Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis.

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled ß agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

Epidemiology of Ice Climbing Injuries Among Recreational Ice Climbers at the 2019 Ouray Ice Climbing Festival.

INTRODUCTION: As a close relative to the sports of mountaineering and rock climbing, water ice climbing has been traditionally considered "high risk." There is little data to support or refute this assertion. Prior estimates of the injury rate range from 4.8 to 248 injuries per 1000 participation hours. In this study, we characterized the types of injuries and determined an injury incidence among water ice climbing participants at the 2019 Ouray Ice Festival climbing manmade ice walls. METHODS: A survey was distributed during the 2019 Ouray Ice Festival in Ouray, Colorado. Respondents were asked to include festival-related injuries and estimate their participation time at the 4-d festival. Individuals who reported an injury were asked to provide additional details with regard to injury type, location, and timing. The injury incidence rate was calculated as the total number of injuries reported divided by the total number of participation hours and is reported as injuries per 1000 participation hours. RESULTS: A total of 75 surveys were analyzed. A total of 16 injuries, all which were minor, and 912 participation hours were reported, resulting in an injury incidence of 17.6 injuries per 1000 participation hours. CONCLUSIONS: This study reports an injury incidence based on an unselected sample of water ice climbers at an ice climbing festival. Water ice climbing at festivals appears to result in injuries of minor severity with no major accidents or fatalities. This study could be repeated to confirm its validity with a larger sample size.

Effort Thrombosis Presenting as Unilateral "Pumped" Arm in a Climber.

Upper extremity injuries are common among the growing population of climbers. Although conditions affecting musculoskeletal structures are the most common causes of symptoms, a comprehensive differential diagnosis is necessary to avoid the misdiagnosis of high-morbidity conditions in this patient population. We present a case of a climber with acute edema, erythema, and pain of the entire right upper extremity. After confirmation of an upper extremity deep vein thrombosis by ultrasound, and in the absence of secondary causes for his thrombotic process, he was diagnosed with effort thrombosis. The patient was treated acutely with anticoagulation, catheter thrombectomy, direct thrombolysis, and balloon angioplasty followed by surgical decompression of the subclavian vein. Owing to the importance of early diagnosis and initiation of treatment, it is critical to keep disorders affecting the upper thoracic vascular structures in consideration.

Subarachnoid Mirage: A Case of Pseudosubarachnoid Hemorrhage.

A 22-year-old man with a history of intravenous methamphetamine use presented with severe headache for 5 days, was afebrile, and had nuchal rigidity. Computed tomography and magnetic resonance imaging results were interpreted as revealing acute subarachnoid hemorrhage. Twenty-four hours later, he developed acute neurologic deterioration. A lumbar puncture was performed, revealing the presence of Staphylococcus aureus. The false-positive image mimicking blood was potentially a result of an extremely high protein concentration present in the cerebrospinal fluid, provoked by an intense inflammatory reaction leading to disruption of the blood-brain barrier. Pyogenic meningitis is one of the causes of pseudosubarachnoid hemorrhage, or a false diagnosis of subarachnoid hemorrhage, when one does not actually exist.

Mode of transportation of out-of-hospital cardiac arrest patients, the role of community actions and interventions.

The Emergency Medical Services constitutes a critical component in treating patients with out-of-hospital cardiac arrest (OHCA). Activating the EMS system is the first important step in deploying resources, but community involvement in the care of emergent patients is multifaceted and complex. How does the public access EMS services versus other modes of transport remains under investigated; and if the public opts for a different mode of transport to the hospital, how does this affect outcomes?

Clinical staging of accidental hypothermia: The Revised Swiss System: Recommendation of the International Commission for Mountain Emergency Medicine (ICAR MedCom).

Clinical staging of accidental hypothermia is used to guide out-of-hospital treatment and transport decisions. Most clinical systems utilize core temperature, by measurement or estimation, to stage hypothermia, despite the challenge of obtaining accurate field measurements. Recent studies have demonstrated that field estimation of core temperature is imprecise. We propose a revision of the original Swiss Staging system. The revised system uses the risk of cardiac arrest, instead of core temperature, to determine the staging level. Our revised system simplifies assessment by using the level of responsiveness, based on the AVPU scale, and by removing shivering as a stage-defining sign.

[Limitation of life-sustaining treatment. A prospective study in a clinical ward]. / Limitaciones de esfuerzos terapéuticos. Resultados de un registro prospectivo en una sala de clínica médica.

The purpose of this study is to describe the limiting life-sustaining treatment process of patients admitted to a general ward. A prospective descriptive study was designed. The setting was the general ward of universitary hospital. Study participants were patients assisted by the internal medicine department during a 60-consecutive days period who had limitations of life sustaining treatments. During the study period, 402 patients were hospitalized, 62 (15%) of them had limitations of life support care. The median patient age of the last group was 86 years (78-90), 66% were women and the length of stay was 12 days (8-18). A low quality of life was the most frequent cause of limitation (69%). Information about the limitations was provided to 43 families (69%) and 8 patients (13%). The primary care physician participated in the decision in 50% of the cases, while the attending physician, the resident in charge, patient's family and patients themselves participated in 50%, 40%, 42% and 11% of the cases respectively. The decision of limiting life-sustaining treatments was recorded in seven patient's charts (11%). Seventeen (27%) patients with limitations died during the hospital stay while 44 (71%) were discharged. In conclusion, we found a frequent life sustaining treatment limitation in our patients. These decisions did not follow a uniform or systemized process. The need of guidelines to sort the medical and ethical challenges imposed to the medical team is undeniable.

Limitaciones de esfuerzos terapéuticos: Resultados de un registro prospectivo en una sala de clínica médica / Limitation of life-sustaining treatment: A prospective study developed in a clinical ward

El objetivo de este trabajo fue describir el proceso de limitación de los esfuerzos terapéuticos (LET) en los pacientes internados en una sala general. Para ello se realizó un estudio prospectivo descriptivo, desarrollado en la sala de internación general de un hospital universitario. Fueron evaluados pacientes que tuviesen alguna LET, asistidos por el servicio de clínica médica en un período de 60 días consecutivos. Durante el mismo se hospitalizaron 402 pacientes, 62 (15%) tuvieron algún tipo de LET. Este último grupo estaba compuesto por un 66% de mujeres, la mediana de edad fue de 86 años (78-90) y de la duración de hospitalización de 12 días (8-18). La mala calidad de vida fue la causa más frecuente de LET (69%). Se brindó información acerca de las limitaciones a 43 familias (69%) y 8 pacientes (13%). En la decisión participaron el médico de cabecera (50%), médicos de planta (50%), residentes (40%), la familia (42%) y los propios pacientes (11%). En 7 casos hubo constancia en la historia clínica (11%). Diecisiete pacientes (27%) con LET fallecieron durante la internación, mientras que 44 (71%) fueron dados de alta. En conclusión, la limitación de esfuerzos terapéuticos en nuestros pacientes constituyó un hecho frecuente. No se logró identificar un proceso uniforme o sistematizado para la toma de la decisión de LET. Resulta innegable la necesidad de normativas que guíen al equipo de salud en la toma de decisiones, tranquilicen a familiares y acompañen a los pacientes en sus reales necesidades.

The purpose of this study is to describe the limiting life-sustaining treatment process of patients admitted to a general ward. A prospective descriptive study was designed. The setting was the general ward of universitary hospital. Study participants were patients assisted by the internal medicine department during a 60- consecutive days period who had limitations of life sustaining treatments. During the study period, 402 patients were hospitalized, 62 (15%) of them had limitations of life support care. The median patient age of the last group was 86 years (78-90), 66% were women and the length of stay was 12 days (8-18). A low quality of life was the most frequent cause of limitation (69%). Information about the limitations was provided to 43 families (69%) and 8 patients (13%). The primary care physician participated in the decision in 50% of the cases, while the attending physician, the resident in charge, patient's family and patients themselves participated in 50%, 40%, 42% and 11% of the cases respectively. The decision of limiting life-sustaining treatments was recorded in seven patient's charts (11%). Seventeen (27%) patients with limitations died during the hospital stay while 44 (71%) were discharged. In conclusion, we found a frequent life sustaining treatment limitation in our patients. These decisions did not follow a uniform or systemized process. The need of guidelines to sort the medical and ethical challenges imposed to the medical team is undeniable.