LIFE-THREATENING PROBLEMS - Medicine for Mountaineering and Other Wilderness Activities - page 30

taneous clot formation may allow safe delayed evacuation. One of the authors witnessed
this dilemma on the Western Breech of Mount Kilimanjaro in 2005. A young climber was
struck by a rock that fractured his pelvis. He was reportedly initially conversant but unable
to ambulate. The local guides fashioned a sling from a tarp and transported the climber
down the Breech. Unfortunately, over the ensuing hours, he became progressively lethar-
gic and then somnolent from continued bleeding into his pelvis. Shortly before we arrived
on scene, he suffered a refractory cardiopulmonary arrest. We speculate that wrapping the
climber's pelvis and awaiting transport on a firm stretcher could have been life saving.
The decision of when to evacuate any seriously injured person should be determined
ideally by radio communication with a physician.
Cardiogenic Shock/Tension Pneumothorax
In the wilderness, the most likely cause of cardiogenic shock—which is shock resulting
from the inability of the heart to pump blood—is a punctured lung (pneumothorax) from
a fractured rib. (In urban surroundings, heart disease of various types is the most common
cause.) A wound on the surface of the injured lung can act as a one-way valve that allows
air to enter the space surrounding the lung (pleural space) but does not allow it to escape.
If air accumulates progressively within the pleural space, the lung of the injured side col-
lapses and pressure eventually rises to a point that interferes with blood traveling through
the heart. This process is termed tension pneumothorax and requires release of the abnor-
mal collection of air in the pleural space. Typically, tension pneumothorax requires consid-
erable time to develop.
The injured person initially complains of shortness of breath, the breathing rate in-
creases progressively, and then the heart rate increases. Ultimately, the person becomes
confused and then unconscious. Optimally, release of the air under pressure surrounding
the lung should be done by a health care provider familiar with the process but, under des-
perate conditions, this could be accomplished with instruction by radio. A tube is intro-
duced between the ribs—tube thoracostomy ( Chapter 9: Chest Injuries ) —and ideally con-
nected to a one-way valve, which could be fashioned from the finger of a rubber glove.
Another cause of cardiogenic shock following trauma is direct injury of the heart, but
such injuries are nearly always fatal in the wilderness and no temporizing interventions
other than the general supportive care for shock are available.
Neurogenic Shock
Neurogenic shock refers to signs of shock similar to those observed with acute blood
loss that occurs in individuals with spinal cord injury ( Table 3-1 ) manifested by paraplegia
or quadriplegia. The symptoms are due to a reduction in oxygen delivery to vital organs
resulting from a greatly expanded capacity for the individual's circulating blood volume,