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

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Wilderness and Rescue Medicine

It is important to remember that ASR can coex- ist with shock. In cases where the patient has both a mechanism of injury for true shock and the signs and symptoms to go with it, you must treat it as such. Within a short time, ASR will improve; shock will not. Field Treatment of ASR Allowing the patient to lie down, providing calm reassurance, and relieving pain should result in immediate improvement in symptoms. Note that this is the traditional treatment for shock described in many first aid texts. In the ambulance setting, the difference between ASR and shock is less important because both are managed as shock during the short period of treatment and trans- port. For long-term management in the remote setting, recognizing ASR for what it is can save a lot of resources and risk, not to mention your peace of mind. Risk Versus Benefit in Shock Shock is a serious critical system problem that will kill the patient if it is not corrected. The ide- al treatment is evacuation to definitive medical care, but in the wilderness or offshore setting, it is reasonable to anticipate improvement with treat- ment on scene when the mechanism is reversible. Dehydration and anaphylaxis are the most obvi- ous examples. Care may be definitive and evacu- ation unnecessary.

Cases where you cannot reverse the progression of shock, such as internal bleeding or heart attack, may be worth a high-risk evacuation, but beware of committing to a process during which you will be unable to maintain oxygenation, perfusion, and body core temperature. You must balance the risks associated with an unstable evacuation against the benefits of moving fast. A desperate sprint for the hospital is one option, but rarely the best. Critical thinking about a critical system injury in a difficult and dangerous place requires time and effort. Consider stabilizing and protecting the patient on scene while advanced care is brought to you. Consider a slower carry out during which bleeding can be monitored and controlled rather than risking loss of control during a helicopter hoist. Remember that a cold patient has a much lower chance of surviving shock. Consider the possibility that even a severely injured patient may have a better chance of sur- vival by remaining aboard the boat rather than being dunked in the ocean during a difficult extri- cation at sea. And, finally, remember that most people live.

General Principles

Shock

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Wilderness Perspective

High-Risk Problem: • Cannot stop fluid loss • Cannot replace fluids • Persistent chest pain • Coexisting major problems

• Cannot maintain body core temperature • Persistent s/sx of shock despite treatment

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