Overview: Medical vs. Trauma
Medical emergencies (as opposed to trauma) include illnesses like stroke, seizures, heart attacks, and diabetic crises. Unlike trauma, which is usually obvious, medical emergencies can be subtle. This lesson covers recognition and field management of common medical emergencies in wilderness settings.
Key Points
AEIOU-TIPS mnemonic covers most causes of altered mental status
When in doubt about cause, treat for hypoglycemia (glucose won't hurt a hyperglycemic patient significantly)
Chest pain could be cardiac even in young people; always evacuate if cardiac suspected
FAST stroke assessment: Face, Arm, Speech, Time
Time is brain: stroke is time-sensitive condition where early hospital care prevents brain damage
Altered Mental Status (AMS)
AEIOU-TIPS Mnemonic
Systematic approach to causes of altered mental status:
A Alcohol/toxins
E Epilepsy/seizure (postictal state)
I Insulin (hypoglycemia, hyperglycemia)
O Overdose (medications, drugs)
U Uremia (kidney failure)
T Trauma (head injury, hypoxia, shock)
I Infection (sepsis, meningitis, encephalitis)
P Psychosis (psychiatric emergency)
S Syncope/Stroke/Shock
Assessment Approach
- Rapid AVPU: What is patient's level of consciousness?
- SAMPLE history: Any clues to cause?
- Blood glucose: Check if glucometer available (hypoglycemia is reversible and immediate threat)
- Vital signs: Fever (infection), tachycardia (shock, overdose), bradycardia (head injury)
- Physical exam: Look for clues: needle marks (overdose), head trauma, focal neurologic deficits
Universal AMS Treatment
- Airway management: Position to protect airway
- Position: Recovery position if unconscious (no spine concern)
- Keep warm: Prevent hypothermia
- Glucose: If hypoglycemia suspected AND patient can swallow, give glucose
- Oxygen: If available and hypoxia suspected
- Evacuation: Any persistent AMS requires evaluation
Seizures
Types of Seizures
- Generalized tonic-clonic (grand mal): Loss of consciousness, stiff body (tonic), then jerking (clonic). Most dramatic.
- Absence: Brief staring episodes, no jerking
- Focal/partial: Jerking in one limb or one side of body
Causes
- Epilepsy (seizure disorder)
- Head trauma
- Hypoglycemia (low blood sugar)
- Hypoxia (low oxygen)
- Hyponatremia (low sodium)
- High fever
- Toxins/drugs
Field Management DURING Seizure
- DO NOT: Restrain patient (can cause injury)
- DO NOT: Put anything in mouth (can damage teeth/airway)
- DO: Protect head from injury (padding if nearby)
- DO: Time the seizure (important for medical team)
- DO: Clear area of hazards
- DO: Position on side if possible (protects airway)
- Monitor: Breathing, color (cyanosis risk)
Post-Ictal Phase
- After seizure: Confusion, drowsiness lasting minutes to hours — this is NORMAL
- Patient may not remember seizure occurred
- Reassure and reorient patient
When to Evacuate
- Always evacuate if:
- First-ever seizure
- Prolonged seizure >5 min (status epilepticus — life-threatening)
- Multiple seizures without full recovery between
- Focal deficits after seizure
- Known epileptic with unusual seizure pattern
- Seizure following head trauma
- Known epileptic: If seizure is typical for patient and they recover normally, may not need evacuation IF seizure is short and patient fully recovers. Still monitor closely.
Diabetic Emergencies
Hypoglycemia (Low Blood Sugar)
Definition: Blood glucose <70 mg/dL
- Onset: RAPID (minutes to hours)
- Signs:
- Confusion, altered mental status
- Diaphoresis (sweating), tremor
- Tachycardia (rapid heart rate)
- Pale, cool skin
- Hunger
- Anxiety, personality change
- Treatment (conscious patient):
- Glucose tablets, juice, candy, sugar
- Reassess in 15 minutes
- If improved, follow with longer-acting carbs (granola, crackers)
- Treatment (unconscious patient):
- NOTHING by mouth — no food, drink, or glucose gel (aspiration risk; absorption through the cheek is negligible)
- Protect the airway: place in recovery position
- EMERGENT evacuation — an unconscious diabetic cannot be treated in the field
Hyperglycemia (High Blood Sugar)
Definition: Blood glucose >300 mg/dL (may be >400-500 in DKA)
- Onset: GRADUAL (hours to days)
- Signs:
- Excessive thirst and urination
- Fruity-smelling breath (ketones in DKA)
- Kussmaul respirations (deep, rapid breathing in DKA)
- Dehydration
- AMS in severe DKA (diabetic ketoacidosis)
- Treatment:
- Hydration is primary treatment
- Encourage drinking water
- NO field treatment reverses hyperglycemia quickly
- Evacuation for DKA (serious condition)
When in Doubt: Give Sugar
Rule: If uncertain whether AMS is hypoglycemia or hyperglycemia, give glucose — only if the patient is awake enough to swallow safely. Glucose won't significantly harm a hyperglycemic patient but can be lifesaving for hypoglycemic patient.
Chest Pain & Cardiac Emergencies
Differential: Cardiac vs. Non-Cardiac
Cardiac causes: ACS (acute coronary syndrome = angina or MI), pericarditis
Non-cardiac: Musculoskeletal, esophageal, pleurisy, pulmonary embolism, pneumothorax, HAPE
- Signs favoring CARDIAC:
- Crushing/pressure quality
- Radiates to arm, jaw, or back
- Diaphoresis (sweating), nausea
- History of cardiac disease or risk factors
- Age >45 years
- If ANY concern for cardiac: Treat as ACS until proven otherwise
Field Management of Suspected Cardiac Chest Pain
- Position: Usually sitting upright (position of comfort)
- Aspirin: 325 mg regular or 4 × 81 mg chewable — have the patient CHEW the aspirin for faster effect (if patient not allergic, no active bleeding/ulcer)
- Nitroglycerin: ONLY if patient has their own prescription. Do NOT use someone else's.
- Oxygen: If available and SpO2 low
- URGENT EVACUATION for all suspected cardiac chest pain
Stroke: Time is Brain
FAST Stroke Assessment
F Face droop: Ask to smile; one side drooping?
A Arm weakness: Raise both arms; one drift down?
S Speech: Repeat simple phrase; slurred or strange?
T Time: Call for help NOW. Thrombolytics effective within 3-4.5 hours.
BE-FAST extension: Add Balance (sudden loss of balance or coordination) and Eyes (sudden vision loss or change) to FAST. Strokes in the back of the brain (posterior circulation) can be missed by FAST alone.
Other Stroke Signs
- Sudden severe headache (worst of life)
- Vision changes
- Sudden confusion or difficulty understanding
- Sudden unilateral weakness or numbness
Why "Time is Brain"
- Thrombolytics (clot-busting): Effective within 3-4.5 hours of symptom onset. Can prevent permanent brain damage if given early.
- Outside this window: Limited options; brain damage already occurring
- Field implication: Recognize stroke signs and URGENT evacuation. Every minute counts.
Field Management
- Monitor airway: Stroke affects swallowing; aspiration risk
- Head position: Slightly elevated (15-30°) if no hypotension
- Nothing by mouth: Due to aspiration risk
- Nothing reversible in field: Can't undo a stroke in the field
- URGENT EVACUATION: Time to hospital is treatment
Stroke Mimics
- Hypoglycemia: Can present like stroke. Check blood glucose FIRST — treat if hypoglycemic
- Todd's paralysis: Post-seizure weakness (temporary, resolves)
- Complex migraine: Can cause focal neurologic symptoms
Case Scenarios
Scenario 1: Sudden Weakness on Backpacking Trip
Setting: On day 3 of a 7-day trip, a 55-year-old develops sudden unilateral arm weakness and mild speech difficulty. Group is 8 hours from trailhead. No cell service but satellite communicator available.
Recognition: STROKE — sudden onset, FAST assessment positive (arm weakness + speech)
Field Actions:
- Do FAST assessment completely
- Check blood glucose (to rule out hypoglycemia as cause)
- Activate satellite communicator immediately — note time of symptom onset (critical for thrombolytic window)
- Position: head elevated if no hypotension
- Nothing by mouth
- Monitor airway, breathing
Evacuation: URGENT — helicopter or fastest possible evacuation. Goal is hospital within 3-4.5 hours of symptom onset for thrombolytic therapy.
Scenario 2: Diabetic Confusion at Camp
Setting: A diabetic patient on a guided trip becomes confused and irritable after hiking 10 miles. Group has glucometer and first aid kit. Patient says they didn't eat lunch (too busy hiking).
Recognition: Hypoglycemia likely (skipped meal, confusion, irritability)
Immediate Actions:
- Check blood glucose with glucometer
- If <70 mg/dL: Give glucose tablets or juice immediately
- Reassess in 15 minutes
- If improved: Follow with more substantial carbohydrates + protein
Evacuation: If glucose improves confusion and patient fully recovers, may not need evacuation. Rest, eat, monitor. Ensure patient eats before continuing activity.
Knowledge Check
10 questions. Pick an answer to get immediate feedback. Answer order is shuffled each attempt, and your best score is saved on this device.
Lesson Summary
Key Concepts
AEIOU-TIPS covers most causes of altered mental status
Hypoglycemia is reversible; always consider and treat if suspected
Seizure management: protect, don't restrain; time the event
Diabetic emergency: hypoglycemia (rapid, emergency treat) vs. hyperglycemia (slow, comfort care)
Chest pain: if cardiac concern, treat as ACS; aspirin + urgent evacuation
FAST stroke assessment: Time to hospital is treatment (thrombolytics within 3-4.5 hrs)
When in doubt about cause: treat the most immediately life-threatening condition