Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

Section VI: Backcountry Medicine 207

can irritate the gut. If opioids are available, inject- able medication is preferred. Pain medication should not be withheld in the belief that it will mask serious symptoms or inhibit diagnosis in the emergency room. Abdominal pain labeled as not serious can be treated symptomatically with due attention to hydration and calories. To avoid further irritat- ing the gut, the patient should still avoid NSAIDs. Acetaminophen would be a better choice. Gut soothers like bismuth subsalicylate and antacids are generally safe. Food should be restricted to eas- ily digested carbohydrates and sugars. Vomiting and diarrhea can be treated with antiemetics like meclizine or diphenhydramine and with mild opioid antispasmodics like loperamide, provid- ed there are no signs of bacterial infection. The patient should be frequently monitored for the development of peritoneal signs or dehydration.

been learned by the use of sophisticated imaging over the past three decades: a lot of people survive serious abdominal injury and illness without sur- gery. Doctors have been able to monitor a bleed- ing spleen or liver and operate only if necessary to save the patient’s life. Infection can be evaluated and monitored for response to antibiotics before surgery is performed. To those of us in the field, this means that a patient with a serious condition may well survive if we pay attention to good basic life support (BLS), hydration, and calories. Remote expeditions and offshore sailors should carry antibiotics useful in intra-abdominal infec- tion as well as tools for hydration and pain control. The benefit of good basic treatment on site may well outweigh the risk associated with a desperate evacuation to what may be inadequate medical care somewhere else.

General Principles

Serious Abdominal Pain

Anticipate: • Volume shock • Systemic infection Treatment: • Maintain hydration • Maintain body core temperature • Restrict foods to easily absorbed sugars • Emergency evacuation

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Risk Versus Benefit Although the evolution of CT, MRI, and ultra- sound has vastly improved the diagnosis of abdominal problems in the hospital setting, lit- tle has changed for the practitioner in the field. Assessment still depends on a good history, care- ful exam, and a few simple diagnostic tools like a stethoscope and thermometer. Fortunately, peri- toneal signs are relatively easy to identify and gen- erally become steadily worse as you monitor your patient. The outcome is usually poor and probably worth a high-risk evacuation. If evacuation is unavailable or exceptionally dangerous, you can take some comfort in what has