QUIZ ANSWERS ONLY
Cardiogenic shock can occur with: (select all that apply)
A severe heart attack (Myocardial Infarction or MI) A blunt injury to the chest, mid-sternum Congestive heart failure
All orthopedic injuries should be splinted in:
Anatomical position
Those at higher risk of cardiac emergencies include all of the following except:
Asthma
A sunburn on the surface of the eye can occur when traveling:
At high elevation, on snow/ice and/or on water when less than adequate or no eye protection is worn
What is the main vital sign change when a person goes into decompensatory shock?
BP drops assessed by absent bilateral radial pulses
If you render care to a trip participant who is alert and oriented without obtaining consent you may be charged with?
Battery/Assault
How often should CSM be checked during the splinting process?
Before and after
Why do diabetics often get into trouble more easily while in the backcountry?
Caloric intake that does not match environmental demands. Increased physical demand resulting from backcountry travel.
How can you assess for good circulation in the extremities without feeling for pulses?
Capillary refill time of 2-4 seconds
Techniques to aid in dealing with diabetes while in the backcountry include:
Carrying Extra Medication Frequent monitoring of blood glucose levels Frequent opportunities for snacks during exertion
Which of the following are common triggers that can lead to an asthma attack or "flare-up"?
Cold air Smoke from a wildland fire Stress Exercise An illness like a cold Allergy
The signs and symptoms labeled in the diagram below are more common for what type of cardiac emergency and why?
Congestive heart failure (CHF) causing swelling (edema) in the lower legs, ankles and feet or in the lungs due to higher cardiovascular exertion in the backcountry.
An unresponsive patient is encountered in the backcountry. There are no obvious reasons why this patient is unresponsive. What should be done?
Continuously monitor patient for a patent airway, normal respirations and the presence of a pulse. Protect the patient from the environment in any way appropriate. Administer glucose between the patients cheek and gum while the patient is on their side.
Your Primary Assessment reveals that the patient appears tired, continues to shiver, does not complain of any pain and is now able to talk to you in 4-word sentences, which is an improvement. You notice that their coughing is becoming less frequent and you do not hear rales (wet lung sounds) when they take a deep breath. Their chest wall is intact and without pain upon palpation. They do not appear to have any other injuries, bleeding or pain upon palpation. They have strong radial bilateral pulses and are able to remain seated in the boat. They were wearing a helmet, deny hitting their head or losing consciousness, are A on AVPU and are moving all 4 extremities.
Environment life threat; remove all wet clothes and replace with dry clothes.
A person experiencing a severe asthma attack should receive:
Epinephrine injections until normal breathing returns followed by 2-4 puffs of their rescue inhaler and lastly their corticosteroid medication if available.
Which of the following statements concerning epinephrine use for a severe asthma attack is incorrect?
Epinephrine via an auto-injector should be administered into the lateral aspect of the deltoid.
Managing an amputated body part in the field includes all of the following except:
Fully saturate and freeze the amputated portion (detached from body)
Dental problems on a backcountry expedition can be painful, can cause serious infections and/or tooth death. The most proactive action future trip participants can do to prevent these issues is:
Get dental check-up and have any issues completely treated before any trip
The most important single thing a trip leader can do to prevent an entire expedition from getting a common cold, the flu or a sore throat is to be adamant about:
Hand washing and basic camp hygeine
Epistaxis (a nose bleed) is usually benign and bleeding is easily controlled by:
Having the person firmly pinch the bridge of their nose below the cartilage while they sit leaning forward. Pack the bleeding nostril with gauze and evacuate to definitive care if bleeding does not stop after a sustained effort (15-20 minutes).
High-risk wounds like animal bites and facial wounds should be closed immediately in the field to prevent infection.
High-risk wounds should never be closed in the field. Once a wound is closed, anaerobic bacteria (bacteria that strives in a low oxygen environment) can proliferate and cause severe infections. A high-risk wound needs to cleaned in an ER before closing a prescription of antibiotics is commonly started to prevent infections.
How do you assess if an injured trip participant has adequate blood pressure (BP)?
If you feel strong radial pulses
What type of consent would you need to get with an injured adult client on your river trip who swam a rapid. Your client is unresponsive and you have a duty to care as a paid guide.
Implied consent
Things that are likely issues in the wilderness medicine when compared to urban medicine are?
Improvising medical equipment Extended patient care Managing the group Unreliable communication with EMS Challenging terrain with evacuations
What are the body's adaptive measures when in early stages of shock?
Increasing heart rate (tachycardia), increasing respiration rate (tachypnea), peripheral vasoconstriction.
Death of muscle tissue is known as a(n) __________ and can occur when there is a complete blockage of the coronary artery.
Infarct
Hypovolemic shock can occur with: (select all that apply)
Internal blood loss External blood loss Extreme water loss
Impaled objects may be removed in the wilderness if:
It is small, benign, not in the eye, cannot be stabilized in place and/or prevents safe transport
The best way to prevent cold sore outbreaks due to environmental factors such as high altitude while on backcountry trips is:
Keep prone areas covered with sunscreen containing zinc oxide
Sun bumps are:
Little skin eruptions that are due to an allergic reaction to UV rays
The following statements are true regarding MRSA infections except:
MRSA cannot be spread via skin-to-skin contact or contact with contaminated items
Aspirin commonly found in backcountry first aid kits can be:Regular strength aspirin (325 mg ) Low dose aspirin (81 mg)
One regular aspirin (1 x 325mg) Four low-dose aspirins (4 x 81 mg)
You move an unconscious person's arm and they moan in pain. They are _________ on the AVPU scale.
P
Signs and symptoms of compartment syndrome are:
Pain, increased swelling, and decreased CSM's
What are carpopedal spasms?
Painful muscle spasms that occur in the hands and feet as a result of blowing-off too much CO2 from rapid breathing.
If an injury were present, a commercial or improvised pelvic binder would be placed during which section of WFR assessment?
Primary assessment
What should we check when we are asked to take a "set of vitals"?
Pupils Equal, Round & Reactive to Light (PERRL) Level or Responsiveness (LOR) Skin Color, Temperature & Moisture (SCTM) Blood Pressure (BP) Heart Rate (HR) Circulation, Sensory & Motor (CSM) in all four extremities Respiration Rate (RR)
Which of the following are signs of infection in a soft tissue wound?
Pus oozing from wound Red streaks emanating from the wound towards the heart Redness and swelling around the wound
___________ contains kaolin, a natural mineral that accelerates the body's natural clotting mechanism while ___________ contains chitosan extracted from the exoskeleton (shells) of shrimp. Chitosan forms large gel-like clots when it comes in contact with blood and works independent of a person's clotting mechanism. These products are called ____________ agents and are adjunctive to hemorrhage control treatments like direct pressure and/or applying a tourniquet.
Quickclot®; Celox®; hemostatic
What is this pulse point called? (Line of thumb on wrist)
Radial pulse point
When immobilizing a joint it is important to:
Splint the long bone above and below the injury
If caught in a lightning storm with a group, you should:
Spread the group out at least 25 feet apart between each person Assume lightning position on a non-conductive pad Place your hands over your ears and close your eyes
Blunt force trauma and deceleration trauma are the main causes for internal bleeding. Other causes may be orthopedic fractures, anticoagulants or over the counter (OTC) medications like non-steroidal anti-inflammatory drugs (NSAID). Internal bleeding may be hard to detect, especially immediately proceeding an accident. Signs and symptoms of internal bleeding are:(Check all that apply)
Swollen or painful extremities Bleeding from any body orifice. Rigid abdomen. Hematoma
The most important step in the patient assessment when lightning is in the vicinity is:
The scene size up/safety
Vasogenic shock occurs when:
The vessels of the body lose vascular tone (vasodilate) due to a chemical reaction or disruption in the central nervous system.
Research has shown that emergency use of tourniquets, if used correctly, improve survival with minimal morbidity. In a wilderness setting, where evacuation to definitive care is delayed, commercial tourniquets such as the C.A.T. are preferred because (check all that apply):
They are wide enough to provide safe occlusion of all blood flow at a low pressure. A practiced rescuer can apply it very quickly thus minimizing blood loss.
Lightning is unpredictable, but understanding weather patterns, terrain selection, and the time of day to travel can mitigate the chance of being caught in an electrical storm (T/F)
True
Negligence is the failure to exercise reasonable care and to protect others from unreasonable risk of harm? (T/F)
True
Patients with severe wounds to the hands, feet, or genitals need to be evacuated to definitive care.
True
Pressure bandages may be applied when direct pressure alone is not enough or is impractical for the situation at hand.
True
Submersion refers to the airway being under water and immersion refers to the airway being above water with intermittent splashing of water over the mouth an/or nose. (T/F)
True
The most common diabetic issue encountered in the backcountry is hypoglycemia.
True
Type II Diabetics should be able to control their condition on a backcountry trip with an appropriate and carefully planned diet.
True
Wilderness medicine protocols are practiced in remote backcountry settings when the rescuers are 1 hour or more from definitive care. (T/F)
True
With all major wounds, the individual requires a tetanus booster if they have not had one within 5 years. (T/F)
True
Due to the their location, junctional hemorrhages have different protocols for bleeding control than those of the extremities.
While applying pressure, pack the wound, full, with gauze and hold pressure for 3-5 minutes if using a hemostatic agent and 15-20 minutes if using regular gauze. Use aggressive direct pressure using your body weight with regular or hemostatic gauze. Quickly swipe the pool of blood on the surface of the skin to locate the source of the bleed.
All blood is red due to the iron binding capacity of red blood cells. Arterial blood is ________ in color due to high _________ saturations, while venous blood is __________ due to higher __________ concentrations.
bright red ; oxygen; dark red; carbon dioxide
In terms of hemorrhage control, ____________ bleeds are the easiest while ___________ bleeds are the most difficult to control and may require aggressive measures. Hint: think blood supply.
capillary; arterial
Why is it important to document the exact time a tourniquet was applied?
-For patient safety when considering tourniquet conversion in the backcountry. -So that healthcare providers can make informed decisions once the patient arrives to definitive care (i.e., an emergency room). -For safe tourniquet conversion. -When prioritizing patient evacuation from the backcountry
Once applied, a well placed tourniquet should never be released in the field if:
-The patient is showing signs and symptoms of shock -The tourniquet has been occluding blood flow for more than 2 hrs. -The patient is on blood thinners such as Coumadin. -The patient has a blood disorder like hemophilia.
The therapeutic dose of epinephrine for a severe asthma attach is _____ for adults and _____ for children.
0.3mg; 0.15mg
The wilderness medicine protocols that wilderness first responder are taught but can only legally execute when acting as a paid outdoor professional with current standing orders, medical direction or a physician advisor are:
1. Shoulder reductions with non-direct force dislocations 2. The use of epinephrine when treating severe asthma 3. The use of epinephrine for the treatment of anaphylaxis
What is the normal range for the respiration rate in adults?
12-24 breaths per minute
An adult has between ___ & ___ of circulating blood. Small cells within the blood called ___________ form clots along the surface of injured blood vessels to stop hemorrhages.
5L ; 6L; platelets
What is a normal HR range in a healthy 90 year-old female?
60-100 beats per minute
The common cold can ail a trip participant for:
7-10 days
Depending on size & age, an average child has ___ of blood circulating within their body and will go into ___________ shock once they lose 25 % of their blood volume.
80mL/kg: hypovolemic
Which professionals are part of the EMS system?
911 Dispatch Emergency Medical Technicians (EMT - Basic, Advanced, Paramedic) Ambulance Medevac Fire Department Police Department County Sheriff Park Rangers Wilderness First Responders Ski Patrollers Wildland Firefighters First Responders Emergency Departments Hazmat Teams Search and Rescue
What type of inhaler should a person suffering from an asthma attack use?
A rescue inhaler containing a short-acting bronchodilator like albuterol.
Which of the following may help you differentiate a mild/moderate asthma attack from a severe asthma attack?
Ability to speak Breath sounds Heart rate
The anticipated worse-case scenario (A') of a myocardial infarction is:
Decompensatory cardiogenic shock
Which steps should you follow when treating a wound in the field:
Determine if wound is high or low risk, irrigate with 500 ml. of sterile water, put antibiotic ointment on wound edges, close the wound if low risk or pack open if high risk, dress and bandage the wound, and determine tetanus status
What are the signs and symptoms of Flash Pulmonary Edema?
Difficulty breathing Severe coughing Unresponsiveness and foam emanating from the mouth
The lightning mechanism that has the highest mortality rate is:
Direct
What is the most common cause of epistaxis (nose bleed) in the backcountry?
Dry, cold air, especially at higher altitudes
The most important way to prevent hyponatremia in the field is to:
Eat plenty of foods, especially high in salt and/or supplement with salt pills. Alternate 1 L of pure water with 1 L of electrolyte water while exercising in a hot environments.
Antibiotic ointment should be applied directly into wounds. (T/F)
False
Exercise-associated hyponatremia is a result of decreased sodium intake and decreased water intake. T/F?
False
Insulin should be administered to anyone suffering from hyperglycemia.
False
The main difference between hyponatremia and dehydration is the severity of the headache. T/F?
False
On a backcountry ski trip your diabetic participant presents as irritable, weak and thirsty. Upon your patient assessment you learn that they have had a full breakfast and lunch but have neglected to take their insulin today. You suspect that they are possibly suffering from:
Hyperglycemia
A commercial traction device, such as a Slishman or KTD, can be utilized for what type of fracture?
Mid shaft Femur
Thirty minutes after rescuing your friend from the cold swim through Lava Falls rapid in the Grand Canyon you have provided an adequate assessment based on your medical training. As a result of your treatment, they are no longer shivering, they are speaking in full sentences and are no longer coughing. At this point you have performed a full primary and secondary assessment, including taking and documenting three sets of vital signs. Their last set of vitals are noted below: HR: 94 RR: 18 BP: Strong at the radial SCTM: Cyanotic lips are starting to turn pink, they are warming up with slightly cold extremities and feel dry LOR: X4 CSM: X4 with slower cap refill (continuing to improve) PERRL: WNL (within normal limits)
Monitor the patient for the next six hours for signs and symptoms of flash pulmonary edema. If the patient does not develop signs and symptoms of flash pulmonary edema up to six hours post incident then they are probably in the clear and can continue down river.
Which medication is in an NSAID?
Motrin
Which of the following are contraindications of taking nitroglycerine?
No radial pulse Erectile dysfunction (ED) drugs within 24 hours
Hydrocortisone cream is a common item found in backcountry first aid kits and can be used for?
Red, Itchy, scaly skin as a result of fungal infections
What is Hyponatremia?
Salt dilution
Types of vasogenic shock are: (select all that apply)
Septic Neurogenic Anaphylactic
It is mid-June in Escalante Canyon, Utah, with an air temperature of 92˚F (~33˚C). You come across a 30-year old male who appears disoriented, lethargic, and is complaining of a throbbing headache and mild nausea. Without any other information and based on these symptoms, you suspect what condition(s)?
Severe dehydration Hypoglycemia Hyponatremia
Albuterol, used to treat asthma, is considered a:
Short-acting bronchodilator
Treatment of an infected wound involves:
Soaking the wound 3x/day in a warm providone-iodine solution and redressing wound
What learning pearls does the 1-10-1 Principle offer us to better understand the physiological effects and consequences in regards to an unexpected and thermally unprotected immersion event in cold water (<65°F/18°C)?
The principle refers to the stages of cold water shock; hyperventilation (loss of breathing control) during the the first minute, loss of meaningful movement after 10 minutes, and severe hypothermia at approximately 1 hour of immersion in cold water (<65°F/18°C). The principle reminds us that the risk of water inhalation is high during the first minute, that self rescue becomes impossible at around 10 minutes, and that unresponsiveness sets in at approximately 1 hour. The principle helps us understand why a properly fitted protective flotation device (PFD) is critical to increase a person's survival during the stages of cold water shock
Which of the following signs/symptoms are not consistent with hypoglycemia:
Thirsty with frequent urination
Why is the TIME of onset important to ascertain with a Cerebral Vascular Accident (CVA) or stroke?
Time of onset or when the person was last seen normal helps the receiving EMS personnel or emergency department determine the possibility of receiving strong clot busters that may possibly reverse the effects of certain CVAs. Time of onset is a good baseline to have especially if signs and symptoms improve in the field Time of onset can help dictate the speed and priority of field evacuations.
Congestive Heart Failure (CHF) commonly occurs in those with a history of myocardial infarctions (MI's).
True
The four components of blood are __________, __________, __________, and __________. One of these blood components, composed of hemoglobin, is the vehicle that transports oxygen to cells and removes carbon dioxide waste from cells; a process also known as ___________.
WBC, RBC, platelets, plasma; perfusion
Which wilderness medicine course is considered the standard of care when professionally guiding participants on multi-day remote wilderness trips or expeditions.
WFR
If a trip participant, comes into contact with Urushiol you should:
Wash the oil-exposed area with cold water and soap
Treatment for shock is: (select all that apply)
keep the patient calm and warm assess ABC's
What is your trip participant's LOR if they know their name and they know that they are on a Grand Canyon river trip with you. They are disoriented to time and to what just happened.
A&Ox2
Once a guide/instructor treats a trip participant they should remain with that person until deliver to definitive care. Premature termination of patient care may result in a tort claim of ______________ if the patient suffers harm later.
Abandonment
What signs or symptoms, other than those labeled in the diagram below could individuals present with when undergoing a myocardial infarction (heart attack)?
Abdominal pain Back pain Dizziness
Breathing into cupped hands, as a treatment for hyperventilation is intended to:
Allow the patient to re-breathe CO2 returning blood to normal pH.
You are on a multi-day private river trip in late May through the Grand Canyon. Someone in your group flips their boat in a large hydraulic feature known as the "ledge hole" at the top of Lava Falls rapid. This rapid is classified as a 10 on a 1-10 rating scale (see rapid map below). You have already run this rapid and had a clean line and are now located in the "safety eddy" below. Your friend's boat continues to be caught and surfed in the "ledge hole" and they take a big swim through the "V wave" and eventually the "big kahuna wave". They attempt to navigate towards the shore utilizing the whitewater float position (on their back, airway above water, with arms outstretched, feet up, and feet facing downstream). You yell at them to swim towards your boat located in the "safety eddy". They appear tired, and barely make it to your boat. You pull them out of the river, into your boat, and notice that they are coughing, shivering, and have cyanotic (blue) lips. They are wearing splash pants, a splash top (uninsulated rain gear) and a well-fitted personal protective device (PFD). They keep coughing and can only speak in 2-word sentences. They tell you that they inhaled some water since they could not control their breathing while water was splashing over their head.
Ensure that your boat is tied up as part of scene safety, begin the primary assessment starting with CAB
Eyes are PERRL if one pupil is fixed and dilated? (T/F)
False
Hyperventilation is considered a life threatening condition. (T/F)
False
If you do not have a commercial traction device for a mid shaft femur fracture it is ok to improvise one. (T/F)
False
People who have a cardiac Hx and take Rx (prescription drugs) (e.g. metoprolol, atenolol) for high BP or arrhythmias (abnormal heart rhythms) will not have tachycardia (HR above 100 bpm) if in shock since these drugs block the HR from rising above 70-80 bpm. These individuals will be able to compensate for shock as well as those who are not on these drugs.
False
The main issue with wither type of diabetes is that there is too much insulin being produced by the body.
False
Angina pectoris will always progress to a myocardial infarction if not treated with nitroglycerine.
False. The differentiation between angina pectoris and a myocardial infarction (MI) is that angina pectoris will usually subside or disappear with rest and/or nitroglycerine. If a person continues to push themselves cardiovascularly when they feel signs and symptoms of angina pectoris an MI could ensue.
If a person is struck by lightning, they will continue to hold an electrical charge and should not be touched. (T/F)
False. The person who is struck by lightning does not hold an electrical charge in their body. Once the scene is determined to be safe, it is imperative that you assess the patient starting with the ABC's. Patients who have been struck by lighting are at a high risk of cardiopulmonary arrest.
What location on the body lend's itself to feel a general body temperature when a thermometer is not available?
Feel the chest (upper sternum) with the back of your hand
What is your Primary Assessment priority when treating an unresponsive drowning patient who has agonal respirations (inadequate breathing) or is not breathing?
Perform ABCs; open the airway, if they are not breathing or breathing is inadequate, give 5 rescue breaths followed by CPR (30 compressions:2 breaths) until you get a return of spontaneous circulation (ROSC) for up to 30 minutes in a normothermic patient.
Traditional methods for hemorrhage control have been dismissed by EMS and wilderness medicine in 2010. New advances in managing severe arterial and venous bleeds have proven effective on the battle field and these methods have been filtering into civilian first aid.
Tourniquet, Direct pressure, Hemostatic agent
A physician advisor working for an outfitter or school may add wilderness protocols to the standard wilderness first responder curriculum or standards of care? (T/F)
True
Decompensatory shock is defined when all three adaptive measures like increased HR, RR and peripheral vasoconstriction can no longer maintain adequate BP.
True
Inadequate tissue perfusion is the definition of shock. (T/F)
True
Insulin is the hormone that allows our body to use the glucose we ingest.
True
An anaphylactic reaction can be fatal especially if the individual progresses to the decompensatory stage of anaphylactic shock.
True. Anaphylactic shock is a type of vasogenic shock defined by dilating vessels that may lead to a rapid and dangerous drop in BP. To clarify, anaphylaxis is not necessarily fatal unless it leads to decompensatory - anaphylactic shock. The difference here is that the excessive dumping of histamines during an anaphylactic reaction or anaphylaxis causing the more severe s/s (e.g., swelling of lips and/or tongue) may not obstruct the airway or cause an unsafe drop in BP. However, if the person's anaphylatic reaction or anaphylaxis leads to complete airway obstruction, accompanied by a rapid and life threatening drop in blood pressure (assessed by absent bilateral palpable radial pulses and rapid decrease in LOR) then they are in decompensatory - anaphylactic shock which is usually fatal if not treated with epinephrine. The terms anaphylaxis and anaphylactic shock are commonly used interchangeably but they are different.
The anticipated problem/s (A1) or worst case scenario of anaphylaxis is:
Vasogenic shock Anaphylactic shock Respiratory failure