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.

FEVER IN A RETURNED TRAVELER

It is not uncommon to acquire an infectious disease during outdoor travel, particularly to foreign (to the United States) countries. These illnesses are often accompanied by fever. As a general rule, infectious diseases follow periods of incubation. The incubation periods of travel-related infectious diseases, some of which may have fever as a component, are as follows:

COUGH

Cough is a common symptom. It is commonly associated with an upper respiratory infection, but can also be due to throat irritation, drug side effect, sinusitis, bronchitis (see page 205), serious infectious disease (e.g., pneumonia—see page 48), asthma (see page), heart failure (fluid in the lungs—see page 47), reflux esophagitis (“heartburn”—see page 221), allergy, or high-altitude pulmonary edema (see page 340).

Treatment of cough depends on the cause. For instance, the cough associated with asthma requires that the asthma be properly treated. For the cough associated with a minor upper respiratory infection, usually viral, cough medicine may be helpful. Some suggested remedies are listed on page. One favored by experts is dexbrompheniramine 6 mg plus pseudoephedrine 120 mg twice daily for 1 week. An alternative is ipratropium 0.06% nasal spray, two sprays per nostril 3 to 4 times daily for 2 weeks. A U.S. FOOD AND DRUG ADMINISTRATION ADVISORY PANEL IN 2007 RECOMMENDED THAT THERE IS NO EVIDENCE THAT OVER-THE-COUNTER COLD AND COUGH MEDICINES WORK IN CHILDREN AND THAT THE PRODUCTS SHOULD NOT BE GIVEN TO CHILDREN YOUNGER THAN 6 YEARS OF AGE. Children ages 2 to 18 years may benefit from one or two teaspoonsful of buckwheat honey for treatment of nocturnal (nighttime) coughing. It is not advised to feed honey to infants or children under age 12 months because of the risk for infant botulism.

Whooping cough (pertussis) is a highly communicable infectious disease caused by the bacterium Bordetella pertussis. It is transmitted by respiratory secretions or large droplets from the respiratory tract of an infected person. In children, whooping cough is typified by coughing episodes that are sudden, intense, and sometimes accompanied by vomiting and inspiratory “whoops,” indicating throat spasms on inhalation. It is not uncommon for the victim to cough in severe spells and to have gagging or vomiting after a coughing spell. In adults, it most commonly presents like a common cold for a week or two (this is the most infectious period), followed by a mild cough that becomes progressively severe. The cough is as described in children and may also involve difficulty breathing. Untreated, the cough may last for 6 to 10 weeks in children and for more than 10 weeks in adults. If this diagnosis is made, the victim should be treated with azithromycin (10 mg/kg of body weight [not to exceed 250 mg] by mouth once a day on day 1, then 5 mg/kg on days 2 through 5 for children; 500 mg day 1, then 250 mg days 2 through 5 for adults); erythromycin (40 to 50 mg/kg per day in 4 divided doses [not to exceed 2 g per day] for 14 days for children; 500 mg 4 times a day for 14 days for adults); clarithromycin (15 mg/kg per day in 2 divided does [not to exceed 1 g per day] for 7 days for children; 500 mg twice a day for 7 days for adults); or with trimethoprim-sulfamethoxazole (8 mg/40 mg per kilogram per day in 2 divided doses for 14 days for children; 160 mg/800 mg twice daily for 14 days for adults). The protective effect of DTaP (diphtheria-tetanus-pertussis) vaccine wanes rapidly 3 to 4 years after the last dose, so adults remain vulnerable to the disease.

Croup is a disease of children, rarely noted in adults, in which there is hoarseness, raspy breathing on inhalation, and a seal-like, barking cough associated with narrowing of the soft tissues of the larynx. If croup is suspected, the victim should be given a single oral dose of a corticosteroid, such as dexamethasone (0.6 mg/kg [2.2 lb] body weight for a child, up to 4 mg total dose; 4 mg for an adult). While some support the home remedy of breathing cool air, there is no evidence that breathing cool air, warm air, or humidified air makes any difference in resolving the illness. If croup is very severe, a health care practitioner may administer inhaled epinephrine.

COUGHING BLOOD

The blood coughed up by a victim may have originated anywhere from the mouth to the lungs. Causes of coughing blood include the following:

DIZZINESS

Dizziness is a feeling of lightheadedness, with or without a sensation of spinning (vertigo). It often precedes a fainting episode (see page 165) or may accompany a stroke (see page 144), heart attack (see page 50), low blood sugar (see page 142), heat illness (see page 322), ear infection (see page 175), the bends (see page 403), plant poisoning (see page 416), motion sickness (see page 440), and many other disorders. Frequently, dizziness is caused by an infection or disorder of the middle ear, which controls balance. Indeed, if the external ear canals are blocked by wax, this alone can cause dizziness.

If a victim is dizzy, he should lie on his back and attempt to regain orientation to his surroundings. Examine him for obvious causes and treat accordingly. If the dizziness does not resolve, and particularly if the victim is elderly (in which case it might indicate a stroke), he should be taken to a physician. True vertigo is very distressing to the victim and described by him as “the room spinning around,” with nausea and/or vomiting, weakness, ringing in the ears (tinnitus), and occasional slow jerking or fluttering movements of the eyeballs (nystagmus). Benign sudden positional vertigo may be caused by free-floating calcium carbonate crystals in the inner ear. Inflammation of the inner ear (often associated with a recent cold) is known as vestibular neuronitis (“labyrinthitis”). It is treated with the same medications used for motion sickness (see page 440). In addition, a 3-week taper of a corticosteroid (such as methylprednisolone) in a starting dose similar to that for a severe poison oak rash (see page 232) may hasten recovery. Antiviral agents have not been proven effective for this condition. The benzodiazepine class of drugs (including lorazepam or clonazepam 0.5 mg by mouth twice a day, or diazepam 2 to 5 mg by mouth every 6 hours as needed) may be useful to suppress vertigo, but carry the side effect of sedation. Vestibular neuronitis is a diagnosis to be reached by a physician after more serious problems are excluded.

HICCOUGHS

Hiccoughs can be extremely annoying. A few tricks for stopping them include immersing the face in ice water, swallowing in a series of 10 sips without interruption, and hyperventilating for a moment. If none of these work, gently sliding a well-greased length of thin, flexible rubber tubing through one nostril to the point where it just barely touches the back of the throat may terminate the hiccoughs. This must be done while taking care not to injure the sensitive interior lining of the nose.