Wilderness & Environmental Medicine

Cover

2010-06-01

In Tribute to Charlie Houston

Paul S. Auerbach — 2010-06-01

SCIENCE now has proved that flyers and mountain climbers can reach altitudes of almost six miles, remain normal and alert, and come away none the worse for wear—without supplemental oxygen … It is only necessary that they accustom themselves gradually to the decreasing pressures and dwindling oxygen … For this discovery, of much value in the planning of future upper air explorations, credit goes to a pair of venturesome young men of the U. S. Navy—Lieut, (jg) Walter S. McNutt, Jr., and Carlton R. Morris, Hospital Apprentice. Under the supervision of Lieut. Cmdr. Charles S. Houston, U.S.N.R., a flight surgeon and authority on mountain climbing, McNutt and Morris tested for an entire month, in Florida, an odd sea-level combination of mountain climbing and airplane flying called “Operation Everest.” The men lived in a compression chamber. They “flew” or “climbed” almost six miles without supplemental oxygen and suffered no ill effects. They reached a simulated altitude of 29,025 feet—23 feet higher than the unconquered peak of Mount Everest, the highest mountain in the world … The program's purpose was to study the adaptation of the human body to slowly increasing anoxia, or lack of oxygen. As a result of its findings it may be possible to reproduce artificially the necessary physiological changes in an aviator in order to “acclimatize” him quickly before he reaches the upper air … Morris and McNutt reached the “altitude” topping Mount Everest, remained there for almost 30 minutes and didn't lose consciousness … The test chamber was really something to see. It was of steel, about 20 feet long and perhaps 10 feet in diameter, with two doors about six feet apart in one end. Technicians and observers who entered the chamber did so by way of a small lock, remaining there until its air was reduced to the same pressure as that of the volunteers; and when they left the process was reversed. The chamber bristled with control appliances and was operated by a 14-man crew of experts … It was interesting to watch McNutt and Morris as they “climbed” to their record-breaking height of 29,025 feet on the next to the last day. When they reached this height their blue complexions turned to a rather deep purple. (If this sounds a bit wild, let me explain that men start to turn blue in the face after they've been exposed to heights of about 13,000 feet without supplemental oxygen.) At this point they were breathing heavily and looked definitely uncomfortable; but they stayed there without supplemental oxygen for four hours … Other high altitude physiological studies are sure to follow this initial effort …

Search and Rescue Activity on Denali, 1990 to 2008

Timothy R. Hurtado — 2010-06-01

In this issue of Wilderness and Environmental Medicine, McIntosh et al summarize the search and rescue (SAR) activity over an 18-year period on Mt. McKinley, or Denali, the highest mountain in North America. This is an important and needed addition to the literature regarding the incidence of SAR activities on Denali and emphasizes many important points. The authors nicely summarize the climbers' demographics, guide status, nationality, medical complaints, mechanism of injury, cold and altitude injuries, and route information for whom the National Park Service (NPS) provided SAR services. They conclude that there is a wide variety of reasons for SAR activity, that certain groups have a historical higher risk of requiring rescue, and that overall the incidence of NPS SAR responses is low (1.16%). In this editorial, I offer the opinion that the new data, coupled with the recently published article by Heggie et al addressing SAR activities in all US National Parks, suggests that the climbers who use Denali and the NPS which monitors their use, are good stewards of mountaineering in the park, have been effective at mitigating some of the objective risk inherently involved in mountaineering, and that the public perception of the high costs and incidence of mountaineering rescues is unwarranted.

Sidecountry Rescue—Who Should Respond to Ski Resort Out-of-Bounds Rescues?

Christopher van Tilburg — 2010-06-01

The latest buzzword in winter recreation, “sidecountry skiing and snowboarding,” is popping up in magazines, equipment marketing materials, and ski resort websites. The increasing popularity poses several questions. First, what or where is the “sidecountry” aka “slackcountry?” Is it a geographic local, an activity, or both? Simply defined, the sidecountry is the area adjacent to but outside the boundary of winter resorts, which is accessed from the resort by a paying customer. In other words, a skier or snowboarder buys a lift ticket, rides a lift, and then heads out of bounds. This raises many questions and concerns. The biggest quandary: who should respond to sidecountry rescues?

Search and Rescue Activity on Denali, 1990 to 2008

Scott E. McIntosh, Aaron Brillhart, Jennifer Dow, Colin K. Grissom — 2010-06-01

Objective: To describe search and rescue activity performed by the National Park Service (NPS) on Denali, the highest point in North America.Methods: A retrospective review was performed of all search and rescue (SAR) operations by the NPS from 1990 to 2008. Descriptive analysis was used to describe these cases as well as chi-square and logistic regression analysis to determine which mountaineers were more likely to require a rescue.Results: During the study period, 1.16% of all Denali climbers required NPS SAR response. The majority of medical cases (68.9%) were due to high altitude and cold injuries, and the majority of traumatic cases (76.2%) resulted from a fall. Mountaineers that attempt routes other than the standard West Buttress route are more likely to require rescue. Climbers are 3% more likely to require a rescue with each year of advancing age. Similarly, mountaineers from Asia are more likely to require a rescue (odds ratio = 4.1), although this trend has diminished in the past decade.Conclusions: Mountaineers and rescuers should educate themselves on the environmental, logistical, and medical origins of Denali rescues. Certain demographic groups on certain routes are more likely to require a rescue on Denali. Rescuers should be aware of these groups and have the knowledge and capabilities to care for the medical issues that are common on SAR responses.

End-Tidal Partial Pressure of Carbon Dioxide and Acute Mountain Sickness in the First 24 Hours Upon Ascent to Cusco Peru (3326 meters)

Danielle J. Douglas, Robert B. Schoene — 2010-06-01

Objective: To explore the association of end-title partial pressure (Petco2) and oxygen saturation (Spo2) with the development of AMS in travelers rapidly ascending to Cusco, Peru (3326 m).Methods: Using the 715 TIDAL WAVE Sp handheld, portable capnometer/oximeter, we measured Spo2 and Petco2 in 175 subjects upon ascent to Cusco, Peru (3326 m) from Lima (sea level) (a mean time of 3.9 hours.) Symptoms of AMS were recorded at the same initial time on arrival to altitude and 24 hours later using the Environmental Symptoms Questionnaire (ESQ).Results: This study showed that no subjects with the lowest Petco2 of 23 to 30 mm Hg had AMS (P <.044). The data also demonstrate that subjects with a higher Petco2 (36–40 mm Hg) and lower Sao2 (72%–86%) have a higher incidence of AMS.Conclusion: The most important finding of this study is that Petco2 upon ascent was found to have a more significant effect than Spo2 on a subject's ultimate ESQ score. This study demonstrates that those individuals with a brisk ventilatory response upon ascent to moderate altitude, as measured by Petco2, did not develop AMS, whereas a blunted ventilatory response, as reflected in the highest Petco2, was related to the subsequent development of AMS.

Vipera berus Bites in the Region of Southwest Poland—A Clinical Analysis of 26 Cases

2010-06-01

Objective: Vipera berus is the only naturally occurring venomous snake in Poland. Its venom is primarily vasculotoxic and evokes both local and systemic findings. The aim of the study was to review a series of clinical cases of V berus bites occurring in southwest Poland.Methods: The charts of 26 patients (age range, 16–66 years; mean, 42 years) hospitalized with V berus bites were retrospectively analyzed using a data collection tool. Demographic and clinical data were extracted.Results: The most common local findings of envenomation were edema of the bitten limb with associated extravasations observed in 24 (92.3%) patients, but in only 1 (3.8%) case did the edema spread to the trunk. In 22 (84.6%) cases edema disappeared within 2 weeks after the bite. Systemic disturbances observed in the patients were: shock (1 case), mild transient hypotension (1 case), prolonged hypotension (3 cases), bronchospasm and laryngeal edema (1 case), diarrhea (1 case), transient supraventricular arrhythmias (2 cases), neutrophilic hyperleukocytosis (2 cases), and thrombocytopenia below 50000 cells/μL (5 cases). In 16 patients (61.5%) the envenomation was classified as moderate and this type was predominant. Six cases were classified as severe. No fatal case was reported. Treatment included the administration of specific antivenom in 14 cases (in all severe and half of moderate cases) and symptomatic treatment applied in all cases.Conclusions: Moderate envenomation prevailed among the patients analyzed in the study. Antivenom treatment is primarily necessary in cases of severe (grade 3) and in some cases of moderate (grade 2) envenomation, especially in patients with persistent or recurring hypotension.

Large Snake Size Suggests Increased Snakebite Severity in Patients Bitten by Rattlesnakes in Southern California

Donald N. Janes, Sean P. Bush, Gita R. Kolluru — 2010-06-01

Objective: To correlate rattlesnake size and other characteristics of envenomation with the severity of envenomation.Methods: We retrospectively reviewed 145 charts of patients bitten by rattlesnakes in Southern California between 1995 and 2004, measuring Snakebite Severity Scores (SSS) and characteristics of envenomation that might be correlated with snakebite severity, including rattlesnake size, rattlesnake species, patient size, and anatomic location of the bite. Outcomes measured included SSS, complications of envenomation, number of vials of antivenom used, and length of hospital stay.Results: Of the patients bitten by rattlesnakes, 81% were men, and 79% of bites were on the upper extremities. Fifty-five percent of bites were provoked by the patient, and 44% were unprovoked. Neither location of snakebite nor provocation of snakebite affected the SSS. Only 1 patient had a snakebite without envenomation, and only 1 patient died from envenomation. Rattlesnake size was positively correlated with SSS, and SSS was positively correlated with the number of vials of antivenom used and with the length of hospital stay. Rattlesnake species and patient mass did not affect SSS.Conclusions: Larger rattlesnakes cause more severe envenomations, which contradicts popular belief.

Frostbite in a Sherpa

2010-06-01

Frostbite is frequently seen in high altitude climbers. Many Sherpas, members of an ethnic community living high in the Himalayas in Nepal, help the climbers as a guide or an assistant. They often seem to undertake few precautionary measures thus suffer more from frostbite. A young Sherpa, who had reached the top of Mt Kanchenjunga in March 2009, suffered from deep frostbite in his fingers. Fortunately, he recovered well with generous treatment. Though there is no evidence whether Sherpas are more or less prone to frostbite, simple techniques for adequate prevention of hypoxia, hypothermia and dehydration will benefit any climber to the high altitudes.

Bites Caused by Giant Water Bugs Belonging to Belostomatidae Family (Hemiptera, Heteroptera) in Humans: A Report of Seven Cases

2010-06-01

We report 7 cases of patients bitten by giant water bugs, large predatory insects belonging to the Belostomatidae family (Hemiptera, Heteroptera). These insects have toxic saliva capable of provoking intense pain and paralysis in vertebrates. Victims experienced intense, excruciating pain and 1 manifested hypoesthesia in the forearm. Bites by Belostomatidae are often reported by clinicians working in areas where these insects live, but there are no detailed case reports in the medical literature. There are no specific treatment modalities known to be effective, making prevention an important strategy.

Ocular Toxicity Associated with Indirect Exposure to African Spitting Cobra Venom

Darin R. Goldman, Andrew W. Seefeld — 2010-06-01

Direct ocular inoculation with African spitting cobra (Naja nigricollis) venom in the United States is uncommon, especially in an urban setting, but can lead to serious acute and chronic ocular injury depending on the extent of exposure. We report 2 cases of indirect ocular inoculation with venom from an African spitting cobra, manifesting as periocular soft tissue swelling, extensive conjunctivitis, and corneal epithelial erosion. Both of the reported cases involve young male patients who received prompt emergency evaluation and treatment including copious irrigation of the ocular surface, followed by close monitoring by an ophthalmologist resulting in excellent outcomes with minimal visually significant ocular sequelae.

The Ultrasound Identification of Simulated Long Bone Fractures by Prehospital Providers

Jason D. Heiner, Todd J. McArthur — 2010-06-01

Objective: In austere environments, patient management decisions are often limited by obtainable resources. Portable ultrasound may allow for the detection of fractures when imaging modalities such as radiography are unavailable. We used a simulation training model in a pilot study to examine the ability of emergency medical technicians (EMTs) to detect the presence or absence of a variety of simulated fracture patterns with portable ultrasound.Methods: The fracture simulation model is composed of a mechanically fractured bare turkey leg bone housed in a shallow container within a completely opaque gelatin solution. Five different fracture patterns were created. Twenty EMTs sonographically evaluated these models with a portable ultrasound device to determine the presence or absence of a fracture.Results: EMTs correctly identified the presence or absence of a fracture in the no fracture, transverse fracture, and oblique fracture models 95% of the time. They always correctly identified the presence of a fractured model when assessing the comminuted and segmental fracture models. Across all fracture patterns, a final detection sensitivity of 97.5% (95% confidence interval [CI]: 94.1%–100.0%) and a specificity of 95.0% (95% CI: 85.4%–100.0%) were observed.Conclusions: Using portable ultrasound, EMTs correctly detected the presence or absence of simulated long bone fractures with a high degree of sensitivity and specificity. Future studies may evaluate the ability of other groups to use ultrasound to assist in the diagnosis of fractures and examine the clinical impact of this skill in environments where conventional imaging modalities are limited or unavailable.

Detection and Management of Hypothermia at a Large Outdoor Endurance Event in the United Kingdom

Aneel Bhangu, Rinesh Parmar — 2010-06-01

Objective: Optimum detection of hypothermia in athletes during outdoor exposure events remains controversial. The aims of this study were firstly to assess whether temperature readings affected competitor discharge from the treatment station and secondly to assess agreement between oral and tympanic thermometer measurements.Methods: All competitors treated for symptomatic hypothermia at an outdoor endurance event in the United Kingdom during January 2009 were included. Temperature readings were taken using oral (Digitemp digital oral thermometer) and tympanic (Braun Thermoscan IRT 4520 ExacTemp) thermometers, with a temperature <35°C classifying hypothermia.Results: From 4700 competitors, 64 (1.4%) were treated for symptomatic hypothermia. Of these, 92% were male, the mean age was 26 years, and the mean treatment time was 25 minutes. There was no severe/life-threatening hypothermia, and no competitors required transport to a hospital for hypothermia. At discharge, 19% of competitors were still classed as hypothermic in the oral group and 28% in the tympanic group, despite competitors only being discharged when no longer symptomatic. Oral readings at discharge were significantly lower than tympanic readings (33.8°C [95% CI, 33.2°C to 34.5°C] vs 35.0°C [95% CI, 34.6°C to 35.3°C], respectively, P = .003).Conclusions: The use of thermometers had a limited role in discharging competitors at this event, who were apparently safely discharged when no longer symptomatic. Treating clinicians and the thermometers did not always agree on whether a patient was hypothermic or not. Oral and tympanic thermometers had poor agreement. Routine thermometer readings at future events may be unnecessary, although screening competitors of concern will remain useful.

Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness

2010-06-01

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.

Adverse Encounters With Alligators in the United States: An Update

Ricky L. Langley — 2010-06-01

Objective: Severe injuries and fatalities can occur from an alligator attack. Encounters with alligators appear to be increasing in the United States. This review provides information from alligator attacks reported in the United States as well as infections that may occur after an alligator bite.Methods: Telephone interviews were conducted with state wildlife offices in all Southern states in order to collect information on the number of alligator bites, nuisance calls, and the estimated alligator population of each state. Detailed information from alligator attacks in Florida is presented, including basic demographic information on the victims and description of the types of injuries and the activity of the victim at the time of injury. Additional information regarding the size and behavior of the alligator involved in the attack is also provided in many cases.Results: There have been 567 reports of adverse encounters with alligators with 24 deaths reported in the United States from 1928 to January 1, 2009. In addition, thousands of nuisance calls are made yearly and the number of nuisance calls as well as the alligator population is increasing in many states.Conclusions: Injuries from encounters with alligators may range from minor scratches and punctures to amputations and death. The larger the alligator, the more likely that serious injury will occur. As the human population encroaches on the habitat of the alligator, attacks and nuisance complaints will continue to occur. A uniform reporting system among states should be developed to obtain more complete information on alligator encounters. Guidelines have been developed by many state wildlife officials to reduce adverse encounters with alligators.

What's Your Diagnosis?

Nathan Phillip Charlton, Mairin Smith, Christopher Peter Holstege — 2010-06-01

A patient presented to an urgent care facility 15 minutes after contact with the organism depicted in . He described throbbing pain at the site but denied generalized pruritus, edema, fever, chills, and difficulty breathing. All vital signs were normal. Clinical examination revealed wheals surrounded by an erythematous macular halo (). Approximately 40 minutes after envenomation, the wheals resolved and petechiae developed at the site of envenomation ().

Advanced Wilderness Life Support Education Using High-Technology Patient Simulation

Stephanie A. Lareau, Blake D. Kyzer, Seth C. Hawkins, Henderson D. McGinnis — 2010-06-01

Objective: (1) To determine if, after using the simulation mannequin SimMan in a wilderness “megacode” exercise, participants believe high-tech simulators are an effective tool for learning wilderness medicine skills. (2) To determine if participants believe high-tech simulation mannequins should be used with more or less frequency in future wilderness medicine exercises.Methods: After completing a basic training session outlining the capabilities of SimMan and completing a wilderness megacode (defined as a series of progressive conditions that accumulate over time) using SimMan, participants were surveyed to ascertain whether they perceived SimMan to be an effective teaching tool for wilderness medical skills and to determine if they would like SimMan to be used with greater frequency at future wilderness medicine courses. The data were compiled and analyzed using Microsoft Excel.Results: Participants found the wilderness SimMan experience to be an effective tool with an average score of 3.15 on a scale where 4 is most effective and 1 is least effective. Participants also desired to see high-tech simulation more frequently in wilderness courses with a score of 3, on a scale where 4 is more frequently and 1 is less frequently. There was little difference in responses based on previous experience with simulation.Conclusions: High-tech simulation is an underused tool for wilderness medicine education. Currently, several barriers exist to its implementation in wilderness medicine. Participants in wilderness courses feel it is an effective tool and would like to see it used more frequently.

Possible Unilateral Ultraviolet Keratoconjunctivitis During an Expedition-Length Desert Race

Grant S. Lipman, Benjamin B. Constance, Matt Ladbrook — 2010-06-01

A previously well 35-year-old professional photographer from New York City with near-sighted vision had his prescription sunglasses accidentally crushed on the first day photographing a 7-day 150-mile ultra-endurance race through the Gobi Desert near Kashgar, China (altitude 1289 m, latitude 39° N). The conditions were sunny and warm, and while the man usually wears sunglasses while shooting in extreme conditions “from morning to dusk,” he spent the first day without sunglasses (wearing nontinted prescription glasses with mild ultraviolet [UV] protection). In the evening of the first day, a mild discomfort was felt in the right eye, which had spontaneously resolved upon awakening.

Rescuing the Physical Exam

Ethan G. Brown, Jay Lemery — 2010-06-01

Throughout medical school, education of students in the art of the physical exam has been an experience of mixed messages. Early on we are meticulously taught the nuances of examination findings and their significance to diagnosing disease. Educators spend hours emphasizing the sensitivity, thoroughness, and tact that this unique interaction requires. Armed with the foundation of diagnostics, we head to the wards ready to put our new skills to work. There we find that the reality of a busy, modern teaching hospital offers a very different message. We quickly realize that our discovery of heart sounds, abdominal tenderness, and pronator drifts are merely a prelude to echocardiogramss, computed tomography scans, and magnetic resonance images. Our preceptors applaud our enthusiasm, but any therapeutic consideration from our discoveries is trumped for the certainty of gold standards. Exam findings are shrugged off as interesting anomalies, a means to justify further testing rather than significant in and of themselves. Thus encouraged to think efficiently and move quickly through the standard algorithms, medical students wonder if the physical exam is actually a vestigial skill, akin to a history class providing context for a modern political science course.

Editor's Response to “Rescuing the Physical Exam”

Robert L. Norris — 2010-06-01

The message contained in the above letter by Ethan G. Brown and Dr Jay Lemery regarding the enhanced importance of the physical examination of patients in a wilderness setting has been driven home to me. I am now 1 week home after responding as part of an emergency medicine team with the International Medical Corps (along with Dr Paul Auerbach, Dr Anil Menon and other emergency medicine professionals from Stanford University and Columbia University) to earthquake victims in Haiti. We responded to the completely incapacitated Hôpital de l'Université d'État d'Haiti (HUEH) in Port-au-Prince on day 5 after the quake and found ourselves confronted with approximately 800 severely traumatized victims. It was our job to rapidly assess and resuscitate these victims, clean and bandage horrendous wounds, splint shattered extremities, and transport victims by priority of medical necessity to a limited operating room (2 functioning operating tables where dedicated orthopedists performed “battlefield surgery”). We relied solely upon our physical examination skills to make diagnoses—to differentiate crushed and contused extremities from humeral fractures, femur fractures, and pelvic fractures—in the absence of radiographic capabilities for the first week of our stay. We limited administration of tetanus immune globulin to persons with signs and symptoms of early tetanus in order to conserve critically short supplies, and prudently reserved use of precious intravenous fluids and sodium bicarbonate for victims whose exams supported the diagnosis of actual or impending rhabdomyolysis. After several days, when the Mercy class hospital ship, USNS Comfort, anchored offshore, we worked with the Army and the Navy to airlift patients with needs beyond our capabilities to the ship (and to other local medical relief sites). The types of cases these providers sought were precisely defined, which further put our physical diagnosis skills to the test. Anemia was diagnosed by the color of a victim's tongue, conjunctivae, and the soles of his feet; pneumothorax by decreased breath sounds and subcutaneous crepitus; and necrotizing infection by the putrid odor.

Morbidity Related to Urban Summer Camp Activities in Scholars, Caracas, Venezuela, 2008

Alfonso J. Rodriguez-Morales, Alejandro Rísquez, Lino Rivero — 2010-06-01

Summer vacations represent important opportunities for recreation and travel of young people from schools and universities. These students may be involved in many different activities, organized and not. A common source of recreation for such students is participation in summer camps, in the city or outside it. In either case, these activities can result in acute medical problems and exacerbation of pre-existing chronic medical conditions. Here we describe the experience related to the medical needs of students during urban summer camp activities held in Caracas, Venezuela, during school vacation in 2008.

A Review of Lightning Safety Education for Outdoor Adventure Programs

Aram Attarian — 2010-06-01

As an outdoor leader and educator for over 30 years and lightning strike survivor, I decided to conduct an exploratory study into the content of outdoor adventure program lightning education procedures with the primary purpose of identifying commonalities, omissions, and misconceptions based on currently accepted lightning safety education practices. A secondary purpose was to suggest a set of lightning safety education criteria for use by outdoor adventure programs to educate staff and participants on lightning safety. A summary of the investigation is presented herein.

Higher Suicide Death Rate in Rocky Mountain States and a Correlation to Altitude

David Cheng — 2010-06-01

In 2002, the author presented limited data suggesting a higher suicide death rate in the Rocky Mountain states (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming). The data were expanded to cover 1979 to 2006, as well as to address gender, race, and socioeconomics factors. Finally, a correlation coefficient diagram between altitude and suicide death rate was developed.

In Response to “The Impact of Footwear and Packweight on Injury and Illness Among Long-Distance Hikers”

Michael Bogdasarian — 2010-06-01

I found the article “The Impact of Footwear and Packweight on Injury and Illness Among Long-Distance Hikers” interesting, but I feel more questions were raised than answered. I submit the following for consideration with the hope that the raw data may reveal additional useful correlations, possibly establishing specific recommendations or outlining new areas for meaningful research.

Reply to Dr. Bogdasarian's Letter

L. Stewart Anderson, James Feldman, Laura White — 2010-06-01

We thank Dr Bogdasarian for his interest in our article and the many thoughtful questions that he raises. Fundamentally, we agree that research using more rigorous methods will be required to understand the effects of ultra light hiking techniques on illness and injury experienced by long-distance hikers. There are limitations to our use of a structured cross-sectional survey instrument to assess some of the associations between footwear, packweight, and illness and injury experienced by long-distance hikers in a single year. Although we did inquire about diarrhea, we did not include this in our final report because there were concerns with our ability to adjust for many factors that could be associated with this disorder, such as type and frequency of water purification, water sources, and hygiene to name a few. We did not explore the association between diarrhea, packweight, and footwear because the association would be ambiguous at best.

Use of Antivenom in Vipera berus Bites—A Comment

Christine B.M. Karlson-Stiber, Hans E. Persson, David A. Warrell — 2010-06-01

In their recent letter, Moser and Roeggla report severe envenoming by Vipera berus in a 12-year-old boy. Shock, upper airway narrowing, and abdominal pain developed within 10 minutes of the bite. These are familiar early anaphylactic features of envenoming by V berus, possibly attributable to venom autacoids. After an initial response to symptomatic treatment, hemorrhagic swelling spread rapidly to involve the bitten extremity and adjacent hemithorax and he suffered other complications. Such severe systemic and local envenoming fulfils all published criteria for antivenom treatment and yet none was given for fear of an antivenom reaction. However, the only reference cited by the authors to support their nihilistic decision is a study of rattlesnake bites in children in the United States at a time when the notoriously reactogenic Wyeth antivenom was in use (1988–1998). Wyeth was subsequently replaced by the much safer CroFab (Protherics Inc, Nashville, TN). The risk of such reactions with currently available antivenoms for use in bites by European vipers is very low, whereas the risk of death from Vipera bites in Europe is a compelling reason to use antivenom in the treatment of severe envenoming, especially in children. We are anxious to correct the authors' misunderstanding about the validity of the “Stockholm criteria” for antivenom treatment in children. This is supported in the literature, including references quoted by Moser and Roeggla and below. In fact, the agreed indications should be applied even more liberally in children and pregnant women because of the risk of more severe consequences of envenoming. A most important effect of antivenom is that it will prevent or ameliorate the widespread and disabling local swelling. Although initial, dramatic systemic symptoms, often reminiscent of anaphylaxis, can sometimes be managed symptomatically, antivenom treatment shortens the period of circulatory instability, reducing the need for intravenous fluids and hence the risk of volume overload. This is particularly important in small children as pulmonary edema may develop late in the course when large volumes of extravasated fluid in the extremities and trunk are being reabsorbed.

In Reply to “Use of Antivenom in Vipera berusBites—A Comment”

Berthold Moser, Georg Roeggla — 2010-06-01

We would like to thank Drs Persson, Stiber, and Warrell for their helpful comments on our case report of severe envenoming by Vipera berus in a 12-year-old child. We agree that the situation at the time of admission fulfilled the reported criteria for antivenom treatment. The boy was not treated with antivenom therapy because nearly all symptoms of envenoming apart from rapidly spreading swelling improved rather quickly under supportive therapy and the risk of antivenom therapy was considered to be higher than the potential benefit.

UK High Altitude Research: A report from the Birmingham Medical Research Expeditionary Society (BMRES) Altitude Research Conference, December 4, 2009, held at the Birmingham Medical Institute, United Kingdom

2010-06-01

We would like to report on the 1-day altitude medicine research meeting held at the Birmingham Medical Institute, Birmingham, UK on December 4, 2009. The meeting provided an opportunity for researchers from several different high altitude research groups in the United Kingdom to present their findings and share experiences from recent laboratory and field work. In addition, the meeting aimed to welcome newcomers, foster collaboration, and encourage more individuals to get involved in altitude research.

Dermatologic Therapy

2010-06-01

The United States poison control centers reported an average of 2094 yearly calls about caterpillar stings between 2001 and 2005. Most stings involved one individual and symptoms were self-limited, but some stings have caused death and, also, infestations have created epidemics and resulted in school closures. This review article discussed medically important Lepidopterans (moths, butterflies, and caterpillars) in an effort to aid in diagnosis, identification, and treatment.

Annals of Surgery

2010-06-01

Standard treatment in active combat zones has reversed the traditional “A, B, C” approach to trauma and addresses circulation first. On the battlefield, severe extremity hemorrhaging is managed with a tourniquet. This study looked at a larger than previously studied population of trauma patients treated with tourniquets to assess the utility of this treatment.

Circulation

2010-06-01

This retrospective observation cohort study evaluated the introduction of a modified pre-hospital resuscitation protocol. Data spanned 36 months before and 12 months after the implementation of a new protocol by the Kansas City, Missouri Emergency Medical Services System. A total of 492 primary cardiac arrests were analyzed in this study.

Journal of Emergency Medicine

2010-06-01

This case report from the conflict in Afghanistan describes the use of ultrasonography to diagnose and change the management of a decompensating patient during medical evacuation via helicopter. The Afghani blast victim detailed in this case suffered shrapnel injuries to his head, neck, and lower extremities without obvious chest trauma. Initially, he was intubated for a low Glascow Coma Scale, ventilated at a rate of 10 breaths per minute on 100% oxygen, with vital signs as follows: heart rate 110 beats per minute, blood pressure 138/76 mm Hg and oxygen saturation of 92%. During the evacuation, the helicopter climbed to an altitude of 7000 feet (2134 meters), and the patient became more tachycardic, hypotensive, and his oxygen saturation dropped to 86% despite suctioning and subsequent transfer from the ventilator to manual ventilation. A rapid in-flight ultrasound examination revealed a pneumothorax. After needle decompression and chest tube placement the patient's vital signs normalized. This case report is the first of ultrasound being used to alter management of a patient during transport. As the author suggests, further studies would help define the utility of ultrasound in air evacuation.

Journal of Applied Physiology

2010-06-01

It has been postulated that elevated intracranial pressure (ICP) causes acute mountain sickness (AMS). Elevated ICP might result from hypoxia induced cerebral vasodilation or edema. When attempting to correlate AMS with ICP, previous studies have not been able to adequately measure ICP or have been limited by sample size. This cross-sectional study sampled a larger population of climbers while using ultrasonagraphy to measure ICP.