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

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Section VI: Backcountry Medicine

If the pain does not resolve with rest, it may require that the patient use sublingual nitroglyc- erin tablets or spray. Nitroglycerin relaxes the smooth muscle of blood vessels to reduce the resistance to flow and thus the work the heart must do to circulate blood. Usually, a maximum of three doses of nitroglycerin is taken before referral to medical care is considered necessary. Pain that does not resolve as expected should be considered a heart attack and treated as such. Patients with angina are at increased risk of myocardial infarction. Increased exertion and unexpected crisis in the backcountry can create a situation in which rest is not possible. If persis- tent ischemia develops, definitive treatment is a long way off. This elevated level of risk should be discussed with any angina patient contemplating wilderness travel.

hospital. Even if you have a high index of suspi- cion for myocardial ischemia, the evacuation may still represent the greater risk to the patient as well as add the risk to rescuers. On a good day with safe flying conditions, launching a helicopter is the right plan. On a bad day it is worth remember- ing that many people survive myocardial ischemia, but few people survive helicopter crashes.

General Principles

Serious Chest Pain

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Anticipate: • Cardiogenic shock • Respiratory failure Treatment: • PROP: specific treatments if MOI is known. • Pain medication • Maintain hydration. • Maintain body core temperature. • Urgent evacuation.

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General Principles

Stable Angina

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As with abdominal pain, there are times when you can give your patient a better chance of sur- vival, as well as protect the lives of others involved, by performing good basic life support in a stable situation in the field rather than performing a complex and dangerous evacuation through an unstable environment. There are unfortunate examples of trained rescuers suspending or ignor- ing bleeding control, ventilation, or body core temperature in a desperate run for the trailhead or harbor. Remember, the goal is to deliver a liv- ing patient. Quickly is ideal, but not always real.

• History of chronic coronary artery constriction with transient myocardial ischemia • Oxygen demand exceeds supply temporarily • Exacerbated by exertion • Relieved by rest • Treated with nitroglycerin and oxygen • Not urgent if responds to normal treatment

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“Increased exertion and unexpected crisis in the backcountry can create a situation where rest is not possible.”

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Risk Versus Benefit Almost anyone who presents to a hospital emer- gency department with the complaint of chest pain is evaluated for heart attack, even if the probability is low. The risk to patient and medical personnel is minimal and the benefit of detecting a heart attack high. The hospital has the equipment, per- sonnel, and controlled environment necessary to make the specific diagnosis and begin the defini- tive treatment. Unfortunately, these resources are not available in the wilderness environment. You will need to make the generic diagnosis seri- ous or not serious without the benefit of lab tests and cardiology consults and balance your assess- ment against the hazards involved in accessing the