Brazilian pepper, Schinus terebinthifolius,

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ISSN:1059-6518 Volume 29 Number 3

By Brandon Munsell NREMT-P , WEMT-P, SOLO Instructor

As the campfire kicks into high gear, a camper throws on boughs from a nearby tree. Although the tree limbs seem dead, the tree they were taken from is abloom with bright red berries and serrated toothed leaflets. As the now burning branch begins to spew smoke, a wind directs it towards gathered campers. Upon inhalation the members begin to experience irritation to their faces and throats, and they also begin to tear up as they assume tripoding positions to catch their breath. As they retreat from the offending fumes, many begin to wheeze and seek water for their now burning eyes. What has caused this unexpected reaction?

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By Frank Hubbell, DO

Illustrations By T.B.R. Walsh

Places where you used to only see the intrepid adventurer you are now seeing more and more families. These families are recreating with all ages, including the very young. So it seemed like the time was right to review pediatric medical emergencies and management of them in the wilderness environment.

The Principles of Managing Pediatric Medical Emergencies:

Children are not small adults.

A child’s physiology varies greatly based on age and body weight.

A child’s emotional response to a crisis varies greatly with age.

A child’s mental capacity and understanding vary greatly with age.

A child’s speech and communication skills vary greatly with age.

Responding to a Pediatric Emergency – the Pediatric Patient Assessment System:

Initial Impression (PAT) ➡️ Primary Survey ➡️ Secondary Survey

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By Frank Hubbell, DO

Illustrations by T.B.R. Walsh

The Setting:

A small group of kayakers set off for their first run of the season down a local white water river in the early spring. There is still some snow on the banks of the river and ice covering the water in the shaded bends of the river. The water is a perfect height, class 2 – 3, and very cold.

All is going well until the lead boat goes around a bend in the river, sweeps wide, and rolls. The kayaker pops out of his boat and is immediately swept under the sheet of ice by the current. The kayaker right behind him heads straight for the sheet of ice.  As the front of his boat hits the edge of the ice, he leans back, and his boat slides up onto the ice. He slides all the way to the edge of the ice at the riverbank.

Quickly exiting his boat, he begins looking though the ice for his friend. A minute or so  later he can see his friend under the ice, wedged between the ice and the river bottom. By jumping up and down on the ice, he finally breaks through and is able to pull his friend out of the river, up onto the ice, and over to the riverbank.

His friend is unconscious, not breathing, but he does have a pulse.  The “rescuer” gives him two quick breaths and his friend begins to cough and breathe on his own. Within two to three minutes the once ice-trapped victim is conscious, cold, and very shaken.


It is estimated that approximately 400,000 people drown worldwide each year.

This makes drowning the 3rd leading cause of unintentional injury death worldwide, accounting for 7% of all injury-related deaths.

Motor vehicle accidents are the number 1 cause of unintentional injury death, and poisoning is number 2.

It needs to be noted that the global estimates significantly underestimate the actual number of deaths by drowning as few countries maintain any sort of statistics on mortality and morbidity.

(Unintentional injury death is a death that was preventable.)

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Part III of the Airway Series – Advanced Airway Adjuncts

By Frank Hubbell, DO

 Illustrations by T.B.R. Walsh

 In this section we will discuss the use of the endotracheal tube and the remaining airway adjuncts.

 Endotracheal Intubation (ETT)

 Gum Elastic Bougie/Flex-Guide Tube Introducers

 Digital Intubation

 Nasopharyngeal Intubation


 Pulse Oximetry

 Capnography and End-Tidal CO₂ detectors (EtCO₂)


 Stoma and Tracheostomy Care

TOTAL AIRWAY CONTROL – Endotracheal Intubation:

Last, but not least, of the airway adjuncts is endotracheal tube (ETT) intubation.

This is the most advanced airway, and it provides the greatest protection for the airway. This airway technique requires the most knowledge of airway anatomy and many hours of practice to develop the skills of using it. This is also a classic example of a, “use it or lose it” skill, requiring frequent live ETT intubations or practice on airway manikins.




Respiratory or cardiac arrest

Unconscious without a gag reflex

Rapidly deteriorating respirations or impending respiratory failure

Glottis seen through laryngoscopy

Glottis seen through laryngoscopy

Significant risk of aspiration from vomiting and obtundation

Potential airway obstruction from trauma, burns, or anaphylaxis


Epiglottitis (patient is sitting up, in the sniff position, and drooling).

Head, neck, or facial trauma that prevents visualization of the airway anatomy.

Advantages of Endotracheal Intubation:

  Complete control of the airway.

Isolates the airway.

Minimizes the risk of aspiration of gastric contents.

Eliminates the need to maintain a mask seal.

Allows direct suctioning of the trachea and respiratory passages.

It permits administration of some medications via the endotracheal tube –

naloxone, atropine, vasopressin (adults), epinephrine, and lidocaine.


Disadvantages of endotracheal intubation:

The techniques require considerable training and ongoing practice.

Intubation requires specific equipment.

Typically it is necessary to directly visualize the vocal cords.

Intubation bypasses the upper airway, and its functions of cleaning, warming, and

 humidifying the air en route to the alveoli.

Complications of endotracheal intubation:

Risk of equipment malfunction

Soft tissue damage

Broken teeth

Esophageal intubation

Tension pneumothorax

Endobronchial intubation (tube advanced too far into the right or left mainstem bronchus)

Breath sounds present on one side of the chest, diminished on the other side.

 Resistance to ventilations with a bag-valve-mask (BVM).

Pallor, cyanosis, evidence of hypoxia.

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