What medicines do you carry in your wilderness or survival medical kit? Stocking the right medicines can truly be life-saving!
An ongoing debate in my survival and wilderness medicine courses is what medicines should one carry in their backcountry medical kit? Ideally one would carry all the medicines they foresee they would need, but practically we know this is not possible to do in a small lightweight kit. So what medicines can really make a difference?
Epinephrine. Since my wife is allergic to bees and has been hospitalized for anaphylaxis, I always carry epinephrine. Before I met my wife, I did not routinely carry epinephrine (unless I was guiding). But a lot of things change when you get married!
Epinephrine comes packaged in many different forms. Historically my wife would carry two EpiPens with her wherever she would go. EpiPen auto injectors are the standard of care in an urban environment but are a little bulky and heavy for wilderness travel. More importantly you only get one dose per auto injector, unless you know how to cut open the auto injector and access the leftover epinephrine for a second dose (never try this on an unused EpiPen. This technique is not approved by the FDA. Check out this link to learn how). This is certainly possible, but easier said than done, especially in an emergency situation with limited equipment. For the above reasons, I carry a 1 mg ampule of epinephrine (1mg/1ml , 1:1000 concentration) with a 1 cc syringe and a 1″ 22g needle. This will allow me to administer up to 3 doses (a dose is 0.3mg) of epinephrine for anaphylaxis (if needed). This is very important considering recent research has showed that 25 to 35% of anaphylactic reactions may require a second dose of epinephrine to counteract airway swelling and hypotension. Another study(1) showed that up to 20% of anaphylactic attacks may have a biphasic (delayed or secondary) attack hours after the initial exposure, once again requiring additional doses of epinephrine.
So knowing how quickly a lethal anaphylactic attack can occur and that epinephrine is quite effective at reversing the complications(hypotension and airway swelling), no doubt it is my “never leave home without it” medicine.
Antihistamine. I carry an anti-histamine like Benadryl for a variety of reasons. First off, antihistamines are a first-line medication for the treatment of allergic reactions. Anti-histamines work by blocking the H1 receptor site that histamine binds to, reducing urticartia (hives), itching and rhinorrhea. The typical adult dose for diphenhydramine (Benadryl) would be 25-50 mg PO q6h (taken orally every 6 hours as needed).
A secondary reason I carry antihistamines is that they are a recommended adjunct in the treatment of anaphylaxis (only epinephrine has an immediate effect to reverse hypotension and airway construction). As I just mentioned, Benadryl will block the H1 receptor site that histamine binds to, working as an adjunct with the epinephrine to reduce swelling. Because most people would be carrying a tablet form of diphenhydramine, the onset of drug action may not occur for 20 to 30 minutes.
In addition to the histamine blocking effects, I also carry diphenhydramine to use for some of its important side effects. Diphenhydramine works as a sedative in most people (and children it may cause hyperactivity). This can be a useful adjunct when traveling on planes or boats to reduce the symptoms of anxiety and nausea if you don’t have Dramamine with you.
This is my anaphylaxis and allergy medical module. It contains a 1mg ampule of epinephrine, a 1cc syringe with a 1″, 22g needle, an alcohol prep pad and 100 mg Benadryl.
Acetaminophen & Ibuprofen for pain management. In the many search and rescue calls I’ve been on over the years, the number one medicine we administer to injured patients is of course an analgesic. Which analgesic should you carry? That alone could be a whole discussion in itself! A medication that offers substantial pain relief, is easy to administer, is durable, and has minimal side effects would be best. Although the standard of care for a wilderness paramedic is IV narcotics (morphine or fentanyl), a best practice for wilderness adventures would be to start off with a non-opioid. By doing this, we may avoid common side effects of narcotics like respiratory depression, sedation and constipation.
Okay I can hear the comments coming in already! Acetaminophen? Ibuprofen? Why not something much more powerful? How about some Percocet or OxyContin that I have left over from my recent knee surgery? Well I’m certainly not against carrying “stronger” analgesics, but remember these are controlled substances with powerful side effects like respiratory depression and sedation. Ever tried rappelling or climbing on OxyContin? BAD IDEA!!!!!!! Let me tell you about several studies that were conducted about pain relief.
Several prospective randomized controlled studies have shown that combining acetaminophen and an NSAID can reduce pain more than taking acetaminophen or an NSAID alone. The study also concluded that acetaminophen and an NSAID taken together would reduce the pain more significantly than taking one of these medicines with an oral narcotic. For years US Special Forces have used the synergy of acetaminophen and an NSAID (like Ibuprofen), called a “combat pill”. This provided the soldiers with pain relief while still being able to handle their weapon.
Another study looked at oral medications that reduced at least 50% of the pain level in acutely injured patients. Guess what medication scored highest in the study? 600 to 800 mg of ibuprofen relieved 50% of the pain 86% of the time! Ibuprofen scored higher than medicines like oxycodone, naproxin and codeine. Check out the Oxford league table of analgesic efficacy study for more details.
So there’s my first couple of medication choices for my survival medical kit. I look forward to hearing what you would carry with you and why? In a later post, I will tell you my 10 favorite backcountry medications and why.
Disclaimer! Always consult your physician before taking or administering any of the medications below. All medications have some contraindications (who should not take the medicine) and side effects and could have lethal complications or morbidity if not administered appropriately. I am not a medical doctor and am not offering medical advice!
Resources:
As always be safe and enjoy the wild!
Brian
Thanks for carrying the epi for me babe! Hope I never have to use it.
1. Epinephrine- Easy to carry as well as administer, and it saves lives fast.
2.Nitroglycerin- ” ” ” ” “, Can resolve stable angina quickly, lowers BP for hypertension,
3.Penicillin/Amoxicillin: ” ” ” ” “,To prevent bacterial infection of open wounds
Any thoughts on the optimal sedation agent to carry in the back country? This would be for an acute shoulder reduction or other tensely painful procedure that would best be done or acutely. Are there such procedures or would you always try to extricate the patient out of the back country and eliminate the need for sedation.
I have ran several dislocated shoulder SAR calls in the backcountry and it is always very hard to make the patient comfortable, even with narcotics and benzodiazepines. Valium (diazepam) is a common medication routinely administered for painful muscle spasms. NOTE it is extremely dangerous to combine sedatives like valium with any alcohol, narcotic or other central nervous system depressants. Most agencies DO NOT allow the administration of a narcotic (like morphine or fentanyl) and the administration of a sedative (like valium) at the same time or within a short time period of one another. This is known as “conscious sedation” and is usually only performed by docs, or critical care flight nurses, or such. Some EMS agencies are allowed to administer a benzodiazepine (like valium) after they have maxed out the narcotics on the patient and they are still in pain. They usually need to call the doc to get permission to do so and need to have the patient on a cardiac monitor and pulse oximetry…
So even the powerful combination of narcotics and benzos still leaves people quite uncomfortable on a backcountry evacuation. Ideally, one is trained on how to reduce shoulder dislocations in the field (you can learn how to do this in a wilderness first responder or WEMT course). Getting the humerus back into the shoulder socket is what really decreases the pain.
A study done several years ago showed that the success rate from non-medically trained people reducing anterior, interior shoulder dislocations from a non direct injury (like skiing past your pole plant, or doing a high brace while kayaking) had a success rate of 71.8%.
So to answer your question, in my opinion, most backcountry travelers should get trained on proper splinting techniques, dislocation reduction techniques, and rapid evacuation techniques instead of sedating patients in the field (but there are always exceptions). It is also extremely hard to evacuate a sedated person unless you have them in a litter with a bunch of rescuers to carry them out. Having a sedated person trying to hike, ski, paddle, or rappel out could be EXTREMELY dangerous. But, if you do want to carry a sedating agent with you in the backcountry, for back spasms or something, I would consult with your physician and maybe he will write you a prescription for valium tablets.
Thanks for the great question, hope I helped.
Check out this link:
Wilderness Environ Med. 2010 Dec;21(4):357-361.e2. doi: 10.1016/j.wem.2010.06.010. Epub 2010 Jun 19.
Safety and efficacy of attempts to reduce shoulder dislocations by non-medical personnel in the wilderness setting.
Ditty J1, Chisholm D, Davis SM, Estelle-Schmidt M.
Below is a “basic kit list,” to which you can add on as your number of adventurers, length of trip, level of training, or destination dictate. An asterisk marks items that you might include for your week-long trip. For your overnight, you can feel comfortable paring down the quantities.