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HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) 2. Administer oral antihistamines (e.g. diphenhydramine The High Mountain Institute Backcountry Medical Treatment and Evacuation Protocols are based on the Wilderness Medicine Institute of 50mg PO every 4-6 hrs). NOLS Wilderness Medicine Protocol Package © (January 2005 distribution) and have been modified with permission. These medical 3. IfMountain Pt shows S&S of anaphylaxis lipsfaculty and treatment and evacuation protocols are the exclusive property of the High Institute (HMI) and may be(Swollen used onlyface, by HMI tongue; difficulty swallowing; and staff while leading HMI courses and programs. The protocols authorize HMI staff to provide treatment systemic only when hives; workingrespiratory for HMI and inability speak ofinthis more than 1are or 2notword only in a wilderness context (defined as 1 or more hours from definitivedistress; medical care). Theto contents document to be copied or reproduced in any form w/out written permission from HMI. Authorization provided by Dr.administer Lisa Zwerdlinger, the High Mountain clusters; isS&S of shock) epinephrine Institute Physician Advisor. Notes: "Tx" = Treatment. "Evacuate" is an evacuation of a patient .3ml/1:1000 SQ orthat IM.utilizes the resources of the group in the field and HMI to evacuate a patient in an efficient manner (such as4.hiking the patient out to aorroad "Evacuate implies a If reaction reoccurs thehead). epinephrine is Rapidly" ineffective, faster evacuation using, if appropriate and more efficient, exterior support to expedite the evacuation (such as a helicopter or search and continue to administer epinephrine. rescue team). "S&S" = signs and symptoms. "Pt" = patient. "w/" = with. Abdominal Illness and Injury1 Generalized abdominal complaints are common and lead to challenging differential diagnoses. Outdoor leaders must be diligent in the interview and examination of this Pt focusing on identifying critical evacuation triggers. Many serious abdominal problems ultimately result in surgery. Tx: Abdominal Illness and Injury If the Pt does not trigger the evacuation criteria: 1. Allow the Pt to rest. 2. Maintain hydration levels w/ clear fluids. Re-hydrate w/ an electrolyte solution if the Pt is dehydrated. 3. Bland diet. The BRAT diet works well: Bananas, rice, applesauce and toast (HMI rations such as rice, crackers, soup) 4. Consider anti-diarrheals (e.g. Pepto-Bismol) as necessary to maintain hydration levels. 5. If the Pt is constipated, aggressively hydrate, avoid high fat foods and increase grains, vegetables and fruit, attempt to stimulate bowel movements w/ caffeine or alternating hot and cold liquids. 6. Monitor the Pt for worsening S&S. If the Pt does not show improvement in 12-24 hrs consider evacuation. 7. If evacuation is possible w/in a few hrs, give nothing by mouth. Evacuate Rapidly: Any Pt w/ abdominal pain who also has: ● S&S of shock. ● Blood in the vomit, feces or urine. ● Persistent and constant pain longer than 12 hrs. ● Localized pain especially w/ guarding, tenderness, distension, rebound, movement or vibration, or rigidity. ● Persistent anorexia, vomiting or diarrhea greater than 24-72 hrs. ● Fever above 102 °F (39 °C). Evacuate: ● Any Pt w/ abdominal pain that does not improve w/ treatment in 24 hrs. ● Any Pt w/ abdominal pain who is unable to stay hydrated. ● S&S of pregnancy (history of sexual activity, amenorrhea, excessive fatigue, breast tenderness, polyuria and nausea). Allergic Reactions and Anaphylaxis2 The incidence of true anaphylaxis is rare. Most allergic reactions can be managed w/ over-the-counter antihistamines. Epinephrine has been given mistakenly to Pts for mild allergic reactions, hyperventilation syndrome and panic attacks. Tx: Allergic Reactions and Anaphylaxis 1. Remove the allergen or the Pt from the offending environment. Evacuate Rapidly: ● Any Pt who continues to show respiratory compromise or S&S of shock after treatment w/ epinephrine and antihistamines. Evacuate: ● Any Pt who has received epinephrine. Continue to provide anti-histamines during evacuation. Altitude Illnesses3 General Comments: Severe altitude illness (HAPE or HACE) is rare in the United States (except Alaska) when proper acclimatization practices are followed. Mild or moderate altitude sickness (Mild or Moderate AMS) is quite common however and organizations should design programs to allow slow acclimatization in an effort to prevent AMS. Tx: Altitude Illness: 1. Do not continue ascending until symptoms have resolved. 2. Maintain adequate hydration and nutrition. Light exercise. 3. Pain medication as needed for headache. 4. If symptoms do not improve over 24-48 hrs, descend until symptoms abate. Generally 2000 feet (610m) is adequate. 5. If Pt has HAPE or HACE, descent is critical. 2000-4000 feet (610m-1219m) can make a remarkable difference. Evacuate Rapidly: ● Any Pt w/ severe altitude illness. Evacuate: ● Any Pt unable to acclimatize. Burns4 Large burns are uncommon in the backcountry, but even small burns can be debilitating, painful and difficult to keep clean. Small burns are relatively common backcountry injuries, typically secondary to hot water spills. Tx: Burns 1. Ensure the scene is safe. 2. Immediately soak or flush all burns in cold water. Remove clothing and constricting objects (e.g. jewelry, watches, belts). 3. Assess and manage Airway, Breathing and Circulation problems. 4. Gauge the depth, extent and location of the burns. 5. Properly dress the burns w/ antibiotic ointment, burn gel, Silvadene ® cream or 2nd Skin ® covered loosely w/ sterile dressings. In extended care situations debride dead skin around blisters that have self-drained and clean several times daily. Do not drain intact blisters. 6. Pain medication as needed (NSAIDs often recommended). 7. Aggressive hydration. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) 8. If snow blindness is suspected, provide cool water flushes of the eye and cool compresses. Rest and avoid sun exposure until symptoms resolve. Evacuate Rapidly: ● Any Pt w/ S&S of an airway burn. ● Any Pt w/ partial or full thickness burns covering more than 15% TBSA (Total Body Surface Area). ● Any Pt w/ partial or full thickness circumferential burns. Evacuate: ● Any Pt w/ a full thickness burn. ● Any Pt w/ burns to a special function area: face, neck, hands, feet, armpits, or groin. ● Any Pt w/ a burn that can't be managed effectively in the backcountry. Cardiac Emergencies5 Differential diagnosis of non-traumatic chest pain is challenging. Therefore any Pt exhibiting S&S of chest pain that can't be attributed to a non-cardiac origin, should be managed as if the origin is cardiac. Younger people may complain of rapid uncontrolled heart rate w/out chest pain. Tx: Cardiac Emergencies: Reduce anxiety and activity. Place Pt in a position of comfort. Avoid walking if possible. Evacuate Rapidly: ● Any Pt w/ chest pain that does not relieve w/in 20 min. Evacuate: ● Any Pt w/ non-traumatic chest pain that subsided w/ rest or medication. ● Any Pt w/ sustained periods of rapid heart rate. Chest Injuries6 General Comments Lung injury is a primary concern secondary to a blow to the chest wall. Specific diagnosis is difficult, but S&S of dyspnea (difficulty breathing), especially at rest, should trigger evacuation. Lung injury can occur spontaneously and outdoor leaders should be attentive to sudden complaints of difficulty breathing. Tx: Chest Injuries 1. Place the Pt in a position of comfort or on the injured side. 2. Stabilize any injuries. For a fractured rib sling and swathe or tape the affected side. For a flail segment splint w/ a bulky dressing. 3. For an open chest injury seal the wound w/ an occlusive dressing secured on three sides. 4. Pain management. Avoid respiratory depressants (e.g. narcotics). 5. Periodically encourage the Pt to breathe deeply. 6. Monitor for increasing Shortness of Breath (SOB) at rest and diminishing breath sounds. Evacuate Rapidly: ● Any Pt w/ S&S of serious chest trauma or respiratory distress. ● Any Pt exhibiting increasing shortness of breath, especially at rest. ● Any Pt w/ diminished or abnormal lung sounds. Evacuate: ● Any Pt w/ a suspected rib or clavicle fracture. Cardiopulmonary Resuscitation (CPR)7 CPR can be an effective life sustaining intervention in the short-term; however there is no evidence that prolonged CPR is valuable. The standards for performing CPR are well established by the American Heart Association. Contraindications to CPR in the Wilderness: There is no reason to initiate CPR if there is: 1. Any sign of life in the Pt. 2. Danger to rescuers. 3. Dependent lividity (dependent bruising) 4. Rigor mortis. 5. Obvious lethal injury (e.g. decapitation, frozen solid). 6. A well-defined Do Not Resuscitate (DNR) status. Discontinuation of CPR in the Wilderness: Once initiated CPR should be continued until: 1. Resuscitation is successful. 2. The rescuers are exhausted. 3. The rescuers are placed in danger and/or other nonrescuers are in danger w/out the assistance, care, oversight of the rescuers. 4. The Pt is turned over to more definitive care. 5. The Pt is pronounced dead by a qualified person. 6. The Pt does not respond to prolonged resuscitative efforts, greater than 30 min. Dental Emergencies8 Dental emergencies can be remarkably painful and debilitating. There are some simple tools and treatment guidelines that may allow a participant to finish a backcountry expedition in relative comfort. Tx: Dental Emergencies 1. Clean and rinse the mouth. Brush and floss the teeth if the Pt can tolerate it. 2. If a crown or filling is lost or the tooth breaks, cover the “hole” w/ Cavit ®. Cavit ® may also be used to “glue” the crown or filling in place. If you do not have Cavit ® try sugarless gum or wax. 3. If the tooth is knocked out of the socket, irrigate the tooth w/ disinfected water and attempt to replace it in the socket. If tooth can't be replaced, wrap in sterile gauze and have Pt carry the tooth between their cheek and gum. 4. Pain medication as needed. 5. If a periodontal abscess is suspected, clean and floss teeth, gargle w/ warm salty water 3-4 times daily, and administer antibiotics and pain medication. Evacuate Rapidly: ● Any Pt w/ a tooth knocked out of the socket. Evacuate: ● Any Pt w/ a broken tooth w/ exposed pulp. ● Any Pt w/ a periodontal abscess. Diabetic Emergencies9 Well-controlled diabetics perform well in backcountry settings. HMI strives to effectively screen for eligibility; this will vary on program type and location. HMI strives to have a plan for medication storage & administration. The diabetic participant should bring adequate supplies (glucometer, spare batteries, duplicate medications such as insulin, glucagons hydrochloride, and glutose paste or tabs, syringes and ketone strips) and an established sick day plan. Tx: Diabetic Emergencies Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. Pag HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) 1. Check blood sugar using the Pt’s glucometer. 2. If hypoglycemia is suspected, give the conscious Pt sugar (glutose paste or tabs, sweet liquids, table sugar in water) until they regain an adequate level of consciousness. Place the unconscious Pt on their side and rub sugar into their gums repeatedly until they regain an adequate level of consciousness. 3. If hyperglycemia is suspected, check ketone levels w/ ketone urine strips. Assist the Pt to hydrate and adjust insulin dose in accordance w/ his or her sick day plan. If the hyperglycemic Pt is unconscious, do not administer insulin. 4. Recheck blood sugar frequently. Have the Pt continue to eat and/or medicate until an adequate level (80120mg/dl) is obtained. 5. If unknown whether a Pt is suffering from hypoglycemia or hyperglycemia, give sugar to the Pt. Evacuate Rapidly: ● Any Pt who is unconscious due to a diabetic emergency. Evacuate: ● Any diabetic Pt who is unable to keep his or her sugar levels under control in a backcountry setting. ● Any diabetic Pt who experiences: several days of illness, has vomiting or diarrhea for more than 6 hrs, has moderate to large amounts of ketones in their urine, can't moderate their blood sugar readings w/ additional insulin or feels a loss of control of blood sugar levels. Dislocations10 Dislocations of the shoulder, digit and patella are most common. Patients may have a history of chronic dislocations. The mechanism of injury may be direct or indirect, and the dislocation may be associated w/ other injuries such as fractures. In general, the difficulty of reduction and the amount of long-term complications both increase w/ delay in reduction attempts. Tx: Dislocations 1. Assess circulation, sensation and motion (CSM). 2. Consider attempting to reduce the dislocation if evacuation time exceeds 1 hr or CSM has been compromised by the dislocation. 3. Reduction is usually achieved by applying slow, steady and gentle traction-in-line (TIL). Relaxation is key. Slow down or discontinue your attempt if pain increases significantly or you meet resistance. 4. In unable to reduce after multiple attempts, splint in the position found. 5. After reduction, RICE therapy, pain medication and immobilization as needed. 6. Monitor circulation, sensation and motion (CSM) before and after reduction and/or immobilization. 7. Passive range of motion (ROM) 2-3 times per day, or to Pt tolerance. Evacuate Rapidly: ● Any Pt w/ an unreduced dislocation. ● Any Pt w/ altered CSM after reduction. Evacuate: ● Any Pt w/ a first time dislocation, except distal joints of the fingers or toes. ● Any Pt w/ altered CSM prior to reduction. ● Any Pt unable to use the reduced joint. ● Any Pt w/ persistent pain. Eyes, Ears and Nose11 Tx: Eyes, Ears and Nose: ● Black eyes: cool compresses and pain medication. ● Objects in the eye should be flushed out w/ disinfected water or dabbed out w/ a clean cloth. If the object is embedded in the eye it should be stabilized and both eyes bandaged. ● Objects in the ear may be drowned w/ oil, water or alcohol, if needed, and then flushed out w/ an irrigation syringe or grasped w/ tweezers if visible. ● Outer ear infection can be treated by keeping the ear dry & daily flushing w/ dilute alcohol or vinegar solution. ● Bloody noses can be managed by pinching the nose just below cartilage and leaning forward. If unable to control bleeding, consider packing the nose w/ gauze. Evacuate Rapidly: ● Any Pt w/ an uncontrollable nose bleed. Evacuate: ● Any Pt w/ persistent vision changes, extraordinary and persistent sensitivity to light, or discharge of fluid other than tears, or an imbedded objects. ● Any Pt w/ an ear infection not responding to treatment. Female Gender Medical Concerns12 Most female gender medical concerns are manageable in a backcountry setting. It is important to create an environment that encourages participants to discuss these concerns w/ trip leaders. The decision to allow pregnant group members on the trip should be established ahead of time. Tx: Female Gender Medical Concerns 1. Both dysmenorrhea and mittleschmerz can be managed w/ analgesics, mild exercise and heat packs. 2. If vaginitis is suspected, wash the vaginal area thoroughly and air dry. Consider over-the-counter antifungal (e.g. Monistat ®). 3. If a urinary tract infection is suspected, rest the Pt, and provide aggressive hydration. 4. If an ectopic pregnancy is suspected, treat for shock. Evacuate Rapidly: ● Any Pt w/ S&S of urinary tract infection who develops tenderness over the kidneys. ● Any Pt w/ a suspected ectopic pregnancy (low abdominal/pelvic pain, abnormal vaginal bleeding, S&S of shock.) Evacuate: ● Any Pt suspected of being pregnant or w/ pregnancy complications. ● Any Pt w/ vaginitis that does not respond to treatment. ● Any Pt w/ a urinary tract infection. Flu-Like Illness13 General Comments: Viral “flu-like” illness are common on wilderness expeditions. They may include gastrointestinal symptoms (nausea, vomiting and diarrhea) or respiratory symptoms (cough, congestion, runny nose, sore throat). Viral illnesses also cause a viral headache, malaise, fatigue, low-grade fever, muscle aches, body aches, etc. Flu is a medically distinct illness from the “common cold”. It usually has a more abrupt onset than a cold w/ a stronger overall impact on the Pt. The illness can persist for several weeks. Management is focused on symptomatic relief for the Pt. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) Tx: Flu-like Illness: 1. General management for flu-like illness is symptomatic treatment. 2. Rest and hydration. 3. Hand washing and hygiene. 4. Acetaminophen or NSAIDs for fever, sore throat headache and muscle aches. 5. Decongestants (e.g. pseudophedrine) for congestion. 6. Bland diet for gastrointestinal distress. Evacuate Rapidly: Any Pt w/ S&S of flu-like illness who develops: ● Stiff neck, severe headache, difficult breathing or wheezing. ● Gastroenteritis w/ persistent or worsening abdominal pain over 24 hrs, spiking fever, bloody diarrhea or dehydration. ● An inability to tolerate any oral fluids more than 48 hrs, especially if accompanied by diarrhea volume losses, fever or vomiting. ● A headache that does not respond to treatment, sudden severe headaches, or a headache associated w/ altered mental status. Evacuate: Any Pt w/ S&S of flu-like illness who develops: ● Fever persisting more than 48 hrs or is high (>104°F/40°C). ● Signs or symptoms of pneumonia. This is usually associated w/ increasing shortness of breath, decreasing exercise tolerance, worsening malaise and weakness w/ a predominance of cough. ● An isolated sore throat w/ fever and a red throat w/ white patches. ● A sore throat in conjunction w/ inability to swallow water and maintain adequate hydration. ● Any Pt demonstrating increasing disorientation, irritability, combativeness or otherwise altered level of consciousness. ● Any Pt w/ persistent vomiting, lethargy, excessive sleepiness, ataxia (extreme uncoordination), seizures, worsening headache or vision disturbances. ● Any Pt w/ signs of a skull fracture. Evacuate: ● Any Pt who has a change in level of consciousness after a blow to the head (e.g. disoriented, seeing stars, brief period of appearing to be asleep, unknown or unwitnessed loss of consciousness). ● Any Pt whose S&S do not show improvement after 24 hrs. Heat Illness15 Heat illnesses may present due to overexertion, underhydration, and over-hydration. An accurate Pt history is critical to determine the correct origin and treatment. Tx: Heat Illness 1. Change the environment, rest in cool, shady spot. 2. Fluid replacement w/ water, dilute solution of sugar drink w/ a tsp. of salt or sports drink. If hyponatremia is suspected, avoid fluid intake, provide gradual intake of salty foods. 3. For heat stroke provide aggressive cooling, spray w/ water, fan and massage extremities. Evacuate Rapidly: ● Any Pt w/ an altered level of consciousness. Hypothermia16 Most mild-moderately hypothermic Pts are managed effectively in the field and do not require evacuation. Tx: Hypothermia 1. Change the environment and find shelter. Replace wet Head Injuries14 clothing w/ dry clothing and add wind and waterproof Accurate assessment of level of consciousness is critical in layers. Treat gently. determining the severity of a head injury. Patients may 2. Add insulation under and around the Pt. Consider a initially appear well oriented and later demonstrate hypothermia wrap for moderately and severely increasing disorientation as swelling and pressure compress hypothermic Pt. Add external heat sources and wellthe brain. The first 24 hrs are the most critical in observing insulated heat packs at hands, feet, armpits, groin, and the Pt for worsening S&S. neck. Tx: Mild Head Injuries 3. Encourage exercise if the Pt is able and allow shivering in Conservative treatment w/ close observation for 24 hrs in a dry, insulated environment. the field can be done if the Pt did not lose consciousness or 4. Give warm, sweet, non-caffeinated, non-alcoholic liquids was only momentarily dazed or stunned, but recovered and encourage the Pt to eat a meal, if they are able. appropriately and the Pt remains awake w/out negative 5. For a severely hypothermic Pt, assist ventilations for 5-15 change in mental status and has only transient nausea or min prior to movement. vomiting. 6. Avoid chest compressions if there are any signs of life or 1. Monitor the Pt for developing signs of serious head injury. the Pt is rigid from the cold. Perform rescue breathing 2. Let the Pt rest, but wake them up every few hrs to during evacuation. monitor LOC. Evacuate Rapidly: 3. Avoid pain medications for 24 hrs. ● Any Pt w/ severe hypothermia. Tx: Serious Head Injuries Lightning17 1. If the injury is open, use diffuse pressure w/ a bulky dressing to control bleeding. Lightning strikes can cause a multitude of injuries including 2. Manage Airway, Breathing and Circulation. death. The best defense is a strong prevention plan specific 3. Immobilize the spine and elevate the head at for your geographic area and group profile. approximately a 30-degree angle. Consider placing the Pt Tx: Lightning Injuries on his or her side to manage the airway. 1. Scene safety: Lightning will strike twice in the same spot. 4. Evacuate. 2. Aggressive Basic Life Support: Rescuers should be Evacuate Rapidly: prepared to provide prolonged rescue breathing. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. Pag HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) 3. Thorough Pt exam and treatment of any injuries found. 4. Monitor closely for cardiovascular, respiratory and neurological collapse. Evacuate Rapidly: ● Any Pt showing signs of cardiovascular, respiratory or neurological compromise. Evacuate: ● Any Pt struck by lightning even if they appear uninjured. Compression: Elastic Wrap, distal to proximal. Elevation: Above the Pt’s heart. 4. Pain medication as needed. 5. Allow the injury site to passively warm. 6. Assess again for usability. 7. Support the injury w/ tape or other adjuncts. Tx: Obvious Fractures, Open Fractures and Unusable Injuries 1. Assess circulation, sensation and motion (CSM). Local Cold Injuries18 2. If fracture is open, thoroughly irrigate and clean wound It is possible to see both freezing and non-freezing local cold prior to manipulating injury. injuries in the wilderness setting. Both can cause injuries 3. Use gentle traction-in-line (TIL) to establish normal ranging from minor irritation to significant tissue loss and anatomical position. Slow down or discontinue your permanent disability. attempt if pain increases significantly or you meet Tx: Local Cold Injuries resistance. If the bone ends do not reduce, protect them 1. If not frozen: Warm the injury w/ skin-to-skin contact, do from freezing or drying. not massage or use radiant heat. 4. Dress wounds. 2. If frozen: If possible, warm the injury in a circulating warm 5. Splint in a position of function w/ a well-padded and rigid water bath at 104-108°F (40-42°C), otherwise use skinsplint. to-skin contact. Do not massage or use radiant heat. 6. Traction splint mid-shaft femoral fractures. Consider allowing a Pt to walk on frozen feet if it 7. RICE therapy. Pain medication as needed. expedites the evacuation. 8. Monitor CSM before and after TIL and splinting. 3. Protect blisters and damaged tissue, avoid constriction. 9. Monitor wound site for infection (consider antibiotic Protect from re-freezing. Elevate. therapy for open fractures if evac > 8 hrs.) 4. Pain medication as needed (NSAIDs often Evacuate Rapidly: recommended). ● Any Pt w/ an open fracture. Evacuate Rapidly: ● Any Pt w/ altered CSM. ● Any Pt w/ full thickness frostbite. Evacuate: Evacuate: ● Any Pt w/ an unusable musculoskeletal injury. ● Any Pt w/ more than a few, small, isolated clear fluid filled blisters formed after warming a local cold injury. Mental Health Emergencies ● Any Pt unable to use the injured area. Mental health emergencies range from minor feelings of ● Any Pt unable to protect the area from continued exposure to a cold wet environment or from re-freezing. anxiety to severe suicidal ideation. A good Pt history may help you to assist your Pt. ● Any Pt whose pain can't be managed in the field. Tx: Mental Health Emergencies Male Gender Illness And Injury19 ● Calm and comfort the Pt. ● Supervise the Pt in a manner appropriate that they will It can be challenging to differentiate between traumatic and not harm themselves or others. infectious problems w/ the male genitalia. Since delay in ● If the Pt has experienced a similar mental health issues care can result in the loss of a testicle, treatment should in the past discuss and implement strategies that will error on the conservative side. help them to work through the episode. Tx: Male Gender Illness and Injury ● If the Pt has experienced a similar mental health issues 1. Pain management, NSAIDs often recommended. in the past (or you feel you need external assistance) 2. Cool compresses. consider calling the EC so that they can seek advice 3. Elevation/support of the testicles. from the patient’s doctor, the office of the HMI Physician 4. If epididymitis is suspected administer antibiotics. Adviser or other mental health professional. 5. If inguinal hernia is suspected, attempt reduction. Evacuate Rapidly: Evacuate Rapidly: ● Any Pt that poses an immediate and severe threat to ● Any Pt w/ suspected testicular torsion. themselves or others. ● Any Pt w/ testicular pain of unknown origin. Evacuate: Evacuate: ● Any Pt that is a threat to themselves or others. ● Any Pt w/ a suspected epididymitis. ● If the harm to the expedition greatly outweighs the ● Any Pt w/ an inguinal hernia that does not reduce or benefit to the patient staying in the field. reappears after reduction. ● If the mental health condition is beyond the instructors Athletic Injuries And Fractures20 ability to manage in the field. ● If the patient continues to believe that they are Treatment and evacuation decisions are based on the Pt’s completely unsafe or unable to continue. ability to use the injured area. Tx: Strains, Sprains, Tendonitis and Minor Fractures Neurological Emergencies21 1. Assess injury for stability and usability. 2. Assess circulation, sensation and motion (CSM). Strokes are rare events in a backcountry setting, but when 3. RICE Therapy: they do occur require immediate evacuation. Seizures are a Rest: Get the pressure off of the injury site. Ice: Cool the area for 20 min. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) more common occurrence, fortunately they are rarely life threatening. Tx: Neurological Emergencies ● For a suspected stroke or transient ischemic attack (TIA), provide emotional reassurance. Place the Pt in a position of comfort unless unconscious, then place in stable side position w/ the affected airway side down to protect the airway. Administer high-flow/highconcentration oxygen, if available. Document precisely the time of onset of S&S. ● For a Pt w/ a seizure, protect from harm, but do not restrain. Do not place bite stick or any other object in mouth. Place the Pt on side to maintain open airway during post-ictal recovery phase. Perform a complete Pt assessment to check for injuries. Protect the Pt’s dignity. ● For an unconscious Pt of unknown origin, stabilize the spine, manage the airway, consider positioning of the Pt on their side and search for clues to the Pt’s unconscious state. Consider administering oral sugar. Evacuate Rapidly: ● Any Pt w/ S&S of a stroke or TIA. ● Any Pt w/ multiple seizures in a short time period. ● Any Pt w/ an altered mental status of unknown origin. Evacuate: ● Any Pt w/ a first time seizure. ● Any Pt w/ a breakthrough seizure-a seizure that occurred in spite of medication. ● Any Pt w/ an isolated seizure of unknown origin. Poisons22 When dealing w/ possible poisoning gather detailed information about what was ingested, how much, when, body size and age, what is in his or her stomach and was it intentional. Carbon monoxide poisoning is common in outdoor recreation according to the Centers for Disease Control. Tx: Poisons 1. Call the poison control center (1-800-222-1222), if possible. 2. If poison is ingested and is non-corrosive, non-petroleum based and the Pt is fully conscious: Induce vomiting manually and absorb remaining poisoning w/ activated charcoal. Dilute w/ water. 3. If poison is inhaled, remove Pt from exposure. Assist ventilations if necessary. 4. If poison is absorbed, take universal precautions and remove contaminated clothing. Brush dry poison off, flush area w/ water and wash w/ soap. Evacuate Rapidly: Any poisoned Pt who has an altered level of consciousness or shows signs of respiratory distress. Evacuate: Any Pt who has ingested quantities of a potentially harmful substance. Contact the American Association of Poison Control Centers at 1-800-222-1222 for advice. Respiratory Emergencies23 General Comments: Respiratory emergencies range from minor episodes of hyperventilation and asthma to more serious infections, embolisms and severe asthma. A good Pt history will help you determine the likely cause and create the most appropriate management plan. Cold, altitude, dehydration and fatigue can all be complicating factors. Tx: Respiratory Emergencies: 1. For suspected hyperventilation, calm the Pt, be direct but reassuring. Assist the Pt to slow his or her breathing. Oxygen is not indicated. 2. For suspected pulmonary embolism, place the Pt in a position of comfort. 3. For a suspected Upper Respiratory Infection (URI) allow the Pt to rest and hydrate. Consider over-the-counter decongestants and analgesics. 4. For suspected pneumonia, encourage Pt to cough and breathe deeply. Ensure the Pt stays hydrated. Give feverreducing medications. If evacuation is lengthy, administer oral antibiotics. 5. For a suspected asthma attack help calm the Pt and change the environment. Assist the Pt, if necessary, w/ his or her bronchodilators or Albuterol inhaler. Multiple treatments may be required. Encourage pursed lip breathing. Provide hydration and rest. If the attack is severe (unable to speak a full sentence), administer epinephrine .3ml/1:1000 SQ or IM and/or steroids. Evacuate Rapidly: ● Any Pt w/ suspected pulmonary embolus. ● Any Pt w/ a severe or unbreakable asthma attack. Evacuate: ● Any Pt w/ suspected pneumonia. ● Any Pt w/ increased frequency or duration of asthma attacks or who does not show improvement w/ medication. ● Any Pt using a respiratory inhaler more than 3 times per week (excepting prescribed inhaler used pre-exercise for exercise induced asthma). ● Any Pt waking up at night and needing to use their inhaler. Shock24 General Comments: In wilderness settings shock is most commonly brought on by loss of fluid volume from bleeding, sweating, vomiting, diarrhea and/or severe burns. Outdoor leaders should focus on early recognition and intervention to control fluid loss and maintain Pts in the field. Tx: Shock: 1. Treat before serious signs develop. 2. Treat the cause. Keep the Pt calm. 3. Keep the Pt warm. 4. Keep the Pt flat w/ legs elevated no more than 12 inches (30.5 cm)(Head or lower extremity injury may preclude this.) 5. Consider administering oral fluids in an extended care situation (If Pt can tolerate the fluids, mental status is adequate to swallow and there is no abdominal injury.) 6. Monitor the Pt closely for deteriorating vital signs. Evacuate Rapidly: ● Any Pt w/ S&S of cardiogenic or vasogenic shock. ● Any Pt w/ decreased mental status or worsening vital signs. ● Any Pt w/ an absent radial pulse (not otherwise explainable by an injury to that extremity). Evacuate: ● Any Pt unable to stay hydrated in spite of concentrated efforts. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. Pag HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) ● Any Pt for whom you can't treat the underlying cause of shock. Skin Irritation25 Many skin irritations can be prevented though improved hygiene practices and appropriate clothing. The active ingredient in poison ivy, oak and sumac is urushiol. This oil can be transferred to the skin regardless of whether or not the plant has its traditional shiny three leaves in bloom. Inhaled smoke from burning plants can also cause a significant reaction. There are barrier creams for hypersensitive individuals. Tx: Skin Irritation: 1. Fungal infections of the skin can be treated by washing the area thoroughly w/ soap and water, air drying and applying a thin layer of 1% hydrocortisone cream or a topical anti-fungal (e.g. Tinactin ®). 2. For a suspected contact w/ poison ivy, oak or sumac, wash the area immediately after exposure w/ soap and cool water. Wash all clothes and equipment that may have been exposed. Once the rash appears, apply a thin layer of 1% hydrocortisone cream or calamine lotion to reduce itching. Oral antihistamines may help reduce itching. Evacuate Rapidly: ● Any Pt w/ respiratory distress after inhaling smoke from burning poison ivy, oak or sumac. Evacuate: ● Any Pt w/ a skin irritation that makes them too uncomfortable to continue. North Am. Spiders & Scorpions27 Many spider bites are initially painless making it difficult to identity the specific spider. Fatalities are rare. Scorpion stings are painful, but typically self-limiting. Systemic reactions are possible from scorpions in the extreme southwestern US. Tx: Bites & Stings from N. Am. Spiders & Scorpions 1. Clean the bite/sting site. Continue to clean the site if wound does not heal. 2. Ice the bite site for pain and consider painkillers for abdominal cramps. 3. Monitor the bite site for necrosis. 4. Monitor the Pt for systemic S&S. 5. Administer pain medications. Evacuate Rapidly: ● Any Pt exhibiting slurred speech, difficulty swallowing, blurred vision, seizures, or respiratory or cardiovascular involvement. Evacuate: ● Any Pt w/ a suspected black widow spider bite. ● Any Pt w/ a wound that will not heal. Spinal Injuries28 General Comments: The utilization of the focused spine assessment to determine presence or absence of spinal injury has been well documented. Outdoor leaders should be attentive to suspicious mechanisms of injury and take early spinal precautions w/ Pts prior to the focused spine assessment. Focused Spine Assessment: North American Pit Vipers, Coral Snakes If the Pt has a mechanism for spinal injury but does not exhibit S&S of spinal injury during the complete Pt and Poisonous Lizards26 assessment, perform a focused spine assessment to Fatalities due to envenomation by snakes or lizards are determine whether further spinal immobilization is extremely rare in North America, though tissue loss is a warranted. significant possibility. Not all bites will carry venom, and the Focused Spine Assessment injury should be monitored closely for signs of 1. Patient must be reliable: A+O x 3 or 4, sober, and have envenomation. Anti-venom is available for most bites. no distractions. Tx: Bites from North American Pit Vipers, Coral Snakes 2. Patient must have normal Circulation (unless otherwise and Poisonous Lizards explainable by another injury or illness), Sensation (no 1. Ensure the scene is safe. Remain calm and put the Pt at numbness, tingling or unusual hot or cold sensations) rest. Avoid walking if possible. and Motion (unless otherwise explainable by another 2. Remove constricting clothing and jewelry from the bite injury or illness) in all four extremities. site. 3. Patient must deny spinal pain and tenderness, w/ and 3. Wash and dress the wound. w/out palpation, and, w/ and w/out active and passive 4. Measure and monitor swelling and signs of movement. envenomation. Do not apply cold. 4. If Pt meets all criteria, further spinal immobilization is not 5. A wide elastic bandage wrapped proximal to distal is warranted. recommended for coral snake bites. Tx: Suspected Spinal Injury: 6. Splint the extremity and keep it at the same level as the If the Pt exhibits S&S of spinal injury during either the Pt heart. assessment or the focused spine assessment: 7. Monitor for shock and cardiac and respiratory depression. 1. Stabilize the spine and control the head manually. Evacuate Rapidly: 2. Check circulation, sensation and motion (CSM) in the ● Any Pt exhibiting shock, or cardiac or respiratory extremities. depression. 3. Establish neutral alignment of the spine. Evacuate: 4. Apply a cervical collar. ● Any Pt bitten by a poisonous snake, ideally by carrying 5. BEAM or log-roll the Pt into a commercial litter or onto a or slowly walking. backboard. 6. Secure the entire body to the litter or backboard w/ padding and straps. 7. Secure the head to the litter or backboard. 8. Recheck CSM in the extremities. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) 9. Evacuate. Evacuate Rapidly: ● Any Pt who demonstrates S&S of neurological injury. Evacuate: ● Any Pt being treated for a spinal injury, ideally on a commercial litter or on a backboard. Submersion Incidents29 Rescuer safety is paramount when dealing w/ submersion events. It is common to underestimate the effects of current and temperature on both rescuers and Pts. Tx: Submersion Injuries 1. Scene safety: Reach, Throw, Row, Tow, Go! Get the person onto a safe, firm surface. 2. Aggressive Basic Life Support. Evacuate Rapidly: ● Any Pt who develops: Wet lung sounds, productive cough, rapid, shallow, respirations, cyanosis, substernal burning, inability to take a deep breath, irregular and/or depressed heart rate, or a decreased level of consciousness. Evacuate: ● Any Pt who was unconscious at any time during the submersion. Wounds and Infection30 Wounds and infection are exceedingly common in a wilderness setting. Established infection is challenging to manage so efforts should be directed at aggressive wound cleaning and effective dressing. Tx: Wounds and Infection 1. Control bleeding using direct pressure and elevation, pressure dressings, pressure points and tourniquets. 2. Properly clean the wound: Wash your hands and put on your gloves; Clean around the wound w/ soap and water, an abrasion may be aggressively scrubbed, and rinse w/ disinfected water; Remove any foreign matter w/ disinfected tweezers or by gently brushing it out of the wound; Pressure irrigate the wound w/ disinfected water. 3. Cover wound w/ a thin layer of antibiotic ointment and a sterile dressing and bandage. If the cut gapes open less than 1/2 inch (1 cm), approximate wound edges w/ wound closure strips. Monitor circulation, sensation and motion (CSM). Keep the dressings clean and dry. Change dressings at least every 24 hrs. If using transparent film dressings, dressings may be left in place until wound heals. 4. If the cut causes gaping of more than 1/2 inch (1 cm) or wound is infected, pack the wound open wet-dry and keep the wound moist during evacuation. 5. In case of an amputation, wrap the part in a moist sterile dressing and seal in a plastic bag. Immerse the bag in cool water and transport rapidly to the hospital w/ the Pt. 6. Consider removing an impaled object if it is through the cheek. In remote environments consider removal if the object is metal and the environment is cold or if the object is in an extremity. 7. If the wound shows S&S of infection: Hot soaks for 20-30 min several times daily; Reclean the wound following the hot soak; keep the Pt hydrated; Consider packing the wound open (wet to dry) to allow drainage; Consider antibiotic and fever reducing therapy. Evacuate Rapidly: ● Any Pt w/ an amputation. ● Any Pt w/ an object still impaled. ● Any Pt w/ a wound that: Is heavily contaminated, opens a joint space, involves underlying tendons or ligaments, was caused by an animal bite, is on the face, or was caused by a crushing mechanism. ● Any Pt w/ a wound that shows S&S of serious infection. Evacuate: ● Any Pt w/ a wound that can't be closed in the field. ● Any Pt w/ an infection that does not improve w/in 12-24 hrs. ● Any Pt who starts a course of antibiotic therapy. Zoonoses31 There are a wide-range of diseases transmitted from animals to humans. The ones we worry about the most in the United States are: Tick Fevers, West Nile Virus, Hantavirus, Rabies and Plague. Field diagnosis can be extremely difficult. Fever is a common symptom. The Pt may trigger the flu-like illness evacuation criteria. Educational efforts should focus on effective prevention. Tx: Zoonoses 1. Symptomatic management, e.g. fever reducing medication, pain medication, antihistamines and antibiotic therapy. 2. Treat all mammal bites as a potential rabies exposure. Clean wound thoroughly w/ soap and disinfected water. Evacuate Rapidly: ● Any Pt w/ a mammal bite for initiation of the rabies vaccine. Evacuate: ● Any Pt w/ a history of an embedded tick who develops fever, rash and flu-like symptoms. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. Pag HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) HMI Expedition Drug Kit Before administering any medication read the protocols, confirm the dosage, review contraindications, read the label and confirm the medication, ask the patient about previous history w/ this medication and any known allergies, ask the patient if they are currently on any medication and if so, review the protocols for contraindications. All dosing is indicated for adults, unless noted otherwise. Note: PO = Oral; SQ = Subcutaneous injection; IM = Intramuscular injection; 1kg (kilogram) = 2.2 pounds. 1g (gram) = 1000mg (milligrams), Rx = denotes prescription medication, OTC = denoted over-the-counter medication Tylenol Advil, Motrin Benadryl Sudafed Pseudoephedrine hydrochloride Diphenhydramine hydrochloride Hydrocodone bitartrate/ acetominophen Vicodin Ibuprofen Acetaminophen Classification Non-narcotic analgesic, antipyretic Dose Contraindication Side Effects OTC For symptomatic relief of pain associated w/ Active peptic or headache, colds, flu, gastrointestinal ulcer, frostbite, toothache, Nausea, gastrointestinal arthritis, burns and epigastric pain, menstrual cramps. May be bleeding disorder, dizziness and history of used to reduce fever. For rash hypersensitivity to pain of inflammation and aspirin or other reduction of inflammation NSAIDs. associated w/ muscle, joint and over-use injuries OTC For moderate to severe pain. Narcotic. Good for 5-10mg/4 hrs musculoskeletal and dental PO pain. Good for people allergic to codeine. Suppresses cough reflex. Hypersensitivity. Patients w/ altered mental status or repertory distress. Sedation, decrease in Rx, for HMI blood pressure, admin. sweating and typically flushed face, triggers an evac drowsiness and dizziness For temporary relief of respiratory allergy symptoms and cold Drowsiness, symptoms. Helps relieve Hypersensitivity, dizziness, the itching of allergic skin 25 mg/ 6 hrs acute asthma attack, weakness, reactions. Useful in PO, may give glaucoma, peptic hypotension, dry treatment of moderate Antihistamine 2nd dose if ulcer, hypertension mouth, allergic and anaphylactic ineffective after and COPD (Chronic thickening reactions. May be used as 60 min Obstructive bronchial a mild sedative and for Pulmonary Disease). secretions and insomnia. May help urinary retention. alleviate seasickness. Can be used to treat distonic reactions. Nasal decongestant Notes Hypersensitivity, For relief of pain due to active alcoholism, headache, cold and flu liver disease, 15mg/kg body discomfort, minor muscle hepatitis. mass, and joint discomfort and Acetaminophen is a maximum menstrual cramps. For common ingredient in Hypersensitivity is rare 1000mg/4 hrs reduction of fever. over-the-counter pain, PO, max dose Especially useful for those cold and flu medicine. 4g/24 hrs allergic to aspirin or aspirinBe careful of containing products. Does accidental overdose not control inflammation. in combination w/ other products 10mg/kg body Analgesic, Nonmass, Steroidal Antimaximum of Inflammatory 800 mg/8 hrs. Drug (NSAID), Maximum dose antipyretic 4g/24 hrs Narcotic analgesic, antitussive Indication 60mg per 6-8 hrs PO Decongestant useful in treating upper airway sinuses and nasal passages. Use of more than 5 days may cause reverse effects. Severe hypertension, Nervousness, coronary artery restlessness, disease, lactating insomnia, women, MAO inhibitor trembling and therapy. headache. OTC OTC Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) Adrenalin, EpiPen Polysporin Azithromycin Keflex Tinactin Monistat 3 Miconazole Nitrate Tolnaftate Hydrocortisone Cream 1% Silver Sulfadiazine Cream SSD Cephalexin Azithromycin Polymyxin B sulfate/bacitracin Epinephrine Albuterol Two puffs of metered dose Shortness of breath or inhaler (MDI) respiratory difficulty thought Bronchodilator w/ use of a to be secondary to reactive spacer every 4 airway dysfunction (asthma) or HAPE. hrs and as needed Bronchodilator, 0.3ml 1:1000 antiallergenic, SQ or IM. cardiac Repeat as stimulant. necessary. Antibiotic Topical For severe allergic reactions including anaphylaxis and status asthmaticus. ingredients for prevention of infection in minor wounds. Works as a lubricant, offers some relief from itching. Tachycardia secondary to underlying heart condition. Palpitations, Rx (ref tachycardia and only, not in tremor. HMI kits) Increased heart No true rate, Rx, for HMI contraindications w/ nervousness, admin. anaphylaxis. dizziness, typically Hypertension, cardiac lightheadedness, triggers an disease, glaucoma evac nausea and and shock. headache. Hypersensitivity. Hypersensitivity reactionsburning, itching, inflammation, contact dermatitis OTC Antibiotic Abdominal For sinus, pulmonary, ear, discomfort and Rx, for HMI 500mg/24 hrs Hypersensitivity, liver eye, respiratory and soft cramping, admin. (1 x per day) disease, hepatitis. tissue infections. Useful for nausea, typically for 3 days PO. Allergies to patients who can't take vomiting, triggers an Take w/ food. macrolides. penicillin or cephalosporin. evac diarrhea and rash. Antibiotic 250mg per 6 Oral and vaginal Rx, for HMI Hypersensitivity. hrs (4 x per fungal infections, admin. For skin, bone, pneumonia Sensitivity to penicillin day) for at diarrhea and typically and urinary tract infections. and/or least 5 days abdominal triggers an cephalosporins. PO. cramping. evac Antibiotic Topical, Apply to affected area in a thick layer 2-3 x per day Antipruritic Topical, apply For the temporary relief of to affected itching associated w/ minor area 2-3 skin irritations and rashes. time/day Steroid allergies Allergic reaction OTC Antifungal For treatment of superficial skin fungi such as Topical, 2 ringworm, jock itch and applications/da athlete’s foot. For external y use only (not for UTI's or Vaginitis). Hypersensitivity, patients allergic to tolnaftate. Mild irritation. OTC Antifungal 200mg vaginal suppositories Hypersensitivity, first nightly for Vaginal candidiasis (yeast Itching, burning trimester of infections). and stinging. three nights or pregnancy. topical cream as needed. Burns Sulfa and sulfa drug Allergic reaction allergies Rx Rx Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. Page 2 tablets after first loose For use in the control of stool.1 tablet diarrhea, nausea and upset after stomach. subsequent loose stools Loss of appetite, cramps Tums Loratadine Mild allergy relief Cavit Relieves, Chew 2-4 For use in relieving heartburn, acid tablets, up to heartburn, acid indigestion, indigestion 10 in 24 hours upset stomach Calcium Carbonate Loperamide Antidiarrheal Claratin Imodium HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) Temporary Filling Material 1 tablet daily, no more than one tablet in 24 hours Temporarily relieves sypmtops of upper respiratory allergies As per directions For use as a temporary filling. OTC OTC ? ? ? Pages following this page (the endnotes and references section) are typically omitted for field use. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) ENDNOTES/REFERENCES Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Gastrointestinal.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-70. Schimelpfenig, Tod and Linda Lindsey. “Abdominal Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 8. Specific Protocols for Wilderness EMS Abdominal Pain. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Abdominal Injuries.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 11. Tilton, Buck. “Abdominal Illnesses.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 29. Wilkerson, James A. “Acute Abdominal Pain.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 13. Wilkerson, James A. “Abdominal Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 14. 2 Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Position Statement 26:The Use of Epinephrine in the Treatment of Anaphylaxis.” American Academy of Allergy Asthma & Immunology. 28 Dec. 200 <http://www.aaaai.org/media/resources/position_statements/ps26.stm> Schimelpfenig, Tod and Linda Lindsey. “Poisons, Stings, and Bites.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 11. Specific Protocols for Wilderness EMS Allergic Reactions. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Allergic Reactions and Anaphylaxis.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 28. Wilderness Field Protocols Protocol 1 Anaphylaxis. 200 Wilderness Medical Associates. 2 Dec. 2004 < http://www.wildmed.com/field_protocols/anaphylaxis_protocol05.01.html top> Wilkerson, James A. “Allergies.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 20. 3 Auerbach, Paul S. “High-Altitude Medicine.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 1. Forgey, William. “High-Altitude Illness.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 10. Hackett, Peter H. “The Cerebral Etiology of High-altitude Cerebral Edema and Acute Mountain Sickness.” Wilderness and Environmental Medicine 10 1999: 97-109. Hackett, Peter H. and Robert C. Roach. “Medical Therapy of Altitude Illness.” Annals of Emergency Medicine 16, 9 September 1987: 89-95. Schimelpfenig, Tod and Linda Lindsey. “Altitude Illness.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 14. Schoene, Robert B. “High-Altitude Pulmonary Edema: Pathophysiology and Clinical Review.” Annals of Emergency Medicine 16, 9 September 1987: 99-104. Stewart, Charles E. “Management of Altitude-Related Emergencies.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 6. Tilton, Buck. “Altitude Illnesses.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 18. Wilkerson, James A. “ Disorders Caused by Altitude.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 21. Wilkerson, James A. “ Altitude and Common Medical Conditions.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 22. 4 “Burns.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 3-17. Emergency Medical Technician-Basic: National Standard Curriculum Module 5 Trauma. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Forgey, William. “Burn Management.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 7. Schimelpfenig, Tod and Linda Lindsey. “Burns and Lightning Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 4. Specific Protocols for Wilderness EMS Wounds. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> Stewart, Charles E. “Burns.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 2. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Wilderness Wound Mangament.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 15. Wilkerson, James A. “Burns.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 8. 5 ACLS Provider Manual. Dallas, Texas: American Heart Association, 2002. BLS for Healthcare Providers. Dallas, Texas: American Heart Association, 2002. “Cardiac/Circulatory.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-1. Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Schimelpfenig, Tod and Linda Lindsey. “Respiratory and Cardiac Emergencies, Seizures, Diabetes and Unconscious States.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 18. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Cardiac Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 23. 6 Emergency Medical Technician-Basic: National Standard Curriculum Module 5 Trauma. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Thoracic Trauma.” PHTLS Basic and Advanced Prehospital Trauma Life Support. St. Louis, Missouri: Mosby, 200 Chapter 5. Schimelpfenig, Tod and Linda Lindsey. “Chest Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 7. Specific Protocols for Wilderness EMS Chest Injury. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> Tilton, Buck. “Chest Injuries.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 10. Wilkerson, James A. “ Chest Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 11. 7 ACLS Provider Manual. Dallas, Texas: American Heart Association, 2002. BLS for Healthcare Providers. Dallas, Texas: American Heart Association, 2002. Forgey, William. “Cardiopulmonary Resuscitation.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 2. Goth, Peter and George Garnett. “National Association of EMS Physicians Clinical Guidelines for Delayed/Prolonged Transport Cardiorespiratory Arrest.” Prehospital and Disaster Medicine Vol. 6 No. 3 July-Sept. 1991: 335-339. Specific Protocols for Wilderness EMS Cardio Pulmonary Resuscitation. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 < http://www.wemsi.org/specific.html> Tilton, Buck. “Cardiopulmonary Resuscitation.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 5. Wilderness Field Protocols Protocol 3 Cardiopulmonary Resuscitation (CPR). 200 Wilderness Medical Associates. 2 Dec. 2004 <http://www.wildmed.com/field_protocols/cpr_protocol05.01.html top> 8 Auerbach, Paul S. “Dental and Facial Emergencies.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter23. “Dentistry.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 5-9. Schimelpfenig, Tod and Linda Lindsey. “Dental Emergencies.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 20. Specific Protocols for Wilderness EMS Dental Injury. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. 1 Page HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) Tilton, Buck. “Common Simple Medical Problems.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 31. 9 Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Endocrine.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-27. Schimelpfenig, Tod and Linda Lindsey. “Respiratory and Cardiac Emergencies, Seizures, Diabetes and Unconscious States.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 18. Specific Protocols for Wilderness EMS Diabetes. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Diabetic Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 26. 10 Auerbach, Paul S. “Orthopedics.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 21. Forgey, William. “Orthopedic Injuries.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 8. Goth, Peter and George Garnett. “National Association of EMS Physicians Clinical Guidelines for Delayed/Prolonged Transport Dislocations.” Prehospital and Disaster Medicine Vol. 8 No. 1 Jan.-Mar. 1993: 77-80. Schimelpfenig, Tod and Linda Lindsey. “Fractures and Dislocations.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 5. Specific Protocols for Wilderness EMS Dislocations. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 < http://www.wemsi.org/specific.html> Tilton, Buck. “Dislocations.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 13. “Joint Dislocations.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 3-64. Wilderness Field Protocols Protocol 5 Joint Dislocations. 200 Wilderness Medical Associates. 2 Dec. 2004 <http://www.wildmed.com/field_protocols/joint_dis_protocol05.01.html top> 11 Auerbach, Paul S. “The Eye in the Wilderness.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter22. Auerbach, Paul S. “Dental and Facial Emergencies.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter23. Forgey, William. “Wilderness Eye Injuries.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 9. “General Symptoms.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 3-1. Schimelpfenig, Tod and Linda Lindsey. “Head, Spinal Cord and Eye Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 6. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Common Simple Medical Problems.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 31. Wilkerson, James A. “Eye, Ear Nose, and Throat Disorders.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 17. 12 Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Genitourinary.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-87. “Gynecological Problems.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 337. Schimelpfenig, Tod and Linda Lindsey. “Gender-Specific Medical Concerns.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 16. Specific Protocols for Wilderness EMS Urinary Tract Infection. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Gender-Specific Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 32. Wilkerson, James A. “Genitourinary Disorders.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 18. 13 “General Symptoms.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 3-1. “Respiratory.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-10. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Common Simple Medical Problems.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 31. Wilkerson, James A. “Eye, Ear Nose, and Throat Disorders.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 17. 14 Emergency Medical Technician-Basic: National Standard Curriculum Module 5 Trauma. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Forgey, William. “Head Injury.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 4. McCrory, Paul R. and Karen M. Johnston. “Acute Clinical Symptoms of Concussion Assessing Prognostic Significance.” The Physician and Sportsmedicine Vol. 30 No. 8 August 2002. “Head Trauma.” PHTLS Basic and Advanced Prehospital Trauma Life Support. St. Louis, Missouri: Mosby, 200 Chapter 8. Schimelpfenig, Tod and Linda Lindsey. “Head, Spinal Cord and Eye Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 6. Tilton, Buck. “Head Injuries.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter Wilkerson, James A. “ Head and Neck Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 16. 15 Auerbach, Paul S. “Clinical Management of Heat-Related Illnesses.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 11. Backer, Howard D., Ellen Shopes and Sherrie L. Collins. “Hyponatremia in Recreational Hikers in Grand Canyon National Park.” Journal of Wilderness Medicine: Vol. 4, No. 4, 1993: 391–406. Bouchama, Abderrezak and James P. K Nochel. “Heat Stroke.” The New England Journal of Medicine Vol. 346, No. 25 June 20, 2002: 1978-1988. Casa, Douglas J., Lawrence E. Armstrong, Susan K. Hillman, Scott J. Montain, Ralph V. Reiff, Brent S.E. Rich, William O. Roberts, and Jennifer A. Stone. “National Athletic Trainers’ Association Position Statement: Fluid Replacement for Athletes.” Journal of Athletic Training Vol. 35, No. 2 June 2000:212–224. Forgey, William. “Heat-Related Illnesses.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 13. Schimelpfenig, Tod and Linda Lindsey. “Heat Illness.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 10. Stewart, Charles E. “The Spectrum of Heat Illness.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 1. Tilton, Buck. “Heat-Induced Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 17. Wilkerson, James A. “Heat and Solar Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 24. 16 Auerbach, Paul S. “Accidental Hypothermia.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 6. Forgey, William. “Hypothermia.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 11. Giesbrecht, Gordon G. “Prehospital Treatment of Hypothermia.” Wilderness and Environmental Medicine 12 2001: 24-31. Schimelpfenig, Tod and Linda Lindsey. “Cold Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 9. State of Alaska Cold Injuries and Cold Water Near Drowning Guidelines. Revision 01/9 Hypothermia Prevention, Recognition and Treatment. Articles, Protocols and Research on Life-saving skills. 27 Dec. 200 <http://www.hypothermia.org/protocol.htm> Stewart, Charles E. “Generalized Hypothermia.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 4. Tilton, Buck. “Cold-Induced Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 16. Wilkerson, James A. “Cold Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 23. Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) Auerbach, Paul S. “Lightning Injuries.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 3. Forgey, William. “Lightning Injuries.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 14. Gookin, John. “NOLS Backcountry Lightning Safety Guidelines.” Lander, Wyoming: The National Outdoor Leadership School, 2000. Schimelpfenig, Tod and Linda Lindsey. “Burns and Lightning Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 4. Stewart, Charles E. “Electrical Injuries.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 9. Tilton, Buck. “Lightning.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 20. 18 Auerbach, Paul S. “Nonfreezing Cold Injuries.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 5. Auerbach, Paul S. “Frostbite.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 7. Forgey, William. “Frostbite and Immersion Foot.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 12. Schimelpfenig, Tod and Linda Lindsey. “Cold Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 9. State of Alaska Cold Injuries and Cold Water Near Drowning Guidelines. Revision 01/9 Hypothermia Prevention, Recognition and Treatment. Articles, Protocols and Research on Life-saving skills. 27 Dec. 200 <http://www.hypothermia.org/protocol.htm> Stewart, Charles E. “Frostbite and Cold Injuries.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 3. Tilton, Buck. “Cold-Induced Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 16. Wilkerson, James A. “Cold Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 23. Wilkerson, James A., Cameron C. Bangs and John S. Hayward. “Frostbite.” Hypothermia Frostbite and Other Cold Injuries. Seattle, Washington: The Mountaineers, 198 Chapter 7. Wilkerson, James A., Cameron C. Bangs and John S. Hayward. “Other Localized Cold Injuries.” Hypothermia Frostbite and Other Cold Injuries. Seattle, Washington: The Mountaineers, 198 Chapter 8. 19 Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Genitourinary.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-87. “Male Genital Problems.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 377. Schimelpfenig, Tod and Linda Lindsey. “Gender-Specific Medical Concerns.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 16. Specific Protocols for Wilderness EMS Testicular Pain. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Gender-Specific Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 32. Wilkerson, James A. “Genitourinary Disorders.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 18. 20 Auerbach, Paul S. “Orthopedics.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 21. Emergency Medical Technician-Basic: National Standard Curriculum Module 5 Trauma. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Forgey, William. “Orthopedic Injuries.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 8. “Musculoskeletal Trauma.” PHTLS Basic and Advanced Prehospital Trauma Life Support. St. Louis, Missouri: Mosby, 200 Chapter 10. Schimelpfenig, Tod and Linda Lindsey. “Athletic Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 15. Schimelpfenig, Tod and Linda Lindsey. “Fractures and Dislocations.” Wilderness First Aid. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 5. Tilton, Buck. “Athletic Injuries.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 14. Tilton, Buck. “Fractures.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 12. 21 ACLS Provider Manual. Dallas, Texas: American Heart Association, 2002. BLS for Healthcare Providers. Dallas, Texas: American Heart Association, 2002. Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Schimelpfenig, Tod and Linda Lindsey. “Respiratory and Cardiac Emergencies, Seizures, Diabetes and Unconscious States.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 18. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Neurological Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 25. 22 Auerbach, Paul S. “Toxic Plant Ingestions.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 48. Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Forgey, William. “Botanical Encounters.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 17. Keyes, Linda E., Robert S. Hamilton, and John S. Rose. “Carbon Monoxide Exposure from Cooking in Snow Caves at High Altitude.” Wilderness and Environmental Medicine, 12, 2001: 208-212. Schimelpfenig, Tod and Linda Lindsey. “Poisons, Stings, and Bites.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 11. Stewart, Charles E. “Plants That Poison.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 8. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Poisoning Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 27. 23 Busse, William W. and Robert F. Lemanske. Jr. “Asthma.” New England Journal of Medicine Vol. 344, No. 5 February 1, 2001: 350-362. Emergency Medical Technician-Basic: National Standard Curriculum Module 4 Medical/Behavioral Emergencies and Obstetrics/Gynecology. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Respiratory.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-10. Schimelpfenig, Tod and Linda Lindsey. “Respiratory and Cardiac Emergencies, Seizures, Diabetes and Unconscious States.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 18. Specific Protocols for Wilderness EMS Asthma. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Respiratory Emergencies.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 24. Wilderness Field Protocols Protocol 6 Severe Asthma. 200 Wilderness Medical Associates. 2 Dec. 2004 <http://www.wildmed.com/field_protocols/joint_dis_protocol05.01.html top> Wilkerson, James A. “Respiratory Disorders.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 10. 24 Emergency Medical Technician-Basic: National Standard Curriculum Module 5 Trauma. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> “Shock and Fluid Resuscitation.” PHTLS Basic and Advanced Prehospital Trauma Life Support. St. Louis, Missouri: Mosby, 200 Chapter 6. Schimelpfenig, Tod and Linda Lindsey. “Shock.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 2. Tilton, Buck. “Shock.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 7. 25 Auerbach, Paul S. “Plant-Induced Dermatitis.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 47. “Skin.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton NewMedia, 200 4-38. 17 Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016. Page HMI Backcountry Medical Treatment and Evacuation Protocols (Feb 2016 Edition) Stewart, Charles E. “Plants That Poison.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 8. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Common Simple Medical Problems.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 31. Wilkerson, James A. “Allergies.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 20. 26 Auerbach, Paul S. “North American Venomous Reptile Bites.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 38. Forgey, William. “Reptile Envenomations.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 20. Gold, Barry S., Richard C. Dart and Robert A. Barish. “Bites of Venomous Snakes.” New England Journal of Medicine Vol. 347, No. 5, August 1, 2002: 347-356. Russell, Findlay E. Snake Venom Poisoning. Great Neck, New York: Scholium International Inc., 1983. Schimelpfenig, Tod and Linda Lindsey. “Poisons, Stings, and Bites.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 11. Stewart, Charles E. “Bites and Stings.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 7. Tilton, Buck. “North American Bites and Stings.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 21. Wilkerson, James A. “Animal Bites and Stings.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 25. 27 Auerbach, Paul S. “Spider Bites.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 34. Auerbach, Paul S. “Scorpion Envenomation.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 35. Forgey, William. “Arthropod Envenomations.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 21. MMWR Weekly 45 (21) May 31, 1996: 433-43 “Necrotic Arachnidism -- Pacific Northwest, 1988-1996.” Centers for Disease Control and Prevention. 27 Dec. 200 <http://www.cdc.gov/mmwr/preview/mmwrhtml/00042059.htm> Schimelpfenig, Tod and Linda Lindsey. “Poisons, Stings, and Bites.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 11. Stewart, Charles E. “Bites and Stings.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 7. Tilton, Buck. “North American Bites and Stings.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 21. Wilkerson, James A. “Animal Bites and Stings.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 25. 28 Emergency Medical Technician-Basic: National Standard Curriculum Module 5 Trauma. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Domeier R. M. “Position Paper, National Association of EMS Physicians: Indications for prehospital spinal immobilization.” Prehospital Emergency Care 3(3) 1999: 251–253. Forgey, William. “Spinal Injury.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 5. Hoffman J. R. and W. R. Mower. “Out-of-hospital cervical spine immobilization: Making policy in the absence of definitive information.” Annals of Emergency Medicine 37 June 2001: 632–634. “Spinal Trauma.” PHTLS Basic and Advanced Prehospital Trauma Life Support. St. Louis, Missouri: Mosby, 200 Chapter 9. Schimelpfenig, Tod and Linda Lindsey. “Head, Spinal Cord and Eye Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 6. Tilton, Buck. “Spine Injuries.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 8. Wilderness Field Protocols Protocol 4 Spine Injuries. 200 Wilderness Medical Associates. 2 Dec. 200 <http://www.wildmed.com/field_protocols/spine_man_protocol05.01.html top> Wilkerson, James A. “ Head and Neck Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 16. ACLS Provider Manual. Dallas, Texas: American Heart Association, 2002. Auerbach, Paul S. “Submersion Incidents.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 56. Forgey, William. “Submersion Injuries.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 3. Harries, Mark. “ABC of resuscitation Near drowning.” BMJ Vol. 327 6 Dec. 2003: 1336-1338. Schimelpfenig, Tod and Linda Lindsey. “Cold Water Immersion and Drowning.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 13. State of Alaska Cold Injuries and Cold Water Near Drowning Guidelines. Revision 01/9 Hypothermia Prevention, Recognition and Treatment. Articles, Protocols and Research on Life-saving skills. 27 Dec. 200 <http://www.hypothermia.org/protocol.htm> Stewart, Charles E. “Near-Drowning.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 11. Tilton, Buck. “Immersion and Submersion Incidents.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 19. 30 Emergency Medical Technician-Basic: National Standard Curriculum Module 5 Trauma. 22 June 199 National Highway Traffic Safety Administration United States Department of Transportation. 2 Dec 200 <www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd> Goth, Peter and George Garnett. “National Association of EMS Physicians Clinical Guidelines for Delayed or Prolonged Transport Wounds.” Prehospital and Disaster Medicine Vol. 8 No. 3 July-Sep. 1993: 253-255. Forgey, William. “Wilderness Wound Managment.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 6. Schimelpfenig, Tod and Linda Lindsey. “Soft Tissue Injuries.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 3. Specific Protocols for Wilderness EMS Wounds. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 < http://www.wemsi.org/specific.html> The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “Wilderness Wound Mangament.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 15. Wilderness Field Protocols Protocol 2 Wound Managament. 200 Wilderness Medical Associates. 2 Dec. 200 <http://www.wildmed.com/field_protocols/spine_man_protocol05.01.html top> Wilkerson, James A. “Soft-Tissue Injuries.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 6. 31 Auerbach, Paul S. “Tick-Borne Diseases.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 33. Auerbach, Paul S. “Wilderness-Acquired Zoonoses.” Wilderness Medicine 4th ed. St. Louis, Missouri: Mosby, 200 Chapter 44. Forgey, William. “Tick-Transmitted Diseases.” Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 22. “Infectious Diseases.” United States Special Operations Command. Special Operations Forces Medical Handbook. Jackson, Wyoming: Teton New Media, 200 Chapter 13, 5-33. Schimelpfenig, Tod and Linda Lindsey. “Poisons, Stings, and Bites.” Wilderness First Aid 3rd ed. Mechanicsburg, Pennsylvania: Stackpole Books, 200 Chapter 11. Specific Protocols for Wilderness EMS Rabies. Version 1.2 May 19, 199 The Wilderness Emergency Medical Services Institute. 2 Dec. 200 <http://www.wemsi.org/specific.html> Stewart, Charles E. “Bites and Stings.” Environmental Emergencies. Baltimore, Maryland: Williams & Wilkins, 199 Chapter 7. The Merck Manual 16th Edition. Rathaway, New Jersey: Merck & Co., Inc., 1992. Tilton, Buck. “North American Bites and Stings.” Wilderness First Responder 2nd ed. Guilford, Connecticut: The Globe Pequot Press, 200 Chapter 21. Wilkerson, James A. “Animal Bites and Stings.” Medicine for Mountaineering 5th ed. Seattle, Washington: The Mountaineers Books, 200 Chapter 25. Wilkerson, James A. “Rabies Update.” Wilderness And Environmental Medicine: Vol. 11, No. 1, 2000: 31–39. Medication Kit 29 Wilderness Medicine Institute of NOLS Wilderness Medicine Protocol Package © Modified with Permission by HMI. High Mountain Institute©2016.