Airway
Medical emergencies can come in many flavors, but by learning to deal with the airway first, you can keep you cool and approach things in a logical order. Here we’ll address choking, allergic reactions, unconscious persons, and penetrating neck injury.
Choking
The slap-stick comedy routine which involves a choking restaurant patron is no laughing matter. In fact, it presents a real-life situation where a bystander’s immediate action may save a life. Inhaled foreign bodies can run the gamut from pieces of inadequately chewed food to broken teeth to accidently inhaled nuts or bolts held between the lips while working on a vehicle (we all do it…). A choking person may display the universal sign for choking, where the victim holds his neck with one or both hands. If the person can cough and speak, you should encourage him to keep coughing. If he is unable to speak or cough, you should immediately perform the Heimlich Maneuver, which involves giving five quick abdominal thrusts by wrapping your arms around the victim from the backside and placing the thumb-side of your fist against the middle of his/her abdomen, just above the navel. Grab your fist with the opposite hand and repeat the thrusting motion until the foreign body is expelled. If you’re alone and you are the victim, you can self-administer the Heimlich Maneuver by bending at the waist and quickly lowering your abdominal area onto the back of a chair.
When a child chokes, you should slap their back repeatedly with the heel of your hand. If the child is very small, you can place two or three fingers in the center of the chest, just below the nipple line, and compress the breastbone quickly about one or two inches. Be sure to support the head of infants, always keeping the head lower than the chest so the foreign body falls out of the mouth when expelled.
If a choking victim becomes unconscious, send someone to call 911, lower the person to the floor, tilt the head back to open the airway, and start chest compressions for 30 seconds. Sometimes this will force the object from the airway, so be sure to open the mouth and if you can see the object, reach in and grab it. Perform CPR until help arrives or the object is expelled and breathing resumes.
Allergy
Typically, an allergic reaction involves a diffuse, blotchy, itchy, red rash (called hives), but it can also involve difficulty breathing and swelling of the lips and tongue which block the airway. When an allergy becomes life threatening, it’s called anaphylaxis and it must be treated immediately. Persons with a history of life threatening allergy should carry and know how to use an epinephrine auto-injector, commonly referred to as an Epi Pen. If you carry an Epi Pen, ensure your group members know how and when to use it; if someone in your group carries one, ensure you’ve read the instructions ahead of time and have a thorough understanding of how and when to use it in case the person becomes unable to administer it himself.
Epi-Pens come in adult and child sizes and using one should not intimidate you. There is a blue cap and an orange cap; both will need to be removed prior to use. Grip it like a microphone and jab it at a 90-degree angle to the thigh, holding it there for 10 seconds before you remove and discard it. Do it right through the pants if necessary. Remembering the mantra “blue to the sky, orange to the thigh” and keeping your thumb from covering the end will help you avoid the mistake of injecting your friend’s life-saving medication into your own healthy thumb. The life-saving anti-allergy effects of epinephrine are short-lived, and those within the range of traditional EMS services should immediately go to a hospital or call 911 as more epinephrine may be needed.
Those who travel beyond the range of EMS should consider adding diphenhydramine (Benadryl) pills and prednisone pills (a steroid) to their med kids, as these are also life-saving treatment for allergic reactions. If you cannot get to a hospital after needing epinephrine, consider taking up to a three-day course each of Benadryl and prednisone. Travelers into remote areas should be aware that there is additional epinephrine in an auto-injector, and you can learn how to extract it by searching the internet for “how to get additional doses out of an Epi Pen.” This is controversial and not recommended by any medical professional or the device manufacturer, but if you travel remotely, I believe you should be aware of how to do it. Another more affordable option for wilderness travelers is to ask your physician for a small, multi-dose, glass vial of epinephrine ($20) instead of a single use Epi Pen ($600); as this saves money and space on an expedition. However, the Epi Pen is foolproof and there exists ample room for life-threatening errors of dosing if you break open an Epi Pen or self-administer single doses from a glass vial, so be aware and discuss thoroughly with your physician first.
Unconscious Persons
When a person becomes unconscious from head trauma, seizure, overdose, allergic reaction, drug or alcohol intoxication, heart attack, etc., the muscle tone of the mouth, jaw, and tongue is lost and gravity may cause the tongue to fall back and occlude the airway. You should be aware of two methods to keep the airway open in unconscious persons. If there is no suspicion for neck injury (like from a fall or motor vehicle accident), perform the head-tilt chin-lift maneuver by pushing up under the chin to tilt the head back and pull the jaw forward. Another option is to roll the victim onto his/her side, into the recovery position, which utilizes the victim’s down-side arm to support the head and takes advantage of gravity to pull the jaw and tongue forward. This position has the added advantage of ensuring that vomit and secretions drain from the mouth. This position, however, is not very feasible for transporting an injured person or completing the rest of an examination.
Another method which can be performed by trained rescuers is the insertion of a nasopharyngeal airway (NPA). NPAs are flexible, flanged plastic tubes, about the length of your index finger, which can be lubricated with surgical jelly and inserted along the floor of the nose, extending into the back of the throat and past the tongue. They are extremely useful for persons with swelling of the lips or tongue, and they have the added benefit of being tolerable by semi-conscious persons, when compared to other devices which are inserted through the mouth. A good Wilderness First Responder Course will cover the insertion of NPAs and you should consider attending a course and carrying one in your backcountry medical kit.
Penetrating Neck Injury and Expanding Neck Hematoma
An emergency physician’s worst nightmare is a person with a penetrating neck injury from a gunshot wound or stabbing, or the victim of a hanging or “clothesline” injury about the neck (picture someone running into a clothesline). In these instances, a hematoma (blood collection under the skin) or swelling deep inside the neck starts to press against the airway. This condition is heralded by the onset of stridor, which is a high-pitched sound that comes from the airway during inspiration. Commonly, it’s also present with dysphonia (change in voice quality). These are ominous signs, and coupled with the right mechanism of injury, should prompt you to seek immediate medical help at a hospital or by calling 911.
If you are faced with a true medical emergency, don’t panic! Remember to keep a level head and approach things in a step wise fashion by first addressing the airway. Consider taking a Wilderness First Responder Course, learn how and when to use an Doctor’s orders!