{"title":"Cervical spine management in the wilderness: can we trust our clinical exam?","authors":"Eric Weiss MD","doi":"10.1580/0953-9859-5.2.187","DOIUrl":"10.1580/0953-9859-5.2.187","url":null,"abstract":"The case report by Levitan, 'Occult cervical spine fracture in a wilderness setting' which appears in this issue of the Journal of Wilderness Medicine deals with a current area of controversy. Dr Levitan's article provides another example of the growing body of literature questioning our ability to predict clinically which patients will have an unstable cervical spine injury. Nowhere is this controversy more poignant than in the wilderness, where rescue and evacuation can be arduous when there is a particular need to maintain spine immobilization. In wilderness medicine, as in urban medicine, the indications for placing a victim in cervical spine immobilization pending radiographic analysis include complaints of neck or back pain, neurologic symptoms such as paresthesias, a positive physical examination including pain on palpation of the neck or neurologic signs, or a patient who is intoxicated who also has an altered mental state with a significant mechanism of injury [1-4]. Occult cervical spine injury has been defined previously as a cervical injury in the alert, cooperative, non-intoxicated patient without associated signs or symptoms on exam [5-6]. Several retrospective published reports and anecdotal cases of occult cervical spine fractures have led to a widespread ordering of cervical spine radiographs and a reluctance by physicians to clear the spine clinically. If the presence of a painful, distracting injury away from the neck were to be added as an exclusion factor, then all of the published reports claiming to have identified an occult cervical spine fracture could be criticized for not meeting strict criteria. The \"occult cervical spine fracture\" described by Bresler and Rich [7] occurred in a woman who was drinking alcohol and who had a painful fracture of her radius and ulna. Her neck was also mildly tender to palpation. McKee et al. [8] described an 85-year-old male victim of a motor vehicle accident with multiple rib fractures and an associated hemopneumothorax. Liberman and Maull [9] described an occult cervical spine injury in an intoxicated trauma victim with upper extremity fractures, a renal contusion and a subdural hematoma. Ogden and Dunn [10] reported an occult cervical spine fracture in a 33-year-old woman with bilateral femur fractures and a flail chest. In two cases reported by Haines [11], both patients had either neck pain or paresthesias on presentation. Levitan's report of an occult cervical spine fracture in this issue occurred in a 33-year-old man with bilateral upper extremity fractures and multiple rib fractures. Thus, each of these cases demonstrated signs and symptoms of a cervical spine injury, an altered mental status, or major concomitant distracting injuries. A recent prospective series by Hoffman et al. [12] of 1000 patients undergoing cervical spine radiography following blunt trauma found that all 27 patients with spine fractures had at least one of the following four clinical findings: midline neck te","PeriodicalId":81742,"journal":{"name":"Journal of wilderness medicine","volume":"5 2","pages":"Pages 187-189"},"PeriodicalIF":0.0,"publicationDate":"1994-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1580/0953-9859-5.2.187","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67123724","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"A field survey of the emergency preparedness of wilderness hikers","authors":"Kevin T. Kogut , Lance E. Rodewald MD","doi":"10.1580/0953-9859-5.2.171","DOIUrl":"10.1580/0953-9859-5.2.171","url":null,"abstract":"<div><p>The objective was to describe the health, first aid needs, supplies, and knowledge of wilderness hikers. A cross sectional survey was designed using a structured interview and carried out in Yosemite National Park; July 1991. The subjects were overnight hikers (<em>n</em> = 301) representing 146 groups, spending a minimum of one night at one of nine sites. The average age was 34 years (range 12–84); 63% were male and 37% were female. Of the subjects, 11% had no previous experience and 40% had been on more than ten trips. Over 96% self reported being in excellent or good health; only 10% were smokers. 50% had pre-existing medical conditions requiring additional preparedness; 10% had insect allergies, 6% had asthma. The most common medical problems encountered were insect bites (82%), minor cuts (24%), blisters (24%) and sunburn (22%). Acute mountain sickness (AMS) (6%) and asthma attacks (3%) were the most common serious problems. 6% shortened their current trip due to first aid reasons. Most groups (141 <em>=</em> 99%) had some first aid equipment. On average, groups carried only 48% of the recommended categories of first aid supplies appropriate for their trip duration. The amount of first aid equipment was significantly associated with the maximal score per group on a generalized first aid knowledge test (p < 0.001). 45% had taken at least one first aid course in the last five years; CPR (27%) and basic first aid (20%). 86% desired to learn more wilderness first aid; 85% were willing to take a basic first aid course; 26% felt that proof of first aid knowledge should be required for taking an overnight backpacking trip. Although these wilderness hikers were healthy people, injuries and illnesses requiring first aid attention were common. Current recommendations for minimum first aid supplies were consistent with the medical problems hikers commonly encountered, but groups were not adequately prepared for such situations. Subjects demonstrated considerable knowledge about common first aid topics, while knowledge about injuries with high morbidity and mortality was lacking.</p></div>","PeriodicalId":81742,"journal":{"name":"Journal of wilderness medicine","volume":"5 2","pages":"Pages 171-178"},"PeriodicalIF":0.0,"publicationDate":"1994-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1580/0953-9859-5.2.171","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67123527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"To breathe or not to breathe","authors":"Robert F. Grover MD","doi":"10.1580/0953-9859-5.2.143","DOIUrl":"10.1580/0953-9859-5.2.143","url":null,"abstract":"Anyone who has ever had the misfortune of suffering from Acute Mountain Sickness (AMS) would never question the reality of this affliction. During the first night following rapid ascent to high altitude, being awakened from a restless sleep with a splitting headache, followed by a wave of nausea and perhaps vomiting, is an experience never to be forgotten. Of the millions who visit the mountainous regions of the western United States, approximately one person in four will experience AMS; it is very common. AMS strikes those guilty of \"going too high too fast,\" and \"too high\" is any altitude above 8000 ft (2400 m). In considering the pathogenesis of AMS, the initiating event is unquestionably rapid ascent to high altitude. Unlike decompression sickness in divers, exposure to the decreased atmospheric pressure per se is probably of little consequence at moderate altitude. Rather, it is the associated decrease in the partial pressure of oxygen, i.e., atmospheric hypoxia, that is the culprit. From an evolutionary viewpoint, defenses against hypoxia probably developed to cope with airway obstruction. Impairment of ventilation would result in a fall in airway P02 combined with an increase in airway PC02• The resulting hypoxemia would stimulate the carotid chemoreceptors while, concurrently, hypercapnic acidosis would provide central stimulation. Together, the responses would produce a powerful increase in the effort, to breathe. However, when exposed to atmospheric hypoxia, the respiratory control system is presented with a dilemma. Increased ventilation in response to hypoxemia now lowers airway PC02, and the normal CO2 stimulus is withdrawn, thereby counteracting the hypoxic stimulus. Hence, \"to breathe or not to breathe?\" Those who develop AMS seem to favor the \"not to breathe\" option, for they exhibit less increase in ventilation, i.e., relative hypoventilation, and more severe hypoxemia than do their more fortunate colleagues. Because relative hypoventilation implies not only a greater fall in P02 but also less fall in PC02, the potential role of changes in PC02 in the pathogenesis of AMS should also be considered, as CO2 relates to the way in which the body handles fluid. Recall that one of the earliest responses following ascent to altitude is a rise in hematocrit. This results from removal of water from the plasma, i.e., hemoconcentration, followed by diuresis. The latter accounts in part for the usual loss of body weight at altitude. It has been observed that persons who have a diuresis and lower body weight are less likely to develop AMS [1]. Conversely, persons who gain weight at altitude, i.e., retain fluid, are more prone to develop not only the usual symptoms of AMS but also more serious manifestations, including high altitude pulmonary edema (HAPE) and cerebral edema (HACE). This has led to the concept that altitude illness, in general, reflects abnormal fluid retention, i.e., \"the edemas of altitude\" [2]. Fluid retention appears to be l","PeriodicalId":81742,"journal":{"name":"Journal of wilderness medicine","volume":"5 2","pages":"Pages 143-145"},"PeriodicalIF":0.0,"publicationDate":"1994-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1580/0953-9859-5.2.143","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67123236","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Low altitude sickness","authors":"John E. Simon MD","doi":"10.1580/0953-9859-5.2.229","DOIUrl":"10.1580/0953-9859-5.2.229","url":null,"abstract":"","PeriodicalId":81742,"journal":{"name":"Journal of wilderness medicine","volume":"5 2","pages":"Pages 229-230"},"PeriodicalIF":0.0,"publicationDate":"1994-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1580/0953-9859-5.2.229","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67123474","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"","authors":"","doi":"10.1580/0953-9859-5.2.199","DOIUrl":"https://doi.org/10.1580/0953-9859-5.2.199","url":null,"abstract":"The use ofa thromboxane inhibitor to treat frostbite: The effect ofdelayed presentation after injury Improved tissue survival after frostbite injury has been demonstrated with immediate postinjury use of a thromboxane inhibitor. However, most patients with frostbite injury present to the hospital hours after their injury and the efficacy of thromboxane inhibition at that point is unknown. The current study evaluated the efficacy of a thromboxane inhibitor on frostbite tissue survival when initiated at the time of injury or 4 h postinjury. In a double-blind, prospective study, three groups of nine rabbits received a standardized frostbite injury using a modified Weatherley-White model. A control group received no pharmacologic therapy; the other two groups were treated with 1 mg/kg methimazole orally initiated immediately or 4 h postinjury, respectively. Treatment was given every 8 h for a total of 96 h. Healing was followed until a clear line of demarcation was apparent (10 days). The percentage of viable ear surface area remaining at the end of the study was measured and used to compare the effectiveness of treatments. Analysis of variance was used to determine statistical significance. No significant difference (p = 0.388) was observed among the frostbite injury of the control group and either treatment group. Thirty percent of animals did not reach the study end point secondary to an outbreak of E. coli diarrhea, reducing the study power to a 33% ability to detect a 35% difference in tissue survival. Despite the reduced power, this study questions the efficacy of thromboxane inhibition in improving frostbite tissue survival, whether therapy is initiated immediately or is delayed. These data suggest that further investigation is warranted to determine the role of thromboxane inhibition in the treatment of frostbite injury.","PeriodicalId":81742,"journal":{"name":"Journal of wilderness medicine","volume":"5 2","pages":"Pages 199-204"},"PeriodicalIF":0.0,"publicationDate":"1994-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1580/0953-9859-5.2.199","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"137439421","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Portable hyperbaric medicine, some history","authors":"Claude Dubois , Jean-Pierre Herry , Bengt Kayser","doi":"10.1580/0953-9859-5.2.190","DOIUrl":"10.1580/0953-9859-5.2.190","url":null,"abstract":"<div><p>Since the beginning of this century several portable hyperbaric chambers have been designated for the treatment or prevention of various health problems. The first one was presented in 1919 for the treatment of decompression sickness. Other types were invented to treat allergic disease, to protect from toxic gas in wartime, to transport patients suffering from decompression sickness and to pressurize patients during flight in non-pressurized airplanes. All these chambers have been light enough to be carried and are simple to operate. Since 1979, three portable hyperbaric chambers have been designed specifically for the treatment of altitude sickness. Presently, two of these are frequently used. Working pressures of 104–165 Torr ensure an increase in inspiratory oxygen pressure, significantly increasing oxygen saturation of arterial blood, and as such provide an elegant and inexhaustible means of additional oxygen for patients suffering from altitude sickness. Several studies have reported beneficial effects of pressurization. Portable hyperbaric chambers should be included in the medical equipment of every expedition or trek going to high altitude.</p></div>","PeriodicalId":81742,"journal":{"name":"Journal of wilderness medicine","volume":"5 2","pages":"Pages 190-198"},"PeriodicalIF":0.0,"publicationDate":"1994-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1580/0953-9859-5.2.190","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67123833","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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