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

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Section VI: Backcountry Medicine

be all that is necessary to lubricate and soften stool. An enema is also contraindicated with serious abdominal pain. Constipation can be prevented in the backcoun- try by staying well hydrated and adding fiber to the diet. Carrying dehydrated or high-protein food can make this a challenge. Consider using a bulk agent like psyllium capsules to supplement your diet. It is also important to take the time and find the privacy for a decent bowel movement. Nausea and Vomiting Like diarrhea, vomiting can be the result of a problem with the GI system or a symptom of other problems such as motion sickness, toxic ingestion, head injury, or infection. Finding and treating the primary cause is ideal. You must con- sider the additional problems that can be caused by severe fluid loss as well.

Positioning for drainage and constant monitoring is important if the patient is not A on the AVPU scale or is exhibiting altered mental status. Keep somebody nearby to assist when necessary. Antiemetic drugs can be given by intramuscu- lar (IM) or IV injection, orally, or by rectal sup- pository. The prescription drugs promethazine (Phenergan), ondansetron (Zofran), and pro- chlorperazine (Compazine) are examples. The over-the-counter antihistamines meclizine and diphenhydramine can be effective. If the patient cannot swallow a pill, diphenhydramine can be delivered in the form of an oral dissolving strip and ondansetron comes in an oral dissolving tablet. Acetaminophen is preferred over nonste- roidal anti-inflammatory drugs (NSAIDs) or oral opioids for pain.

Vomiting

General Principles

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Anticipate: • Airway obstruction and aspiration • Volume shock from dehydration Treatment: • Airway control • Hydration and calories • Maintain body core temperature • Antiemetic medication

Vomiting

General Principles

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Serious (Red Flags): • Cannot control airway • Cannot replace fluids

• Cannot maintain calories and body core temp • Associated with red flags for abdominal pain

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Risk Versus Benefit Although a number of drugs are mentioned here, it is worth noting that treating GI problems offers an easy opportunity to make things worse if you are not careful. A mildly annoying but other- wise functioning gut is often best left alone. The problemwill usually resolve itself within 24 hours. Being too quick to add drugs can cause a resolv- ing problem to swing too far the other way. You can easily turn diarrhea into constipation or vice versa. Antibiotics can do more harm than good by killing off beneficial bacteria along with the target organisms and should generally be reserved for serious infections. A day of clear liquids and easily digested foods in small amounts will often do more good with less risk than any medication.

©2018WMA

Treatment of Vomiting Replacement of lost fluid is a priority. Because nausea inhibits oral intake, IV or subcutaneous rehydration may be necessary. Infusing fluid by periodic IV or subcutaneous bolus can be much easier than trying to maintain a continuous drip, especially during a carry out or aboard ship in heavy seas. Oral intake may be successful if the patient can take small amounts frequently enough to maintain hydration. Look for normal urine out- put as evidence of success. Airway obstruction and aspiration is an anticipated problem in any vomiting patient.