Wilderness and Remote First Aid: Emergency Reference Guide

Wilderness and Remote First Aid
Emergency Reference Guide

Wilderness and Remote First Aid
Emergency Reference Guide
Special thanks to the Boy Scouts of America for facilitating the task force that produced the
Wilderness First Aid Curriculum and Doctrine Guidelines.
The following organizations provided review of the materials and/or support for the
American Red Cross Wilderness and Remote First Aid program:
Content in the Wilderness and Remote First Aid Emergency Reference Guide is based on the 2010
Boy Scouts of America (BSA) Wilderness First Aid Curriculum and Doctrine Guidelines and reflects
the 2010 Consensus on Science for CPR and Emergency Cardiovascular Care and the 2010
Guidelines for First Aid. The Wilderness First Aid Curriculum and Doctrine Guidelines were developed
through a task force facilitated by the BSA. The Wilderness and Remote First Aid course carefully
follows these guidelines.
The emergency care procedures outlined in this manual reflect the standard of knowledge and
accepted emergency practices in the United States at the time this manual was published. It is the
reader’s responsibility to stay informed of changes in the emergency care procedures.
PLEASE READ THE FOLLOWING TERMS AND CONDITIONS BEFORE AGREEING TO ACCESS
AND DOWNLOAD THE AMERICAN RED CROSS MATERIALS. BY DOWNLOADING THE
MATERIALS, YOU HEREBY AGREE TO BE BOUND BY THE TERMS AND CONDITIONS.
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Any rights not expressly granted herein are reserved by the Red Cross. The Red Cross does not permit
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The American National Red Cross.
Copyright © 2014 American Red Cross. ALL RIGHTS RESERVED.
The Red Cross emblem, American Red Cross® and the American Red Cross logo are trademarks of
The American National Red Cross and protected by various national statutes.
Published by Krames StayWell Strategic Partnerships Division
ISBN: 978-1-58480-629-5
Acknowledgments
The American Red Cross Wilderness and Remote First Aid program and supporting
materials were developed through the dedication of both employees and volunteers.
Their commitment to excellence made this program possible.
Contents
Skill Sheets
Removing Gloves 2
Checking an Injured or Ill Adult 3
Checking an Injured or Ill Child 5
CPR—Adult or Child 7
AED—Adult or Child 8
Conscious Choking—Adult
or Child 10
Injuries and Illnesses

As Reflected in Boy Scouts of America Wilderness
First Aid Curriculum and Doctrine Guidelines
Wilderness and Remote First
Aid Kits 12
CHECK—CALL—CARE for
the Wilderness 15
Abdominal Problems 20
Allergies and Anaphylaxis 22
Altitude Illnesses 26
Bone and Joint Injuries 29
Burns 40
Chest Injuries 43
Head (Brain), Neck and
Spinal Injuries 47
Heat-Related Illnesses 56
Hypothermia 59
Lightning 62
Shock and Heart Attack 64
Submersion Incidents (Drowning) 67
Wounds and Wound Infection 73
iv wilderness and remote first aid emergency reference guide

Special Situations
Abdominal Injuries and Illnesses 86
Asthma Attack 88
Cold-Related Emergencies 90
Confined Spaces 92
Diabetic Emergency 93
Emergency and
Non-Emergency Moves 94
Emergency Childbirth 98
Eye, Mouth and Lip Injuries 99
Poisoning 101
Seizures 104
Snow Blindness 106
Stroke 107
Wound Care 108
Index 109
Contents
v
Photo Credits
Select Photography: Barbara Proud
Table of Contents Photography: iperdesign, Inc.
Injuries and Illnesses Section Opener: © iStockphoto.com/Arthur Carlo Franco
Special Situations Section Opener: Image Copyright robcocquyt,
2009 Used under license from Shutterstock.com
Many thanks to Keith Van Derzee and the YMCA Camp Ockanickon
staff for opening the camp to us and providing assistance with the
photography shoot.
vi wilderness and remote first aid emergency reference guide

Skill
Sheets
removing gloves
REMOVING GLOVES
AFTER GIVING CARE AND MAKING SURE TO NEVER TOUCH THE BARE
SKIN WITH THE OUTSIDE OF EITHER GLOVE:
PINCH GLOVE
Pinch the palm side of one glove near the
wrist. Carefully pull the glove off so that it is
inside out.
SLIP TWO FINGERS

UNDER GLOVE
Hold the glove in the palm of the remaining
gloved hand. Slip two fingers under the
glove at the wrist of the remaining gloved
hand.
PULL GLOVE OFF

Pull the glove until it comes off, inside out,
so that the first glove ends up inside the
glove just removed.
4 DISPOSE OF GLOVES AND WASH HANDS

After removing the gloves:
■■ Dispose of gloves in the appropriate biohazard container.
■■ Wash hands thoroughly with soap and warm running water, if available.
■■ If soap and running water are unavailable and hands are not visibly soiled,
rub hands thoroughly with an alcohol-based hand sanitizer.
2 wilderness and remote first aid emergency reference guide

injured or ill adult
CHECKING AN INJURED
Checking an
OR ILL ADULT
APPEARS TO BE UNCONSCIOUS
Use disposable gloves and other personal protective equipment (PPE).
AFTER CHECKING THE SCENE FOR SAFETY, CHECK THE PERSON:
CHECK FOR RESPONSIVENESS

Tap the shoulder and shout, “Are you OK?”
IF NO RESPONSE, CALL 9-1-1 OR THE LOCAL EMERGENCY

NUMBER
Send someone to get an AED, if possible.
■■ If an unconscious person is face-down, roll him or her face-up keeping the
head, neck and back in a straight line.
If the person responds, obtain consent and call 9-1-1 or the local emergency
number for any life-threatening conditions. Check the responsive person from
head to toe and ask questions to find out what happened.
OPEN THE AIRWAY

Tilt head; lift chin.
Continued on next page
Skill Sheets 3
injured or ill adult
Continued
4 CHECK FOR BREATHING

Checking an
Check for no more than 10 seconds.

■■ Occasional gasps are not breathing.
5 QUICKLY SCAN FOR SEVERE BLEEDING

WHAT TO DO NEXT
■■ If there is no breathing, perform CPR or use an AED (if AED is immediately
available).
■■ If breathing, maintain an open airway and monitor breathing and for any
changes in condition.

injured or ill child
CHECKING AN INJURED
Checking an
OR ILL CHILD
APPEARS TO BE UNCONSCIOUS
Use disposable gloves and other PPE. Get consent from a parent or guardian,
if present.
AFTER CHECKING THE SCENE FOR SAFETY, CHECK THE CHILD:
CHECK FOR RESPONSIVENESS

Tap the shoulder and shout, “Are you OK?”
IF NO RESPONSE, SEND SOMEONE TO CALL 9-1-1 OR THE

LOCAL EMERGENCY NUMBER
Send someone to get an AED, if possible.
■■ If an unconscious child is face-down, roll him or her face-up keeping the
head, neck and back in a straight line.
If ALONE, give about 2 minutes of care, then call 9-1-1.
If the child responds, call 9-1-1 or the local emergency number for any
life-threatening conditions and obtain consent to give care. Check the responsive
child from head to toe and ask questions to find out what happened.
OPEN THE AIRWAY

Tilt head back slightly; lift chin.
4 CHECK FOR BREATHING

Check for no more than 10 seconds.
■■ Occasional gasps are not breathing.
Continued on next page
Skill Sheets 5
injured or ill child
Continued
5 IF NO BREATHING,
Checking an
GIVE 2 RESCUE BREATHS

■■ Tilt the head back and lift the chin up.
■■ Pinch the nose shut then make a
complete seal over the child's mouth.
■■ Blow in for about 1 second to make the
chest clearly rise.
■■ Give rescue breaths, one after the other.
If chest does not rise with the initial rescue
breath, retilt the head before giving the second breath.
If you witnessed the child suddenly collapse, skip rescue breaths and start CPR.
6 QUICKLY SCAN FOR SEVERE BLEEDING
WHAT TO DO NEXT
■■ If the second breath does not make the chest rise, the child may be choking.
Give care for unconscious choking by performing CPR, starting with
compressions.
■■ If there is no breathing, perform CPR or use an AED (if AED is immediately
available).
■■ If breathing, maintain an open airway. Monitor breathing and for any changes
in condition.

cpr—adult or child
CPR–ADULT OR CHILD
No Breathing
After checking the scene and the injured or ill person:
GIVE 30 CHEST COMPRESSIONS

Push hard, push fast in the middle
of the chest at a rate of at least 100
compressions per minute.
■■ Adult: Push at least 2 inches deep.
■■ Child: Push about 2 inches deep.
The person must be on firm, flat surface.
GIVE 2 RESCUE BREATHS

■■ Tilt the head back and lift the chin up.
■■ Pinch the nose shut then make a
complete seal over the person’s mouth.
■■ Blow in for about 1 second to make the
chest clearly rise.
■■ Give rescue breaths, one after the other.
If chest does not rise with the initial rescue
breath, retilt the head before giving the second breath.
If the second breath does not make the chest rise, the person may be choking.
After each subsequent set of chest compressions and before attempting breaths,
look for an object and, if seen, remove it. Continue CPR.
DO NOT STOP
Continue cycles of CPR. Do not stop except in one of these situations:
■■ You find an obvious sign of life (such as breathing).
■■ An AED is ready to use.
■■ Another trained responder or EMS personnel take over.
■■ You are too exhausted to continue.
■■ The scene becomes unsafe.
WHAT TO DO NEXT
■■ Use an AED as soon as one is available.
■■ If at any time you notice an obvious sign of life, stop CPR and monitor
breathing and for any changes in condition.
Skill Sheets 7
AED—Adult or child
AED–ADULT OR CHILD
OLDER THAN 8 YEARS
OR WEIGHING MORE
THAN 55 POUNDS
No Breathing
AFTER CHECKING THE SCENE AND THE INJURED OR ILL PERSON,

HAVE SOMEONE CALL 9-1-1:
TURN ON AED
Follow the voice and/or visual prompts.
WIPE BARE CHEST DRY

Remove any medication patches with a gloved hand.
ATTACH PADS
Do not use pediatric AED pads or
equipment on an adult or child older than
8 years or weighing more than 55 pounds.
4 PLUG IN CONNECTOR,
IF NECESSARY

AED—Adult or child
5 STAND CLEAR
Make sure no one, including you, is
touching the person.
■■ Say, “Everyone, STAND CLEAR.”
6 LET THE AED ANALYZE HEART RHYTHM

Push the “analyze” button, if necessary.
7 DELIVER SHOCK, IF ADVISED

■■ Make sure no one, including you, is
touching the person.
■■ Say, “Everyone, STAND CLEAR.”
■■ Push the “shock” button, if necessary.
8 PERFORM CPR
After delivering the shock, or if no shock is advised:
■■ Perform about 2 minutes (or 5 cycles) of CPR.
■■ Continue to follow the prompts of the AED.
If at any time you notice an obvious sign of life, stop CPR and monitor breathing
and for any changes in condition.
If two trained responders are present, one should perform CPR while the other
operates the AED.
Skill Sheets 9
conscious choking—
CONSCIOUS CHOKING–
adult or child
ADULT OR CHILD
CANNOT COUGH, SPEAK OR BREATHE
AFTER CHECKING THE SCENE AND THE INJURED OR ILL PERSON,

HAVE SOMEONE CALL 9-1-1 AND GET CONSENT:
GIVE 5 BACK BLOWS

Bend the person forward at the waist and
give 5 back blows between the shoulder
blades with the heel of one hand.
Stand or kneel behind a child, depending
on his or her size.
GIVE 5 ABDOMINAL THRUSTS

■■ Place a fist with the thumb side against
the middle of the person’s abdomen,
just above the navel.
■■ Cover your fist with your other hand.
■■ Give 5 quick, upward abdominal thrusts.
CONTINUE CARE
Give sets of 5 back blows and 5 abdominal
thrusts until the:
■■ Object is forced out.
■■ Person can cough forcefully or breathe.
■■ Person becomes unconscious.
WHAT TO DO NEXT
■■ If the person becomes unconscious, call 9-1-1 if not already done.
■■ Carefully lower him or her to the ground and begin CPR, starting with
compressions.

Injuries
and
Illnesses
As Reflected in Boy Scouts of America Wilderness

First Aid Curriculum and Doctrine Guidelines
Wilderness and Remote
First Aid Kits
Include the following contents in
personal and group wilderness and
remote first aid kits (Figure 1):
Personal First Aid

Kit
n Adhesive bandages (6)
n Sterile gauze pads, 3-×-3-inch (2)
n Adhesive tape (1 small roll)
n Moleskin, 3-×-6-inch (1)
n Soap (1 small bar) or alcohol-based
Figure 1
hand sanitizing gel (1 travel-sized
bottle)
n Wound gel (1 small tube)
n Scissors (1 pair)
n Latex-free medical exam gloves (1 pair)
n Cardiopulmonary resuscitation (CPR) breathing barrier (1)
n Tweezers (1)
n Wilderness and Remote First Aid Report Form/Rescue Request and pencil
Group First Aid Kit

n Gauze bandage, 3-inch rolls (2)
n Self-adhesive bandage, 2-inch roll (1)
n Adhesive tape, 1-inch rolls (2)
n Alcohol pads (12)
n Povidone-iodine pads (12)
n Assorted adhesive bandages (1 box)
n Elastic bandages, 3-inch-wide (2)
n Sterile gauze pads, 4-×-4-inch (12)
n Moleskin, 3-×-6-inch (4)

n Gel pads for blisters and burns (2 packets)
n Wound gel (1 tube)
First Aid Kits

n Hydrocortisone cream 1 percent (1 tube)
n Triangular bandages (4)
n Soap (1 small bar) or alcohol-based hand sanitizing gel (1 travel-sized bottle)
n Scissors (1 pair)
n Tweezers (1 pair)
n Safety pins (12)
n Latex-free medical exam gloves (6 pairs)
n Protective goggles/safety glasses (1 pair)
n CPR breathing barrier (1)
n Wilderness and Remote First Aid Report Form/Rescue Request and pencil
n Optional items:
 Instant cold compress
 Space blanket
 Original size SAM® Splint
Additional Items Mentioned in Course

for Consideration
n Denture adhesive
n Irrigation syringe
n Thermometer
n Commercial tourniquet
n Ibuprofen
n Chewable low-dose aspirin (81 mg each)
n Acetaminophen
n Oral antihistamine
n Properly labeled prescription medications for individuals (e.g., EpiPen®,
nitroglycerin, high-altitude drugs)
n Needle
n Alcohol (and/or vinegar)
n Tampons/pads
n Decongestant nasal spray
n Over-the-counter diarrhea medication
Injuries and Illnesses 13

n Zinc oxide powder

n Chemical heat packs
First Aid Kits
NOTE
The person should only take medication if he or she can swallow and has
no known contraindications. Individuals should read and follow all label
or health care provider instructions. Check state and local regulations
regarding use of prescription and over-the-counter medications. Aspirin
and products containing aspirin should not be given to a child younger
than 19 years of age if he or she has a fever-causing illness.
Other Important Items That Are Useful in

First Aid and Other Emergencies
n Full water bottle(s) (especially in waterless areas)
n Water purification and backup
n Ground insulation (e.g., a “sit-upon” camp mat)
n Shelter (could be a plastic tube shelter)
n SAM® Splint
n Plastic bag
n Emergency blanket
n Signaling device (e.g., mirror, whistle)
n Duct tape
n Identification/medical form
n Special environmental essentials (e.g., ice axe, cold weather sailing gear)
NOTE
No piece of equipment is as valuable as the person who uses it.

heck Call Care
C
for the Wilderness
If you find yourself in an emergency, you should follow three basic emergency
action principles: CHECK—CALL—CARE. These principles will help guide you in
caring for the injured or ill person and will help ensure your own safety.
CHECK:
Check the Scene, the Resources and the Person
CHECK the Scene
n Establish control and recognize the emergency.
n CHECK the scene before you approach to make sure it is safe for you, the
person, other members of the group and any bystanders.
n Follow standard precautions to prevent disease transmission.
n Obtain consent from a conscious person or, if a minor, from the parent or
guardian. If the person is unconscious, consent is implied.
n CHECK for clues about the mechanism of injury (MOI) or nature of the illness.
n Move the person only if necessary to prevent additional harm.
NOTE
If the scene is not safe and there is a way to call for additional help, do
so quickly. Be ready to continue checking and caring for the person if the
scene becomes safe.
CHECK the Resources

n Identify available resources, including materials and additional
trained responders.

CHECK—call—care for
CHECK the Person

the wilderness
Primary (Initial) Assessment

Use the ABCDEs to assess life-threatening
conditions.
n A = If the person is unconscious,
use the head-tilt/chin-lift technique

to open the airway (Figure 1).
A person who is speaking or
breathing has an open airway, but
ask if he or she is having problems
breathing.
n B = Look, listen and feel for
movement, normal breathing
and quality of breathing (for Figure 1
no more than 10 seconds)
(Figure 2). If an unconscious
adult is not breathing or is not
breathing normally, assume a
cardiac emergency and begin
cardiopulmonary resuscitation
(CPR). For a child or a known
drowning or respiratory emergency,
give 2 rescue breaths before
starting CPR.
Figure 2
n C = Assess the person's circulation by
scanning the body for severe bleeding. If severely bleeding, use direct pressure to
control the bleeding.

n D = Look for any disability as a result of damage to the spinal cord. If you
the wilderness
suspect a spinal injury, minimize movement of the head, neck and spine.
Manually support the head in the position found.
n E = Assess the threat of the environment and expose any injuries. Look
for signs and symptoms of exposure to extreme environmental conditions,

especially extreme heat and cold weather, which can cause changes to the
body’s temperature and threaten a person’s life. It is important to protect the
person from extreme conditions, but if necessary, you may expose part of the
person’s skin to assess the damage and to give care.
If you find a life-threatening condition during the primary assessment, CALL for
help if possible and give CARE for the condition found. The caller should be
prepared with information about the person, location/environment and resources
(people and materials). If you do not find a life-threatening condition, continue to
the secondary assessment and SAMPLE history before giving specific care for an
injury or illness.
Secondary (Focused) Assessment

Hands-On Physical Exam
Check the person head to toe during the hands-on physical exam, going in the
following order: head, face, ears, neck, chest, abdomen, pelvis, genitalia, each
arm, each leg and back.
n Look for DOTS:
 D = Deformity
 O = Open injuries
 T = Tenderness
 S = Swelling
n Check circulation, sensation and motion (CSM) at each extremity.
n Assess skin color, temperature and moisture.
Level of Consciousness
Use AVPU to describe the person's level of consciousness (LOC).
n A = Alert and able to answer orientation questions
 A+O×4: knows who (name), where (current location), when (day) and
what happened
 A+O×3: knows who, where and when
 A+O×2: knows only who and where
 A+O×1: knows only who

n V = Responds only to verbal stimuli (e.g., by grimacing or rolling away from

the wilderness
your voice when you speak or shout)

n P = Responds only to painful stimuli (e.g., pinch)
n U = Unresponsive to any stimuli
Normal Vital Signs for an Adult

n Respiratory rate (breath): 12 to 20 breaths per minute; regular and
unlabored pace
n Heart rate (pulse): 60 to 100 beats per minute; strong and regular
n Skin color, temperature and moisture: pink, warm and dry to the touch
SAMPLE History
Use the SAMPLE history to gain essential information about the person's medical
history. Ask the person questions, such as those listed below, and record the
answers on the Wilderness and Remote First Aid Report Form/Rescue Request:
n S = Signs and symptoms. What are your signs and symptoms (i.e., what
hurts)? How do you feel? Are you experiencing any pain, nausea, light-
headedness or other things that are not visible?
n A = Allergies. Do you have any known allergies or allergic reactions? What
happens? Has there been any recent exposure?

n M = Medications. What medications are you taking? Are they over-the-
counter or prescription? What is the medication for? When was it last taken?
Can you tell me where the medication is so we can keep it with you?
n P = Pertinent past medical history. Has anything like this happened before?
Are you currently under a health care provider's care for anything? Could you
be pregnant (if a woman)?
n L = Last intake and output. When did you last eat or drink? How much?
Are you cold, hungry or exhausted? When did you last urinate and defecate?
Were they normal?
n E = Events leading up to the injury or illness. What led up to the incident?
When did it happen? How did it happen, in order of occurrence?
It is often appropriate for the leader of a wilderness group to travel with a health
history for each participant. Those forms, frequently combined with consent for
treatment, may provide useful information to emergency response personnel and
aid in collecting the SAMPLE history. However, each step in the SAMPLE history
still must be asked, even if such forms are available for reference.

CALLing for Help:
the wilderness
Stay or Go, Fast or Slow
Being in the wilderness or remote setting makes CALLing important to everyone
involved. Ideally, immediate verbal communication is available by phone or radio
to predetermined emergency agencies. Primary and backup communication
procedures should be established prior to a remote trip. Such procedures could
include sending members of the party to the closest area where a signal can be
established or to the closest phone.
If advanced care is delayed, a decision to stay or to evacuate must be made. If

the decision is to stay, continue CARE as trained and as needed. If evacuation is
necessary, determine if it should be fast or slow. Implement a pre-trip plan using
available resources. Throughout the evacuation, continue CARE as trained until
the injury or illness is resolved or other help arrives.
CARE
CARE for the conditions found, prioritizing care by the severity of the injury
or illness.
For more information on evacuation guidelines and care, go to the

NOTE
specific injury or illness in this guide.

Abdominal Problems
Abdominal pain and discomfort is a common problem in the wilderness. It ranges
from mild to life threatening. You may never know the source of the problem, but
you must be able to manage mild situations and know when a problem is serious
enough to require evacuation.
Stomachache
When CHECKing the person, look, listen and feel for:
n Gradually increasing, widespread abdominal discomfort, often worse in the
lower abdomen.
n Cramping that comes and goes.
n Nausea and vomiting.
n Diarrhea.
To give CARE:
n Keep the person well hydrated.
n Give the person a bland diet, if he or she is not vomiting.
n Maintain good personal and group hygiene.
Diarrhea
n Frequent loose, watery stools.
n Presence of gastroenteritis (stomach flu).
To give CARE:
For mild diarrhea:
n Give the person water or diluted, clear, non-citrus fruit juices or sports drinks.
n If the person is not vomiting, he or she can eat rice, grains, bananas and oats,
or other bland diet items.

n Avoid fats, dairy products, caffeine and alcohol.

abdominal problems
For persistent diarrhea:
n Replace electrolytes lost in the stool using oral rehydration solutions.
 If available, give a carbohydrate-electrolyte solution such as a commercial sports
drink or fruit juice.

 Or, add 1 teaspoon of salt and 8 teaspoons of sugar to a quart of water.
 Have the person drink about ¼ of the solution every hour, along with as much
water as tolerated.
n Use over-the-counter medication for watery diarrhea, if available.
NOTE
regarding use of prescription and over-the-counter medications.
n Have the person avoid fats, dairy products, caffeine and alcohol.
n If the person is not vomiting, allow him or her to eat rice, grains, bananas and
potatoes, or other bland diet items.
Serious Abdominal Pain

n A fever higher than 102º F, which may present itself as chills or shivers.
n Persistent and/or constant pain lasting more than 12 hours.
n Pain in a specific part of the abdomen, especially if the person guards the
painful area.
n Tenderness, abdominal rigidity (stiffness) and/or distention (swelling).
n Pain that increases with movement, jarring or when putting a foot down
while walking.
n Blood in vomit, feces or urine.
 In vomit, blood looks like coffee grounds.
 In feces, blood may be black, like tar.
 In urine, blood is reddish color.
n Nausea, vomiting and/or diarrhea that persists for longer than 24 hours,
especially if the person is unable to stay well hydrated.
n Pain associated with the signs and symptoms of pregnancy.
n Vaginal bleeding.
n Pain associated with the signs and symptoms of shock.

To give CARE:
n Manage ABCDEs.
 Watch and care for shock.
n Give nothing by mouth, unless evacuation will be delayed by more
than a few hours, in which case give only small sips of water or ice chips,
if tolerated.
CALLing for Help: Guidelines for Evacuation

n Evacuate slowly—GO SLOW—anyone with persistent abdominal discomfort.
n Evacuate rapidly—GO FAST—anyone with signs and symptoms of a serious
abdominal problem.
Allergies and Anaphylaxis

When the body recognizes an allergen, a foreign substance that causes an
allergic reaction, its immune system releases histamines and other chemicals
for protection. An allergic reaction happens when the body produces too much
of these substances. Allergic reactions can be mild and non-life-threatening,
such as itchy skin and a stuffy nose. However, a severe allergic reaction, called
anaphylaxis, is life threatening and must be treated immediately or the person
will die.
Non-Life-Threatening Allergic Reactions

n Hives or rash (Figure 1).
n Itching.
n Gastrointestinal complaints, such
as nausea (in individuals with food

allergies).
Figure 1

To give CARE:
allergies and
n Remove the allergen (e.g., bees, food) or move the person away from the allergen.
anaphylaxis
n If the person can swallow and has no known contraindications, help the person
self-administer an antihistamine.
NOTE
Anaphylaxis
It is important to know the signs and symptoms and be able to differentiate
between a mild allergic reaction and a severe reaction (anaphylaxis). Anaphylaxis
requires special care. The only way to reverse anaphylaxis is by immediately
injecting the person with epinephrine, which
reverses the overproduction of histamines.
Injectable epinephrine systems are available
by prescription only, in spring-loaded syringes
that function when pressed in the thigh. Two
systems widely available are the EpiPen® Figure 2
(Figure 2) and Auvi-Q®.

n Any of the following three scenarios:
 A specific combination of signs and symptoms. First, look for any skin symptom,
such as hives, itchiness or a red or flushed face, or look for swollen lips. Then,
check for trouble breathing or signs of shock, such as pale, cool and sweaty skin;
lightheadedness; weakness; or anxiety.
 When you suspect someone has come into contact with an allergen, look for
at least two of the following signs and symptoms: a skin symptom or swollen lips;
difficulty breathing; signs of shock; or nausea, vomiting or cramping.
 You know someone has come into contact with an allergen and shows any
signs or symptoms of shock.

To give CARE:
allergies and
n Keep everyone calm.

anaphylaxis
n Look for a medical identification
(ID) tag or bracelet that may warn

of a severe allergy or indicate that
the person has been prescribed an
auto-injector (Figure 3).
n Try to determine whether the
substance that triggered the

allergic reaction is still present
and if the reaction is likely to
happen again.
 Remove the allergen or move the Figure 3
person away from the allergen.
n Help the person self-administer an injection of epinephrine, if necessary.
n A second dose should only be given when advanced medical help is delayed
and symptoms do not improve or improve and get worse again.
NOTE n The person should only take medication if he or she can swallow
and has no known contraindications. Individuals should read and
follow all label or health care provider instructions. Check state and
local regulations regarding use of prescription and over-the-counter
medications.
n Make sure you and any others in the group know if a person in the
group has allergies and carries an epinephrine auto-injector and where
the person carries his or her epinephrine auto-injector.
n If using an EpiPen®:
 Check the label to confirm that the prescription of the auto-injector is for
this person.
 Check the expiration date of the auto-injector. If it has expired, DO NOT use it.
If the medication is visible, confirm that the liquid is clear and not cloudy. If it is
cloudy, DO NOT use it.

 Locate the outside middle of one
thigh to use as the injection site
allergies and
anaphylaxis
(Figure 4).
 Grasp the auto-injector firmly in
your fist, and pull off the safety cap

with your other hand (Figure 5).
 Hold the tip (needle end) near the
person’s outer thigh so that the

Figure 4
auto-injector is at a
90-degree angle to the thigh. Do
not place your thumb over the end.
 Quickly and firmly push the tip
straight into the outer thigh (it will

go through light clothing) (Figure
6). You will hear a click.
 Hold the auto-injector firmly in place
for 10 seconds, then remove it from

the thigh and massage the injection
Figure 5
site for several seconds.
 Handle the auto-injector carefully,
placing it in a safe container

(Figure 7). Give the used
auto-injector to more advanced
medical personnel when they arrive.
Figure 6
Figure 7

NOTE n Recheck the person’s airway, breathing and circulation and observe
his or her response to the epinephrine.
n A person’s breathing and heart rate are typically higher after a dose of
epinephrine and the person may also be restless.
n Be aware that EpiPen® and Auvi-Q® auto-injectors only provide one dose.

n Non-life-threatening reactions that can be managed in the field do not
require evacuation.
n Evacuate rapidly—GO FAST—anyone treated for or suffering from anaphylaxis.
During evacuation, the person should be well hydrated and kept on a regimen
of oral antihistamines.
Altitude Illnesses
Altitude illnesses occur when people at a high altitude do not have enough
oxygen in their blood because the air pressure is too low. The three altitude
illnesses most likely to develop in the wilderness are acute mountain sickness
(AMS), high altitude cerebral edema (HACE) and high altitude pulmonary
edema (HAPE).
Acute Mountain Sickness

AMS commonly occurs in a person who has recently reached an altitude of
around 6500 to 8000 feet. If signs and symptoms of AMS appear at lower
altitudes, they are probably the result of another condition, such as dehydration
or heat illness. If untreated, AMS may progress to HACE or HAPE, which is more
severe.

n Someone who has recently arrived at an altitude of around 6500 to 8000 feet
or more.
n Headache.
n Loss of normal appetite.
n Nausea, with or without vomiting.
n Insomnia.
n Lassitude (unusual weariness or exhaustion).

To give CARE:
altitude illnesses
n Descend (go down) to a lower altitude or stop ascending (going up) and wait
for improvement before going higher.
n Administer oxygen if available and you are trained to do so. This is especially
helpful during sleep.

n Help the person self-administer recommended dosages of aspirin or
acetaminophen for headaches (if the person is able to swallow and has no
known contraindications).
n Care for the illness, not just the symptoms.
 If prescribed and recommended by the person’s health care provider, help
the person self-administer medication for altitude illness (e.g., acetazolamide,

dexamethasone) based on label instructions.
 Many persons with AMS usually respond to these medications within 12 to
24 hours.
NOTE
regarding use of prescription and over-the-counter medications. Anyone
going to an altitude greater than around 6500 to 8000 feet should
discuss this with his or her personal health care provider.
High Altitude Cerebral Edema

HACE is caused by swelling of brain tissue, which increases pressure on the
brain until it fails to function properly, eventually resulting in death.

n Loss of coordination (ataxia).
 Inability to walk a straight line or stand straight with feet together and eyes closed
n Severe headache that is not relieved by rest and medication.
n Bizarre changes in personality.
n Possible seizures and/or coma.

To give CARE:
altitude illnesses
n Descend (go down) to a lower altitude as soon as possible.

n Administer oxygen if available and you are trained to do so.
n Keep the person from getting chilled or overheated. Cold temperatures put
more pressure on the respiratory system.
n If prescribed and recommended by the person’s health care provider, help
the person self-administer medication for altitude illness (e.g., acetazolamide,
dexamethasone) based on label
instructions.
n Use a portable hyperbaric chamber
Courtesy of Chinook Medical Gear, Inc.

if available and you are trained to
do so (Figure 1). DO NOT use
a portable hyperbaric chamber
instead of descending. Moving to a
lower altitude is the only definitive
Figure 1
care for the severely ill person.
NOTE
regarding use of prescription and over-the-counter medications. Anyone
going to an altitude greater than around 6500 to 8000 feet should
discuss this with his or her personal health care provider.
High Altitude Pulmonary Edema

HAPE is caused by fluid collecting in the air spaces of the lungs. If enough fluid
collects, the person cannot breathe adequately, and death may result.

n Dry cough, soon followed by shortness of breath, even at rest.
n Shortness of breath that becomes more pronounced.
n Possible chest pain.
n Cough that becomes more productive, first producing frothy sputum, later
producing reddish sputum.

To give CARE:
n Descend (go down) to a lower altitude as soon as possible. A descent of
1000 to 1500 feet may produce remarkable results.
n Keep the person from becoming chilled or overheated. Cold temperatures put
more pressure on the respiratory system, particularly in HAPE.

n Administer oxygen if available and you are trained to do so.
n Use a portable hyperbaric chamber, if available and you are trained to do
so. DO NOT use a portable hyperbaric chamber instead of descending.

Moving to a lower altitude is the only definitive care for a severely ill person.

n Stopping the ascent, descending and evacuation must be considered.
n A person with AMS should stop ascending until the signs and
symptoms resolve.
n A person with AMS does not need to evacuate unless the signs and symptoms do
not resolve. If the illness does not resolve or it gets worse, descent is mandatory.
n Evacuate rapidly—GO FAST—to a lower altitude (descend at least 1000 to
1500 feet) anyone with HACE or HAPE.

 Anyone with HACE or HAPE must be evaluated as soon as possible by a health
care provider once a lower altitude has been reached.
Bone and Joint Injuries

There are four main types of bone and joint injuries:
n Strains: overstretched muscles and/or tendons that attach muscles to bones
n Sprains: injuries to ligaments that hold bones together at joints
n Fractures: a break, chip or crack in a bone
n Dislocations: movement of a bone away from its normal position at a joint
Because these injuries can look alike, you may have difficulty determining exactly
which type of injury has occurred. This should not be a problem because in most
cases, the care you give will be the same.

bone and joint injuries
General Considerations
n Deformity, open injuries, tenderness and swelling (DOTS).
n Moderate or severe pain or discomfort.
n Bruising (may take hours to appear).
n Inability to move or use the affected body part normally.
n Broken bone or bone fragments sticking out of a wound.
n Feeling of bones grating or the sound of bones grating.
n Feeling or hearing of a snap or pop at the time of injury.
n Loss of circulation, sensation and motion (CSM) beyond the site of the injury,
including tingling, cold or bluish color.
n Cause of injury (e.g., a fall), that suggests the injury may be severe.
To give CARE:
n Determine if the person can use the injured body part.
n Have the person rest and relax.
n Carefully remove clothing to look at the injury site if the area is not
already exposed.
n Ask how the injury happened and if there are any painful areas. (High-speed
impacts cause more damage than low-speed impacts.)
n Visually inspect the entire body from head to toe. Compare the two sides of
the body, then carefully check each body part.
n Notice if the person can easily move the injured part or if he or she guards it to
prevent movement.
n Give care using the RICE method:
 R = Have the person rest the injured area and avoid any movement that
causes pain.
 I = Immobilize the injured area. Stabilize or immobilize the injured part on the
ground or with a splint if movement is needed.

 C = Apply a cold pack or an ice and water mixture in a plastic bag to the injured
area. Place a layer of gauze or cloth between the cold or ice pack and the skin
to prevent damaging the skin. Leave the ice pack on for about 20 minutes. If you
do not have ice or a cold pack, soak the injured part in cold water or, in warmer
months, wrap the part in wet cotton. DO NOT apply an ice or cold pack directly on
an open fracture site.

 E = Elevate the injured area above the heart level if possible. DO NOT elevate if
you suspect a fracture or if moving the injured area causes pain.

n After about 20 minutes of RICE, remove the cold and let the joint warm
naturally for 10 to 15 minutes before testing to determine whether the joint can
be used.
n The injury will heal faster if RICE is repeated 3 to 4 times a day until pain and
swelling subside.
Splinting
Follow These Principles:
n In a wilderness or remote setting, chances are the person will need to
be moved. The general rule in the delayed-help situation is: “When in
doubt, splint!”
n Splint only if you can do so without causing more pain.
n Remove rings, bracelets or watches from injured extremities.
n Make the splint out of something rigid enough to provide support, and always
place padding between the splint and the body part.
n Fill in any hollows with soft padding.
n Be sure the splint is long enough to restrict the movement of the joints above
and below a broken bone, or the movement of the bones above and below an
injured joint.
n Prepare the splint before moving the limb.
n Splint an injury in the position of function or as close to it as possible.
These positions include spine, neck and pelvis in-line, with padding in
the small of the back (Figure 1); legs almost straight with padding
behind the knees for slight flexion (Figure 2); feet at 90 degrees to
Figure 1 Figure 2

Figure 3 Figure 4
legs (Figure 3); arms flexed to cross

the heart (Figure 4); and hands in a
functional curve with padding in the
palms (Figure 5).
n Splint the injured area and the
bones or joints above and below
the injury.
n Attach the splint with a number of
Figure 5
bandages tied securely with knots.
n Monitor the injured area. Check CSM below the site of the injury before and
after splinting and with every vital signs check. If there is no CSM, remove,
loosen or reposition the splint.
Application of a Sling-and-Swathe (Sling and Binder)

n Support the injured body part above and below the site of the injury.
n Check for feeling, warmth and color.
n Place a triangular bandage under the injured arm and over the uninjured
shoulder to form a sling, keeping
the wrist higher than the elbow.
n Tie the ends of the sling at the
side of the neck, placing padding
beneath the knot.
n Bind the injured body part to
the chest with a folded
triangular bandage.
n Recheck for feeling, warmth and
color (Figure 6). Figure 6

Application of an Anatomic Splint
n For arms or legs, place several
folded triangular bandages above

and below the injured body part.
n Place the uninjured body part next
to the injured body part.

n Tie triangular bandages securely
(Figure 7). For fingers or toes,

secure fingers to fingers and toes to
toes with tape. Figure 7
n Recheck for feeling, warmth
and color.
NOTE
If you are not able to check warmth and color because a sock or shoe is
in place, check for sensation.
Application of a Soft Splint

n Place several folded triangular
bandages above and below the
injured body part.
n Gently wrap a soft object
(e.g., a folded blanket or pillow)
around the injured body part.
n Tie triangular bandages securely
with knots (Figure 8).
n Recheck for feeling, warmth and Figure 8
color.
NOTE
If you are not able to check warmth and color because a sock or shoe is
in place, check for sensation.

Application of a Rigid Splint

n Place the rigid splint (e.g., a board)
under the injured body part and the

joints that are above and below the
injured body part.
n Tie several folded triangular
bandages above and below the

injured body part (Figure 9).
n Recheck for feeling, warmth
and color. Figure 9
NOTE
If a rigid splint is used on an injured forearm, immobilize the wrist and
elbow. Bind the arm to the chest using folded triangular bandages or
apply a sling.
Strains and Sprains

When CHECKing the person:
n Have the person actively move the injured joint and evaluate the pain involved.
n Move the joint yourself and evaluate the person's response.
n If the joint appears to be usable, have the person test it with his or her
body weight.
n Tell the person not to use the injured part if movement causes pain.
n If the injury is to the lower part of the body and the person can use the injured
part without pain, offer to provide an appropriate support (e.g., for an injured
knee, provide a walking splint, which restricts movement of the knee without
putting pressure on the kneecap).
To give CARE:
n Splint any injured bone or joint that the person cannot use.

Fractures
When CHECKing the person for a suspected fracture:
n Determine if the injured part looks broken by comparing it to the uninjured
side. Ask the person if he or she thinks the part is broken.
n Gently touch the injured area and look for these signs of a fracture:
 The person reacts to your touch.
 The muscles appear to be spasming.
 The injured area feels unstable.
 One spot hurts noticeably more than others.
n Check for CSM beyond the site of the injury. Loss of a pulse,
numbness, tingling and inability to move are all signs of serious
fracture-related complications.
To give CARE:
General:
n Splint any injury that you suspect is a fracture. Always use padding between
the splint and the body part.
n Continue to check CSM after splinting to ensure that circulation is not cut off.
For a jaw fracture:

n Hold the jaw in place with a wide wrap that goes around the head.
n Make sure the wrap can be removed quickly if the person needs to vomit.
For a collarbone fracture:

n Secure with a sling-and-swathe.
n Make the sling from triangular bandages or improvise by lifting the tail of the
person's shirt up over the arm on the injured side and pinning it in place.
n Be sure the sling lifts the elbow to take pressure off the shoulder.
For a lower arm fracture (including the wrist and hand):

n Secure the injured part to a well-padded, rigid support and place it in a
sling-and-swathe.
n Place a roll of something soft in the hand to keep it in a position of function. If
bones of the hand are damaged, be sure to secure the hand to the splint with
lots of padding.

For a broken finger:

n Tape the broken finger to nearby uninjured fingers with padding between
the fingers.
For an upper arm fracture:

n Place the arm in a sling-and-swathe.
n Secure the broken bone to the person’s chest with a wide, soft wrap.
For a rib fracture:

n Protect the injured rib by supporting the arm on the injured side with a
sling-and-swathe.
n DO NOT wrap a band snugly around the person’s chest.
n Encourage the person to take deep breaths regularly, even if it hurts, to keep
the lungs clear.

n Watch the person for increasing trouble breathing.
For a pelvis or hip fracture:

n Secure the person on a rigid litter
(stretcher) before attempting a
carry-out.
n Place wide conforming wraps (e.g.,
a sheet or blanket) and tie around

the pelvis to provide some support
and security.
Figure 10
n Secure the legs comfortably to
each other (Figure 10).

n Be sure to watch the person for signs and symptoms of shock due to internal
bleeding, which is common with pelvic fractures.
For a leg fracture (including ankle and foot):

n Secure the injured part on a well-padded, rigid support that includes
immobilization of the ankle and foot.
n Pad behind the knee for comfort.

Complicated Fractures
To give CARE:
For an angulated fracture:
If the limb is severely deformed or distorted, the bones may be straightened
through gentle in-line traction to reduce pain. To do this:
n Pull with gentle traction along the line in which the bone lies. This will relax the
muscle and reduce the pain.

n Slowly and gently move the broken bone back into normal alignment.
n DO NOT use force.
n DO NOT continue if the person complains of increasing pain.
n Splint the injury once the injured part is aligned.
For an open fracture:

n Irrigate the wound and dress it appropriately. (Go to “Wounds” section for
information on how to irrigate and dress the fracture.)
n If bone ends stick out of the wound and a health care provider is longer than 4
to 6 hours away:
 Clean the wound and bone ends without touching them.
 Apply gentle in-line traction to the fracture to pull the bone ends back under
the skin.
 Dress the wound.
 Splint the fracture.
Dislocations
Follow These Principles:
n The only treatment available for certain dislocations that occur in the
wilderness is splinting in the most comfortable position.
n In other cases, the joint can be put back in its normal position through
a process called reduction. If you are going to attempt a reduction, it is

important that you:
 Work quickly but calmly. Usually, the sooner a reduction is done, the easier it is on
the injured person and the responder.

 Encourage the person to relax, with particular concentration on the injured joint.
 Stop if the pain increases dramatically.
 Splint the injury after the joint is back in its normal position.


n A joint that does not look “right.” (Shoulder dislocations are the most
common type.)
n Pain and/or loss of normal range of motion.
n A bump, ridge or hollow that does not normally exist.
To give CARE:
For a shoulder dislocation:
n Use the Stimson technique right away:
 Position the person face-down across a firm surface (e.g., a rock or log) with the
arm on the injured side dangling

down vertically.
 Help the person to relax.
 With a soft cloth, tie something that
weighs about 5 to 10 pounds to the

dangling wrist.
 Wait. This process takes about 20
to 30 minutes to work (Figure 11).

Figure 11
OR
n Have the injured person perform a
similar technique on him- or herself

right away:
 Standing or sitting, the person
should pull the injured arm straight

and forward, away from the body,
by gripping the wrist with the
opposite hand (Figure 12).
Figure 12
n Place the injured arm in a sling-and-
swathe as soon as the shoulder is returned to its normal position.
n DO NOT bind the person’s arm in case he or she needs to use the arm in an
emergency (e.g., escaping from an overturned raft).

For a finger or toe dislocation:
n Keeping the injured finger or toe
partially flexed (bent), pull on the
end with one hand while gently
pressing the dislocated joint back
into place with your other thumb
(Figure 13).
n Place a gauze pad between
Figure 13
the injured finger or toe and an
uninjured neighboring finger or toe.
n Tape the injured finger or toe to the uninjured neighboring finger or toe.
n DO NOT tape directly over the joint itself.
For a kneecap dislocation:

n Apply gentle traction to the leg to straighten it out. This may cause the
kneecap to pop back into place without any further treatment.
n If the kneecap does not pop back into place after the leg is straightened,
massage the thigh and use your hand to push the kneecap gently back into
normal alignment.
n Apply a splint that does not put pressure on the kneecap. This way, the person
may be able to walk.

n If a person is able to use the injured body part, the person’s degree of
discomfort should determine whether and how to evacuate.
n Evacuate slowly—GO SLOW—anyone who cannot use the injured body part
or who is suffering from a first-time dislocation. You might be able to avoid

evacuation if the injury is to the outer joints of the fingers or toes.
n Evacuate rapidly—GO FAST—anyone with an angulated fracture; open fracture;
fracture of the pelvis, hip or thigh; or more than one long bone fracture.
n Evacuate rapidly—GO FAST—anyone whose injuries create a decrease in CSM
beyond the injury itself.

Burns
Burns are caused by heat, chemical reactions, electricity (including lightning) and
radiation (including sunburn). The severity of a burn is determined by its depth
(superficial, partial-thickness or full-thickness) and its extent (how much of the
body’s surface it covers).
When CHECKing the person,

determine the depth of
the burn:
n Superficial burns (Figure 1, A and B)
 Red, painful and possibly swollen skin
Figure 1A Figure 1B
n Partial-thickness burns (Figure 2,

A and B)
 Red, painful and swollen skin
 Blisters, which sometimes form more than
an hour after cooling
Figure 2A Figure 2B

n Full-thickness burns (Figure 3,
A and B)
 Painless skin
burns
 Pale skin (if injured by scalding)
 Charred skin (if injured by fire)
Figure 3A Figure 3B
When CHECKing the person, determine the extent of

the burn:
n Percentage of total body surface area (TBSA) that is burned
 Use the Rule of Palmar Surface: The person’s palmar surface (inner surface of
palm and fingers) equals 1 percent of TBSA.

 The more TBSA that is burned, the more serious the injury.
NOTE n Suspect possible airway

complications with:

 Burns to the face and/or
neck (Figure 4).
 Soot in the mouth and/

or nose.
 Singed facial hair.

 A dry cough.

n Major electrical burns (e.g.,
those caused by lightning or Figure 4
electrocution) may affect cardiac or respiratory systems. Always care
for cardiac and respiratory problems before caring for burns.

To give CARE:
n Remove the person from the source of the burn and immediate danger.
n Stop the burning process quickly, within 30 seconds if possible.
burns
 Remove the heat source.

 Smother flames.
 DO NOT try to remove tar, melted plastic or other material stuck to the burn.
 If electrical, turn off electricity FIRST.
 If dry chemical, brush off the chemical or remove contaminated clothing, then flood
with water. Take precautions from breathing in dust. Make sure the chemical is not
flushed onto other parts of the body.
n Manage ABCDEs and protect the person from shock and hypothermia.
n Cool or flood the burn with cold
water for at least 20 minutes
(Figure 5).
n Leave burn blisters intact.
n Remove jewelry from burned
area, if possible, to prevent

complications resulting from
swelling.
n Dress the burn with a thin layer of
Figure 5
wound gel.
 If wound gel or dressings are not available, leave the burn alone. The burn’s
surface will dry into a scab-like covering that provides a significant amount of
protection.
n Cover the burn with a gauze pad
or a thin layer of roll gauze or apply
clean clothing (Figure 6).
n DO NOT pack burn wounds or the
person in ice.
n Elevate burned extremities to
minimize swelling.
n Have the person gently and
Figure 6
regularly move burned areas as
much as possible.
n Keep the person well hydrated and monitor burns as you would any
open wound.

n Re-dress the injury twice a day by:
 Removing old dressings by soaking off with clean, tepid water if needed.
 Rewashing the wound to remove the old wound gel.
 Applying a clean covering.
n Re-dressing or re-examining a burn for infection is most likely going to be
very painful. If evacuation is imminent (within hours to a day)—do not re-dress
the burn.

n Evacuate rapidly—GO FAST—anyone with:
 Trouble breathing.
 A partial- or full-thickness burn that covers 10 percent or more of the
person’s TBSA.
 A partial- or full-thickness burn that is circumferential (wrapping around the body
part), covering the entire hand, foot or other body part.

 Serious burns of the head, face, neck, hands, feet or genitals.
 A full-thickness burn that covers more than 5 percent of the TBSA.
 Burns caused by chemicals, explosions or electricity.
 Any partial- or full-thickness burn to a child or an elderly person (younger than
about age 5 or older than about age 60).
Chest Injuries
Any significant injury to the chest may lead to difficulty breathing, a potentially
serious and life-threatening problem.
Chest Injuries (General)

n Deformity, open injuries, tenderness and swelling (DOTS).
n Windpipe/trachea pushed to one side of the neck.
n Abnormal breathing (posture, rate, quality).
n After exposing the chest and back:
 Bleeding or holes, with or without bubbles, and bruising.
 Unusual noises like gurgling.
 Abnormal chest rise.

n Guarding of the injury (person is protecting it from being moved or touched).
chest injuries
n While exerting some pressure with your hands:

 Cracking or crumbling sounds or depressions.
 Pain or point tenderness along the ribs or clavicle.
Rib Injuries
n Pain in the rib or clavicle area.
n Pain that increases when a deep breath is taken.
n Discoloration (bruising) where a rib may be broken and/or swelling.
n Guarding of the injury (person is protecting it from being moved or touched).
n A point where the injury is most intense when touched.
To give CARE:
n For a simple fractured rib, apply
a sling-and-swathe to help ease
discomfort and protect the area.
n DO NOT wrap a band snugly
around the person’s chest.
n Encourage the person to regularly
take deep breaths, even if it hurts,
to keep the lungs clear of fluid,
particularly if an evacuation will
be lengthy.
n Be aware of increasing
trouble breathing.
n Offer the person a bulky jacket or
pillow to hold against his or her side
for added comfort and secure with Figure 1
an elastic bandage (Figure 1).

Lung Injuries
chest injuries
n Presence of a pneumothorax (air escaping the lung and collecting in the
chest). Signs and symptoms include:
 Increased trouble breathing.
 Rising level of anxiety.
n Presence of a tension pneumothorax. Signs and symptoms include:
 Inability to breathe adequately, which can lead to death.
NOTE
Evacuate the person rapidly—GO FAST—as these are life-
threatening conditions.
Flail Chest
n A segment of ribs broken in two or more places; this part of the chest wall will
move opposite of the rest of the chest (Figure 2, A and B).
Figure 2A Figure 2B

To give CARE:
chest injuries
n Tape a bulky dressing over the flail to allow the person to breathe more easily.
 DO NOT tape around the entire chest. This makes breathing more difficult.
NOTE
Evacuate the person rapidly—GO FAST—as this is a
life-threatening condition.
Sucking Chest Wound

n Bubbling and noises coming from the wound when the person breathes.
To give CARE:
n Immediately cover the hole with an occlusive dressing that does not let air or
water pass through. Clear plastic will work.
n Tape the dressing down securely on
three sides (Figure 3).
n If the person has difficulty breathing,
remove the dressing. A tension
pneumothorax could be developing.
Removing the plastic may allow
air in the chest to be released
(Figure 4).
n If removing the dressing does not Figure 3
help breathing, consider gently
pushing a gloved finger into the hole
to release trapped air.
n If an object is sticking out of the
chest, stabilize and pack it. DO
NOT remove the object.
Figure 4

n Evacuate rapidly–GO FAST—anyone with a pneumothorax or tension
pneumothorax. These are life-threatening injuries. There is no wilderness first
aid treatment available other than care for a fractured rib.
n Evacuate rapidly–GO FAST–anyone who has sustained a chest injury
associated with increased trouble breathing.

 In this circumstance, the person will need to be transported.
n Evacuate rapidly—GO FAST—anyone with a flail chest. This is a life-
threatening injury.
 Evacuate anyone with flail chest on his or her side with the injured side down or in
another position of comfort.

 Give rescue breaths during evacuation, if necessary.
n Evacuate slowly—GO SLOW—anyone with a suspected fractured rib.
 Often, a person with this injury is able to walk. A simple fractured rib must be
evaluated by a health care provider.

 Be sure to watch the person for increased breathing difficulty. If this happens—
GO FAST.
Head (Brain), Neck and

Spinal Injuries
A significant blow to the head can cause bleeding and swelling of the brain. The
skull is not large enough to handle much swelling, so brain injuries can cause
death relatively quickly.
Superficial Scalp Injuries

n Bleeding, which may be heavy at times.
n A bump on the head.

head (BRAIN), neck and
To give CARE:
spinal injuries
n Care for wounds as appropriate.

 For a bleeding scalp, apply several
dressings with your gloved hand.

Press gently because the skull
may be fractured. If you feel a
depression, spongy area or bone
fragments, DO NOT put direct
Figure 1
pressure on the wound. Control
bleeding with diffuse pressure (Figure 1).
 For a bump, apply a cold pack to reduce swelling.
Mild Brain Injuries

n Short-term (less than 3 minutes) or no loss of consciousness.
n Short-term amnesia (memory loss).
n Briefly blurred vision.
n Nausea.
n Headache.
n Dizziness.
n Lethargy (extreme tiredness and sluggishness).
n Possible neck pain or tenderness (if associated with spinal injury).
To give CARE:
n Care for wounds as appropriate.
 Apply pressure from a bulky dressing on the bleeding scalp.
 Apply a cold pack to a bump.
n Monitor the person for 24 hours.
n Awaken the person every 2 hours to check for signs and symptoms of serious
brain damage.

Serious Brain Injuries
spinal injuries
n Prolonged unconsciousness with no response to aggressive stimulation, such
as shouting or tapping the shoulder.
n Possible skull fracture. Signs and symptoms of a skull fracture include:
 A depression (pressed-in area) in the skull. (DO NOT push on the area.)
 A fracture that is visible where the scalp has been torn.
 Bruising around both eyes (raccoon
eyes) (Figure 2) or behind both ears

(Figure 3).
 Clear fluid and/or blood dripping
from the nose or ears.

n Inability to sense touch or
move extremities.
n Eyes that do not respond to light
appropriately or equally. (Check Figure 2
pupil response, one eye at a time,
by shading the eyes with a hand
and then exposing the pupils
to light.)
n Mental status deterioration (from
disorientation, to irritability, to
combativeness, to coma).
n Personality changes.
n Loss of coordination, balance Figure 3
and/or speech.
n Extremely bad headaches.
n Vision problems.
n Seizures.
n Nausea and vomiting that does not go away.
n Relapsing into unconsciousness.

In later stages:
spinal injuries
n Heart rate that slows down (less than 40 beats per minute [BPM]), then
speeds up.
n Erratic (irregular) respiratory rate.
n Unequal pupils.
NOTE
Without an obvious skull fracture, the person may at first appear to
have recovered, but later may start to deteriorate. Watch for signs
and symptoms of brain injury whether or not you find evidence of a
skull fracture.
To give CARE:
n Immobilize the person and assume he or she may also have a spinal injury.
See Spinal Injuries.
n Keep the person calm and reassured.
NOTE
Evacuate the person rapidly—GO FAST—as this could become a life-
threatening condition.

n Evacuate anyone who sustained a blow to the head and does not respond
initially to aggressive arousal attempts.
n If the person is responsive and there is no indication of serious head or neck
injury, he or she can walk out.

 Make sure the person is able to walk by testing his or her balance. Ask the person
to stand still with eyes closed. Swaying and/or falling may indicate brain injury.
 Make sure the terrain is safe. If the terrain does not allow a second person to
assist directly, DO NOT allow a person with questionable balance to walk out.
n Evacuate rapidly—GO FAST—anyone with signs and symptoms of severe head
(brain) injury, especially a skull fracture or stroke, and/or a decrease in mental
status.
n A person with a serious head injury should be carried.

n If the person is unconscious, the
spinal injuries
airway must remain open
during evacuation.
 Keep the airway open by keeping
the person in a stable side position

(the high arm in endangered spine
[H.A.IN.E.S.] position).
 Alternatively, if a person has been
Figure 4
placed on a rigid backboard for a
spinal injury, elevate the head end of the board approximately 6 to 8 inches (Figure
4). See Spinal Injuries.
Spinal Injuries
Damage to the spinal cord can cause permanent paralysis or death. Any possible
spinal injury warrants evacuation, and due to the severity of the situation you must
seek professional evacuation by an organized rescue party.
Mechanism of Injury
Suspect a spinal injury if the mechanism of injury (MOI) involves any of the following:
n Falling from a height or landing on the head or spine
n Falls on the buttocks that transmit force to the spine
n Any fall of a distance greater than the person’s height
n Having the chin forced to the chest
n Excessive extension or rotation, such as tumbling downhill without skis releasing
n Pulling/jerking of the head from the neck
n Gunshot, stabbing or other injury that penetrates the body in the area of
the spine
n Sudden and violent deceleration (decrease in speed)
n Any injury that causes a helmet to break
n Any diving mishap
n A motor vehicle crash involving a driver or passengers not wearing safety belts
n Being thrown from a motor vehicle or by an animal
n A lightning strike

A person found unconscious for unknown reasons should be considered

spinal injuries
spine injured.

n Spinal pain or tenderness to the touch.
n Obvious injury to the spinal column.
n Altered sensations in the extremities, such as numbness, tingling, unusual
weakness, inability to move or unusual hot or cold sensations.
n Respiratory difficulty.
n Loss of bowel control.
n Signs and symptoms of shock.
To give CARE:
n During the primary assessment,
keep the person’s head still by
placing hands on both sides of the
person’s head, gently holding and
supporting the head in the position
in which it was found (manual
stabilization) (Figure 5).
n Manage ABCDEs.
Figure 5
 Use a modified jaw thrust to open
or maintain airway if trained and if needed.

 If you must remove a helmet, keep the person’s head still while removing the
helmet. Remove a helmet only if:

 The face mask cannot be removed reasonably quickly to gain access to
the airway.
 The design of the helmet and chin strap, even in the absence of the face mask,
does not allow for an open airway or adequate breathing.
 The design of the helmet and chin straps does not hold the head securely in
place (immobilization of the helmet does not also immobilize the head).
 The helmet prevents immobilization of the person for transport in an
appropriate position.
n Prevent further injury by immobilizing the head, neck and back.
n Check circulation, sensation and motion (CSM) before and after any
movement of the person.

n In a delayed-help situation, you may need to apply a cervical collar to restrict
spinal injuries
motion. The person's head and body must be aligned.
 If the person’s head lies at an odd angle, straighten it with slow, gentle movement
to line it up with the rest of the spine. This improves the airway and makes
immobilization easier.
 If this movement causes pain or meets resistance, stop and immobilize the
person’s head as it lies.
 If the person is found crumpled into an odd body position, straighten the body with
slow, gentle movement of one body part at a time. This typically makes the person
more comfortable and provides for better immobilization.
n Once the spine is in alignment, apply a cervical collar.
 Use a commercial collar, if available,
or improvise one using such items

as rolled clothing, a piece of a
foam sleeping pad or rolled towels
(Figure 6).
 Make sure the collar goes
completely around the person’s

neck. If the improvised collar varies
in thickness, place the thickest part
Figure 6
between the chin and chest.
 Be careful not to exert pressure on the trachea (windpipe).
n Maintain in-line stabilization, if possible, while you wait for a rigid litter
(stretcher) to arrive for evacuation. If not possible, place barriers on either side
of head to prevent movement (e.g., sand bags, large water containers).
n When a litter arrives, make sure the person is made free of any movement
(FOAM) on the litter.

 Use pads to fill any spaces under
the knees, in the small of the back

and any other space that would
allow the person to shift.
 Strap the person’s head down last
(Figure 7).
n Repeat hands-on physical exam
periodically. Observe and record for
Figure 7
at least 24 hours.

Moving a Person with a Head or Spinal Injury

spinal injuries
Log Roll (To check for injury)

A log roll can be used to roll a person with a suspected spinal injury onto his
or her side to check the back for injuries. It can also be used to place a pad
underneath the person. Although it is possible for one responder to perform a log
roll, two or three responders make the job easier and safer for the person.
To give CARE:
n Have one responder position
him- or herself at the injured
person’s head and perform manual
stabilization.
n At the command of that responder,
roll the person as a unit, keeping the
neck and back in line (Figure 8).
n Hold the person stable while the
Figure 8
back is checked for injuries.
n Roll the person back using the same precautions.
NOTE The log roll can be used to move an injured person from side to back and
from face-down to back.
BEAM (To move a short distance)

The body elevation and movement (BEAM) technique can be used to move
a person with a possible spinal injury a short distance when there are other
responders available to help.
To give CARE:
n Designate and prepare the spot to which the person will be carried.
n Have one responder position him- or herself at the person’s head and perform
manual stabilization.
n Have the other responders kneel on both sides of the person. These
responders gently slide their hands under the person.
n At the command of the head-holder, the group lifts the person as a unit with
as little spinal movement as possible.
n The group carries the person to the designated spot and then, at the
command of the head-holder, lowers the person.

Cautions About Moving a Spine-Injured Person
spinal injuries
n The only reasons to move a spine-injured person in a safe scene are to
improve long-term comfort, give essential care and/or to protect the person
from the environment.
n The least amount of movement is best. More harm can be done during
improper transfer than through any other action associated with first aid.
n Transfer of a person should be done only when absolutely necessary or when
the risk for further injury is low.
n Always make sure the airway is open and serious bleeding has been stopped.
n Before moving the person, make sure initial pain and fear have subsided and
be sure to reassure the person.
n Plan ahead so that the person is moved only once.
n Prepare any insulating materials or shelter before the person is moved.
n Rehearse and practice the process before moving the person.
n The rescuer supporting the head is the leader and should act and be treated
as such.
n Protection of the person’s entire body must be assured during the move. The
body should be kept in a straight line.
Special Considerations: Focused Spine Assessment

If the MOI caused you to suspect a spinal injury but a full assessment did not
reveal any signs and symptoms, perform a focused spine assessment. If you
answer “yes” to all of these questions, discontinue spinal immobilization:
n Is the person fully reliable (assessed on the AVPU scale as at least A+O×3)?
Does he or she appear sober and without distractions, such as severely

painful injuries or deep psychological distress?
n Is the person without altered sensations in the extremities, such as tingling,
and does he or she have the ability to move the extremities?

n Does the person demonstrate grip strength and the ability to lift the legs
against resistance?
n Does the person deny feeling spinal pain and tenderness to the touch of the
spine, and does he or she have normal range of motion?

n Possible spinal injury is a serious condition. Always seek professional
evacuation by an organized rescue party.
n Evacuate rapidly—GO FAST—anyone with the signs and symptoms of spinal
cord injury.

Heat-Related Illnesses
Heat Cramps
Heat cramps are the least severe of the heat-related illnesses and often the first
signal that the body is having trouble with the heat.

n Painful muscle spasms, usually in the legs and abdomen.
To give CARE:
n Help the person move to a cool place to rest.
n If available, give a carbohydrate-electrolyte solution such as a commercial
sports drink or fruit juice. Water may also be given.
n Lightly stretch the muscle and gently massage the area.
n DO NOT give salt tablets.
n When cramps stop, the person usually can resume activity. Monitor the
person for further signals of heat-related illness.
Heat Exhaustion
Heat exhaustion is a result of a combination of factors that may include heat
stress, water and electrolyte loss (most often via sweat), and inadequate
hydration, usually by a person who has been exercising.

n Sweating.
n Exhaustion.
n Pale, sweaty or flushed skin.
n Headache.
n Nausea and/or vomiting.
n Thirst and decreased urine output (urine is yellowish).
n Dizziness when the person stands up quickly.
n Elevated heart rate and respiratory rate.
n Slightly elevated core temperature (not common).

heat-related illnesses
To give CARE:
n Have the person stop activity and rest, preferably in a cool, shady place.
n Help the person replace lost fluids and salt.
 If available, give small amounts of a carbohydrate-electrolyte solution such as a
commercial sports drink or fruit juice.

n DO NOT give salt tablets, as they are too concentrated.
n Loosen or remove as much clothing as possible.
n Wet down and fan the person to increase the rate of cooling.
n If drowsy, allow the person to sleep.
n Allow the person to continue with normal activity if he or she feels better.
n Recovery may take up to 24 hours. Continue to observe the person
for recurrences.
Heat Stroke
Heat stroke is a serious medical emergency. It often occurs when a person is
over-exerting him- or herself and/or seriously dehydrated. The body produces
heat faster than it can be shed.

n Core temperature of 105° F (104º F oral temperature) or more.
n Disorientation and bizarre personality changes.
n Skin that may be hot and dry or moist.
n Elevated heart rate and respiratory rate.
n Headache.
n Seizures.
To give CARE:
n Rapid cooling is the only way to
save the person.
n Move the person to a
cooler environment.
n Remove heat-retaining clothing and
immerse the person up to the neck

in cold water (if available and safe
to do so) until he or she becomes
Figure 1
alert (Figure 1).

heat-related illnesses
n If a large enough source of water is not available for immersion, drench the
person with cold water.
 Concentrate on the head and the neck.
 Use cold packs on the neck, armpits, groin, hands and feet.
 Fan the person constantly to increase evaporation.
n Monitor the person closely and stop cooling efforts when a normal mental
status returns.
n Give cool water or a sports drink if and when the person is able to accept and
drink it.
n DO NOT give fever-reducing drugs.
n The person must see a health care provider as soon as possible, even if he or
she appears to have recovered.
n Carefully watch the person during evacuation. Relapses are common.
Hyponatremia
Hyponatremia is a condition that occurs when the sodium level in a person’s
blood falls too low to maintain normal body function. It is usually the result of
drinking too much water and failing to eat. If untreated, hyponatremia will result in
seizures, coma and death.

n Headache.
n Weakness and fatigue.
n Light-headedness.
n Muscle cramps.
n Nausea, with or without vomiting.
n Sweaty skin.
n Clear urine; person has recently urinated.
n Person recently drank a lot of water.
n Normal core or oral temperature.
n Normal or slightly elevated pulse and breathing.
n Increasing level of anxiety.
n Altered mental status including disorientation, irritability and combativeness (in
severe cases, this is referred to as water intoxication).

To give CARE:
n Have the person rest in shade with no fluid intake and a gradual intake of salty
foods while the kidneys re-establish a sodium balance.
n Once a person develops hunger and thirst combined with normal urine output,
the condition has resolved. Evacuation is not necessary unless the person has
an altered mental status.
NOTE n A person with hyponatremia will appear to have heat exhaustion. DO NOT
treat it as heat exhaustion (i.e., give water). This will harm the person.
n Use these guidelines to distinguish between heat exhaustion
and hyponatremia:

 Persons with heat exhaustion typically have a low output of
yellowish urine (urinating every 6 to 8 hours) and are thirsty.
 Hyponatremic persons have urinated recently and the urine was

probably clear.
 Hyponatremic persons will also claim to have been drinking a lot of

water and/or deny being thirsty.

n Evacuate rapidly—GO FAST—anyone with an altered mental status or who has
had a seizure as a result of heat stroke.
n Evacuate slowly—GO SLOW—anyone who does not fully recover from heat
exhaustion or mild hyponatremia.
Hypothermia
Hypothermia is the lowering of the body’s core temperature to a point at which
normal brain and/or muscle function is impaired. This condition can be mild,
moderate or life threatening.
Mild to Moderate Hypothermia

With mild hypothermia:
n Shivering.
n The “umbles”:

 Inability to perform complex tasks (“fumbles”).
 Confusion, apathy and sluggish thinking (“grumbles”).
hypothermia
 Slurred speech (“mumbles”).

 Altered gait (“stumbles”).
n The person being able to eat and talk and usually complaining of feeling cold.
With moderate hypothermia:

n Worsening of the “umbles.”
n Uncontrollable, violent shivering.
n Confusion or unusual behavior.
n Impaired judgment.
To give CARE:
For mild to moderate hypothermia:
n Change the environment to prevent heat loss.
 Place the person out of wind and cold and into some kind of shelter, even if this is
only waterproof, windproof clothing.

n Cover all exposed skin, including
the person’s head and neck.
n Replace wet clothes with
something dry.
n If the person can eat, give simple
carbohydrates, such as candy and

juice (Figure 1).
 If the person can drink, give fluids,
preferably a warm, sweet drink

(e.g., warm gelatin dessert). Give
cold fluids if warm ones are
not available.
 Do not give the person caffeine
and/or alcohol. Figure 1

n If the person cannot exercise
muscles easily, try to keep him or her warm by:
 Insulating him or her from the ground.
 Bundling him or her in dry insulation.
 Having him or her snuggle with warm people, such as in a sleeping bag. If the
person goes to sleep, wake him or her periodically.

 Placing a hot water bottle or chemical heat packs near the heart and in the armpits
and groin area (but not against bare skin).
hypothermia
n Wait until the person returns to normal and is able to exercise muscles before
you keep moving.
n If the person can still exercise easily, you can continue activity after initial care.
Severe Hypothermia
n Person stops shivering.
n Increasing muscle rigidity.
n Worsening mental state, moving from stupor to coma.
n Decreasing pulse and breathing that become difficult to detect (but are
still present).
n Semi-consciousness or unconsciousness.
n Person stops complaining.
n A core temperature lower than 90° F.
To give CARE:
n Handle the person with severe
hypothermia gently—roughness can
overload a cold heart and stop it.
n If breathing is undetectable, perform
cardiopulmonary resuscitation
(CPR) for at least 3 minutes prior
to any movement.
n Take steps to get the person warm
(see mild to moderate hypothermia Figure 2A
care steps).
n Create a “hypothermia wrap” vapor
barrier to trap any heat still left in

the person.
 Wrap the person with a tent fly,
sheet of plastic, garbage bags or

other items available to trap any
heat remaining in the person
(Figure 2, A and B). Figure 2B

 The hypothermia wrap should resemble a cocoon in that it only opens to the mouth
and nose.
n DO NOT try to force food or drink.
n Care for severe hypothermia even if the person appears dead. DO NOT
assume a person is dead unless he or she has been re-warmed and is not
responding to any care given.
n Call for help immediately.
n Evacuate the person gently. DO NOT evacuate if it cannot be done gently.
NOTE Warming the body too quickly or moving the person too much will likely
send the cold blood to the core, causing the body temperature to drop
even further. This can be fatal because the heart does not function
properly when it is cold.

n Anyone who has recovered from mild to moderate hypothermia may remain in
the field.
n Evacuate rapidly—GO FAST but with extreme gentleness—anyone with
severe hypothermia.
Lightning
Prevent Lightning Injuries
What to do (before a possible lightning storm arrives):
n Pick campsites that meet safety precautions.
n Know local weather patterns, especially in summertime.
 Plan turnaround times (the amount of time you need to get back) in lightning-prone
areas, based on your research, and stick to the plan.

n Plot storms using the following method:
 When the flash of lightning precedes the boom of thunder by 5 seconds, the storm
is approximately 1 mile away.

 Follow the 30-30 rule: Seek a safe location when the storm is no less than 6 miles
away. That is 30 seconds from flash to boom. Stay in the safe location for
30 minutes after the storm passes.

Reaching Safety in a Lightning Storm
What to do:
lightning
n Move downhill.
n DO NOT stay in a meadow or any other wide-open space.
n Seek uniform cover (e.g., low rolling hills or trees of about the same size).
n Take shelter in a steel-framed building or a hard-topped motor vehicle. Keep
the windows of the vehicle rolled up.
n If you are boating or swimming, get to land and move away from the shore.
n AVOID all of the following:
 Metal
 Anything connected to electrical power
 High places and high objects (e.g., tall trees)
 Open places
 Damp, shallow caves and tunnels
 Overhangs
 Flood zones
 Places obviously struck by lightning in the past
 Long conductors (e.g., fences)
n To assume a safe position
when outdoors:
 Squat or sit in a tight body position
on insulating material (e.g., sleeping

pad, life jacket) (Figure 1).
 Take off any metal-framed packs
and toss hiking poles away from

the group.
Figure 1
 Do not lie down.
 If you feel your hair stand on end or your skin get tingly, cover your ears with your
hands, close your eyes and get your head close to your knees.
n Spread groups out wide with about 100 feet or more between individuals.
Keep everyone in sight if possible.

Lightning Injuries
Lightning can produce several types of injuries, including cardiac and pulmonary
arrest, neurological problems, blindness, deafness, burns and trauma.

n Burn marks on the skin (entry and exit of current).
n Unconsciousness.
n Trauma (e.g., fractures or dislocations).
n Dazed, confused behavior.
n Trouble breathing.
n Weak, irregular or absent pulse.
To give CARE:
n Begin cardiopulmonary resuscitation (CPR) immediately if needed.
n Treat any injuries as needed.
n Be ready to treat secondary issues (e.g., hypothermia in a wet,
injured person).

n Evacuate rapidly—GO FAST—anyone who has been struck by lightning.
n Even if the person seems to have recovered soon after the injury, serious
problems can develop later so you must still evacuate rapidly.
Shock and Heart Attack

Shock
Shock is a condition that develops when the body’s vital organs, including the
brain, heart and lungs, do not get enough oxygen-rich blood to function properly.
Shock is likely to develop after any serious injury or illness, including severe
bleeding, severe allergic reaction, serious internal injury, significant fluid loss or
dehydration, heart attack or other conditions. The goals of first aid are to get help
quickly and give care to minimize shock while caring for the injury or illness.

shock and heart attack
In the early stages of shock:
n Anxiousness, restlessness and/or disoriented level of consciousness (LOC).
n Rapid and weak or otherwise irregular heart rate.
n Rapid and shallow respiratory (breathing) rate.
n Pale, cool, clammy skin color, temperature and moisture.
n Pink and warm skin color, temperature and moisture if shock was caused by
an allergic reaction.
n Nausea and sometimes vomiting.
n Dizziness.
n Thirst.
In later stages of shock:

n LOC that continues to decrease.
n Eventual unconsciousness.
n Heart rate in which the radial pulse (the pulse at the wrist) grows increasingly
rapid, weakens and eventually disappears.
To give CARE:
n Identify and treat shock early, before serious signs and symptoms develop.
n Care for the condition that is causing the shock (e.g., bleeding, dehydration)
immediately if it can be identified.
n Keep the person calm and reassured.
n Have the person lie down or move him or her into a position of comfort.
n Maintain an open airway.
n Keep the person from getting chilled or overheated (e.g., use a sleeping pad
to insulate the person from the ground or cover the person if shivering).
n DO NOT give fluids to an unconscious person or to a person with a serious
head or abdominal injury.
n If the person vomits, do not give fluids.
n If evacuation will be delayed more than 2 hours, give a conscious person small
sips to drink every 5 minutes if tolerated without vomiting.

n If shock is not treated, it can lead to death. Options for care are limited in the
wilderness, so early recognition and management are critical. Evacuation must
be considered.

shock and heart attack
n Evacuate anyone with signs and symptoms of shock that do not stabilize or
improve over time.
n Evacuate rapidly—GO FAST—anyone with decreased mental status or
worsening vital signs, especially if the person’s heart rate keeps speeding up.
The person must be carried.
Heart Attack
Heart attack, due to an inadequate supply of oxygen-rich blood to the heart
muscle, is the leading cause of death in the United States. A heart attack can,
but does not always, lead to shock. Not only does shock make the situation more
serious, it is usually fatal.

n Center-chest discomfort (e.g., crushing, squeezing pain, heavy pressure).
n Pain (e.g., crushing, squeezing pain, heavy pressure), mostly on the left side,
which may radiate to the shoulder, down the arm or into the jaw.
n Nausea, sweating and shortness of breath.
n Denial of the possibility that this could be a heart attack.
n Unexplained fatigue.
To give CARE:
n Keep the person physically and emotionally calm.
n DO NOT allow the person to walk—even a short distance.
n Give the person two to four chewable low dose aspirins (81 mg) or one
325-mg aspirin, if the person can swallow and has no known

contraindications. Coated aspirin takes too long to dissolve to be effective,
but can be taken if it is all you have on hand.
n If the person has a strong radial
pulse and has been prescribed

nitroglycerin, help him or her self-
administer one pill; it should be
taken under the tongue with the
person sitting (Figure 1). Follow the
instructions on the prescription.
Figure 1

n If the person is unconscious and not breathing, immediately begin
cardiopulmonary resuscitation (CPR) or use an automated external
defibrillator (AED), if one is available.
NOTE The person should only take medication if he or she can swallow and has

n Evacuate rapidly—GO FAST—anyone whom you assess as having a heart
attack. The person will need to be carried.
Submersion Incidents
(Drowning)
The first step when dealing with any emergency is to determine that the scene
is safe for the rescuer. A drowning person in the water can place a responder in
a hazardous situation if the responder is unskilled in water rescue, particularly
in an unsafe area. Fortunately, drowning can often be prevented with simple
precautions, including the use of a safe area for swimming and matching activities
to swimming ability. In murky water, where it would be difficult to find someone on
the bottom, limit depths to shallow water or have all swimmers wear a life jacket.
All boaters should wear a U.S. Coast Guard-approved life jacket and be skilled
with their craft in the local environment. It is important to gather rescue aids and
discuss and practice rescue procedures before engaging in water activities.
You must first recognize that someone is in trouble and then choose a safe rescue
procedure based on the behaviors you observe.

submersion incidents
Helping a Person in Trouble in the Water

(DROWNING)
When CHECKing the person, look for these behaviors:

n Distressed swimmer (Figure 1)
 Can breathe and might call for help
 Can float, scull or tread water;
might wave for help

 Could be in horizontal, vertical or
diagonal body position, depending

on means of support
 Makes little or no forward progress;
less and less able to support self

 May reach for rescue aids Figure 1
extended, thrown or pushed nearby

n Active drowning victim (Figure 2)
 Struggles to breathe; cannot call
out for help

 Arms to sides alternately moving
up and pressing down; no

supporting kick
 Vertical body position
 No forward progress (has only 20 Figure 2
to 60 seconds before submerging)

 Unable to reach for or move even a
short distance to a rescue aid, but

may be supported by an aid placed
within his or her grasp
n Passive drowning victim (Figure 3)
 Not breathing
 No arm or leg action
 Horizontal or vertical body position; Figure 3
could be face-down, face-up

or submerged
 No forward progress
 Unable to grasp a rescue aid; assist normally requires contact by rescuer

To assist the victim in the water:
n Continue to monitor the safety of everyone else (or have someone else do so)
(DROWNING)
when attention is focused on an individual in trouble.
n Follow the progression of Reach, Throw, Row, Go based on your level of
training. Out-of-water assists are safer for the responder. Ensure that you
talk to the victim throughout the rescue to keep him or her calm and aware
of your presence.
n If conditions are unsafe and beyond your level of training, stop your rescue
efforts if the risk becomes unacceptable. For example, you should not attempt
a rescue of a kayaker pinned in heavy white water unless you have specialized
training in swift-water rescue.
n Remember the progression of
Reach, Throw, Row, Go.

1. Reach out to the person with a
hand, foot, clothing, stick, paddle
or anything that allows you to
remain safely on land or in a boat
(Figure 4).
 Brace yourself on the pier
surface, shoreline or another Figure 4
solid surface. Extend the object to the victim or reach with your arm and grasp the
victim. When the victim grasps the object or when you grasp the victim, slowly and
carefully pull him or her to safety. Keep your body low and lean back to avoid being
pulled into the water.
 If you are in the water, hold on to a piling or another secure object with one
hand. Extend your free hand or one of your legs to the victim. Do not let go of
the secure object or swim out into the water. Pull the victim to safety.

(DROWNING)
Figure 5A Figure 5B
 If the water is safe and shallow enough (not higher than your chest), you can
wade in to reach the victim. Do not enter the water if there is a current, if the
bottom is soft or if you do not know the condition of the bottom. If possible,
wear a life jacket when attempting a wading assist, and take a buoyant object
to extend your reach. Wade into the water and extend the object to the victim
(Figure 5, A and B). When the victim grasps the object, tell him or her to hold on
to the object tightly for support and pull him or her to safety. Keep the object
between you and the victim to help prevent the victim from clutching at you in a
panic.
2. Throw something that floats to the person so he or she can hold on to it. You can
also throw a rope and tow the person to safety.
 Get into a stride position; the leg opposite your throwing arm is forward.
 Step on the end of the line with
your forward foot.
 Shout to get the victim’s
attention. Make eye contact and
say that you are going to throw
the object now. Tell the victim to
grab it.
 Bend your knees and throw the
object to the victim. Try to throw
the object upwind and/or up
current, just over the victim’s
head, so that the line drops
within reach (Figure 6).
Figure 6

 When the victim has grasped the object or the line, slowly pull him or her to
safety. Lean away from the water as you pull.
(DROWNING)
 If the object does not reach the victim, quickly pull the line back in and throw it
again. Try to keep the line from tangling, but do not waste time trying to coil it.
If using a throw bag, partially fill the bag with some water and throw it again.
3. Row to the person, or get to the
person in some sort of watercraft,
using reaching or throwing devices
as appropriate, with safety as a top
priority (Figure 7).
4. Go. “Go” is ONLY appropriate for
good swimmers with water rescue
training and when it is possible
to safely reach the victim. The Figure 7
responder may wade or swim with
a flotation aid toward a conscious victim, stop a safe distance away and then pass
the flotation aid within the victim’s grasp. Recovery of an unconscious victim may
require a surface dive and contact tow. In murky water, limit water depth and/or
require participants to wear life jackets to make underwater recovery easier if an
incident occurs.
Caring for a Near-Drowned Person (Once

the person is removed from the water)
n Unconsciousness.
n Airway.
n Breathing.
n Circulation.
n Disability.
n Environmental conditions.

To give CARE:
n If the person is unconscious and not breathing, give 2 rescue breaths. If the
(DROWNING)
chest clearly rises, immediately begin CPR.

 If the chest does not clearly rise with the initial breath, retilt the head before giving
the second breath.

 If the second breath does not make the chest rise, the airway may be blocked.
After each subsequent set of chest compressions and before attempting breaths,
look for an object and, if seen, remove it. Continue CPR.
n DO NOT attempt to clear the person’s lungs of water.
n Be ready to roll the person to clear the airway if water or vomit comes up.
n If the person has a suspected head, neck or back injury, take steps to
immobilize the spine.
NOTE Techniques for providing in-line stabilization for suspected head, neck
and back injuries in the water for both face-up and face-down victims
are covered in water rescue courses, such as American Red Cross
Lifeguarding or Basic Water Rescue.
n Care for shock, hypothermia or other conditions as appropriate, including

anything that might have caused the person’s distress in the water (e.g.,
diabetic emergency).
NOTE Scuba diving introduces risks from breathing compressed air. Certified
scuba divers are trained to avoid, recognize and arrange care for such
problems. Care may require transport to a hyperbaric chamber.

n Evacuate rapidly—GO FAST—anyone who was unconscious, no matter
how short a time, during a submersion incident. This situation can become
life threatening.
n Evacuate rapidly—GO FAST—anyone with signs and symptoms of respiratory
problems after a submersion incident or anyone who ingested water during a

submersion incident. This situation can become life threatening. The person
should seek medical attention as soon as possible.
NOTE Secondary drowning is an aftereffect of water entering the lungs. It may

take several days to appear. It can be fatal due to the water damage that
occurs in the lungs.

Wounds and Wound Infection
Always follow standard precautions when dealing with bleeding to prevent the
risk of disease transmission.
Bleeding
n Bleeding that spurts from the arteries each time the person’s heart beats.
(This is life threatening.)
n Smooth and rapid bleeding from veins and at the surface. (This is
also serious.)
n Signs of bruising. (This signals internal bleeding.)
To give CARE:
n Look for serious bleeding with a
quick visual scan (Figure 1).
n Check for bleeding inside clothing
if the person is wearing bulky winter

or rain gear. Be sure to look for the
site of the bleeding.
n Check for bleeding underneath the
person if he or she is lying in sand,

rocks, snow or other terrain that
Figure 1
could hide blood loss.
n Cover the wound with a sterile
dressing and apply direct pressure

to the bleeding wound with a barrier
and your hand (Figure 2).
 If there is no time to get a sterile
dressing, grab anything absorbent

to press into the wound.
 If bleeding is severe, initially
pack the wound with your fingers

and then switch to packing with Figure 2
absorbent material.

n DO NOT apply direct pressure to bleeding wounds of the head.
wound infection
 For skull fractures: Cover the wound with a bulky dressing and press lightly.
wounds and
n Monitor the person for shock.
Impaled Objects
To give CARE:
n DO NOT remove an object unless it interferes with urgent first aid (e.g.,
cardiopulmonary resuscitation [CPR]).
n Control severe bleeding by packing a bulky dressing around the object.
n Apply gentle pressure and
immobilize the object by bandaging
around it (Figure 3).
n Reduce the size and weight of the
object if possible (e.g., by cutting

off a tree limb).
n Remove a small impaled object
in the skin (e.g., a splinter) with

tweezers or similar tool. Figure 3
Tourniquets
Use a tourniquet on an arm or leg ONLY if blood loss is uncontrolled by direct
pressure or if direct pressure is not possible. Situations might include:
n A disaster scene with multiple persons and limited rescuers.
n One person with multiple injuries and one first aid provider.
n A person who needs to be moved quickly or who is trapped without access to
the wound.
To give CARE:
n Tie a band of soft material, about
1 to 2 inches wide, approximately
2 inches above the wound but not
over the joint (Figure 4). DO NOT
use anything narrow (e.g., rope
or string).
Figure 4

n Tie a short, sturdy stick or another
wound infection
rigid object into the material
wounds and
and twist it (called the windlass
technique) (Figure 5).
n Tighten the tourniquet by twisting
until bleeding stops, and no more.

n In a non-delayed-help situation,
continue to monitor and care for

Figure 5
shock and keep the tourniquet tight
and in place until the person reaches advanced medical
care (surgery will most likely be required).
n Note the time that you applied the tourniquet.
n Tag the person in an obvious place with information about when and where
the tourniquet was placed.
n DO NOT cover the tourniquet with clothing.
n DO NOT remove the tourniquet unless advised to do so by a health care
provider (by phone or radio while awaiting help).
NOTE n C ommercial emergency tourniquets are available and recommended.

Follow manufacturer’s instructions.
n If a tourniquet is required for a lower leg wound and bleeding is not
stopped when a tourniquet is placed near the wound, relocate the
tourniquet to just above the knee. (This may work better because it is
easier to compress the artery against the femur.)
n It is better to continuously use a tourniquet than to allow additional
blood loss.
Wound Cleaning
After bleeding is controlled, the wound should be properly cleaned, closed and
dressed to prevent infection, promote healing and reduce scarring. This is often
referred to as irrigating the wound.
To give CARE:
n Wash your hands.
n Put on clean, latex-free medical exam gloves.
n Remove any large materials with tweezers or gauze pads before washing
the wound.

n Vigorously wash and rinse dirty wounds with large amounts (at least 1 quart)
wound infection
of disinfected water or water that is potable (safe to drink). Disinfected water

wounds and
has been treated via boiling, chemicals or filtration—or some combination—to

make it potable.
n Direct a high-pressure stream of
water into the wound through an

irrigation syringe, if available
(Figure 6).
 Draw the water into the syringe,
hold the syringe about 2 inches

above and perpendicular to the
wound and push down forcefully on
Figure 6
the plunger.
 Keep the wound tipped so the water runs out.
n If no irrigation syringe is available, improvise by:
 Using a biking water bottle.
 Melting a pinhole in the center of the lid of a standard water bottle.
 Punching a pinhole in a clean plastic bag.
n If the wound was initially washed using water that was not disinfected, follow
up with a final flush of disinfected or potable water.
n DO NOT use hydrogen peroxide, rubbing alcohol or tincture of iodine, as
these can further damage tissue.
NOTE n Flaps of skin may need to be held open while the wound is
being washed.
n Skin around a laceration should be washed clean before irrigating
the wound.
n Puncture wounds need considerable irrigation because they are deep
and have the potential for infection, especially with animal bites.
Wound Dressing and

Closing
Lacerations
Lacerations are cuts through the skin
that have even or ragged edges
(Figure 7).
Figure 7

To give CARE:
wound infection
n If the wound is a laceration that you
wounds and
held open while cleaning, close the
wound with wound closure strips or
thin strips of tape (Figure 8).
 If hair gets in the way of laceration
closure, carefully clip it short. DO

NOT shave.
Figure 8
 If using closure strips, apply one
end of one strip to one side of the wound and another to the opposite side.
 Using the opposing strips as handles, you can pull the wound edges together,
pulling the skin in as close as possible to where it should lie naturally.

n Apply a thin layer of wound gel or a microthin (transparent) film dressing. DO
NOT use wound gel with a microthin film dressing.
n Cover the wound with a sterile dressing and bandage. If possible, the
dressing should completely cover the wound and extend ½ inch beyond the
wound’s edge.
n Remove rings or anything that could cut off circulation if swelling occurs.
n Check bandages often.
n If possible, change the dressing daily. Microthin film dressings may be left in
place until healing is complete.
NOTE n Wounds gaping more than ½ inch should not be closed in the field but
instead evacuated for closure by a health care provider.
n L arge dirty wounds; wounds that expose bones, tendons or ligaments;
and wounds caused by animal bites should be left open. These are
difficult to clean well enough to prevent infection.
n E xceptionally dirty wounds should be packed open with sterile gauze
and covered with dry gauze to allow them to drain until a health care
provider can be consulted.

Abrasions
wound infection
wounds and
Abrasions are shallow and often dirty

wounds that occur when some skin has
been scraped away (Figure 9). They
are often infected and can be painful.
To give CARE:
n If cared for within 10 minutes,
apply a thick layer of wound gel
and cover with a sterile dressing,
then bandage.
n If cared for after 10 minutes or
there are items (e.g., sand, Figure 9

pebbles) in the wound:
 Scrub the abrasion clean with a gauze pad or a clean, soft cloth and soap
and water.
 Follow scrubbing with irrigation or rinsing.
 Apply a thin layer of wound gel and cover with a dressing and bandage.
Friction Blisters
To give CARE:
n Clean around the site thoroughly.
n Sterilize the point of a needle or knife to open the blister wide.
n If possible, leave the roof (separated skin layer) of the blister intact to ease
discomfort and speed healing.

n Wash with soap and water.
n If the roof has been rubbed away, care for as an open wound.

n In all cases, apply a dressing that
wound infection
limits friction.
wounds and
 If available, use a commercial
product or improvise with duct tape

and gauze.
 Building a “donut” by cutting a hole
in the center of a rounded piece of

moleskin (Figure 10) or improvising
Figure 10
something similar separates
irritated skin from friction.
 Center the blister site in the hole
and fill the hole with wound gel.

 Tape the moleskin or put another
strip of moleskin on top of the donut

to keep the gel in place (Figure 11).
This also prevents the blister from
refilling with liquid.
Figure 11
Chafing
Chafing occurs from excess friction, often in the groin area and between
the thighs.
To give CARE:
n Apply a layer of lubricating oil or ointment (e.g., petroleum jelly or cooking oil)
or fragrance-free baby powder or cornstarch.
Ear Problems
To give CARE:
For objects lodged in the ear:
n DO NOT use force to remove the object.
n If it is small, attempt to rinse it out with water by flooding and draining the
ear canal.
 For insects, use cooking oil instead of water.

For ear infections:
wound infection

wounds and
n Pain when the ear is pulled on.

n Vertigo (dizziness).
To give CARE:
n Rinse the ear daily with a solution of 50 percent water and 50 percent alcohol
or vinegar.
n Seek medical help if pain persists.
Nosebleeds
To give CARE:
n Have the person sit down, lean
forward and pinch the meaty part
of the nose, just below the bridge,
firmly shut (Figure 12). You may
have to do this if the person
is unable.
n Hold or have the person hold the
nose shut for 10 minutes.
Figure 12
n If bleeding persists, have the
person continue pinching the nose shut for another 10 minutes and repeat
until bleeding stops.
n Care for continued bleeding by packing the nostrils gently with gauze soaked
with a decongestant nasal spray.
n If the person suffered a blow to the nose that caused a deformity, care for the
injury with cold packs.
n Ask the person not to blow his or her nose for 10 days because this could
restart bleeding.
n Have the person seek professional help within 10 days if the nose was
deformed by trauma.
NOTE Blood running down the throat when leaning forward may indicate a
serious nosebleed. The person will need rapid evacuation and a health
care provider’s attention.

Teeth Problems
wound infection
wounds and
To give CARE:
For a cavity or missing filling:
n Rinse the area clean.
n Make a temporary filling by mixing zinc powder oxide and eugenol or use
candle wax, ski wax or sugarless gum.

n To hold a dislodged crown back in place, use temporary filling material or a
commercial dental adhesive product (e.g., Fixadent®).
For a knocked-out tooth:

n Bleeding can be controlled by biting down on a rolled gauze pad. Have the
person rinse his or her mouth out.
n Hold the tooth by the crown and avoid touching the root.
n Rinse the tooth with clean water. DO NOT scrub.
n Gently press the tooth back in the socket.
n If the tooth will not go back in, save it until the person can get to a dentist.
n To store the loose tooth, have the person hold it in his or her mouth, taking
care not to swallow it.
n If the person cannot hold the tooth in his or her mouth, ideally store the tooth
in milk or a 0.9 percent saline solution.
For an infected tooth:

n Pain and swelling in the gum and cheek near the tooth.
n Possible discoloration of the gum.
To give CARE:
n Place cold packs on the cheek.
n If evacuation is delayed, have the person rinse out his or her mouth several
times a day with warm, salty water.
n Aspirin may help alleviate pain.
NOTE
Evacuate the person rapidly—GO FAST.

NOTE
wound infection

wounds and

Mosquito Bites
To give CARE:
n Care for with topical over-the-counter agents.
n To avoid creating open wounds that can become infected, Do not scratch.
n If flu-like symptoms develop within 2 weeks of a mosquito bite, see a health
care provider for evaluation.
Tick Bites
To give CARE:
n Remove the tick immediately.
 Grasp the tick as close to the skin as possible, perpendicular to its long axis and
pull it out slowly using tweezers or gloved fingers.

n Wash the bite area and apply wound gel to prevent infection.
n Wash your hands.
n If flu-like symptoms develop within 2 weeks of a tick bite, see a health care
provider for evaluation.

n If the tick was attached for longer than 48 to 72 hours, the person should see
a health care provider upon returning home.
Bee or Wasp Stings

To give CARE:
n Carefully remove the stinger with tweezers or scrape it away from the skin
using your fingernail or a plastic card (e.g., a credit card). Wasps do not lose
their stinger. If you use tweezers, grasp the stinger, not the venom sac.
n Wash the site and cover it to keep the site clean.
n Apply cold to the area.

Venomous Snakebites
wound infection
wounds and
n One or more fang marks, with or without bleeding.
n Localized pain.
n Swelling, possibly of the entire limb.
n Nausea, vomiting and tingling (signs of moderate envenomation [poisoning]).
n Shock, coma and paralysis (signs of severe poisoning).
n Necrosis (tissue death) at site.
To give CARE:
n Keep the person physically and emotionally calm.
n Gently wash the bite site.
n Apply an elastic (pressure immobilization) bandage to slow the spread of
venom from the lymph nodes. You should still be able to slip a finger between
the bandage and skin.
n Keep the bite site lower than the person’s heart.
n Do not cut the wound. Do not apply ice, suction or a tourniquet.
n Go for help.
n Unless it is unavoidable, DO NOT allow the person to walk.
n Have the snakebite evaluated by a health care provider.
NOTE Care for snakebites as puncture wounds that might cause infections,
including tetanus.
Wound Infection
In mild infections:
n Pain, redness and swelling.
n Small amount of light-colored pus.
In serious infections:
n Increasing pain, redness and swelling.
n Increasing heat at the site.
n Foul-smelling pus that increases and grows darker in color.
n Appearance of red streaks just under the skin near the wound.
n Systemic fever.

To give CARE:
wound infection
For mild infections:

wounds and
n Re-clean with soap and water and re-dress the wound.

n Apply wound gel.
n Monitor for signs of serious infection. For any large bruised areas, bites or
poisoning incidences, outline the affected area in pen and indicate the time
that the wound occurred to help you determine if the area is growing over
time. Act early if signs of infection are seen.
For serious infections:

n Re-clean the wound with water and apply wound gel.
n Allow the wound to re-open and let it drain. Soak the wound in water as hot as
the person can tolerate.
n Pack the wound with moist, sterile gauze to keep it draining.
n Dress the surface of the wound with dry, sterile gauze.
n Re-clean and repack the wound twice a day during an extended evacuation.
n Monitor the wound closely.

n Evacuate slowly—GO SLOW—anyone with a wound that cannot be closed in
the field.
n Evacuate rapidly—GO FAST—anyone with a wound that:
 Is heavily contaminated.
 Opens a joint space or body cavity.
 Involves tendons or ligaments.
 Was caused by an animal bite.
 Is deep and on the face.
 Involves an impalement.
 Was caused by a crushing injury.
n Evacuate rapidly—GO FAST—anyone with an infected wound or skin infection
that does not improve within 12 hours of care or that spreads to other parts of
the body.
n Evacuate rapidly—GO FAST—anyone with signs and symptoms of a
serious infection.
n If more than one person breaks out in skin boils or abscesses, evacuate all
rapidly and immediately seek advanced medical care. This may be a sign
of group contamination with methicillin-resistant Staphylococcus aureus
(MRSA), a serious staphylococcal infection.

Special
Situations
Abdominal Injuries
and Illnesses
Giardia (Parasite)
With acute infection:
n Diarrhea lasting 10 days or more.
n Foul-smelling stools and gas.
n Fatigue.
n Abdominal distention (swelling).
With chronic infection:

n Intermittent episodes of:
 Mushy, foul-smelling stools.
 Abdominal pain and distention.
 Gas.
 Loss of appetite.
 Weight loss.
 Fatigue.
To give CARE:
n Care for persistent diarrhea. See Diarrhea.
n Have the person examined by a health care provider as soon as possible.
Open Abdominal Injuries

n Visible or protruding intestines.

abdominal injuries
To give CARE:
and illnesses
n Do not apply direct pressure.
n DO NOT attempt to push intestines
back into the cavity.
n Remove clothing from around
the wound.
n Apply moist, sterile dressings
loosely over the wound (Figure 1).
n Cover dressings loosely with plastic
wrap, if available. Foil or a plastic Figure 1
bag will also work.

n Give nothing by mouth.
Closed Abdominal Injuries

n Mechanism of injury (e.g., blunt force) associated with closed
abdominal injuries.
n Signs and symptoms of shock.
n Bruising.
n Abdominal rigidity or tenderness.
n Gradually increasing pulse.
n Pale skin.
n Nausea.
To give CARE:
Upper right Upper left
n Closely observe the person. quadrant quadrant
n Carefully position the person on his
or her back with the knees bent, if it
does not cause more pain.
n Care for shock.
n Evacuate as soon as possible.
n Note quadrant of pain (Figure 2) and
describe it on report form.
Lower right Lower left
quadrant quadrant
Figure 2
Special Situations 87
Asthma Attack
Asthma is a condition that narrows the air passages in the lungs and makes
breathing difficult.

n Coughing or wheezing.
n Shortness of breath.
n Rapid, shallow breathing.
n Inability to talk without stopping for a breath.
n Tightness in the chest.
n Feelings of fear or confusion.
n Sweating.
To give CARE:
n Reassure the person that you are
going to help.
n Have the person rest in a
comfortable position.
n Administer oxygen, if trained.
n Assist the person with or have the
person self-administer a prescribed

inhaler (Figure 1). Figure 1
NOTE The person should only take medication if he or she has no known
contraindications. Individuals should read and follow all label or health
care provider instructions. Check state and local regulations regarding
use of prescription and over-the-counter medications.
 Help the person sit up and rest in a position comfortable for breathing.
 Ensure that the prescription is in the person’s name and is prescribed for “quick
relief” or “acute” attacks.
NOTE Some inhalers contain long-acting, preventive medication that should not
be used in an emergency.

 Ensure that the expiration date of the medication has not passed.
asthma attack
 Read and follow all instructions
printed on the inhaler prior to

administering the medication to
the person.
 Shake the inhaler.
 Remove the cover from the inhaler
mouthpiece. Some inhalers have

extension or spacer tubes that fit
between the mouthpiece and the Figure 2
medication canister (Figure 2). If
present, attach and use.
 Tell the person to breathe out as much as possible.
 Have the person place his or her lips tightly around the mouthpiece. The person
may use different techniques.

 As the person breathes in slowly, administer the medication by quickly pressing
down on the inhaler canister, or the person may self-administer the medication.
 The person should continue a full, deep breath.
 Tell the person to try to hold his or her breath for a count of 10. When using
an extension tube, have the person take 5 to 6 deep breaths through the tube
without holding his or her breath.
 Note the time of administration and any change in the person’s condition.
 The medication may be repeated once after 1 to 2 minutes.
NOTE The medication may be repeated every 5 to 10 minutes thereafter

as needed. These medications might take 5 to 15 minutes to reach
full effectiveness.
 Stay with the person and monitor his or her condition and give care for any other
injuries. Have the person rinse his or her mouth out with water.
 Care for shock. Keep the person from getting chilled or overheated.
If a person has an inhaler, you may assist with administration if you are
NOTE
trained to do so and local and state protocols allow.

n Evacuate rapidly—GO FAST—if breathing does not improve within
15 minutes.
Cold-Related Emergencies
Frostbite
Frostbite is the freezing of body parts exposed to the cold. Severity depends on
the air temperature, length of exposure and the wind. Frostbite can cause the loss
of fingers, hands, arms, toes, feet and legs.

n Numbness or lack of feeling in the
affected area.
n Skin that appears waxy, is cold
to the touch or is discolored (i.e.,

flushed, white, yellow or blue).
n More serious cases; blisters may
form and the affected part may

turn black and show signs of deep
tissue damage (Figure 1).
Figure 1
To give CARE:
n Handle the area gently.
n Never rub an affected area. Rubbing causes further damage to soft tissues.
n Protect the person from further exposure and give care for hypothermia.
n DO NOT attempt re-warming if
there is a chance of re-freezing or
help is more than 2 hours away.
n For minor frostbite, rapidly rewarm
the affected part using skin-to-skin
100-105F
contact such as with a warm hand.
n For more serious frostbite—if you
are in a remote area and close to a
medical facility—slowly re-warm the Figure 2
frostbitten part by soaking it in water
not warmer than 105°F (Figure 2). Keep the frostbitten part in the water until
normal color returns and it feels warm.
n Loosely bandage the area with a dry, sterile dressing.

n If fingers or toes are frostbitten,
place cotton or gauze between
cold-related
emergencies
them (Figure 3).
n Do not break any blisters.
Immersion Foot
Immersion foot occurs when feet have
been exposed to more than 12 hours
of cold, wet conditions. If the person
has experienced immersion foot before
or does not have healthy feet, it can
occur in as little as 3 hours. Tissues
do not freeze, but there is nerve and
Figure 3
circulatory damage.

n Initial signs and symptoms:
 Swollen, cold, waxy feet
 Peeling skin (Figure 4)
 Reduced sensitivity to touch
 Wooden feeling in feet
 Delayed capillary refill time (nail beds
stay white after you squeeze them)

n After the foot warms up:
 Warm, dry, red skin
 Pain
 Increased sensitivity to cold
 Blisters
 Tingling or itching
Figure 4
To give CARE:
n Care for the affected part by applying warm packs or soaking in warm water
(102° to 105° F) for approximately 5 minutes.
n Elevate the affected area.
n Clean and dry feet.
n Give plenty of fluids to drink.
n DO NOT allow the person to wear wet socks or shoes.
n Obtain medical assistance as soon as possible.
Confined Spaces
If a person becomes injured or ill in a confined space, you will need to take
specific precautions before attempting to respond to the emergency. A confined
space is any space that has limited access and is not intended for continuous
human occupancy. At a worksite, a confined space would be large enough that an
employee could enter and perform assigned work.
Examples of confined spaces include:

n Tunnels.
n Agricultural silos, grain bins and grain elevators.
n Underground vaults.
n Utility vaults for water, sewers or electrical power.
n Spaces that result from cave-ins.
In the wilderness or remote areas, examples of confined spaces include:

n Crevasses.
n Caves.
n Abandoned mines.
n Wells, culverts and cisterns that could contain water.
Rescues in confined spaces are usually for falls, explosions, asphyxia, medical
problems or machinery entrapment.
CHECKing the Scene and the Resources and

CALLing for Help
When checking a confined space scene, determine if the situation is too
dangerous for you to reach the injured or ill person safely. Examples of unsafe
conditions include the presence of:
n Fire.
n Smoked-filled spaces.
n Poison gas or hazardous material (HAZMAT) markings.
n Possible natural or propane gas explosions.
n Collapsed or partially collapsed structures.
n Confined areas with no ventilation or fresh air.

Avoid entering areas that require special training and equipment (e.g., respirators,
self-contained breathing apparatus [SCBA]).
Without entering the confined space, try to determine how many people are
involved and whether there are any hazards present. Next, call for help and be
as specific as possible about the situation, so the appropriate personnel can be
dispatched. Establish a safe perimeter around the area, preventing anyone from
entering. Do not enter the scene unless you are sure it is safe. When able, assist
in the rescue and offer medical assistance if appropriate.
NOTE Avoid the use of oxygen combined with the use of an automated external
defibrillator (AED) in a confined space.
Diabetic Emergency
People with diabetes sometimes become ill because there is too much or too little
sugar in their blood.

n A medical identification (ID) tag, bracelet or necklace.
n Light-headedness, dizziness, confusion or weakness.
n Irregular breathing.
n Irregular pulse (rapid or weak).
n Feeling or looking ill.
n Changes in levels of consciousness (LOC).
n Gradual or rapid onset of confusion or disorientation.
n Dry, red skin.
n Pale, moist skin.
To give CARE:
n Reassure the person that you are going to help.
n If the person is alert and can safely swallow food or fluids and is known to have
diabetes, give sugar (e.g., fruit juices, non-diet soft drinks, sugar packets, cake
decorating gel, candy, oral glucose).
n Monitor the person for changes in consciousness.
n Have the person check his or her own sugar level, if he or she knows how.
n If the person has insulin, you can get it for the person. The person must
self-administer the insulin.
n If the person is unconscious:
 DO NOT give anything to eat or drink.
 Care for the conditions you find.

n Evacuate rapidly—GO FAST—anyone who does not feel better in about
5 minutes.
n Evacuate rapidly—GO FAST—anyone who is unconscious.
Emergency and
Non-Emergency Moves
One of the most dangerous threats to a seriously injured person is unnecessary
movement. Moving a seriously injured person can cause additional injury and
pain and make the recovery more difficult. You should move a person only in the
following three situations:
n When you are faced with immediate danger (e.g., fire).
n When you must get to another person who may have a more serious injury
or illness.
n When you must move the person to give proper care.
If you must move the person for one of these reasons, you must quickly decide
how to do so. Carefully consider your safety and the safety of the injured person.
To avoid hurting yourself or the injured person, use your legs, not your back,
when you bend. Bend at the knees and hips and avoid twisting your body. Walk
forward when possible, taking small steps and looking where you are going. Avoid
twisting or bending anyone who you think has a possible head, neck or back
injury. If you cannot move a person safely, do not move the person.

non-emergency moves
Walking Assist
emergency and
To help a person who needs help
walking to safety:
1. Place the person’s arm around your
shoulders or waist, depending on his
or her size, and hold it in place with
one hand.
2. Support the person with your other
hand around the person’s waist
(Figure 1).
3. Move the person to safety.
Another person, if present, can support

Figure 1
the person in the same way on the
other side.
Pack-Strap Carry
To move either a conscious or an
unconscious person when you do not
suspect a head, neck or back injury:
1. Position yourself in front of the
person with your back to the
person’s front.
2. Place the person's arms over your
shoulders and cross them in front of
your neck, then grasp the person's
wrists.
3. Lean forward slightly and pull the
person onto your back (Figure 2). To
do this, you may have to kneel close
to the ground. Then, when you lift, Figure 2
use the power in your legs to get up
and move.
non-emergency moves
Two-Person Seat Carry

emergency and
To carry a person who cannot walk and

who you do not think has a head, neck
or back injury:
1. Put one arm under the person’s
thighs and the other across the
person’s back, under his or her arms.
2. Interlock your arms with another
person’s arms under the person’s
legs and across the person’s back.
3. Lift the person in the “seat” formed
by your interlocked arms (Figure 3).
Figure 3
Clothes Drag
To move a person who may have a
head, neck or back injury:
1. Gather the person’s clothing behind
his or her neck. While moving the
person, cradle the head with his or
her clothes and your hands.
2. Pull the person to safety (Figure 4). Figure 4
Blanket Drag
To move a person in an emergency
situation when equipment is limited:
1. Keep the person between you and
the blanket.
2. Gather half the blanket and place it
against the person’s side.
3. Roll the person toward you as a unit.
4. Reach over the person and place the
blanket under the person. Figure 5
5. Roll the person onto the blanket.

6. Gather the blanket at the head and move the person to safety (Figure 5).

non-emergency moves
Foot Drag
emergency and
To move a person who is too large to
carry or otherwise move:
1. Firmly grasp the person’s ankles and
move backward (Figure 6).
2. Pull the person in a straight line and
be careful not to bump his or her
head. Figure 6
Stretchers
A stretcher (litter) can be used to move a person a short distance to a better site
for giving care. A stretcher can also be used to transport an injured or ill person
a longer distance. Choose one of the following methods based on the person’s
injuries:
n Blanket stretcher
n Rope stretcher
n Coat stretcher
n Improvised sled
n Pack frame stretcher
Assess what equipment you have to improvise a stretcher.

n Rope
n Backpack
n Pack frame and pole
n Tent fly
n Webbing band
n Tent poles or wooden poles
n Toboggan or ski sled
n Plastic tarp
A good stretcher:
n Is stable.
n Can be tipped over without the person falling out.
n Keeps the person safe and does not make the person’s injuries worse.
n Will not injure the person carrying it.
n Is strong enough to deal with the terrain.
n Is strong enough to deal with the movement it will be subjected to.
n Makes the person feel safe and comfortable (within reason).
n Can be controlled from both ends at the same time.
When carrying a stretcher, make sure:

n The person in the stretcher is wearing eye protection so debris does not get
into his or her eyes.

n The person’s head is pointing uphill.
n There are three people on each side to carry the stretcher over rough or
steep terrain, plus one leader and two people with ropes to control the rate of
descent or uphill movement.
Emergency Childbirth
To give CARE:
If a woman is giving birth:
n Talk with the woman to help her stay calm.
n Place layers of newspaper covered with layers of linens, towels or blankets
under the woman.

n Control the scene so that the woman will have privacy.
n Position her on her back with knees bent, feet flat and legs spread wide apart.
n Remember, the woman delivers the baby, so be patient and let it
happen naturally.
n Keep the baby warm.
Caution:
n Do not let the woman get up or leave to find a bathroom. (Most women have a
desire to use the restroom.)
n Do not hold her knees together; this will not slow the birth process and may
complicate the birth or harm the baby.

n Do not place your fingers in the vagina for any reason.
n Do not pull on the baby.

n Evacuate slowly—GO SLOW—if possible. Give advanced medical personnel
the woman’s name, age, expected due date, how long she has been having
labor pains and if this is her first child.

Eye, Mouth and Lip Injuries
Eye Injuries
To give CARE:
n If an eye is burned by a chemical, flush the affected eye with large amounts of
water for at least 20 minutes.
n Care for open and closed wounds around the eye as you would for any other
soft tissue injury.
n DO NOT put direct pressure on the eyeball.
n Remember that all eye injuries should be examined by a health care provider.
n If foreign bodies get in the eye (e.g., dust), tell the person not to rub the eyes.
DO NOT touch the eye.
 Have the person blink several times.
 If the object is visible on the lower eyelid, pull the eyelid down and try to
remove the object with the corner of a sterile gauze pad. Be careful not to touch
the eyeball.
 Gently flush the eye with irrigation, saline solution or water.
 After irrigating, if the object is visible on the upper eyelid, gently roll the upper
eyelid back over a cotton swab and attempt to remove the object with the corner
of a sterile gauze pad, being careful not to touch the eyeball.
 If the object remains, the person should receive advanced medical care.
 Cover the injured eye with an eye pad/shield.
n If an object is impaled in the eye, DO NOT attempt to remove it.
 Keep the person on his or her back and have someone perform
manual stabilization.
 Stabilize the object by encircling the eye with a gauze dressing or soft sterile cloth,
being careful not to apply any pressure to the area.

 Position bulky dressings around the impaled object (e.g., roller gauze) and then
cover it with a shield (e.g., a paper cup). Do not use Styrofoam®-type materials,
as small particles can break off and get into the eye. The shield should not touch
the object.
 Bandage the shield and dressing in place with a self-adhering bandage and
eye, mouth and
roller bandage covering the person’s injured eye to keep the object stable and
lip injuries
minimize movement.
 Comfort and reassure the person.
 Do not leave the person unattended.
Mouth Injuries
To give CARE:
n Make sure the person is able to breathe as injuries to the mouth may cause
breathing problems if blood or loose teeth obstruct the airway.
n If the person is bleeding from the mouth and you do not suspect a serious
head, neck or spinal injury, place the person in a seated position with the head
tilted slightly forward.
n If this position is not possible, place the person on his or her side in the
recovery position to allow blood to drain from the mouth.
Lip Injuries
To give CARE:
n Place a rolled dressing between the lip and the gum.
n Place another dressing on the outer surface of the lip.
n If the tongue is bleeding, apply a dressing and direct pressure.
n Apply cold to the lips or tongue to reduce swelling and ease pain.

Poisoning
A poison is any substance that causes injury, illness or death if it enters the
body. A person can be poisoned by swallowing poison, breathing it, absorbing it
through the skin and having it injected into the body.

n Nausea, vomiting and/or diarrhea.
n Chest or stomach pain.
n Sweating.
n Changes in alertness.
n Seizures.
n Burns around the lips or tongue or on
the skin.
n Open or spilled containers.
n Overturned or damaged plants. Figure 1A
n Unusual odors, flames and/or smoke.
n Headache.
n Dizziness.
n Exposure to plants, such as poison
ivy (Figure 1, A), poison sumac
(Figure 1, B) or poison oak
(Figure 1, C).
Figure 1B
Figure 1C

To give CARE:
n Look for any containers that may contain a harmful or poisonous substance.
poisoning
n If necessary, move the person to safety, away from the source of the poison.
n Check the person’s level of consciousness (LOC), movement and breathing.
n If you suspect a conscious person has been poisoned and no immediate life-
threatening condition is found and you have access to a phone, call the National
Poison Control Center (PCC) hotline at 800-222-1222.
n DO NOT give the person anything to eat or drink and do not induce vomiting
unless directed to do so by PCC or emergency medical services (EMS) personnel.
n If you suspect a person has swallowed a poison, try to find out the type of poison,
how much was taken and when it was taken.
n If the person vomits, position him or her in a recovery position.
Poisonous Plants
To give CARE:
n If skin is exposed, immediately wash the affected area thoroughly with soap and
water (wear disposable gloves).
n If a rash or open sores develop, apply a paste of baking soda and water several
times a day to reduce discomfort.

n Apply lotions (e.g., Caladryl™) which may help soothe the area, if the person has
no known contraindications.
n Wash clothing exposed to plant oils with soap. Wash your hands thoroughly after
handling exposed clothing.
Scorpion Stings and Spider Bites

To give CARE:
If someone has been stung by a scorpion or bitten by a black widow spider or
brown recluse spider:
n Wash the wound.
n Apply wound gel.
n Bandage the wound.
n Apply a cold pack to the site.

n If it is available, give the person antivenin (a medication that blocks the effects of
poisonous venom).
n If signs of allergic reaction or anaphylaxis develop, treat with antihistamines
poisoning
or epinephrine, if the person has an auto-injector. Life-threatening signs and
symptoms require evacuation to advanced medical care. See Allergies and
Anaphylaxis.
Animal Bites
To give CARE:
n Control bleeding first if the wound is bleeding seriously.
n Do not clean serious wounds; the wound will be cleaned at a medical facility.
n Wash minor wounds with soap and water. Then, irrigate with large amounts of
clean running water.
n Control any bleeding.
n Apply wound gel and a dressing.
n Watch for signs of infection.
Marine Life Stings

To give CARE:
n If signs of allergic reaction or anaphylaxis develop, treat with antihistamines, or
if the person has an auto-injector, treat with epinephrine. Life-threatening signs
and symptoms require evacuation to advanced medical care. See Allergies and
Anaphylaxis.
For a jellyfish sting:

n Irrigate the injured part with vinegar for at least 30 seconds. If vinegar is not
available, use a baking soda slurry.
n When stinging stops, care for pain with hot water immersion.
or a Portuguese man-of-war sting, flush with ocean water instead of vinegar.

NOTE F

For a stingray sting:
n Flush the wound with tap water or ocean water.
n Immobilize the area.
n Soak the area in non-scalding hot water until pain goes away.
n Clean and bandage the wound.
n Watch for signs of infection.

n Evacuate slowly—GO SLOW—anyone with conditions that are worsening or
affect large areas of the body or face.
n Evacuate rapidly—GO FAST—anyone who is unconscious, or if there is a change
in the level of consciousness (LOC) or another life-threatening condition is

present. Care for any life-threatening conditions, if found.
n Evacuate rapidly—GO FAST—anyone who exhibits a severe reaction to a sting
or bite by bugs or marine life.

n Evacuate rapidly—GO FAST—anyone with a wound that is bleeding seriously
from an animal bite or if you suspect the animal might have rabies.
Seizures
When the normal functions of the brain are disrupted by injury, disease, fever,
poisoning or infection, the electrical activity of the brain becomes irregular. The
irregularity can cause a loss of body control, known as seizure.
Seizures may be caused by a condition called epilepsy, which is usually

controllable with medication. Some children and infants have seizures that are
caused by a sudden high fever.

n Unusual sensation or feeling such as a visual hallucination (person is
experiencing an aura).
n Irregular or no breathing.
n Drooling.
n Upward rolling of the eyes.
n Rigid body.

n Sudden, uncontrollable, rhythmic
muscle contractions (convulsions)
(Figure 1).
seizures
n Decreased level of consciousness
(LOC).
n Loss of bladder or bowel control.
To give CARE:
Figure 1
n Reassure the person that you are
going to help.
n Remove nearby objects that might
cause injury.
n Protect the person’s head by placing
a thinly folded towel or clothing
beneath it (Figure 2). DO NOT
restrict the airway doing so.
n DO NOT hold or restrain the person.
n DO NOT place anything between the Figure 2
person’s teeth.
n Place the person on his or her side to drain fluids from the mouth.
n If the seizure was caused by a sudden rise in body temperature, loosen
clothing and fan the person. Do not immerse in cold water or use rubbing
alcohol to cool.
n When the seizure is over, be sure that the person’s airway is open and check for
breathing and injuries.
n Comfort and stay with the person until he or she is fully conscious.

n Evacuate rapidly—GO FAST—anyone who has a seizure that lasts more than a
few minutes or has repeated seizures.
n Evacuate rapidly—GO FAST—anyone who is pregnant or has diabetes and has
a seizure.
n Evacuate rapidly—GO FAST—anyone who has a seizure in the water or who
does not regain consciousness following a seizure.

Snow Blindness
Snow blindness is a radiation burn (sunburn) of the eye. It is named for the
reflection off snow, but can also happen due to bright sunlight. After giving care,
the person may be able to self-evacuate with help. Improvised sunglasses (e.g.,
cardboard with narrow slit) may aid the person.
To give CARE:
n Stop the burning by wearing sunglasses or covering eyes.
n Have the person remove contact lenses and rest.
n If the person can swallow and has no known contraindications, the person can
self-administer aspirin.
NOTE The person should only take medication if he or she can swallow and has

Stroke
Internal injury to the brain can be a stroke—with catastrophic results. A stroke is
caused when blood flow to a part of the brain is cut off or when there is bleeding
into the brain.
When CHECKing the person:

n Use FAST to determine if the person is having a stroke:
 FACE—Weakness on one side of the face
 Ask the person to smile
(Figure 1).
 ARM—Weakness or numbness of
one arm
 Ask the person to raise both
arms (Figure 2).
 SPEECH—Slurred speech or
trouble getting words out

 Ask the person to speak a Figure 1
simple sentence.
 TIME—Note the time that the signs
and symptoms were first observed.

If the person shows one sign or
symptom, he or she is having a
stroke.
To give CARE:
n Note the time that the signs and Figure 2
symptoms began.
n Monitor and care for the ABCDEs.
 If the person is unconscious, make sure he or she has an open airway and care for
life-threatening conditions.
 If fluid or vomit is in the person’s mouth, turn him or her on one side to allow fluids
to drain.
NOTE Evacuate the person rapidly—GO FAST—as this is a life-threatening condition.

Wound Care
Avulsion
Avulsion is an injury in which a portion of the skin, and sometimes other soft
tissue, is partially or completely torn away.
To give CARE:
n Control external bleeding.
n Never remove the portion of the skin or soft tissue.
n Care for it as you would an open wound, stabilizing the part.
Amputation
Amputation is the complete removal or severing of an external body part.
To give CARE:
n Control external bleeding.
n If the amputation is incomplete, never remove the portion of the skin or
soft tissue.
n If the body part is completely severed, once it has been found, wrap it in
sterile gauze, moistened in sterile saline if available.
n Place it in a plastic bag and label it with the person’s name and the time and
date it was placed in the bag.
n Keep the bag cool by placing it in a larger bag or container of an ice and water
slurry, not on ice alone and not on dry ice.
n Transfer the bag to the advanced medical care transporting the person to
the hospital.

n Evacuate slowly—GO SLOW—anyone with an avulsion.
n Evacuate rapidly—GO FAST—anyone with an amputation.

Index
ABCDEs, 16–17 Anatomic splint, 33
Abdominal illness, Giardia, 86 Animal bites, 103
Abdominal injury, 86 Antihistamines
closed, 87 allergic reactions, 23–24, 26
open, 86–87 marine life stings, 103
Abdominal pain scorpion stings, spider bites, 102–103
diarrhea, 20–21 Aspirin
evacuation, 22 AMS, 26
first aid for, 22 children, 14
signs and symptoms of, 21 heart attack, 66
stomachache, 20 snow blindness, 106
Abdominal thrusts, 10 teeth problems, 81
Abrasions, 78 Assessment
Active drowning victim, 68 primary (initial), 16–17
Acute mountain sickness (AMS) secondary (focused), 17–18
evacuation, 29 Asthma attack
first aid for, 27 evacuation, 89
signs and symptoms of, 26 first aid for, 88–89
AED signs and symptoms of, 88
for adult or child, 8–9 AVPU, 17–18
CPR, 7 Avulsion, wound care, 108
Airway, primary (initial) assessment, 16
Allergic reactions BEAM, 54
anaphylaxis, 23–26 Bee stings, 82
non-life-threatening, 22–23 Blanket drag, 96
Altitude illnesses Bleeding, wounds, 73–74
AMS, 26–27, 29 Body elevation, 54
HACE, 27–29 Bone injury
HAPE, 28–29 evacuation, 39
Amputation, wound care, 108 first aid for, 30–31
AMS. See Acute mountain sickness RICE method, 30–31
Anaphylaxis signs and symptoms of, 30
Auvi-Q®, 23 splinting, 31–34
epinephrine, 23 types of, 29
EpiPen®, 23–25 Brain injury
evacuation, 26 evacuation, 50
first aid for, 24–26 first aid for, 50
signs and symptoms of, 23 H.A.IN.E.S., 51
Index
109
Brain injury (continued) Circulation, sensation and motion
mild, 48 (CSM)
serious, 49–50 bone and joint injuries, 29
Breathing, primary (initial) fractures, 35
assessment, 16 secondary (focused) assessment, 17
Burns spinal injury, 51
evacuation, 43 splinting, 33
first aid for, 42–43 Clothes drag, 96
full-thickness, 41 Cold-related
partial-thickness, 40 frostbite, 90–91
Rule of Palmar Surface, 41 immersion foot, 91
signs and symptoms of, 40–41 Confined spaces, 92–93
superficial, 40 CPR. See Cardiopulmonary resuscitation
TBSA, 41–42 CSM. See Circulation, sensation
and motion
Cardiopulmonary resuscitation (CPR)
adult and child, 7 Diabetic emergency, 93–94
drowning, 72 Diarrhea, 20–21
heart attack, 67 Disability, spinal injury, 17
hypothermia, 61 Dislocation
lightning injuries, 64 evacuation, 39
primary (initial) assessment, 16 first aid for, 38–39
Chafing, 79 principles of, 38
Check—Call—Care principles reduction, 38
care, 19 signs and symptoms of, 38
check scene, 15 Stimson technique, 38
help, calling for, 19 Distressed swimmer, 68
primary (initial) patient assessment, DOTS, 17
16–17 Drowning
SAMPLE history, 19 active victim, 68
secondary (focused) patient assist, 69–71
assessment, 17–18 distressed swimmer, 68
vital signs, 18 evacuation, 72
Chest injury first aid for, 72
evacuation, 48 passive victim, 68
flail chest, 45 signs and symptoms of, 71
signs and symptoms of, 43–44
sucking chest wound, 46–47 Ear problems, 79–80
Childbirth, 98 Electrical burn, 41
Choking Emergency action principles
conscious, 10 evacuation, 19
Circulation primary (initial) patient assessment,
primary (initial) assessment, 16 16–17

resources, 15 Giardia, 86
SAMPLE history, 17 Glove removal, 2
scene, 15
secondary (focused) patient HACE. See High altitude
assessment, 17–18 cerebral edema
vital signs, 18 H.A.IN.E.S., 51
Epinephrine HAPE. See High altitude
anaphylaxis, 23 pulmonary edema
marine life stings, 103 Head injury
scorpion stings, spider brain, mild, 48
bites, 102–103 brain, serious, 49–51
EpiPen®, 23–24 evacuation, 50–51
Evacuation H.A.IN.E.S., 51
blanket drag, 96 scalp, superficial, 47
clothes drag, 96 Heart attack
emergency, 94 evacuation, 67
foot drag, 97 first aid for, 66–67
non-emergency, 94 signs and symptoms of, 66
pack-strap carry, 95 Heart rate, normal, 18
stretchers, 97–98 Heat exhaustion, 56–57
two-person seat carry, 96 Heat-related illnesses
walking assist, 95 heat exhaustion, 56–57
Exposure, environmental, 17 heat stroke, 57–58
Eye injury, 99–100 hyponatremia, 58–59
Heat stroke, 57
First aid kit High altitude cerebral edema (HACE)
additional items, 13–14 evacuation, 29
group, 12–13 first aid for, 28
personal, 12 signs and symptoms of, 27
Flail chest, 45 High altitude pulmonary
FOAM, 53 edema (HAPE)
Foot drag, 97 evacuation, 29
Fracture first aid for, 29
evacuation, 39 signs and symptoms of, 29
first aid for, 35–36 Hyperbaric chamber, portable, 28
signs and symptoms Hyponatremia, 58–59
of, 35 Hypothermia, mild to moderate,
Fracture, complicated 59–61
angulated, first aid for, 37 Hypothermia, severe, 61–62
evacuation, 39
open, first aid for, 37 Immersion foot, 91
Friction blisters, 78–79 Impaled objects, 74
Frostbite, 90–91 Infection, wounds, 83–84
Index
111
Jellyfish stings, 103 Pneumothorax, 45, 47
Joint injury Poisoning
evacuation, 39 animal bites, 103
first aid for, 30–31 evacuation, 104
signs and symptoms of, 30 first aid for, 102
splinting, 31–34 marine life stings, 103
sprains, 34 poisonous plants, 102
strains, 34 scorpion stings, 102–103
types of, 29 spider bites, 102–103
Poisonous plants, first aid for, 102
Lacerations, 76–77 Primary (initial) assessment,
Level of consciousness (LOC), 16–17
17–18 Puncture wounds, 76
Lightning injuries, 64 Pupils
Lightning storm, safety measures, response, 49
62–63 unequal size, 50
Lip injury, 101
LOC. See Level of consciousness Reach, Throw, Row, Go, 69–71
Log roll, 54 Reduction, 37
Lung injury Rescue breathing
evacuation, 47 drowning, 71
signs and symptoms of, 45 heart attack, 66
hypothermia, 61
Marine life stings, 103–104 primary (initial) assessment, 16
Mechanism of injury (MOI), 15, 51–52 Respiratory rate, normal, 18
Methicillin-resistant Staphylococcus Rib injury
aureus (MRSA), 84 evacuation, 47
Mosquito bites, 82 first aid for, 44
Mouth injury, 100 signs and symptoms of, 44
MRSA. See Methicillin-resistant RICE method, 30–31
Staphylococcus aureus Rigid splint, 34
Rule of Palmar Surface, 41
National Poison Control Center
(PCC), 102 SAMPLE history, 18
Nitroglycerin, 66 Scalp injury, 47–48
Nosebleeds, 80 Scorpion stings, 102–103
Secondary (focused) assessment,
Pack-strap carry, 95 17–18
Parasite, Giardia, 86 Seizures
Passive drowning victim, 68 evacuation, 105
PCC. See National Poison first aid for, 105
Control Center signs and symptoms of, 104

Shock TBSA. See Total body surface area
evacuation, 65 Teeth problems, 81–82
first aid for, 65 Tension pneumothorax, 45, 47
signs and symptoms of, 65 Tick bites, 82
Skin color, normal, 18 Total body surface area (TBSA), 41
Sling-and-swathe, 32 Tourniquets, 74–75
Snakebites, 83 Two-person seat carry, 96
Snow blindness, 106
Soft splint, 33 Unconsciousness assessment, 3–6
Spider bites, 102–103
Spinal injury Vital signs, 18
BEAM, 54
evacuation, 55 Walking assist, 95
first aid for, 52–53 Wasp stings, 82
focused assessment, 55 Water rescue
log roll, 54 active drowning victim, 68
MOI, 51–52 distressed swimmer, 68
moving patient, 55 passive drowning victim, 68
signs and symptoms of, 52 Reach, Throw, Row, Go, 69–71
Splinting Wound care
anatomic splint, 33 amputation, 108
bone injury, 31 avulsion, 108
principles of, 31–32 Wounds
rigid splint, 34 abrasions, 78
sling-and-swathe, 32 bleeding, 73–74
soft splint, 33 chafing, 79
Sprain, 34 cleaning, 75–76
Stimson technique, 38 dressing and closing, 76–77
Stingray stings, 104 ear problems, 79–80
Stomachache, 20 evacuation, 84
Strain, 34 friction blisters, 78
Stretchers, 97–98 infection, 83–84
Stroke, 107 mosquito bites, 82
Submersion incidents MRSA, 84
active drowning victim, 68 nosebleeds, 80
distressed swimmer, 68 snakebites, 83
near-drowned person, care, 71–72 teeth problems, 81–82
passive drowning victim, 68 tick bites, 82
water rescue, 68–71 tourniquets, 74–75
Sucking chest wound, 46–47
Index
113
I am trained, empowered and prepared.
I am the American Red Cross.
Training for Emergencies in Wilderness and Remote Environments
Whether you’re a scout, an outdoor enthusiast or you work in a remote
environment, our Wilderness and Remote First Aid course gives you the
skills you need to respond to an emergency when help may be delayed.
Course participants must be at least 14 years of age and possess current
certification in adult CPR/AED.
Wilderness and Remote First Aid Topics

• Head (Brain), Neck and Spinal Injuries • Heat-Related Emergencies
• Hypothermia • Altitude-Related Illnesses
• Allergies and Anaphylaxis • Burns
• Bone and Joint Injuries • And more
• Wounds and Wound Infection
Helping Everyday People Learn to Save Lives for 100 Years

Since 1910, communities, schools and businesses nationwide have
turned to the Red Cross for quality first aid training. Remember, when
you participate in Red Cross health and safety programs, you help the
Red Cross fulfill its mission of providing relief to victims of disasters and
helping people learn how to save lives.
Based on the Boy Scouts of America

Wilderness First Aid Curriculum and Doctrine Guidelines
Offers Enhanced Content to Meet OSHA’s
Best Practices for Workplace First Aid Training Programs

Wilderness and Remote First Aid: Emergency Reference Guide

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Wilderness and Remote First Aid

Emergency Reference Guide

Copyright © 2014 American Red Cross. ALL RIGHTS RESERVED.

Published by Krames StayWell Strategic Partnerships Division

Injuries and Illnesses

iv wilderness and remote first aid emergency reference guide

vi wilderness and remote first aid emergency reference guide

SLIP TWO FINGERS

PULL GLOVE OFF

4 DISPOSE OF GLOVES AND WASH HANDS

2 wilderness and remote first aid emergency reference guide

Use disposable gloves and other personal protective equipment (PPE).

AFTER CHECKING THE SCENE FOR SAFETY, CHECK THE PERSON:

CHECK FOR RESPONSIVENESS

IF NO RESPONSE, CALL 9-1-1 OR THE LOCAL EMERGENCY

OPEN THE AIRWAY

Continued on next page

4 CHECK FOR BREATHING

Check for no more than 10 seconds.

5 QUICKLY SCAN FOR SEVERE BLEEDING

4 wilderness and remote first aid emergency reference guide

AFTER CHECKING THE SCENE FOR SAFETY, CHECK THE CHILD:

CHECK FOR RESPONSIVENESS

IF NO RESPONSE, SEND SOMEONE TO CALL 9-1-1 OR THE

OPEN THE AIRWAY

4 CHECK FOR BREATHING

Continued on next page

GIVE 2 RESCUE BREATHS

6 QUICKLY SCAN FOR SEVERE BLEEDING

6 wilderness and remote first aid emergency reference guide

After checking the scene and the injured or ill person:

GIVE 30 CHEST COMPRESSIONS

GIVE 2 RESCUE BREATHS

AFTER CHECKING THE SCENE AND THE INJURED OR ILL PERSON,

WIPE BARE CHEST DRY

8 wilderness and remote first aid emergency reference guide

6 LET THE AED ANALYZE HEART RHYTHM

7 DELIVER SHOCK, IF ADVISED

AFTER CHECKING THE SCENE AND THE INJURED OR ILL PERSON,

GIVE 5 BACK BLOWS

GIVE 5 ABDOMINAL THRUSTS

10 wilderness and remote first aid emergency reference guide

As Reflected in Boy Scouts of America Wilderness

Personal First Aid

Group First Aid Kit

12 wilderness and remote first aid emergency reference guide

First Aid Kits

Additional Items Mentioned in Course

Injuries and Illnesses 13

n Zinc oxide powder

Other Important Items That Are Useful in

14 wilderness and remote first aid emergency reference guide

CHECK the Resources

Injuries and Illnesses 15

CHECK the Person

Primary (Initial) Assessment

use the head-tilt/chin-lift technique

16 wilderness and remote first aid emergency reference guide

for signs and symptoms of exposure to extreme environmental conditions,

SLIP TWO FINGERS

4 DISPOSE OF GLOVES AND WASH HANDS

IF NO RESPONSE, CALL 9-1-1 OR THE LOCAL EMERGENCY

4 CHECK FOR BREATHING

5 QUICKLY SCAN FOR SEVERE BLEEDING

IF NO RESPONSE, SEND SOMEONE TO CALL 9-1-1 OR THE

6 QUICKLY SCAN FOR SEVERE BLEEDING