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

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Wilderness and Rescue Medicine

of acute stress reaction, however, it gets better with time, reassurance, and pain control. Telling the patient that hyperventilation is the cause of his or her symptoms almost always cures it. Decreased nervous system drive is less common, but more serious. If the brain is not functioning correctly, breathing may be irregular or slow. If the brain stops working, breathing will stop. The possible causes include low blood sugar, hypo- thermia, and toxins. The symptoms present in marked contrast to the other forms of respira- tory distress. Decreased nervous system drive is not noisy or fast. Because the patient is already V, P, or U on the AVPU scale mental status is no longer a reli- able indicator of oxygenation and perfusion. The patient is not awake enough to tell you that he or she is having trouble breathing. You won’t see it unless you look for it. Observing skin color or measuring oxygen saturation may help. Any injured or ill person with inadequate respi- ration and reduced level of consciousness needs positive pressure ventilation and oxygen. Do not be timid about this. PPV carries a very low risk of causing harm and provides great benefit. Risk Versus Benefit As with shock, the ideal treatment for respira- tory distress is evacuation to definitive medical care. In the wilderness or offshore setting where evacuation may be impossible or involve a high level of risk, field treatment may be prolonged. In some situations, such as with asthma, anaphy- laxis, or airway obstruction, field treatment may be definitive. Your worry list includes situations in which you cannot reverse the progression of respiratory dis- tress or signs and symptoms that indicate a poor response to treatment. These cases may be worth a high-risk evacuation or an attempt to bring advanced-level care to the patient. The balance of risk versus benefit will depend on the situation and on the experience and skill of the practitioner making the judgment.

Respiratory Distress Wilderness Perspective

General Principles

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High-Risk Problem: • Cannot improve respiratory status • Persistent altered mental status • Coexisting major problems • Cyanosis • Cannot maintain body temperature • Cannot maintain hydration and calories • The patient is getting worse

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“These cases may be worth a high risk evacuation or an attempt to bring advanced level care to the patient.”

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