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

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Wilderness and Rescue Medicine

Nonsteroidal drugs like ibuprofen do not significantly affect brain function. The patient remains awake and functional, which is a distinct advantage in a hazardous setting. Another advan- tage is that the best NSAIDs are widely available without prescription. For these reasons, NSAIDs are the first-line medication for the treatment of pain, inflammation, and fever in most backcoun- try situations. Just be sure to maintain adequate hydration to prevent kidney damage when using NSAIDs.

respond to pain impulses from the site of injury. Unfortunately, opioids depress other brain func- tion as well. Side effects include increased reaction time, drowsiness, and depressed respiratory drive. Opioids also reduce gut motility causing consti- pation, and suppress shivering which can make it difficult to maintain body core temperature in cold weather. In some wilderness and rescue situ- ations these side effects may be unacceptable. Despite these disadvantages opioids are often the best choice for severe pain if the patient can be monitored and protected. In most of the world opioids are controlled substances and should be used only under the guidance of a medical practi- tioner. This would be a good reason for basic level personnel to call for advanced life support (ALS) help on scene or to meet an evacuation underway. For backcountry use, opioids are most eas- ily administered orally and usually combined with an NSAIDs or acetaminophen in a single tablet. Vicodin, for example, is a brand name for a combination of hydrocodone and acetamino- phen. Vicoprofen is hydrocodone combined with ibuprofen. Percocet is oxycodone combined with acetaminophen. If basic level practitioners are authorized to use opioids in the field, it will likely be this type of medication. To avoid an overdose be sure that you know what you are dispensing, and what medications your patient is already using. Many cold and flu preparations also contain acetaminophen or an NSAID. To avoid liver damage, do not exceed a total acetaminophen dose of 3000 mg per day for an adult. Many other drugs like alcohol and antihistamines are also respiratory depressants, so beware of the effects when combined with an opioid. Anesthetics, or “numbing agents” (like lido- caine and bupivacaine), relieve pain by block- ing the function of nerve cells. They are injected into joints, fracture sites, and wounds to block the pain of local injury or for doing procedures. Hematoma block (injection into a fracture site) and wound infiltration are relatively safe and easy for trained personnel to perform and can make a big difference in the comfort and effectiveness of treatment. Even topical preparations such as

General Principles

Alternating Dose For Moderate Pain

1200 hours: ibuprofen 400mg 1500 hours: acetaminophen 500mg 1800 hours: ibuprofen 400mg 2100 hours: acetaminophen 500mg 0000 hours: ibuprofen 400mg 0300 hours: acetaminophen 500 mg Continue as needed… Time Dose

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The primary side effects of NSAIDs include stomach irritation and increased bleeding. These drugs may not be a good choice for someone with nausea from sea sickness, or for a patient where life-threatening bleeding is an anticipated problem. A better non-opioid analgesic for these patients would be acetaminophen. Like NSAIDs, acetaminophen provides good pain relief and fever reduction. Unlike NSAIDs, it tends not to cause stomach upset or increased bleeding. Acetaminophen, however, does not have sig- nificant anti-inflammatory effects and will not help reduce swelling or tissue damage caused by inflammation. Carrying both an NSAID like ibuprofen, and acetaminophen, offers the opportunity to com- bine the two. The effect is synergistic and is a very good way to manage moderate pain with minimal side effects. The dose can be alternated to keep the blood level of at least one of the medications above therapeutic levels at all times. Unlike NSAIDS and acetaminophen, opioids relieve pain by reducing the brain’s ability to