Med Protocol - Crested Butte Search & Rescue

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Crested Butte Search and Rescue

Wilderness Medical Protocols


Purpose


These protocols have been developed for use by appropriately trained members
of The Crested Butte Search and Rescue Team operating during official SAR
missions. They are adapted from th
e field protocols of Wilderness Medical
Associates, Inc..


General Authorization Criteria


Current certification in these specific procedures at the Wilderness First
Responder (WFR), or Wilderness Emergency Medical Technician (WEMT) level
through training

programs conducted by Wilderness Medical Associates, The
Wilderness Medicine Institute, or SOLO. Similar certification by other training
organizations will be considered by the Board and the Medical Advisor or her
designee on a case
-
by
-
case basis.


OR


Cu
rrent EMT certification and attendance and satisfactory performance at a
protocol specific training session approved by the Medical Advisor. This route is
intended for use only by experienced CBSAR members with the approval of the
Board, and will be availa
ble for a period of one year from the date of approval of
these protocols by the Board.


AND


Operating in a Wilderness Context: A situation in which evacuation to definitive
medical care will exceed two hours from the time of injury, or where evacuation
w
ithout the application of these protocols will be unreasonably difficult or
dangerous to perform, or where immediate, life saving, treatment is necessary.


Documentation


Any use of these protocols will be documented in standard medical format and
submit
ted to the Medical Advisor for review.


_______________________________________ Medical Advisor



________________________________________ For the Board of Directors

Crested Butte Search and Rescue

Wilderness Medical Protocols


Protocol 1:

Anaphylaxis


Anaphylaxis is an allergic reaction that has life
-
threatening effects on the major
body systems. It can be caused by foreign material ingested, injected, inhaled,
or absorbed. Early recognition and prompt treatment, particularly in a wilderness
setting, is

essential to preserve life.


Symptoms include; hives, generalized itching, facial swelling, shortness of
breath, weakness, and in severe cases, airway obstruction and shock.
Epinephrine is used only in patients having acute systemic (generalized)
sympto
ms. Epinephrine is not used to treat local allergic reactions, such as a
swollen arm from a bee sting.


1.

Maintain open airway, PPV if necessary, position of comfort. CPR if necessary.

2.

Inject 0.3 ml of 1/1000 epinephrine intramuscularly into the lateral asp
ect
deltoid muscle or anterior thigh. (Dose is 0.005ml/lb of body weight if under
60#).

3.

Repeat injections every 5 minutes if condition worsens or every 15 minutes if
condition does not improve, for a total of three doses.

4.

Administer 50


100 mg of diphenhy
dramine by mouth, or 50 mg IM as soon
as possible. May be repeated every 6 hours if necessary.

5.

Evacuate to medical care.

6.

Rebound reactions should be treated in the same manner as the original
reaction.


Authorization Criteria:

General and CBEMS EMT I, Par
amedic



Crested Butte Search and Rescue

Wilderness Medical Protocols


Protocol 1a: Severe Asthma


Asthma is a condition causing respiratory distress secondary to lower airway
constriction. Patients often have an inhaled bronchodilator (eg: albuterol)
p
rescribed, which they use regularly or as needed. Occasionally, the inhaler is
not available or is ineffective leading to severe respiratory distress and hypoxia.
Early recognition and prompt treatment, particularly in a wilderness setting, is
essential t
o preserve life.


Symptoms include; shortness of breath, weakness, cyanosis, altered mental
status, and wheezing. Patient will report history of asthma.


1.

Maintain open airway, PPV if necessary, position of comfort. Oxygen.

2.

Assist patient in using own in
haler if not already tried.

3.

Inject 0.3 ml of 1/1000 epinephrine intramuscularly (adult epi
-
pen) into
the lateral aspect deltoid muscle or anterior thigh. (Dose is 0.005ml/lb of
body weight if under 60#
-

or pediatric epi
-
pen).

4.

Repeat injections every 5 mi
nutes if condition worsens or every 15
minutes if condition does not improve, for a total of three doses.

5.

Evacuate to medical care.

6.

Rebound exacerbations should be treated in the same manner as the
original reaction.


Authorization Criteria:

General and C
BEMS EMT I, Paramedic


Protocol 2:

Wound Management


In the management of all wounds, bleeding must be controlled using well
-
aimed
direct pressure with whatever means are necessary. Control of severe bleeding is
a higher priority than wound cleaning. Once

bleeding has been controlled:


Open Wounds


1.

Remove foreign material as completely as possible.

2.

Wash the surrounding skin with soap and water, and/or dress skin with
betadine.

3.

Irrigate the wound with copious amounts of clean water (drinking quality, at
lea
st).

4.

Highly contaminated wounds should be irrigated with and covered by a
bandage soaked in a 1% povidine iodine solution (iodine diluted to look like
weak iced tea).

5.

Cover the wound with sterile bandage and immobilize the wound area if
possible. Splint i
f necessary. Do not close the wound with tape or sutures.

6.

Change the bandage and clean the wound at least every 24 hours.

7.

Facilitate drainage of all infected wounds.

8.

Assess the need for tetanus and rabies prophylaxis. High
-
risk wounds
required tetanus prop
hylaxis every five, all others can go ten years.

9.

If the wound was the result of an animal bite, assess the risk of rabies
exposure from animal bites varies by geographic location.


Shallow Wounds (Abrasions and Burns)


1.

Cleanse the wound with soap and dri
nking quality water.

2.

Apply antibacterial ointment and cover with sterile bandage. Immobilize
wound area if possible.

3.

Inspect and clean the wound at least daily.


Impaled Objects


1.

Remove impaled objects only when they interfere with safe transport or
canno
t be effectively stabilized, and only if the removal can be done safely
and easily. Do not remove impaled objects that may have penetrated the
skull.

2.

Treat as with any open wound.


Authorization Criteria:

General.


Protocol 3:

Cardiopulmonary Resuscitat
ion (CPR)


This protocol applies only to normothermic patients (core temperature > 90F) in
cardiac arrest.


Blunt Trauma


Cardiac arrest which is obviously the result of massive blunt trauma or severe
blood loss will not benefit from CPR, and resuscitatio
n should not be initiated.


Other Mechanisms



Assess and treat according to standard CPR protocols. If cardiac arrest persists
continuously over 30 minutes of sustained CPR, treatment may be stopped.


Authorization Criteria
: General.
Protocol 4:

Spine Inj
uries


In a wilderness context, clearing a potential spine injury when there is a positive
mechanism for such an injury requires careful evaluation that focuses on patient
reliability, nervous system function, and spinal column stability. Adequate time
mus
t be allowed for the evaluation. Repeat examinations may be necessary.


1.

Assess for mechanism of spine injury. If positive or uncertain mechanism
exists, protect the spine in the in
-
line position.

2.

Do a thorough evaluation including history and examination.

To rule out a
spine injury in the presence of a positive or uncertain mechanism:

a.

The patient must be reliable, calm, cooperative, sober, and alert, and free
of distracting injuries significant enough to mask the pain and tenderness
of a spine injury.

b.

The

patient must be free of spine pain and tenderness to exam.

c.

The patient must have a normal motor/sensory exam in all four
extremities including:


-

Finger abduction and hand extension

-

Foot plantar flexion and foot or great toe dorsiflexion

-

Normal sensation
to light touch in all four extremities

-

If reduced function in one extremity can be attributed with certainty to
a condition unrelated to the spine (e.g. wrist fracture), that deficit
alone will not preclude ruling out a spine injury.


3.

If a spine injury can
not be ruled out, the patient should be fully immobilized
except that, in patients with isolated lumber spine injury in the wilderness
context, the neck may be left free.


Note 1: A patient who is immobilized due to an unreliable exam or questionable

findings, may be examined later during the evacuation process, and cleared, if
the evaluation is now reliable and findings are negative.


Note 2: A patient who has been properly cleared, and later develops neck pain in
the absence of additional traum
a, does not need immobilization. It may be
assumed that the development of pain is the result of the normal inflammatory
process of minor injury.


Authorization Criteria:

General

Protocol 5: Joint Dislocations


This protocol specifically applies to simp
le dislocations of the shoulder, patella,
and digits resulting from indirect force; all other potential dislocations should be
treated as any other unstable joint injury (splint in a position that maintains
stability and neurovascular function while facili
tating transport).


Shoulder:

1.

Check and document distal neurovascular function including sensation
over the deltoid region of the injured arm.

2.

With the patient supine, and while sitting adjacent to the dislocated
shoulder, apply gentle traction to the arm

while slowly abducting and
externally rotating the arm until it is at approximately 90 degrees to the
patient’s body (baseball position). Maintain traction in this position until
the dislocation has been reduced. This may take 20 minutes. Pause the
proces
s if pain increases or significant resistance is met. Discontinue the
process if pain or resistance persists over several attempts.

3.

Once either the dislocation is reduced or the rescuer decides to abort the
process, the arm should be returned to the positi
on across the body and
splinted with a sling and swathe.

4.

Check and document distal neurovascular status.

5.

Transport to medical care.


Patella:

1.

Check and document distal neurovascular status.

2.

Gently straighten the patient’s knee while flexing the hip. If t
he patella
does not reduce spontaneously, gently guide the patella medially into its
normal anatomic position.

3.

Splint the knee in the position of comfort.

4.

Check and document distal neurovascular status.

5.

Transport to medical care.


Digits:

1.

Check and documen
t distal neurovascular status.

2.

Apply axial traction until the dislocation has been reduced.

3.

Splint in position of comfort.

4.

Check and document distal neurovascular status.

5.

Transport to medical care.


Authorization Criteria:

General.




Protocol 6: Nifedi
pine and High Altitude Pulmonary Edema


High Altitude Pulmonary Edema is thought to be the result of hypoxia
-
induced
vasoconstriction in parts of the pulmonary circulation, causing a reflex pulmonary
hypertension in the unaffected areas of the lung. This h
ypertension causes
capillary dilation and leakage, producing the characteristic patchy pulmonary
infiltrates. The net result is less alveolar surface for gas exchange, and thus,
respiratory distress. Nifedipine, often used to control high blood pressure,
r
educes the vasoconstriction, reducing the development of edema. Its effects are
almost immediate. Contraindications include; myocardial infarction and profound
hypotension.


Diagnosis of HAPE

-

Recent arrival at altitude (generally within past 7 days).

-

Respi
ratory distress with cough and rales.

-

Cough may be productive of white or pink sputum.

-

HAPE can cause fever and chest pain.

-

HAPE can coexist with respiratory infection.

-

HAPE can develop in persons with previous uneventful altitude
experience.


BLS Treatme
nt of HAPE

-

High flow oxygen by nrb. Use low flow with cannula if oxygen supply is
limited and evacuation is long.

-

PPV if necessary to maintain oxygenation.

-

Position of comfort


do not force patient to lie down.

-

Immediate descent of 1500


2000 feet.


Indi
cations for Nifedipine

-

Obvious respiratory distress due to HAPE.

-

Immediate descent not possible (within minutes).

-

Systolic BP > 100.

-

Minimal suspicion of myocardial infarction.


Use of Nifedipine

-

Contact Lee Lynch, MD or Jeff Isaac, PA
-
C if possible.

-

Give
one 10 mg capsule sub
-
lingual by breaking it open and squirting
the contents into the patient’s mouth. Have them rub it around the
inside of the lips and cheeks.

-

Immediately give a second capsule, unbroken, to be swallowed.

-

Continue BLS support and evacu
ate to the hospital.


Authorization Criteria:
WFR, EMT, and above, after completing specific CBSAR
training by the Medical Advisor or her designee.