Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

What’sinYourBackpack? WildernessMedications JenniferRoehrsDO UniversityofKansasSchoolofMedicineͲ Wichita FamilyMedicineResidencyProgramatViaChristi April10th,2015

Goalsandobjectives • Preparefortheseconditionsinyourfirst aidkit – Dermatitis – InsectBites – Anaphylaxis – Allergy – Sunprotection – Infections – Trauma 1

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Plantdermatitis • Anacardiaceae andrelated • families:PoisonOak,Sumac, Ivy • • PlantToxin:Urushiol in sap/oil(bothirritantand • allergen) • Blackspottest:crushplant contentsthoroughly, especiallyleafstalksbtwthe foldsofwhitepaper.Urushiol willturndarkbrownin10 minutesandblackin24hours • Willbeabletoseeoilyblack spotsontheleavesofthe plant

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IfburnpoisonIvy,thesmoke isapotentirritant Blisterfluiddoesnotspread disease Steroids,Diphenhydramine (Benadryl®),Aloe,Honey

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Whoshouldyoubemoreafraidof?

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Bites:Insectrepellants • Keepcoveredwithclothing • Allyouneedis30%Deet or20%Picaridin • Picaridin isaseffectiveasDeet andsafeon plastic • PermethrinͲ waterinsolubleͲ cantreatclothes upto50washesdependingonstrength • SulfurͲ “ChiggerAway”Ͳ onlyworksonchiggers • CitronellaͲ havetoapply3xperhour – Notaseffective:KansasBBQvs Africansafari

• Deet +Permethrin =bestcombination

WhoisthemostDeadly?

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Anaphylaxis • Epinephrine(EpiPen®) – 0.3mgperdose (0.3mlof1:1000) – Willget4Ͳ5more treatmentsper EpiPen®

• Epinephrine – IM1:1000 – Multipledoses withoutextra work

Allergy • Diphenhydramine

• Honey

(Benadryl®)

– Oral • Decreasesensitivityto localallergensby consuminglocalhoney – Topical • Notrecommendedif bearsarearoundoryou arehavingdifficultywith bugs• AntiͲbacterialandantiͲ inflammatoryproperties • Darkerthehoneythe strongertheeffect

– Localanesthetic – Sleepaid/sedation – AntiͲhistaminicwith allergicreaction – NauseaandVomiting – Pain/Analgesia – AntiͲitch

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

SunProtection • UVABlockers

• ParticulateBlockers (inorganics)

– *Benzophenones (oxybenzone and dioxybenzone)

– TitaniumDioxide(UVB) – ZincOxide(UVA+UVB)

• UVBBlockers – – – –

• Octocrylene

PABA/PABAEsters Cinnamates Salicylates Ensulizole

– Stabalizes avobenzone – Noncomedogenic $$$$$

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Infection • Don’tDelayAntibiotics:InjuryandDiarrhea – Commonthingsarecommon – Longerincubationtime:lyme,histoplasmosis,etc

• Muchworsebacterialinfectionsarepresentin thehospitalÆ LesslikelytofindMRSAinthe woods,exceptcolonizedonyou • BringProbiotics! – SomuchgoodforGIandGUtract – Lactobacillus

CampinginupstateNewYork

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

TraditionalMayanCuisine

Infection • Amoxicillin/clavulanic • Metronidazole(Flagyl®) acid(Augmentin®) – Giardia – OtitisMedia – Abdominalinfections – AbdominalInfections – Amebiasis – Cellulitis – STDs – Sinusitis • Doxycycline – Pneumonia • Increasedsunsensitivity [cansubstituteCefuroxime • Givedoxycyclinehyclate (Ceftin®)Ͳmayneedadditional todecreaseGIside anaerobe] effects • Ciprofloxacin – TickBornillnesses:i.e.Lyme disease – Traveler’sdiarrhea – MRSA – UTI – Salmonella 9

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Infection • Irrigation/cleanse – Alcohol(over80proof)andIodinewillkillallcells includingWBC – Chlorhexidine (Hibiclens®): won’tdestroyWBC’sin thewound

• TopicalCreams – polymyxin,bacitracin,neomycin – Honey(bothantiͲbacterialandantiͲinflammatory properties)

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

WoundCare • Chitosan(Celox®)

• Burns

– Madefrom CrustaceanShells – Granulessprinkled overactivebleeding

Aloe Honey TopicalAntibiotic NSAIDs/ Acetaminophen(Tylenol®) – AppropriateDressing – – – –

OralMedications – Pain – Antibiotics/Antifungal • ASA325mg • Ciprofloxacin(Cipro®)500mg • Acetaminophen(Tylenol®) • Amoxicillin/clavulanic acid 500mg (Augmentin®)875/125mg • Ibuprofen400mg • Doxycycline100mg – Diarrhea • Fluconazole150mg • Loperamide 2mg • Metronidazole(Flagyl®)500mg – Altitudeillness – Antihistamine • Acetazolamide(Diamox®) • Diphenhydramine(Benadryl®) 125mg 25mg • Dexamethasone4mg • Ranitidine150mg • Nifedipine 10mg – Miscellaneous – Motionsickness • Probiotic • Meclizine25mg • Honey – Malaria • Phenazopyridine 100mg • Mefloquine 250mg 11

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

TopicalMedications – – – – – – – – –

AntibioticOintment:polymyxin,bacitracin,neomycin Mediumpotencysteroid:Fluocinolone cream0.025% Gentamicinsulfate(Gentamicinopthalmic ointment®) Miconazole cream2% Oxymetazoline nasalspray(Afrin®) AloeVeragel Sunscreen15Ͳ30SPF DEET/Permethrin Zincoxidecement(Cavit Dental®)/Eugenol/Floride topical (Biotene®)

– – – –

2Ͳoctylcyanoacrylate(Dermabond®) PovidoneͲIodine Aceticacid/Vinegar Honey

Questions?

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Thankyou!

References 1. 2. 3. 4. 5. 6. 7. 8.

Auerbach,P.WildernessMedicine,6th ed.2012 UptoDate WMSstudentelectiveandconferences2013Ͳ2015 http://www.todayifoundout.com/index.php/2012/05/howͲtoͲtreatͲaͲ jellyfishͲsting/ http://www.mpcp.com/articles/noͲbleachͲpleaseͲhowͲtoͲtreatͲ poisonͲivy/attachment/poisonͲivyͲimage/ www.mynatureplace.org www.coolasuncare.com AmericanJournalofEmergencyMedicine,2008,Theintravenoususe ofcoconutwater

Iwouldliketothankinparticular,Dr.AmyCurry,Dr.Lary Hill, SarahShingler,WCGMEandViaChristiforalloftheirhelpand contributions. 13

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

SlidesforAdditionalReference • • • • • • •

WaterPurification Dehydration AltitudeEnvironmentalConcerns Chronicmedicalconditions ToolsandMedicalBag SnakeBites NematocystStings

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

MuddyWater • Clarification – Alum1/8Ͳ1/4tsp/gallon • Bindstosedimentsandsinkstothebottom • Allow30Ͳ60minutestosettle,thenusecoffeefilter

• Runningthroughcottonshirt

WaterPurification • Clearwater • Disinfectants:Halogens – Iodinetablets • 2%Iodine(Betadine =10%organiciodinecomplex) • Toremoveiodinetaste:ascorbicacid(powder electrolytesolution),sodiumthiosulfate

– Chlorinedioxide • Increasedcoverageagainstcrypto/protazoa • Sensitivetosunlight • 4hourstowork,limitedactivity

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

#1Problem=Dehydration • WHOrehydration packets(needatleast saltandsugar) • HomemadeORS:1L H2O,½teaspoonsalt, 6teaspoonssugar

• CoconutWaterfororal orIVFasitisIsotonic – usedinthePacificfront duringWWII

– i.e.Gatoradepowder – Acutetraveler’s diarrheacanloseupto 6L/hourofwaterin thestool.

Epinephrineretrievalvideo • https://www.youtube.com/watch?v=sbpmY uixMAg

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

EnvironmentalConsiderations • Altitude – Treatmentfor AMS,HACEand HAPE • Diamox 125mg • Dexamethasone 4mg • Nifedipine 10 mg

Altitudeillness • AcuteMountainSickness(AMS) – Headache+1ofthefollowing • • • •

GIupset Fatigue/weakness Dizziness/lightheadedness Difficultysleeping

• HighAltitudepulmonaryedema • HighAltitudeCerebralEdema – AtaxiaorLossofConsciousnessinpatientwithpreͲ existingAMSorHAPE

• GoldStandard:“Ifeelsick”=reduceactivity • Altitude:9000ft

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

AMS • • • • • • •

Tylenol/Ibuprofen Rest Rehydrate Zofran Acetazolamide 5mg/kg/day Descendifnoimprovement Ascendwhensymptomsresolve

HACETreatment AMS+ Oxygen Organizeddescent Dexamethasone 8mgIVthen4mgq6hours HyperbaricchamberͲ (Gamowbag)until descentpossible • IVrewarming,rehydrationandantiͲemetics • • • • •

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

HAPE • MCCofdeathfromHigh • altitudeillness • • Nowarningsigns,canbe • veryabrupt • Oftenoccursthesecond • night • • Mayoccurintheabsence ofAMS • • CXRlookslikenonͲ cardiogenic pulm edema •

NotARDS Vasogenic pulm edema Vasocontriction +intense hypoxiagoingonallday PApressureshigh Nodyspnea untilleak begins FrothingatthemouthͲ willsoundlikedrowning Noninflammatory,high permiability leak

HAPEtreatment • Oxygen • • Nifedipine orPDEͲ5 Inhibitor • • CPAP • Gamowbag/hyperbaric chamber

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CPAPwilluseupO2 tankin10minutes Gamowbag – Canonlystandtobein for45minutes – Condensationfrom breathing,havetopee – Havetopumpevery5 secondstogetridofCO2 andkeeppressureinbag

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

ChronicConditions • Writtenmedicalhistoryofeachmember – COPD/Asthma – Diabetes • Nometforminifinaltitude/hypoxia(over9,000ft)

• StresstestingͲ preͲopclearanceifindicated • BringEKGforallcardiacpatients(andASAand Nitrates) • Anemia:forevery1%fallinHct,maxO2 consumptiondecreasesby1%andendurance decreasesby2%.

Tools • DuckTape – Butterflybandages – Blistercare – Removespinesof bugs/cactus – SnowGlassesͲ cutslitsto seethrough • Tweezers/Misquito forceps • Gloves – Irrigation:fillglovewith waterandpokea pinholeinfinger – Canusepalmofgloveas dressingwithburnsͲ sterile 20

Swissarmyknife KnifeBlades:#10and#11 Adhesivetape2” Needles:25G,18G,12G 10ccSyringe Foleycatheter – Chesttube – Nosebleeds – Urinarycatheter – Airway – Venoustourniquette • 550paracord

• • • • • •

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Tools SafetyPins MoleSkin Steri Strips Thermometer – Lowreadingfor hypothermia • SAMsplint – UsetoprotectIV Medications • Needledriver – Removeforeignbodies • • • •

• Superglue – Skinlesionrepair – Holddownsteri strips • DentalFloss – Threadforclothing/equipment repair – Suturesubstitute • Smallplasticbags – Coverwounds – Coversuckingchestwounds (leaveonesideopen) – Irrigationbymakingsmallhole • LargePlasticBags – Hypothermiawrap – Rainponcho

Tools • Suture:5.0nylonand5.0dexon (totieoffa bleeder) – Canusethepatient’shairifscalplacandlong enough

• Vasaline gauze – Burndressing – Toenailoffwithopennailbed – Suckingchestwound – FireͲstarter 21

Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

SafetyPins

1. 2.

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Replacingthelostscrewsinyourglasses Improvisedglasses– Draw2circlesinapieceofducttapewhere youreyeswouldfit.Usethepintomakeholesinthecirclesand thentapethistoyourface.Willpartiallycorrectnearsightedness Skintestingforsensation Irrigationofwoundswithasafetypinpuncturedbaggie Removingimbeddedforeignbodiesfromskin Draininganabscessorblister Drainingahematomaunderafingernail Fishhook Holdgapingwoundstogether Replacingabrokenzipper Holdingglovesormittensonyourclothing Uncloggingjetsoncampstoves Pintriagenotetovictims Slingandswathforarmandshoulderinjuries

MedicalBag • • • • •

Compartmentalize:Brightlycolored KeepContentslistatthetop Don’tmixpillsinbottles. Noacronyms StoreMedicationsinaPelicanbox – HasSealonitandwaterproofdownto60feet

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Wilderness Medications Jennifer Roehrs DO

Family Medicine Spring Symposium April 10, 2015

Bites:Snake • Keepbittenarea dependentͲ donot elevate • Notourniquet • Placeinsplint/Ace wrap(stops movement) • Markareaofedema • Removejewelryand tightclothing • Gettonearestfacility forantivenomͲ can takeupto10vialsfor response

Bites:Jellyfish/Nematocyst • Vinegar/AceticAcidforjellyfish/nematocyst stings – VenomisheatlabileͲ soakinhotwatersolution: 105°F • Ideallypourvinegarfor30secondsandthensoakfor30 minutes

– DonotusefreshwaterͲ hastobesaltwater(with bakingsoda worksbest) – DonotpeeonthestingͲ pHhastobe5 – Removestingerbyscrapingwithflatobject – ReapplyVinegar,bakingsoda/saltwatersolution afterstingerremoved.

• Aboverulesforjellyfishstingsdonotapplyto theMano’War 23