Q:  I went to the pharmacy looking for ampules of epinephrine, but they do not sell it. Instead, they sold me Xylocaina EV – HCl Lidocaine and epinephrine.. Each ml has Lidocaine HCl monohydrate equal to 20mg of HCl of Lidocaine and ‘bitartrato of epinephrine equal to 0.005mg of epinepherine. In an emergency situation, where we are over 2 hours away from definitive care, would an injection of this drug do more harm than good to a normal patient with anaphylactic shock from a bee or wasp sting? I was also told that this drug is beneficial for stingray attacks. Is this true? If so, could you please recommend a dosage for each scenario.

A:  Thanks for the query.  Simply put, delivering the proper dose of epinephrine using this mixture would require a large volume and a toxic dose of lidocaine.  If you do the math, you would need 60 mL to administer 0.3mg of epinephrine which would include 1200 mg (1.2 gm) of lidocaine.  Anything over 300 mg of lidocaine is considered potentially toxic in an adult.

Could this combination help with a stingray puncture?  Lidocaine is a local anesthetic used for suturing so theorectically it could help to temporarily ease the pain if injected locally.  But remember, injecting lidocaine is not part of the scope of practice of a WFR and would therefore be a real stretch.  Besides, immersion in hot water works quite well.

Q: It is my understanding that once you begin CPR you can not stop until the patient’s pulse and breathing resumes or paramedics arrive on the scene. Otherwise, it would be considered an abandonment of care. Is this true and are you familiar with any legal issues of administering CPR in the backcountry?

A: I cannot give you a simple answer to this one.  My opinion is based on my interpretation of published data and personal experience.

Here is what the American Heart Association published last month as part of their 2010 CPR Guidelines:

When not to start:

  • Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril
  • Obvious clinical signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, or decomposition)
  • A valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR order

Terminating Resuscitative Efforts in a BLS Out-of-Hospital System

Rescuers who start BLS should continue resuscitation until one of the following occurs:

  • Restoration of effective, spontaneous circulation
  • Care is transferred to a team providing advanced life support
  • The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
  • Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation (TOR) are met.

Unfortunately, the criteria for TOR referenced generally depend on tools or capabilities that most of us don’t have in the field (e.g., automatic external defibrillator).

There is literature supporting the notion that if spontaneous circulation is not restored within 30 min of initiating resuscitative efforts (some would say 20), the chance of survival is nil.  The outcome is even more grim without an AED and when good quality CPR is not started promptly and sustained without interruption.  Trauma arrests have the worse prognosis of all.  Unfortunately, the AHA, et al have yet to explicitly offer a specific guideline that uses time as a criteria under any circumstances.  Their reluctance and/or lack of interest is understandable because their focus is on situations where a call to and timely response from advanced-level EMS is the norm.

So is it abandonment to stop?  That is a legal concept that one can only speculate about.  It would be unlikely if one made a decision to stop based on the AHA criteria listed above.  In remote, low resource settings (e.g., no likelihood of an AED or advanced capabilities), the physical toll even if one could maintain good quality CPR indefinitely would be substantial making prolonged resuscitation efforts potentially risky for the rescuer(s).  Low benefit and significant risk.  What do you think?

We and others have advocated stopping CPR in non-hypothermic arrests after reasonable efforts have been made, usually after 20 to 30 minutes of continuous CPR.  There are many urban-based EMS systems that use the same time-based benchmark.  Unfortunately, stories of rescuers continuing CPR for time periods up to 2 hours are still reported.  I suspect some do so out of fear they will be accused of abandonment and/or hope their efforts will make a difference.  Not surprisingly, the results are the same; no survival.

Bottom line: The legal system is the final arbiter of what abandonment is and when it has occurred.  CPR, even good CPR, cannot sustain a person’s viability indefinitely.  From published reports and studies, 30 minutes seems to be a reasonable time frame.  Regardless of time, do not put yourselves or others at risk.

Q: For the first time I am hearing about the use of prednisone in the field as a follow up to epinephrine after an anaphylactic reaction. Is this being used in place of benadryl? If so, what are the reasons and how does it affect the protocols for trip leaders in the backcountry?

A: The symptoms of anaphylaxis are related to chemical mediators that result in direct stimulation of target organs and inflammation.  Epinephrine works quickly and directly to constrict vessels and dilate lower airways.  It also helps to decrease the release of these chemical and inflammatory mediators from mast cells and basophils.  Although epinephrine is oftentimes sufficient treatment for anaphylaxis, we add antihistamines and corticosteroids to sustain the effect and help prevent recurrences (e.g., biphasic reactions).

Antihistamines are slower acting.  Though not as potent or effective as epinephrine, they help block the effects of mediators that have already been released.  Prednisone, a prescription medication, is a corticosteroid that binds to receptors to help modulate inflammatory responses.  Because of their delayed onset of action (4 – 6 hr) the real purpose of prednisone is to help decrease the chance of a biphasic reaction by suppressing inflammation.  Interestingly, this is a different sort of anti-inflammatory effect from what we see with non-steroidal anti-inflammatories (NSAIDS) like ibuprofen.  In fact, in some people the NSAIDS actually stimulate the production and therefore the concentration of some of the mediators of inflammation that are responsible for the symptoms of anaphylaxis.  DON’T substitute a NSAID for prednisone in anaphylaxis.

Bottom line: Prednisone is an important adjunct in the management of anaphylaxis, especially where an evacuation is many hours away.  For a dose or 2 in a person not allergic to them (yes, people can be allergic to prednisone), prednisone offers an excellent insurance policy.  For most programs I would consider it to be optional.

Q: I am a nursing student and I have always dreamed of traveling with science and humanitarian expeditions and, as a future nurse, it may be possible. My question to you is, how can I use my RN degree to become an expedition medic? Is it possible as a nurse to contract myself out or apply for jobs as the medic on a science team exploring who knows what? Any advice and information would be fantastic!

A: I suspect being an RN will open doors not open to many EMS practitioners.  Getting EMS training (Basic good; Paramedic much better) is still a good idea though, because you will get a level of practical training not provided in most RN programs.  Becoming a nurse practitioner would be a great additional upgrade because on top of everything else you would have prescription writing capabilities.

is a good place to start to make some contacts.  Don’t be bashful about going to organizations that do things you know something about.  In the beginning most opportunities will be as a volunteer.  Once you develop a positive reputation, people may come looking for you.

Q: It seems counter intuitive that in anaphylaxis, the systemic capillaries dilate and the bronchial constrict. Histamine signals dilation (relaxation of the smooth muscles) of blood vessels, and increased permeability of capillaries, causing edema / inflammation. The bronchial tree also has smooth muscle around it, why would it constrict and the other relax?  Can the tissue around the body swell without causing the constriction of the blood vessels? And the lungs can’t do that?

A: You are not alone in your confusion.  One of the beauties (in a mysterious way) and perils of medicine is that logic does not always work or at least it becomes complicated and convoluted.

There are different kinds of receptors for specific chemicals; their locations vary by end organs.  In turn, not all end organs have the same distribution of these sites.  Although histamine is the quintessential mediator, there are a variety of others that either act directly or stimulate the release of other mediators resulting in organ responses and/or inflammation.  Responses are therefore dependent on the mediators and the location of the receptors.

As I understand it, vascular dilation and change in permeability is at the capillary bed level and is direct, perhaps related to nitric acid.  This is not a smooth muscle issue.  On the other hand, bronchoconstriction is based on muscular spasm and swelling the occurs as a result of fluid accumulation from leaky, dilated vessels in the bronchial capillary beds.

Epinephrine has its major effects directly via vascular constriction and bronchial dilation and indirectly by halting vascular leakage.  Epinephrine also helps to stabilize the mast cells from which histamine and other mediators are released.  The effects of antihistamines is more local and slower.

Bottom line: Don’t lose the forest for the trees.  Epinephrine works.

Q:  We routinely use Silvadene for burn treatment at our hospital.  I understand that you are not too keen on it.  Why?

A:   We have steered away from silver sulfadiazine (e.g., Silvadene) at work for years.  We have found that products like a vasoline-type gauze, e.g., Xeroform, is more comfortable and easier to maintain requiring fewer banadage changes.  In a 2008, a Cochrane review of dressings for superficial and partial thickness burns noted that silver sulfadiazine delayed healing and that moist dressings seem to decrease the pain and decrease healing times.

Bottomline: Fewer, less vigorous washings with less frequent bandage changes adds up to important practical advantages.

Q: With respiratory distress in anaphylaxis, if no epinephrine is available could an albuterol inhaler be used until the benedryl takes effect?

Good question.

If the symptoms are isolated to the lower airways as manifested by wheezes, an inhaled Beta agonist like albuterol will probably help with the symptoms.  But remember that unlike asthma, anaphylaxis is a systemic, not a local, problem.  In anaphylaxis chemical mediators are released in the circulation and then migrate to sites around the body.  Albuterol works locally and will have no effect on the generation of these mediators.  If the manifestations are shock or upper airway obstruction (the two most lethal manifestations of anaphylaxis), the albuterol will not be useful.

Jack, a Wilderness First Responder from Ohio, sent us this amazing story.

“Hi there. Just wanted thank Wilderness Medical Associates (especially Phil, Robin, and Stephen) for their great instruction in last January’s Wilderness First Responder course at the University of Alabama.

This summer, I utilized my skills in the backcountry to treat many routine issues, and some minor emergencies. The training was very useful, but I didn’t really appreciate how valuable the course really was until Friday of last week, when I drove up to the scene of a grisly motorcycle wreck, only seconds after the crash. I first secured the scene, and made sure that 911 was dispatched for the motorcyclist who had presumably lost control of his bike, and crashed into a tree on a winding back road.

After identifying myself as a wilderness first responder, I began stabilizing the semi-conscious man’s cervical spine with in-line stabilization while I completed the initial assessment, which yielded findings of a rigid abdomen, presumably shattered pelvis, and fractures to both legs. In addition to complaining of intense pain, the patient also was devoid of sensation his legs, making tedious stabilization of the spine even more vital. I continued to hold stabilization and kept other bystander “rescuers” from moving the patient during the ten minute response times for local fire/rescue.

Once EMS arrived on scene, I presented my initial assessment to paramedics, and then assisted in log rolling the patient onto a backboard. Air Care Cincinnati was called to the scene and the man was flown by medical helicopter to the local trauma center for emergency surgery.

Last I have heard, he survived the surgery to repair damages to his internal organs and pelvis, and is beginning to regain feeling in his legs. Thanks to the realistic simulations, and thoughtful instruction I knew exactly what to do, and was able to make a positive impact. As a high school student, I surprised all of the adult bystanders on scene by taking control of the situation, and acting immediately to assist the injured man. Thank you!”

Click here for a list of in your area.

Q: Is there a connection between shellfish allergies and iodine?

Equating an allergy to shellfish with an allergy to iodine is a fairly common misconception.  Fish and radiographic contrast allergies are also erroneously equated with iodine allergies.

Iodine is essential for proper thyroid function.  Without it, people become ill with thyroid problems.  As it turns out, seafood and crops fertilized with seaweed are a good source of iodine.  As people moved from coastal areas inland, the incidence of thyroid deficiency increased.  Beginning in the 20th century, it became a common additive in many varieties of table salt.  As a result, now you have to work hard to completely avoid it.

The allergen in shellfish is a protein, not iodine.  Some people with iodine allergies really have a topical sensitivity to iodine (e.g., povidone iodine; Betadine), usually a much different kind of reaction than the immediate reaction found with anaphylaxis.

Bottom line: A shellfish allergy should almost never preclude the use of iodine for water disinfection. If you are concerned, get more information about the true nature of the allergy.  If the person has not had problems with other seafood (saltwater) or table salt, iodine is not the culprit.  There are, of course, other reasons for not using iodine as a water disinfectant.

Where’s the Man?: Belize

Here is the man (with me) in front of and inside Actun Tunichil Muknal, a 3.5 mile long Mayan Cave in Belize in the San Ignacio Cayo. The ATM is a national archeological site and considered a “living museum” with over 1500 Mayan artifacts inside including 14 skeletons from sacrafices. 2nd photo taken over 1km underground.

Click on the photos to enlarge. These entries were submitted by , a WMA instructor, while on a course in Belize.

Send in Your Photos!

Send an email to with a picture of you wearing your ‘Where’s the Man?’ t-shirt alongside a caption to be eligible to win. At the end of the year, we will select three entries to receive $50 gift certificates to our online gear store.