Transport the not be performed:
patient rapidly to an appropriate destination with notification of
the situation w hile en route so that the receiving hospital can 1. Rest. Some recommendations insist that those who
make preparations to receive and treat the patient.
have been bitten should always avoid exertion. Deaths
Extremity Immobilization
from North American snakebite are very rare,76 and it
Pressure immobilization has been used effectively in Australia
for field management of elapid (cobra, mambas, North American is very unlikely that the exertion of hiking out from a
Coral) snakebites, but newer evidence indicates that this proce-
dure may be be neficial with pit viper bites in the United States wilderness area will make a victim of a snakebite sig-
(Figure 23-20).75 This technique involves immediately wrapping
the entire bitten extremity with an elastic wrap or crepe bandage nificantly more ill. If the victim can be carried out, that
as tightly as would be done for a sprain, and then splinting and
immobilizing the extremity. This technique resulted in signifi- is ideal. However, ifwaiting for a carryout will delay the
cantly longer survival, but higher intracompartmental pressures
after artificial, intramuscular western diamondback rattlesnake victim's arrival at a hospital, the victim should walk out
envenomation in a pig model.
with whatever assistance can be given.
Ifthe patient is more than 2 hours from medical atten-
tion, and the bite is on an arm orleg, use the pressure immo- 2. Catching the snake and bringing it to the hospital.
bilization technique. Place a 2- by 2-inch (5- by 5-centimeter
[cm)) cloth pad over the bite site. Next, apply an elastic wrap There are numerous reports of bystanders who tried
firmly around the involved limb directly over the padded bite site
with a margin of at least 4 to 6 inches (10 to 15 cm) on either to catch a suspected poisonous snake and were bitten
side of the wound. Take care to check for adequate circulation in
the fingers and toes (normal pulses, feeling, and color). An alter- during the attempt. A single antivenin is used for all
native method is to simply wrap the entire limb as tightly as for
a sprain with an elastic bandage. The wrap is meant to impede pit viper venoms in the United States, and treatment
absorption of venom into the general circulation by containing
it within the compressed tissue and microscopic blood and lym- is based on clinical degree of envenomation, r ely-
phatic vessels n ear the limb surface. Finally, splint the limb to
prevent motion. Ifthe bite is on a hand or arm, also apply a sling. ing on the previous signs and symptoms. Therefore,

identifying a domestic snake is of minor importance

compared with the dangers of attempting to catch

th e s nake. A digital photograph of the snake might be

useful, but identification is not worth the risk of an

additional bite.

3. Suction or incision. Suction, with or without cutting,

has been shown to be useless for poisonous snake-

bite. Snakebite kits consisting of suction devices

should be left out of all first-aid kits and should never

be u sed.77•78

4. Electric shock. Electric shock applied to the snakebite

has been shown to be totally ineffective and should

n e v e r b e used . 79 80


Figure 23-20 Pressure immobilization technique.
Source:© Jones & Bartlett Learning. Photographed by Darren Stahlman.

CHAPTER 23 W ilderness Trauma Care 651

5. CoUi packs. Cold packs have been shown to increase when should we think and work differently from what we do on
tissue damage from North American pit viper bites and the street?" The short answer: "It depends."
should not be used.81
'Tune, distance, weather, and terrain all enter into the
6. Splinting, arterial or venous tourni quets, lymph con- decision. The decision that a particular patient, in a particular
strictors, or elastic bandages. Although widely rec- situation, with a particular set of ir\juries, needs wilderness care
ommended, none of these treatments has been shown rather than street care is a medical decision--one best made
to be effective and may worsen local damage to the by the prehospital care provider directly attending the patient
bite area.81•82 Ifthe prehospital care provider at the scene can contact a knowl-
edgeable EMS physician, especially one with wilderness EMS expe-
The Wilderness EMS rience or training, the advice is definitely worth seeking. Ultimately,
Context Revisited the decision is up to the prehospital care provider at the scene.

At the beginning of this chapter, we asked when EMS is wiUier- PHTLS believes that, given a good fund of knowledge and
ness EMS. "When should we think about wilderness EMS; that is, key principles, prehospital care providers are capable of making
reasoned decisions regarding patient care.

While many of the principles of wiUierness EMS are the same as street EMS, preferences and practice may
change because of the unique circumstances.
• Wilderness patients seldom need more or different invasive procedures; they do usually need prehospital
care providers with keen critical-thinking skills.
• Clinical situations in which wilderness care is different include clearing the cervical spine, irrigating wounds,
reducing dislocations, and terminating CPR.
• Managing patients in the wilderness setting requires that the wilderness medicine providers have a good
understanding of environmental medical issues (see the Environmental Trauma I: Heat and Cold and the
Environmental Trauma II: Drowning, Lightning, Diving, and Altitude chapters).
• When managing patients in the wilderness, the wilderness medicine providers have to also consider food and
water requirements and elimination needs.
• A basic principle of wilderness care is that all patients are hypothermic, hypoglycemic, and hypovolemic.

Your SAR team is called out at 2130 hours to support the county's volunteer fire fighters in t he technical rescue of a trauma victim in a
remote location. Early reports indicate that one member of the three-person rock climbing group, a 31 -year-old man, fell at around 2030
hours from the cliff edge to the rocky floor 80 feet (24 m) below, sustaining multiple long-bone fractures. One member of the group ran
back to his truck, grabbed a sleeping bag to keep the patient warm, and instructed t he other climber to go get help.

The volunteer technical rescue team includes a paramedic and an ED nurse. They arrive at the incident command post at about
2230 hours. Following an incident briefing, the initial rescue team comprised of six personnel drive several miles on a trail using all-ter-
rain vehicles and then hike for 60 minutes up a creek bed with gear to arrive at the scene. When you arrive after midnight, it is raining
lightly and the ambient temperature is 50°F (10°C). You and the initial rescue team find the patient at the bottom of the cliff sitting up
with his back against a rock.

• How would you begin managing this patient in this wilderness setting with limited resources?
• What are the major concerns when treating this patient's injuries?
• What w ill be the best way to evacuate this patient?

6 5 2 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

As with street EMS, good medicine and optimal ca re can be provided in an austere environment with the right training and preparation.
First and foremost you should be concerned about scene safety. One member of the SAR team should be designated safety lookout as
the wilderness medicine providers start to stage gear and begin the patient assessment process.

The victim's face appears severely traumatized, with his jaw broken on both sides. A rapid t rauma assessment reveals t hat the
patient has multiple fractures to the face, both upper and lower extremities, and a suspected pelvis fracture. Your concerns include
hypothermia, internal bleeding, hypotension, and shock. Your next challenge is protecting his airway. Initially it is best to leave him in
the seated position against the rock wall as found . Besides the sleeping bag covering him, some additional insulat ion, if available, can
be placed under and behind him to protect him from conductive heat loss to the rock.

The next concern is to determine his hemodynamic stabi lity with a quick assessment of his radial pu lse, ventilatory rate, and level
of consciousness. Asking the patient about neck pain, in this case, is not a reliable assessment due to his many distracting injuries. You
need to start an intravenous line, which can prove to be difficult due to hypotension and ongoing blood loss. Alternatively, intravenous
fluid management can be started with an intraosseous device, but this may not be t he best choice due to his many fractures. For this
patient, the best option may be an external jugular vein if another peripheral vein cannot be found.

You realize the patient cannot be transported in the litter supine over rough terrain for any distance wit hout a secure airway device
because his mandible fracture, blood, and tissue will collapse back, obstructing his ai rway. You can attempt to place a nasopharyngeal
airway initially, but you may be hesitant due to concern for potential basal skull fracture. Attempting a supraglottic airway and endo-
tracheal intubation w ithout sedation is out of the question due to his alert level of consciousness, and many of t hese advanced supra-
glottic airways require intact airway anatomy. You determine that the best way to manage t he airway will eit her be with rapid sequence
intubation or a surgical airway. Once the airway is controlled, the patient can be placed in the supine posit ion. As additional personnel
arrive from the staging point, the patient can be safely rolled onto a backboard and lifted into the Stokes litter for the long ground
evacuation. You assign one paramedic and a nurse to remain at the patient's head to monitor vital signs, airway, and level of sedation
during the long evacuation.

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Circulation. 1986;74(6, pt 2):29. Med. 2004;43(2):181.
79. Davis D, Branch K, Egen NB, et al. The effect ofan electrical current
66. Zell SC. Epidemiology of wilderness-acquired diarrhea: implica- on snake venom toxicity. J Wi ld Med. 1992;3(1):48.
tions for prevention and treatment. J Wild Med. 1992;3(3):241. 80. Howe NR, Meisenheimer JL Jr. Electric shock does not save snake-
bitten rats. Ann Emerg Med. 1988;17(3):254.
67. Lloyd EL. Hypothermia and Cold Stress. Rockville, MD: Aspen 81. Gill KA Jr. The evaluation of cryotherapy in the treatment of snake
Systems; 1986. envenomation. South Med J . 1968;63:552.
82. Norris RL. A call for snakebite research. Wilderness Environ M ed.
68. Maningas PA, DeGuzman LR, Hollenbach SJ, et al. Regional blood 2000;11(3):149.
flow during hypothennic arrest. Ann Emerg Med. 1986;15(4):390.
Suggested Reading
69. Gaudio F, LameryJ, Johnson D. Recommendations on the use of epi-
nephrine in outdoor education and wilderness settings. Wilderness Auerbach PS, ed. Wilderness Medicine. 6th ed. Philadelphia, PA: Elsevier
Environ Med. 2010;21:185-187. Mosby; 2012.

70. Hawkins S, Weil C, Fitzpatrick D. Letter to the editor: epinephrine Goth P, Garnett G. Clinical guidelines for delayed or prolonged transport:
autoiltjector warning. Wilderness Environ Med. 2012;23:371-378. II. Dislocations. Rural Affairs Committee, National Association of
Emergency Medical Services Physicians. Prehosp Disaster Med.
71. Paw Nation. Snake bite death statistics worldwide. http://animals. 1993;8(1):77.
pawnation.com/snake-bite-death-statistics-worldwide-2431.html.
Accessed September 15, 2013. Goth P, Garnett G. Clinical guidelines for delayed or prolonged trans-
port: IV. Wounds. Rural Affairs Committee, National Association of
72. Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global Emergency Medical Services Physicians. Prehosp Disaster Med.
burden of snakebite: a literature analysis and modelling based 1993;8(3):253.
on regional estimates of envenoming and deaths. PLoS Med.
2008;5(ll):e218.

73. O'Neil ME, Mack KA, Gilchrist J, Wozniak EJ. Snakebite iltju-
ries treated in United States emergency departments, 2001-2004.
Wilderness Envircm Med. 200718(4):281-287.

74. Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm
for the management of crotaline snakebite in the United States:

At the completion of this chapter, the reader will be able to do the following:

• Describe the components of tactical emergency • Relate how remote assessment methodology may
medical support (TEMS). be used on a tactical mission.

• Understand the operational and support • Describe the role of medical support for
functions of TEMS. counterterrorism operations.

• Explain the benefits of a TEMS program.

• Discuss how emergency medical care differs in
each of the three phases of care in TEMS.

656 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Your emergency medical services (EMS) agency provides coverage for the local special weapons and tactics (SWAT) team and has a rig-
orous, integrated training program with local law enforcement. Your tadical emergency medical support (TEMS) team is called out for a
high-risk w arrant service just before sunrise on a cold w inter morning. As you are prepari ng for entry, two SWAT officers cross the sus-
ped's yard and approach the house to prepare for a door pull. Shots ring out from the front w indow , w ounding the SWAT officers. One
SWAT officer falls in the doorway of the susped's house. The second falls near a low dividing cinderblock w all. A patrol officer standing
next to you yells, "We need to go get them . Come on!" You grab the patrol officer by the arm and look to the SWAT commander.

• What should your adions be?
• How will you assess and treat the fallen SWAT officers given the danger of the scene?

History and Evolution Over the years, the CONTOMS course has struggled with
of Tactical Emergency funding issues and at times has not been extremely active.
Medical Support There are many courses like CONTOMS that can fill the void.
The Tactical Combat Casualty Care (TCCC) course, developed
Tactical Emergency Medical Support (TEMS) is an out-of- by the Committee on Tactical Combat Casualty Care, part of
hospital system ofcare dedicated to enhancing the probability of the Defense Health Board of the U.S. Department of Defense,
special operations law enforcement mission success, reducing teaches the essential medical interventions needed in the tacti-
mission medical liability and risk, and promoting public safety.1 cal environment, dependent upon the specific tactical situation.
TEMS builds upon the principles of military medicine, wilder- However, the 1&-hour course does not teach operational com-
ness medicine, disaster response, urban search and rescue, ponents of a tactical incident. Knowledge of tactical movement
and conventional emergency medical services (EMS) to create and planning are needed for a complete, well-developed TEMS
a system of care that supports law enforcement missions and program. The TCCC program and its medical objectives should
maximizes the clinical outcome for casualties in what is often a be included within any TEMS educational program to address
resource-poor, prolonged-transport environment while minimiz- emergency medical care issues in the tactical environment.
ing the threat to the prehospital care provider.
The Uniform Crime Report of the Federal Bureau of
This chapter provides a brief overview of TEMS and how it Investigation (FBI) revealed an increase of 33% in the number of
has evolved int o being accepted as the prehospital standard of law enforcement officers killed in the line of duty between 1999
care for high-threat situations, providing accepted tactical med- and 2010. This, in cortjunction with an ever-increasing incidence
ical interventions. Participation in TEMS and the provision of of active shooter incidents nationwide, has reinforced the need
tactical casualty care (TCC) requires specific training and exper- for TEMS.2 The National Tactical Officers Association (NTOA) has
tise, just as for any other special operations situation. endorsed TEMS beginning with its original position statement in
1994 and continues to view it as "an important element of tacti-
The first special weapons and tactics (SWAT) team was cal law enforcement" for tactical medics.3 After the September 11,
developed in Los Angeles in 1968. Shortly thereafter, the concept 2001, attacks, both the National Association of Emergency Medical
of having a "medic" attached to the SWAT team was advanced, Service Physicians (NAEMSP) and the American College of
similar to the military model of having a combat medic assigned Emergency Physicians (ACEP) formally endorsed integrating EMS
to the squad. Today, TEMS encompasses a broad spectrum of capabilities into law enforcement special operations.4•5
medical services modified in structure and function to operate
within the high-risk, high-paced tactical environment. Broad sup- The TCCC guidelines, established by the Committee on
port for TEMS now exists within both the law enforcement and TCCC (CoTCCC), are currently considered to be the standard
the medical communities. of care for military prehospital medicine. Both the American
College of Surgeons Committee on Trauma (ACS-COT) and
Over 20 years ago, the Counter Narcotics and Terrorism the National Association of Emergency Medical Technicians
Operational Medical Support (CONTOMS) course was devel- (NAEMT), through its Prehospital Trauma Life Support (PHTLS)
oped. This program was developed as an evidence-based TEMS program, endorse the TCCC guidelines and offer TCCC training.6
curriculum that selected seasoned emergency medical provid- Though military and law enforcement special operations are
ers and immersed them in providing medical care in the tactical unique, similarities exist in the tactical medical care aspects. The
environment over the course of 56 hours. Through CONTOMS, TCCC guidelines, supported by its endorsement by the NTOA,
an injury database was developed providing the research data have provided a strong foundation for the standardization of
needed t o support the efficacy of tactical medicine. TEMS protocols.

CHAPTER 24 Civilian Tactical Emergency Medical Support (TEMS) 6 5 7

With the growing recognition that tactical medical care Barriers ta Traditional
has become an important issue and the work of the CoTCCC EMS Access
to develop the military TCCC educational program, efforts
have been underway to adapt the military information to civil- The scene of a law enforcement special operation presents
ian setting. In addition to the efforts of PHTLS, a number of numerous barriers to traditional EMS access. A geographic
organizations and educational agencies have been created to perimeter is usually secured. Within that perimeter, it is rarely
provide this information including: obvious which, if any, areas are safe for EMS passage or for per-
formance of medical activities. It is imperative that the medical
• The Georgia Regents University, which along with component not become a liability to the SWAT team's mission.
NTOA developed the Specialized Tactics for Already-scarce law enforcement resources should not need to be
Operational Rescue and Medicine (STORM) programs diverted to the medical support mission.

• A civilian CoTCCC counterpart, the Committee on The time interval from EMS arrival on scene to patient
Tactical Emergency Casualty Care (C-TECC), which contact has been identified as a significant source of delay in
has developed a set of tactical emergency casu- the initiation of prehospital care in conventional EMS oper-
alty care (TECC) guidelines that closely resemble ations. In one study, the police action required to secure the
the CoTCCC guidelines and are tailored to address scene caused delay in 12% of all observed EMS runs and was
the prehospital high-threat needs of civilian law the source of the longest delay (39 minutes) from time of EMS
enforcement7 arrival to patient contact.10 This type of delay can be much lon-
ger during tactical missions. Integrated TEMS programs min-
The TECC guidelines have since been incorporated into imize delays because the TEMS providers routinely function
the National Joint Counterterrorism Awareness Workshop inside t he perimeter as a vital part of the tactical team and can
used by the FBI, The Federal Emergency Management Agency, begin treatment of wounds within the "platinum 10 minutes" of
and the National Counterterrorism Center.8 PHTLS and NAEMT an officer being injured.11•12
have developed a TECC course for civilian prehospital care
providers. This text will primarily utilize the standard TCCC Some fire and rescue chiefs and EMS administrators may
nomenclature. object to their personnel practicing tactical medicine because
they perceive it to be too dangerous. When asked why fire
TEMS Practice fighters under their command enter burning buildings-a
Components clearly dangerous situation- they often respond that firefight-
ing is different from law enforcement operations because fire-
Tactical emergency medical support has several distinctions fighting personnel are well trained and appropriately equipped
from conventional EMS. Unlike conventional EMS, compre- against the fire threat. The same argument is true for TEMS
hensive TEMS programs include health maintenance, preven- (Figure 24-1).
tive medicine (e.g., immunizations, proper sleep practices,
and physical fitness), medical threat assessments, and coor- It is a violation of basic scene safety principles to utilize
dination of care with a variety of local medical assets. From EMS personnel who are inadequately trained or equipped for the
an operational perspective, TEMS providers are frequently assignment to enter a secure police perimeter that has not been
faced with treat-and-release decisions. These situations will madesafe. However, simply waiting for the patientto be delivered
vary from the TEMS operator who has become dehydrated to outside the perimeter will result in the unnecessary loss oflife or
the angry prisoner who may have been injured in the tactical function, whereas far-forward (as close to the point of wound-
operation. ing as possible) medical care in the military has been shown to
reduce both mortality and morbidity.13•14 The obvious solution is
Many states include specific addendums to their EMS pro- for the medical support of law enforcement special operations
tocols that address TEMS practice.9 TEMS providers and their to be performed by well-trained and properly equipped TEMS
medical directors must be familiar with their local protocols
when operating in the tactical environment. Figure 24-1

The TEMS medical skill set is consistent with, but often Only properly trained prehospital care providers should
expanded from, conventional EMS. Though skill sets may be be in a zone other than the safe zone. Just as an
similar, in TEMS the application of these skills is often heav- emergency medical technician (EMT) or paramedic
ily influenced by the tactical situation and mission profile. should not enter the hot zone of a hazardous materials
For example, t he use of a laryngeal mask airway (LMA) may incident or a f ire scene without appropriate personal
be clinically indicated for a casualty under normal opera- protective equipment and training, the same holds true
tional conditions, but, if the casualty will need to be dragged for the tactical setting.
across a linear danger zone or carried over rough terrain,
the LMA is not a secure airway and, t herefore, may not be
appropriate.

6 5 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

providers who can operate safely within the secured operational Figure 24-2
perimeter. There are many models for forward operating TEMS
personnel. Some include TEMS personnel with the entry team,
within the "stack" of the team conducting the operation. Others
place the TEMS providers within the secured perimeter but not
in the direct line of:fire, usually near the transport vehicles.

Zones of Operation Immediate or Care under fire Direct t hreat care
active threat
During tactical missions, the tactical law enforcement team Tactical field Indirect threat care
concept of operation divides the target area into zones of opera- Threat contained care
tion. The tactical teams establish an inner perimeter and outer but could
perimeter as geographic boundaries that define the safe zone resume Tactical Evacuation care
(outside the outer perimeter where no threat should exist), the evacuation
warm zone (between the outer and inner perimeter where the No threat care
danger of threat could exist), and the kill zone (the area that
poses an immediate hazard or in which a responder can become Whether using the TCCC or TECC guidelines, the care that
a clear target).15 In many ways, this structure is analogous to the is provided in each phase is essentially the same. The phases of
zones ofoperation at a hazardous materials incident. Just as may care are more dynamic, influenced by minute-to-minute threat
occur at a hazardous materials incident, the geographic bound- assessments, and need not be concentric or contiguous; threat
aries of the various zones may change as the situation changes. levels change rapidly in the tactical environment. Accordingly,
Therefore, TEMS providers must always maintain situational the phases of care may not always coincide with the zones of
awareness to minimize risk to themselves and their patient. operation. TEMS personnel must understand the relationship of
the two paradigms in order to function effectively in a tactical
Phases of Care environment (Figure 24-3).

The TCC guidelines, whether from TCCC or TECC, divide the
delivery of emergency medical care into phases of care, based
upon the tactical situation and the associated threat at the time
care is being provided (Figure 24-2). 7

Figure 24-3

Care Under Fire {Direct Threat Care) b. Breathing : Assess and treat for penetrating chest
1. Maintain tactical supremacy: Neutralize the threat as wounds, sucking chest wounds, and tension
pneumothoraces.
soon as possible (e.g., directed fire, smoke, threatening
posture, fire suppression, hazardous material mitigation). c. Circulation: Assess for shock. Establish intraosseous
2. Ensure cover and concealment: Prevent further injury to
casualty or rescuer. or intravenous access and initiate fluid resuscitat ion
3. Use tourniquet for life-threatening extremity hemorrhage if medically indicated. (This decision will be based
4. DO NOT: on unit training and protocols.)
a. Perform invasive airway management d. Disability: Splint any major fracture, and provide
b. Perform cardiopulmonary resuscitation cervical spine immobilization for high-risk
mechanism of injury.
c. Employ strict spinal precautions e. Exposure: Protect the casualty from hypot hermia.
Heat, chemical, or toxic exposures may also be risk
Tactical Field Care {Indirect Threat Care) factors.
1. Control bleeding (tourniquet, hemostatic dressing,
Tactical Evacuation Care {Evacuation Care)
conventional pressure dressing) for life-threatening 1. Provide conventional EMS and t ransport care
hemorrhage 2. Ensure clear routes of egress for prehospital care
2. Manage ABCDEs:
a. A irway: Assess for obstruction and secure airway providers and ambulance
3. Attend to staging considerations
with nasopharyngeal airway, supraglottic device, 4. Stay alert for secondary devices and unconventional
endotracheal tube, or surgical airway. (This decision
will be based on unit training and protocols.) threats (e.g., flood, crowds, fire)

CHAPTER 24 Civilian Tactical Emergency Medical Support (TEMS) 6 5 9

Care Under Fire (Direct Threat Care) and potentially places the tactical team in jeopardy during the
extraction process from exposure to hostile fire while in a vul-
During care under fire, the threat is direct and inrmediate. Limited nerable situation dealing with a casualty.
protection exists for the casualty and the responder. Operations
inside this area are extremely dangerous and should be limited to Prior to extracting any casualty, the medical officer should
reconnaissance and tacticalteam operators. Safe operationwithin analyze the transit risk and likelihood of casualty survival.19 The
the kill zone during care under fire requires the use of appropri- time required to move a casualty to the safe zone is influenced
ate personal protective equipment (e.g., ballistic helmets, goggles, by the ability of the casualty to assist, the distance involved, the
vests, shields, boots) and tactical movements (e.g., light/noise dis- casualty's gear load, relative threat levels ofthe area, and physical
cipline, use of cover/concealment). An officer down in the front fitness ofthe team. In some situations, the perpetrator may have a
yard of a home with a barricaded gunman shooting from a win- commanding field offire, creating large unsafe areas, as is the case
dow exemplifies a typical care under fire situation. with the opening scenario. In many civilian tactical operations,
the target ofthe mission may only be one or two perpetrators in a
Casualty care during this phase entails enormous risk and relatively confined location. Missions of these types include high-
deviates significantly from the principles of conventional EMS. threat warrant service, narcotics interdiction, and dignitary pro-
Immediate actionsincludesuppression ofthe threatand evacuation tection details. These missions tend to be accomplished quickly
ofthe casualty to cover/concealment. The sooner the threat can be with the perpetrator(s) taken into custody or subdued. In these
neutralized or controlled, the sooner full medical care resources cases, once the area is secured, quick advancement to tactical
can be brought to bear to treatthe casualty. Until that occurs, trying field care and then to "normal, everyday" EMS care takes place.
to have the casualty get to cover is appropriate. If the casualty is
responsive and able to move, he or she is directed to move to cover. The second component of transit risk is the route of travel.
If the casualty cannot move, a plan for possible rescue may be Zones of fire are irregularly shaped, incongruous geographic
considered. Medical care in this phase ofthe operation is directed areas with dynamic risk levels. Extraction may require crossing
toward reducing further iitjury to the casualty, avoiding responder linear danger zones, in which case the value of treating in place
iitjury, subduing the threat, and controlling life-threatening extrem- must be weighed against the need for inrmediate advanced life-
ity hemorrhage. Time is not spent on cervical spine inrmobilization savinginterventions. Commanders must consider their resources
for penetrating neck trauma, airway management, or other "heroic" prior to initiating a rescue mission. Multiple factors play a role in
measures such as cardiopulmonary resuscitation (CPR). these high-threat rescues and have historically involved ineffec-
tive and unrealistic methods that ultimately increase the risk of
Self-aid and buddy aid are critical components of care unnecessary iitjury and death. Asymmetric rescues require mul-
under fire. Most nonlethal penetrating iitjuries sustained by offi- tiple personnel, potentially specialized equipment (e.g., poleless
cers are usually not fully incapacitating and will not necessarily litter, harnesses, drag straps), and aggressive protective posture
remove the officer from the operation entirely.16 Data from mil- prior to implementing egress options2il (Figure 24-4).
itary operations in Vietnam, Iraq, and Afghanistan indicate that
training soldiers in self-aid and buddy aid significantly decreased Finally, TEMS providers must consider their ability to
mortality.14•17 For example, self-application of a tourniquet to a deliver care during transit; for example, during rapid litter move-
life-threatening ballistic injury to an extremity could save the vic- ments across a substantial zone offire, TEMS providers may not
tim as well as prevent the TEMS providers from unnecessarily be able to maintain a manual trauma jaw thrust. In this case,
exposing themselves to hostile fire. inserting an airway adjunct prior to movement may be prudent.

Direct pressure and pressure dressings are difficult to per-
form in a care under fire tactical setting and may result in unnec-
essary blood loss and delay in the evacuation of the casualty to
cover. Tourniquet use for control of extremity hemorrhage is the
gold standard during the care under fire phase, with the bene-
fits of stopping the bleeding clearly outweighing the low risk of
nerve or vascular damage.18 The tourniquet should be placed
overthe clothing as "high and tight" on the extremity as possible.
It is vital to ensure that arterial blood flow has been stopped.
Non-extremity andjunctional wounds are difficultto treat in this
phase. An attempt should be made to provide direct pressure to
these wounds as the casualty is rapidly moved to a covered posi-
tion and treatment transitions into the tactical field care phase.

Extraction and Evacuation of Casualties Figure 24-4 Care under fire and extraction.

Casualty movement, extraction, and evacuation in the tactical Source: Courtesy of Commander Al Davis, Ventura Police Department.
environment pose many unique challenges. Casualty extraction
is a physically demanding process that interrupts mission flow

6 6 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

The transit risk, or risk of moving a casualty through a potential casualty's stable or unstable medical condition should motivate
zone of fire, is related to the time it takes to traverse the zone this decision. If the casualty is unstable, the risk of extraction
and the risks associated with both the route of travel and those must be weighed against the benefits of immediate access to
risks incurred from providing essential care during transit. As medical care. Although this is a command decision, the com-
with most decisions in the tactical environment, experience and mander will rely heavily on the TEMS provider's assessment of
judgment are critical. the patient's condition and the need for immediate extraction.
If the benefit-risk ratio is sufficiently high, the extraction may
Rapid and Remote Assessment proceed.
Methodology {RAM)
This approach may seem relatively self-evident, but it is
The Rapid and Remote Assessment Met1wdology (RAM) was important to have a decision structure that fosters good assess-
developed by the CONTOMS Program at the Uniformed Services ment before emotion overtakes reason and a needless rescue is
University of the Health Sciences, the U.S. Department of risked. The military experience is filled with examples of numer-
Defense's medical school.20 The principle purpose of this assess- ous casualties incurred to recover a body or attempt to rescue
ment algorithm is to maximize the opportunity to extract and a casualty who eventually stood up and ran to cover without
treat a salvageable casualty while minimizing risk to TEMS assistance.21
providers from attempting an unnecessary rescue, and the
algorithm is most applicable during the care under fire phase Tactical Field Care (Indirect Threat
of TCC. Unnecessary rescues fall into two categories: those in Care)
which the casualty can extract himself or herself and those in
which the casualty is already dead (more appropriately termed During the tactical field care phase, threats may continue to
a "body recovery"). The RAM provides an organized approach to exist but are not direct or immediate. For example, in the case
evaluate the totality of circumstances from a protected position of the tactical officer down in the front yard, tactical field care
before recommending a rescue attempt to the commander. principles would apply once the casualty has been moved behind
adequate cover (e.g., a thick brick wall out of the gunman's line
The first step in conducting a RAM is to determine ifthe area of sight) or the threat has been suppressed. Threat levels vary
is secure. Ifit is, standard EMS care is appropriate after ensuring significantly in this phase of the operation, mandating a flexible
that the casualty cannot harm TEMS providers. If the area is not and fluid medical response. The TEMS provider must be capable
secure, use available intelligence to determine if the casualty is ofanalyzing dynamic factors, rapidly acquiring data, and quickly
a perpetrator or otherwise represents a threat. Under such cir- weighing all medical decisions in terms of the risks to the casu-
cumstances, no further medical intervention is indicated until alty and to the provider. In a TEMS scenario, the relatively secure
the threat has been controlled. To do otherwise might jeopar- environment may return to a care under fire situation at any
dize the safety of tactical officers, TEMS providers, and innocent point (Figure 24-5).
parties. If the casualty is not deemed a perpetrator, a remote
assessment should be initiated to attempt to evaluate the nature Figure 24-5 Tact ical field care. Note the cover and concealment
ofthe injury and the stability of the casualty's condition. from the armored vehicle at the top of the photo.

Remote observation is the first technique to be employed Source: Courtesy of CPL Mat t Cain, Ventura Police Department.
during the remote assessment because it allows TEMS provid-
ers to gather information without revealing their position or
intent to the hostile force. Technology available to SWAT teams
can improve the reliability of this assessment. For example, a
good pair of binoculars or night-vision goggles can often help
to ascertain if the casualty is breathing, the rate and quality of
respiration, the presence of life-threatening hemorrhage, and
the presence of obvious wounds incompatible with life. In cold
weather, a respiratory condensation plume can often be seen
from the casualty's mouth if the casualty is breathing. Acoustic
surveillance equipment, if available, can be deployed to detect
speech, moans, groans, and even respiratory sounds. Thermal
imaging technology has improved in recent years and may be
considered for application in the RAM.

If the casualty's condition appears stable, self-care instruc-
tions and reassurance should be communicated to the casualty,
ifpossible, and medical extraction should await an improvement
in the tactical situation. The commander may elect to do a tacti-
cal extraction at any time, but the tactical situation and not the

CHAPTER 24 Civilian Tactical Emergency Medical Support (TEMS) 661

Figure 24-6 to a tourniquet. These agents have shown significant potential in
combat and military research labs.23 However, exercise caution
An armed operator (law enforcement officer) with an when using some older powder- or granule-type agents, as they
altered mental status is a significant risk to himself or have been shown to cause thermal burns, foreign body emboli, and
herself and others in the unit. Reasons for an altered endothelial (internallining ofblood vessels) toxicity.24 As a result, it
mental status include, but are not limited to, shock, is recommended to use a packable hemostatic-impregnated gauze
pain, traumatic brain injury (such as a concussion), for wounds to transition zones (i.e., neck, axilla, and groin) that
hypoxia, and the administration of analgesic medications. are not amendable to tourniquet placement. The use ofhemostatic
Immediately disarm any casualty experiencing an altered agents must be approved in advance by the unit's medical director.
mental status, including secondary weapons systems and
explosive devices.15 Breathing Management

During tactical field care, if tactically appropriate, care The management of blunt and penetrating chest trauma is
should include a rapid trauma assessment by exposing and especially important for TEMS providers. In particular, the
assessing all injuries. Interventions should focus on quickly sta- TEMS provider must be comfortable treating penetrating chest
bilizing the major causes of preventable traumatic death in the wounds and tension pneumothoraces. Cover all open or sucking
tactical environment: compressible hemorrhage, tension pneu- penetrating wounds on the torso from the lower neck to the
mothorax, simple airway compromise, and hypothermia.16•17 umbilicus with an occlusive dressing; numerous different mate-
rials are available for improvised use as well as commercially
Hemorrhage Control fabricated chest seals, many with excellent adhesive properties.
Vented chest seals are preferred, but, if not available, any dress-
Control of compressible external hemorrhage during tactical ing that seals the wound may be utilized. The casualty should
field care is critical. Compressible severe external hemorrhage then be placed in a position of comfort, if applicable, and mon-
can usually be quickly controlled and should be the first priority. itored for the development of a tension pneumothorax, which
Tourniquets are the first-line treatment of choice for potentially should be treated as described next.17
life-threatening extremity hemorrhage when and where applica-
tion is possible. Any tourniquet placed on an extremity during In a casualty with penetrating chest trauma and progressive
the care under fire phase should be re-evaluated to determine respiratory distress, it is reasonable to presume the presence of
the need for its continued use. If bleeding from the injury is a tension pneumothorax and perform a needle decompression
determined to not be life threatening, transitioning from a tour- (on the side of the penetrating trauma) to stabilize the patient.25
niquet to an appropriate pressure dressing may be performed. Do not rely on findings such as tracheal shift or jugular vein dis-
If the bleeding is life threatening, a tourniquet should be placed tension, as these signs are late findings and not always present
2 to 3 inches (5 to 8 centimeters) above the injury, directly on in an early tension pneumothorax or may be difficult to detect in
the skin and free of any clothing, and the more proximal tourni- a tactical setting. Even the gold standard of determining absent
quet removed. It should be placed as snuggly as possible, with as breath sounds may not be able to be obtained in many tactical
much slack removed from the tail as possible before the windlass environments; increasing respiratory distress in the presence of
is tightened. No more than three revolutions (540 degrees) of the penetrating thoracic trauma is enough to justify performing nee-
windlass should be performed to avoid deforming the chassis of dle decompression (Figure 24-7).
the device.22 In the event that one tourniquet does not stop the
bleeding, it is acceptable and highly recommended to use addi- Treat a tension pneumothorax by inserting a 14-gauge (or
tional tourniquets side by side until bleedingis controlled, as this larger), 3.25-inch (8-centimeter) long needle with catheter into
provides compression of the artery over a wider area.17•22 the casualty's second intercostal space at the midclavicular
line. Ensure that the needle enters the chest wall lateral to the
It is important to note that after a tourniquet has been
applied, a distal pulse should be assessed to ensure that arterial Figure 24-7
blood flow has been stopped. Failure to ensure the absence of
an arterial pulse can lead to compartment syndrome as blood In a casualty w ith penetrating chest trauma and
continues to enter the extremity but cannot exit. All tourniquets progressively worsening respiratory distress, it is
should be reassessed routinely, especially after repositioning or reasonable to presume the likelihood of tension
transporting the patient. pneumothorax and perform a needle decompression
(on the side of the penetrating trauma).
Multiple hemostatic dressings are currently available on the
market for compressible hemorrhage in locations not amenable

6 6 2 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

nipple line and is not directed toward the heart. A casualty with of secretions (Figure 24-8). If airway obstruction develops or
penetrating chest trauma, even if a tension pneumothorax is persists despite the use of an NPA, a properly trained TEMS pro-
not present, will generally have some degree of hemothorax or vider may consider inserting an endotracheal tube or supraglot-
pneumothorax as a result of the primary wound. The additional tic airway device as the tactical situation allows. These devices
trauma caused by a needle decompression will not worsen the are not well tolerated unless the casualty is obtunded.
casualty's condition in the absence of a tension pneumothorax.
Successful decompression is confirmed by improvement in the In some cases, a surgical cricothyroidotomy may be indi-
casualty's respiratory status and, if conditions allow, by hearing cated. Casualties with airway compromise due to maxillofacial
a rush of air through the decompression needle as the pressure trauma or inhalation burns often warrant a cricothyroidotomy
within the chest is relieved. as the first-line airway procedure of choice.6•17•26 Obviously, this
requires a formalized training program and a risk analysis by the
After placement, remove the needle and leave the cathe- TEMS medical director. The tactical situation may require oper-
ter buried to the hub in the casualty. The TEMS provider must ations in low-light environments with significant restriction of
monitor the casualty after the procedure to ensure the catheter movement; therefore, proper realistic training is critical.
has not become dislodged or clotted with blood and that respi-
ratory distress symptoms have not returned. If respiratory dis- Hypothermia
tress symptoms return or the catheter becomes obstructed or
dislodged, flush the catheter or perform a second needle decom- Hypothermia in trauma patients results in the inhibition of the
pression adjacent to the first. 17 After a needle decompression is coagulation cascade, thus exacerbating the bleeding problem.
performed, proper documentation ofthe indications for the pro- Trauma patients are at high risk for hypothermia, which can
cedure is important, as the casualty will require a subsequent occur regardless ofthe ambient temperature. The longer a patient
chest tube or further interventions. is exposed to the environment during treatment and evacuation,
especially in wet conditions, the more likely the development of
Airway Management hypothermia.27•28 The TEMS provider must minimize the casu-
alty's exposure to the elements. Whenever possible, replace or
Airway management during this phase of care is appropriate if remove any wet or bloody clothing. Use any methods available to
the casualty shows signs of impending airway obstruction or keep the casualty warm, such as dry blankets, jackets, sleeping
cardiovascular collapse. The respiratory drive is one of the most bags, etc. If practical, keep all protective gear on the casualty
primitive human reflexes. Therefore, as tactically feasible, the after ensuring that all iajuries have been treated, as this gear will
conscious casualty should be allowed to assume a position of afford protection to the casualty should hostile fire erupt again.
comfort. In an unconscious casualty, with or without signs ofair-
way compromise, a trauma jaw thrust followed shortly after by Vascular Access
a nasopharyngeal airway (NPA) is recommended as a first-line
option. After inserting the NPA, place the casualty into the recov- Many studies now show the benefit of hypotensive ("balanced")
ery position to maintain the open airway and prevent aspiration resuscitation in trauma patients (see the Shock chapter for a
detailed discussion).29•30 Accordingly, delayed intravenous (lV)
Figure 24-8 A patient who has been placed in the recovery access is acceptable in certain tactical scenarios. Obtain IV
position. access during the tactical field care phase if medically indicated.
Source: ©Cordelia Molloy/Science Photo Library/Science Source. While traditional trauma training teaches starting two large-bore
(14- or 16-gauge) IV catheters, the use of a single 18--gauge cath-
eter is preferred in the tactical setting. The 18--gauge catheter is
adequate for rapid delivery of resuscitation fluids and medica-
tion, is easier to insert, and conserves the supplies available in
a medic aid bag. An IV should not be attempted on an extremity
that may have a significant wound proximal to the IV insertion
site. The use of a "ruggedized" IV securing system is advisable if
the casualty has to be transported a distance before the hand-off
to conventional EMS.

Ifthe casualty requires fluid resuscitation or IV medications
and IV access cannot be obtained, intraosseous (IO) access is
an alternative, as permitted by the TEMS medical director. IO
devices are available for use on the sternum and extremities
in the absence of a significant injury to the selected site. As
with most advanced medical interventions, this procedure will
require a strong training program instilling confidence and com-
petence in the TEMS provider. While the military prefers the
sternal approach to IO secondary to massive lower extremity

CHAPTER 24 Civilian Tactical Emergency Medical Support (TEMS) 6 6 3

injuries seen with improvised explosive devices, in the civilian Tactical Evacuation Care
TEMS environment these types ofinjury patterns have been rare. (Evacuation Care)
Therefore, it may be appropriate to use the tibial approach for the
establishment of the IO line. While the proximal humerus can be Tactical evacuation care takes place in the operational safe
used, it has been noted that during movement of the casualty in zone, beyond the outer perimeter, and is an area of relatively
the tactical environment, the location of the IO device at the wid- low risk. The outer perimeter isolates the incident and is typi-
est part of the body can easily lead to inadvertent dislodgment. cally manned by conventional law enforcement patrol personnel
with the primary mission of scene control, event isolation, and
Based on currently accepted hypotensive resuscitation pro- general public safety. During the tactical evacuation care phase,
tocols, fluid administration should be reserved for causalities medical care continues during transport to the receiving trauma
experiencing hemorrhagic shock, as indicated by altered mental center. This care most resembles conventional EMS care of the
status in the absence ofa head injuryand a weak or absent radial trauma patient and may include the transfer of the casualty to an
pulse. These findings are indicative of an approximate blood ambulance or the use of alternative emergency vehicles such as
pressure below 80 mm Hg (millimeters of mercury) systolic (or an armored vehicle (Figure 24-9). Care in this phase is situation
the absence of a radial pulse) and warrant the administration of dependent and based on team standard operating procedures
fluid. 17,26 and incident commander decisions. At the incident commander's
discretion and as necessary, medical control may be established
The choice ofresuscitation fluid depends in large part upon out of reach of the weapons being used by the perpetrator(s),
local protocol and preference. Normal saline and Ringer's lac- and additional EMS medical resources may stage in this area.
tate are commonly used crystalloid solutions for trauma patient
fluid administration. The U.S. military prefers 6% hetastarch In the event alternative emergency vehicles are used in
(Hextend) as the recommended fluid for resuscitation. Hextend transporting the casualty, standard operating procedures should
is preferred by the military over standard crystalloid fluids be rehearsed in depth to include the roles of team members who
because one 500-milliliter (ml) bag of Hextend is physiologically have no medical training. Additional medical equipment should
equivalent to three 1,000-ml bags of lactated Ringer's solution,
weighs 6 pounds less than the equivalent amount of crystal-
loid, and remains in the intravascular space for at least 8 hours.
Hextend is given as an initial 500-ml Hextend IV bolus, and, if
after 30 minutes the patient still does not have a palpable radial
pulse or has altered mentation in the absence of a head injury, a
second 500-ml Hextend bolus is administered.

Additional Considerations

Common conventional EMS interventions may be inappropriate Figure 24-9 Nonstandard tactical evacuation care vehicle.
in the tactical situation-in particular, cervical spine immobiliza-
tion and CPR. Cervical spine immobilization is a time-consuming Source: Courtesy of Commander Al Davis, Vent ura Police Department.
intervention with relatively little value in penetrating trauma.31•32
An experienced two-person paramedic team requires on average
5.5 minutes to properly perform cervical spine immobilization.
This time delay and exposure may be deadly, not only for the
casualty but also for the TEMS providers. Accordingly, if the
threat of further injury outweighs the risk of spinal injury, cervi-
cal spine immobilization may be deferred. However, blunt injury
from falls or motor vehicle collisions is a high-risk exception and
warrants consideration for cervical spine immobilization if the

tactical situation allows.
CPR provides little benefit in traumatic arrest and increases

responder exposure.33 Accordingly, CPR has a very limited role
in tactical medical response, and its consideration should be
reserved for victims of near-drowning, electrocution, hypother-
mia, and some toxic exposures.

The diminished emphasis on cervical spine immobilization,
CPR, and IV access in both the care under fire and the tactical
field care phases illustrates some of the distinctions between
TEMS and conventional EMS. These examples are not meant to
substitute for the clinical judgment of the TEMS provider.

664 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

be prestaged in these vehicles, and all team members should be bridge law enforcement with fire departments and/or EMS
cross-trained in treating the four preventable causes of death by systems. Second, TEMS providers are accustomed to working
administering lifesaving interventions such as using tourniquets, in chaotic, dangerous, and resource-poor environments. Third,
NPAs, and chest seals, and preventing hypothermia. TEMS providers have broad experience in utilization ofvarious
communication mediums, immediate action drills, and mission
Even in an area deemed secure, all emergency respond- planning. Finally, MCI events become increasingly danger-
ers must remain vigilant. Tactical operations are complex and ous and potentially violent, with the Newtown, Connecticut,
dynamic. During the 1999 Columbine High School shootings, the elementary school shooting being one tragic example. TEMS
assailants targeted emergency responders byplacingpipe bombs providers are the medical linchpin in a coordinated MCI
and improvised explosive devices. Fortunately, due to technical response system.34
failures, these devices did not detonate. Similarly, the perpetrator
of the 2012 Aurora, Colorado, movie theater shooting prepared MedicaI Inte11igence
and placed explosives in his apartment. These devices included
Part of the role of the TEMS provider is to gather and maintain
trip wires and booby traps with flammable material capable of medical intelligence and planning. On local and regional teams,
killing officers responding to the scene and destroying the build- the TEMS provider should have an in-depth lmowledge of the
ing. All ofthese devices were handled by astute law enforcement local EMS and trauma systems. This lmowledge will allow the
personnel without iajury. TEMS provider to make appropriate decisions regarding evac-
uation care and patient destination if a casualty should occur
The FBI has reported several incidents of intentional on the mission. TEMS teams that function remotely in unlmown
ambushes of law enforcement personnel. In addition, there have areas, such as wilderness locations, will have to conduct much
been terrorist training manuals explicitly detailing operations more in-depth medical planning to develop an operable evacua-
that use a barricaded suspect to lure law enforcement personnel tion plan.
to a scene in order to ambush them. Diligence and situational
awareness are the cornerstones to safe operationsby responding The role of aeromedical evacuation platforms in TEMS may
law enforcement officers and TEMS providers. be of great use; however, the TEMS provider must constantly
monitor the availability of dedicated aeromedical assets. In addi-
Mass-Casualty Incidents tion, the response of an aeromedical evacuation platform to a
tactical situation must include appropriate safety precautions
Mass-casualty incidents (MCis) involving active shooters are lest the aeromedical unit come under hostile fire.
increasingly more common and present a complex interagency
collaboration environment. TEMS providers have a unique
role to play in these MCI events. First, TEMS teams tend to

In general, the principles ofmedical care in the tactical environment are the same as those to which prehos-
pital care providers are accustomed.
• The austerity and danger of the operational environment require that the benefit of every medical inter-
vention be weighed against the risks inherent in delivering that intervention. This requires a unique set of
decision-making skills.
• The TEMS provider constantly needs to balance the benefit of a particular intervention against the special
risks inherent in performing the intervention in this environment.
• The three phases of care in the tactical situation are:
• Care under fire (Direct threat care)-the medical care that is provided while under hostile fire or in an

actively hazardous situation
• Tactical field care (Indirect threat care)-the medical care that is provided once the immediate hazard

has been suppressed or controlled, lmowing that the situation could revert to care under fire
• Tactical evacuation care (Evacuation care)-the medical care that is provided once the situation has

been deemed safe, very similar to a standard civilian EMS call
• Medical intelligence gathering allows the TEMS provider to lmow the environment, geography, and available

resources of the area in which the tactical operation will be undertaken.

CHAPTER 24 Civilian Tactical Emergency Medical Support (TEMS) 6 6 5

Your EMS agency provides coverage for the local SWAT team and has a rigorous, integrated training program w ith local law enforce-
ment. Your TEMS team is called out for a high-risk warrant service just before sunrise on a cold winter morning. As you are preparing
for entry, two SWAT officers cross the suspect's yard and approach the house to prepare for a door pull. Shots ring out from t he front
window, wounding the SWAT officers. One SWAT officer falls in the doorway of the suspect's house. The second falls near a low dividing
cinderblock wall. A patrol officer standing next to you yells, "We need to go get them. Come on!" You grab the patrol officer by the
arm and look to the SWAT commander.
• What should your actions be?
• How will you assess and treat the fallen SWAT officers given the danger of the scene?

The SWAT commander orders you to utilize your Rapid and Remote Assessment Methodology (RAM) to determine the utility of a res-
cue effort. You use your binoculars and the SWAT team acoustic device to examine the two fallen officers. The first officer, lying in t he
doorway of the gunman's house, shows no chest wall movement or signs of condensation near his mouth. Despite calls from his f ellow
officers, you are unable to detect a response on the acoustic device.

The second officer has moved behind a low brick wall. You can visualize bleeding from his lower thigh. Fortunately, you have
conducted extensive tactical medical training for your officers. You communicate with him via t he secure team radio and instruct him
to apply a tourniquet two finger breadths above his wound. He secures the device and communicates that he has no f urther injuries.

Based upon your recommendation and the threat assessment, the SWAT commander chooses not to undertake a high-risk rescue
of the officer showing no signs of life. You remain in contact wit h the second injured officer w hile the negot iators w ork t o convince
the suspect to surrender. You contact the local trauma center and inform them of a potential incoming casualty. Thirty minutes later,
the suspect surrenders and is taken into custody. Your team evacuates the casualty to the local hospital where he undergoes a vascular
repair, saving both his leg and his life.

SSS PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

References 20. Callaway DW. Emergency medical services in disasters. In: Hogan
DE, Burstein JL, eds. Disaster Medicine. 2nd ed. Philadelphia, PA:
1. Rinnert KJ, Hall WL. Tactical emergency medical support. Emerg Lippincott, Williams and Williams; 2007:127-139.
Med Clin N Am. 2002;20:929-952.
21. Cloonan C. In: Proceedings of the Third I nternati-Onal Conference
2. Federal Bureau Investigation. Uniform crime reports. http://www. on Tactical EmergencyM edical Support. Bethesda, MD: Uniformed
tbi.gov/about-us/cjis/ucr/leoka/2012/leoka-home Accessed January Services University ofthe Health Sciences; 1999.
20, 2014.
22. Kragh JF, O'Neill ML, Walters TJ, et al. The military emergency
3. National Tactical Officers Association. Position statement on the tourniquet program's lessons learned with devices and designs. Mil
inclusion of physicians in tactical law enforcement operations. Med. 2011;176:10, 1144.
http://ntoa.org/site/ternsltems-position-statement.html. Accessed
January 20, 2014. 23. Kheirabadi BS, Scherer MR, Scot EJ, et al. Determination of effi-
cacy of new hemostatic dressings in a model of extremity arterial
4. Heck JJ, Pierluisi G. Law enforcement special operations and med- hemorrhage in swine. J Trauma Acute Care Surg. 2009;67(3):
ical support. Prehosp Emerg Care. 2001;5:403-406. 450-459.

5. American College of Emergency Physicians. Policy statement on 24. Kheirabadi BS, Edens JW, Terrazas IB, et al. Comparison of new
tactical emergency medical support. Ann Emerg Med. 2005;45:108. hemostatic granules/powders with currently deployed hemostatic
products in a lethal model of extremity arterial hemorrhage in
6. McSwain NE, Salomone JP, Pons PT, eds. Prehospital Trauma L ife swine. J Trauma. 2009;66(2):316--326; discussion 327-328.
Support Manual. 7th ed. St. Louis, MO: Mosby; 2011.
25. Tien HC, Jung V, Rizoli SB, et al. An evaluation of tactical combat
7. Callaway DW, Reed S, Shapiro G, et al. The Committee for Tactical casualty care interventions in a combat environment. J Am Coll
Emergency Care (C-TECC): evolution and application of TCCC Surg. 2008;207(2):174-178.
guidelines to civilian high threat medicine. J Special Operati-Ons
Med. 2011;11:2. 26. Butler FK Jr, Hagmann J, Butler EG. Tactical combat casualty care
in special operations. Mil Med. 1996;16l(suppl):3-16.
8. Callaway DW. Personal communication, 2012.
9. Massachusetts Department of Public Health. Emergency Medical 27. McKeague AL. Evaluation of patient active warming systems.
Military Health System Research Symposium, Tactical Combat
Services Pre-hoS'f)i tal Treatment Protoco/.s. Version 7.02, Appendix U. Casualty Care breakout session. Ft. Lauderdale, FL. August 2012.
http://www.harwichfire.com/Forms/OEMS702.pdf. Accessed January
20, 2014. 28. Allen PB, Salyer SW, Dubick MA, et al. Preventing hypothermia:
10. Campbell JP, Gratton MC, Salomone JA ill, et al. Ambulance arrival comparison of current devices used by the U.S. Army in an in vitro
to patient contact: the hidden component of prehospital response warmed fluid model. J Trauma. 2010;69(l):Sl 54--Sl 61.
time intervals. Ann Emerg Med. 1993;22:1254.
11. Kanable R. Peak performance: well-trained tactical medics can help 29. Revell M, Greaves I, Porter K Endpoints for fluid resuscitation in
the team perform at its best. Law Enforcement Tech. August 1999. hemorrhagic shock. J Trauma. 2003;54(5 suppl) :S63-S67.
12. Cooke, MC. How much to do at the accident scene? BMJ.
1999;319:1150. 30. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resusci-
13. Jagoda A, Pietrzek M, Hazen S, et al. Prehospital care and the mili- tation strategy reduces transfusion requirements and severe post-
tary. Mil Med. 1992;157:11. operative coagulopathy in traumapatients with hemorrhagic shock:
14. Bellamy RF. The causes of death in conventional land warfare: impli- preliminary results of a randomized controlled trial. J Trauma.
cations for combat casualty care research. Mil Med. 1984;149:55. 2011;70(3):652--663.
15. Callaway DW. Tactical emergency services. In: Hogan DE, Burstein
JL, eds. Disaster Medicine. 2nd ed. Philadelphia, PA: Lippincott, 31. Rasumoff D, Carmona R. Suggested guidelines for TEMS policy and
Williams and Williams; 2007. SOP. Tactical Edge J. 1999;summer:95--96.
16. Gerold KB, Gibbons M, Mc Kay S. The relevance of Tactical Combat
Casualty Care (TCCC) guidelines to civilian law enforcement oper- 32. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization
ations. National Tactical Officers TEMS Overview. http://ntoa.org/ of penetrating neck wounds in a hostile environment. J Trauma.
site/images/stories/tccc_guidelines_ntoa.pdf. Updated November 1, 1989;29:332-337.
2009. Accessed January 20, 2014.
17. Parsons, DL, Mott JC. Tactical Combat Casualty Care Handbook: 33. Rosemary AS, Norris PA, Olson SM, et al. Prehospital traumatic car-
Observations, Insights, andLessons. Fort Leavenworth, KS: Center diac arrest: the cost of futility. J Trauma. 1998;38:468--474.
for Army Lessons Learned; 2012.
18. Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency 34. Tang N, Kelen GD. Role of tactical EMS in support of public
tourniquet use to stop bleeding in major limb trauma. Ann Surg. safety and the public health response to a hostile mass casu-
2009;249(1):1-7. alty incident. Disaster Med Public H ealth Prep. 2007;1(1 suppl):
19. McKay S, Hoyne S. High threat immediate extraction: The Immediate S55--S56.
Reaction Team (IRT) model. The Tactical Edge; Spring 2007: 50-54.
Suggested Reading

National Association of Emergency Medical Technicians. PHTLS:
PrehoS'f)ital Trauma Life Support. Military 8th ed. Burlington, MA:
Jones & Bartlett Learning; 2015.

CHAPTER 24 Civilian Tactical Emergency Medical Support (TEMS) 667

Ruggedized Intravenous Line

Principle: To insert and secure an intravenous (IV) line when a trauma patient has to
be moved, carried, or transported manually over a distance.

When a trauma patient has to be moved, carried, or manually transported over a distance, IV lines placed in the patient often
become dislodged in the effort. The U.S. military has developed a method for initiating and securing IV lines that allows for
this kind of movement w ithout loss of the IV access. The skill demonstrated has been modified from the military for civilian
application.

(j) (j)

gg
mI)!
"=~' "=~'
"~" "~"
mm
3 ~-

~

";] "s;]

s
..8 ..8
OJ OJ
"3- }

~ a.

~~

~~

~ g;
~
ror
?
~

The TEMS operator obtains IV access according The TEMS operator attaches a saline lock to the
• to the usual procedure, using an 18- or • IV catheter.

16-gauge IV catheter.

The TEMS operator covers the IV catheter and The TEMS operator flushes the saline lock with 5
• saline lock completely with a transparent wound • milliliters of normal saline by puncturing directly

dressing film (e.g., Tegaderm). through the dressing film and rubber stopper of
the saline lock.


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