UNCONSCIOUS (OR SEMICONSCIOUS) VICTIM

As discussed in detail in the section “Major Medical Problems” (see page 21), a proper approach to the unconscious (comatose) victim may make the difference between life and death. You must evaluate the semiconscious (stuporous, dazed, confused, or combative) individual with the same degree of concern. To discover the cause of an altered mental status, you must be a bit of a detective, while also performing the tasks that prevent the victim from hurting himself. Always assume that an unconscious person may be seriously injured.

Don’t:

FAINTING

Fainting is defined as sudden brief loss of consciousness not associated with a head injury. There are innumerable causes of fainting, but most episodes are associated with decreased blood flow (oxygen and/or glucose) to the brain. This may be caused by low blood sugar (hypoglycemia—see page 142), slow heart rate (vagal reaction, in which the vagus nerve, which slows the heart rate, is overstimulated: fright, anxiety, stomach irritation, bowel dilation, drugs, fatigue, prolonged standing in one position), rhythm disturbances of the heart, dehydration, heat exhaustion, anemia, or bleeding.

If you witness a fainting episode, or are with someone who is becoming lightheaded (sweating, weak, ashen colored, dizzy), quickly help the person lie down and elevate his legs 8 to 12 in (20 to 30 cm). This position increases venous blood flow back to the heart, which in turn pumps more blood to the brain. If the victim begins to vomit, turn him on his side. If he has fallen, examine him for injuries. A cool, moistened cloth wiped on his forehead, on his face, and behind his neck may make the victim feel better. Do not splash or pour water on his face or routinely use smelling salts or ammonia inhalants. Do not slap the victim’s face.

After a victim suffers a fainting episode, he should be examined for any sign of serious illness or injury. If you don’t suspect anything serious, have him lie still for a few minutes, and then sit for a few minutes. If the victim is alert and capable of purposeful swallowing, offer him cool sweetened liquids to drink—preferably one that contains electrolytes (see page 208)’to correct dehydration. When the victim feels normal, he may slowly regain an upright posture. If the victim is elderly, and particularly if his pulse is irregular or he has chest discomfort, seek immediate medical assistance. Anticipate a heart attack (see page 50).

FATIGUE

Fatigue (lethargy, tiredness, exhaustion, generalized weakness, decreasing exercise tolerance) can be a sign of any disorder or dysfunction that diminishes a person’s energy level. Accompanied by fever, it can be indicative of an infection; accompanied by certain associated symptoms, it may indicate a hypoactive thyroid. In the outdoors, anyone who began the trip in good condition but is now fatigued should be examined carefully for signs and symptoms of hypothermia (see page 305), hyperthermia (see page 322), high-altitude illness (see page 335), infection, mental depression (see page 301), anemia (pale membranes inside the eyelid, pale fingernail beds, sallow skin complexion), dehydration (see page 207), or starvation. A diabetic who becomes fatigued may suffer from high or low blood sugar (see page 142). If fatigue is accompanied by shortness of breath, do not travel any farther from civilization until you determine a treatable cause, or the victim clearly improves. Sudden onset of fatigue can be indicative of a heart attack (see page 50).

If a person is suffering physical exhaustion, allow him at least 12 hours of rest, encourage adequate food intake, and take particular care to correct dehydration.

In a situation of extreme exercise within a particular muscle group—the legs during forced or military-style marching, or long-distance or marathon running; the arms during repetitive, relentless exertion such as weight lifting—muscle tissue can be broken down. This is more common under conditions of environmental heat (see page 322). Substances (particularly myoglobin, a pigment that carries oxygen) are released into the bloodstream, which in large concentrations can cause the kidneys to fail. The victim has very darkened (brown) urine (myoglobinuria), sore muscles, and extreme fatigue. In this situation, remove the victim from environmental heat, place him at as near complete rest as possible, and encourage him to drink as much liquid as he can to correct dehydration and flush the pigment from his system (see page 208).

FEVER AND CHILLS

Fever is an elevation in body temperature caused by infection. The causative organism (most commonly a bacterium or virus) releases substances into the bloodstream; these quickly reach the part of the brain that acts as the body’s thermostat. Thus, body temperature is “reset” at a higher level. This probably helps fight infection, but the temperature may need to be lowered if the elevation is extreme or prolonged.

Normal body temperature is 98.6°F (37°C) measured orally, and 99.6°F (37.5°C) measured rectally. To convert degrees Fahrenheit (F) into degrees Centigrade (C, or Celsius), subtract 32, then multiply by 5, then divide by 9. To convert degrees C into degrees F, multiply by 9, then divide by 5, then add 32. A temperature conversion chart is found on page 509.

Temperature should be measured with a thermometer. Electric (digital) thermometers are easiest to use and require the least time to record a temperature. If you use a mercury or alcohol thermometer, first shake it to pool the mercury or alcohol below the 94°F (35°C) marking. If you suspect the victim to be hypothermic, a special thermometer is necessary (see page 305). To take a temperature by mouth, place the thermometer under the tongue, close the mouth, and take a reading after 3 to 4 minutes. To take a temperature rectally (the more reliable method, and necessary in a case of suspected hypothermia), the thermometer is gently placed—ideally lubricated with oil or petroleum jelly—1 in (2.5 cm) into the rectum. It is held for at least 2 minutes and then read. Never leave a child or confused adult unattended with a thermometer in the mouth or rectum. Do not rely on skin temperature to vary consistently with changes in core body temperature.

Armpit (axillary) temperatures are far less reliable, because they may underestimate the temperature elevation. However, a high temperature recorded from the armpit may be interpreted to mean that there is some elevation in body temperature. An armpit temperature may be the only one you get in an uncooperative child less than 2 years of age. Since such a temperature tends to read on the low side, add 1.4°F (0.8°C) to obtain the equivalent rectal temperature.

Generally, an infection will not elevate the core (rectal) body temperature higher than 105°F (40.5°C). Anyone with a temperature measured above that level should be examined for heat illness (see page 322), stroke (see page 144), or drug overdose. Vigorous prolonged muscular activity (seizure or marathon running) can raise the core temperature above 107°F (41.7°C).

A child is considered to have a fever if his rectal temperature is greater than 100.4°F (38°C), oral temperature is greater than 100°F (37.8°C), or armpit temperature is greater than 99°F (37.2°C). You should be concerned about a fever greater than 100.4°F (38°C) in an infant less than 3 months of age or greater than 104°F (40°C) in any small child, because this can indicate a severe infection. If a child greater than 2 years of age has a fever greater than or equal to 106°F (41.1°C), and if there is no clear diagnosis of a viral infection, he should be treated with a broad-spectrum antibiotic (e.g., amoxicillin-clavulanate), on the rationale that there is a significant likelihood of a bacterial infection. Prolonged fever in a child should be investigated by a physician. Signs of a serious infection in an infant include lethargy (“floppy baby”), pain (persistent crying), labored breathing, purple skin rash, excessive drooling, a bulging “soft spot” (fontanel) on the top of the head, or a stiff neck.

If a person has a temperature higher than 100.5°F (38°C) that is thought to be due to an infection, he will be made more comfortable (fever lowered) by the administration of aspirin, ibuprofen (Motrin or Advil), or acetaminophen (Tylenol). To avoid Reye syndrome (postviral encephalopathy and liver failure), do not use aspirin to control a fever in a child under age 17. The traditional teaching is that infants and small children with fevers (usually due to ear infections or viral illnesses) should be treated as soon as any elevation of temperature is noted to prevent febrile seizures, although this may not actually be the case. An infant (younger than 6 months) with a fever should be seen as soon as possible by a physician. Sponging a child with cold water doesn’t help much to reduce fever and can even be counterproductive if the child struggles or begins to shiver, both of which generate heat. If the fever is greater than 104°F (40°C), however, sponging can be attempted using lukewarm water. Never sponge a child with alcohol, because it can be absorbed through the skin and act as a poison.

If the victim suffers from environmental heat-induced illness (see page 322), he will not benefit from and should not be given aspirin or acetaminophen. Ibuprofen is not as dangerous but is also not helpful.

Whether to use an antibiotic for a “fever of unknown origin” (a fever that cannot be definitively linked to a specific site of infection) is a judgment call. If a person has an altered immune system (acquired immunodeficiency syndrome [AIDS], cancer, diabetes, chronic corticosteroid administration) and a high or persistent fever not associated with symptoms suggestive of a particular infection, it is probably wise to administer a “broad-spectrum” antibiotic, such as ciprofloxacin or azithromycin. If there are symptoms that lead you to a specific site of infection (such as cough—pneumonia; burning on urination and flank pain—kidney infection), the appropriate antibiotic should be started. Finally, any feverish small child can become rapidly debilitated; he will rarely suffer from the initiation of a common antibiotic, such as amoxicillin or trimethoprim-sulfamethoxazole.

Chills are caused by the release of bacteria or viruses (or their toxins) into the bloodstream. The victim will suddenly feel very cold and begin to shiver, with teeth chattering, goose bumps (piloerection), and weakness. The “chill” may actually occur during a temperature spike within a fever.