Healthy Baby/Healthy Child
Wilderness Medicine
Amy Liu, MD, MPH
ABSTRACT
With more families spending time outdoors
or embarking on wilderness adventures, pe-
diatricians may be tasked with providing ap-
propriate counseling to parents and children.
Although the breadth of wilderness medicine
can be extensive, this article will focus on pre-
ventive measures, common injuries, and in-
jury treatment options in an outdoor environ-
ment. [Pediatr Ann. 2021;50(6):e234-e239.]
W
ilderness medicine is defined
as the practice of medicine
in resource-limited environ-
ments or any health care that is delivered
in an austere environment.1 The scope is
broad, ranging from search and rescue to
natural disasters to space medicine. The
Wilderness Medical Society (WMS) was
founded in 1982 to incorporate medicine
within the wilderness setting and to fur-
Amy Liu, MD, MPH, is an Assistant Professor
and General Pediatrician, Division of General Pe-
diatrics and Adolescent Medicine, University of
North Carolina School of Medicine.
Address correspondence to Amy Liu, MD,
MPH, Division of General Pediatrics and Ado-
lescent Medicine, University of North Caro-
lina School of Medicine, 333 S. Columbia Street,
Room 231 MacNider Hall, CB 7225, Chapel Hill,
NC 27599-7225; email: amy.liu@med.unc.edu.
Disclosure: The author has no relevant finan-
cial relationships to disclose.
doi:10.3928/19382359-20210514-01
e234
ther the scientific knowledge base in this
field.1 Over the past 2 decades, the inter-
est in wilderness medicine has grown, and
there are currently 18 non–Accreditation
Council for Graduate Medical Educa-
tion-accredited fellowships offered in the
United States.2-4
EPIDEMIOLOGY
According to the Outdoor Founda-
tion, approximately 65% or 32.3 mil-
lion children age 6 to 17 years partici-
pate in outdoor activities, with the top
five most popular outdoor activities be-
ing biking, running, camping, fishing,
and hiking.5 One study that looked at
data from the National Electronic In-
jury Surveillance System—All Injury
Program from 2004 to 2005 found that
the annual rate of injuries was 72.1 per
100,000 population, with a higher prev-
alence in males between ages 15 and 19
years.6 Wilderness injuries in the US
tend to be seasonal in nature, with many
occurring between May and August.7
The most common injuries included
soft tissue (laceration, contusion/abra-
sion, burn, bite/sting, blister) and mus-
culoskeletal injuries (fracture, disloca-
tion, sprain/strain).6-8 Approximately
one-half of all nonfatal outdoor recre-
ation injuries were secondary to falls,
followed by being struck by or against
an object (18%) and overexertion
(10%), with 5% of all injuries requiring
hospitalization or transfer to a facility
for treatment.6
PREPARATION
More important than treating any
injuries that may arise during a recre-
ational outing is preparing for the activi-
ties. The duration of the trip, location,
and specific environmental hazards and
diseases particular to that locale will be
important to assess as well as any partic-
ipant’s preexisting medical illnesses and
access to medical care. For younger chil-
dren, flexibility and readjusting goals of
the trip may be necessary. Additionally,
the physical condition of each child will
be different as well as the amount of ac-
tivity that can be accomplished in a day.
Child carriers (most go up to 40 lbs) may
be useful to allow infants and toddlers
to participate. Appropriate footwear and
moisture wicking socks can prevent in-
juries such as blisters. Wearing ultravio-
let protection factor long-sleeved shirts
and pants can also provide sun protec-
tion and potentially mosquito and tick
protection if pre-treated with permethrin
(Table 1). Wide-brimmed hats and sun-
glasses that block ultraviolet A and B
rays can provide additional sun protec-
tion. Once at the location, passive mea-
sures to protect participants from inju-
ries are more effective than instructing
a child to avoid these dangers. An ex-
ample would be choosing safe campsites
away from water hazards, steep drops, or
snake habitats. Other examples of strate-
gies to reduce wilderness events such as
a lost child may be a whistle for the child
to blow when they are lost or wearing
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 Healthy Baby/Healthy Child

TABLE 1. TABLE 2.

Mosquito and Tick Prevention Wilderness Emergency Kit

• First aid supplies
Insect repellent Coverage time Precautionsa Waterproof-cloth first-aid tape, safety pins
DEET 10%-30% 2-12 hoursb AAP recommends no more than 30% DEET for  Wound care supplies (gauze, irrigation
children syringe with 18-gauge needle, tweezers,
May use in infants as young as age 2 months scissors, skin adhesives, povidone-
b iodine swab packets, hand sanitizer,
Picardin 5%-20% 3-12 hours May use in infants as young as age 2 months
petroleum jelly)
IR3535 7.5%-20% 2-10 hoursb May use in infants as young as age 2 months
P
 ersonal protective equipment (gloves,
2-undecanone 7.75% 5 hours for May use in infants as young as age 2 months face mask, cardiopulmonary resuscita-
mosquitoes tion mask, eye shield)
2 hours for ticks  Medicines (topical antibiotics/analgesics,
Para-menthane-diol 2 hours Not recommended for children younger than nonsteroidal anti-inflammatory drugs/
8%-10% age 3 years acetaminophen, epinephrine autoinjector)
Oil of lemon 6 hours Not recommended for children younger than • Navigation (compass or map)
eucalyptus 30%-40% age 3 years • Sun protection (sunscreen, sun hat, sun
Permethrin 0.5% Kills ticks on Should not be applied to skin protection clothing, sunglasses)
contact May be applied to clothing (lasts through • Light source (headlamp, flashlight, extra
several washings) or outdoor equipment batteries)
• Repair kit (multitool, duct tape)
Abbreviations: AAP, American Academy of Pediatrics; DEET, N,N-Diethyl-meta-toluamide; IR3535, insect repellent 3535.
a
Adult supervision of any insect repellent usage with sparing application in young children. Apply sunscreen first, then apply repellent. • Fire starter (windproof and waterproof
b
Increasing estimated protection times with higher concentrations. matches, flint, lighter)
Adapted from the American Academy of Pediatrics.26,27
• Nutrition (nonperishable high energy bar)
• Hydration (safe water, water filter)
life jackets to prevent drowning.9 De- prevalent.10 In comparing all venomous • Insulation (clothing, sleeping bag)
spite the best preparation, injuries do animal deaths in the US over the past • Emergency shelter (emergency bivouac
still occur, and it is important to know 3 decades, insects in the order Hyme- sack or large plastic garbage bag)
basic first aid and prepare a wilderness noptera, which includes hornets, wasps, • Search and rescue (whistle, small reflec-
first-aid kit that can be modified depend- yellow jackets, and bees, account for tive mirror, nylon cord)
ing on each person’s specific travel plans the majority, ranging from approxi- Adapted from Auerbach.28,29

and needs. Table 2 provides an example mately 70% to 73% of all deaths, with
of typical supplies in a basic emergency venomous snakes and spiders each
kit that should be stored in a waterproof coming in next with approximately 7%
bag. There are many ready-to-use ones to 9% of all deaths.11 Hymenoptera ac-
available that can be modified based on count for about 60 deaths annually,
the trip’s needs. most frequently caused by anaphylax-
is.12,13 Treatment includes removing
ARTHROPOD BITES the stinger, washing the area with soap
Insect bites and stings can lead to and water, icing the area, and treating
pain, discomfort, infection, and in some anaphylaxis with epinephrine and/or
cases anaphylaxis. Among people seen diphenhydramine.14,15
in the emergency department, the high- The two spiders in the US that are
est rates of non-canine bites and stings medically relevant with regard to ven-
are among children, during summer omous bites are the black widow spi-
months, and in the South.10 The most der, whose venom causes a presynap-
common type of arthropod bites are hor- tic release of acetylcholine, and the
net/wasp/bee stings, followed by spider brown recluse spider, whose venom
bites, with scorpion stings as the least causes neutrophil activation and skin
necrosis.16 Both spiders can be found
outside, typically near woodpiles and
debris. Black widow spider bites to the
upper extremity or lower extremity may
result in crampy muscle spasms in the
chest or abdomen, respectively, which
can resemble a myocardial infarction
or acute abdomen.15 Treatment involves
analgesics and secondarily benzodiaze-
pines. Antivenom may be of benefit for
those children who have muscle pain
as well as abnormal vital signs such as
hypertension and tachycardia, nausea/
vomiting, or headaches.16 The treat-
ment of brown recluse spider bites can
range, but typically is aimed at wound

PEDIATRIC ANNALS • Vol. 50, No. 6, 2021 e235

 Healthy Baby/Healthy Child
management. Antihistamines may be
considered adjunct therapy, but studies
demonstrating benefit are limited.16
SNAKE BITES
Venomous snakes account for ap-
proximately 7,000 human injuries per
year in the US, with 6 annual fatalities.17
Native to the US are pit vipers (subfamily
Crotalinae, which includes copperheads,
rattlesnakes, cottonmouths, water mocca-
sins) and coral snakes (subfamily Elapi-
dae). About 50% of most reported snake-
bites were venomous, with copperheads
(39%) and rattlesnakes (31%) as the most
common source of venomous snake bites.
Approximately 40% of all snakebites in
the US were reported in Texas, Florida,
Georgia, and North Carolina. Almost
40% of pediatric cases resulted in hospi-
tal admissions, and 20% were admitted
to intensive care units.18 Despite popular
belief that younger venomous snakes are
more dangerous than adult snakes, larger
snakes do in fact have a larger volume of
venom available.19 Most bites tend to be
associated with intentional interactions
with snakes so appropriate knowledge of
snake habits and avoidance provides the
best protection.19
In the event of a snake bite, immedi-
ate management should include moving
away from the snake to avoid another
bite, assessing whether it is a venom-
ous versus non-venomous bite, and po-
tentially taking a picture of the snake
from a safe distance. A venomous bite
is a medical emergency, and the patient
should be transported immediately to
the nearest emergency department. For
those patients in a remote location where
evacuation may be difficult, it will be
important to assess if the nearest health
care facility has access to antivenom.
While on the way to the emergency de-
partment, basic wound management
should be provided, and the time and
date of the bite documented, as well as
e236
the circumference above and below the
snakebite to assess swelling. The mea-
surement of the circumference may be
repeated every 15 to 30 minutes to docu-
ment swelling changes. Any clothing or
jewelry that could potentially constrict
the area secondary to swelling should be
removed. The snake bite victim should
also be monitored for any local (erythe-
ma, swelling, tenderness) and systemic
symptoms (hypotension, bleeding, an-
gioedema, vomiting, neurotoxicity).19
Many myths surround the appropri-
ate care of a snake bite and could have
potentially harmful effects including in-
creased local tissue injury and increased
infection risk. It is not recommended to
provide either oral or mechanical suc-
tion, to further cut open or bleed the site,
to use electricity or electrotherapy, to use
cryotherapy or cooling, or to use tourni-
quet placement or pressure bandaging.
Some studies have indicated benefits of
pressure bandaging for certain neuro-
toxic snakebites (eg, coral snakes); how-
ever, concern has been raised that inap-
propriate technique could lead to more
damage than benefits.19
Opioids are preferred for pain man-
agement given that nonsteroidal anti-
inflammatory drugs (NSAIDs) may
increase bleeding, platelet dysfunction,
and potential renal effects with rhab-
domyolysis.19 Antivenom is the corner-
stone for crotaline envenomation man-
agement and should be given to patients
with progressive local tissue findings
(≥2 cm of erythema expansion), system-
ic toxicity, or high-risk anatomical sites
(hands, joints, face) with minor enven-
omation. If there is concern regarding
management, the local poison control
center can provide additional assistance.
Approximately 8% and 13% of patients
may experience antivenom-induced hy-
persensitivity reactions or serum sick-
ness, respectively.19 As such, patients
should be monitored for serum sick-
ness or delayed coagulopathy with re-
peat laboratory studies (complete blood
count, prothrombin time/international
normalized ratio, fibrinogen).
ANIMAL BITES
The most common human injury
from wildlife not involving a vehicle
or aircraft in the US is from rodents, at
27,000 annual cases with no fatalities.17
After venomous snakes, the next highest
human fatality secondary to wildlife are
alligators at 9 annual cases with 1 death
and black bears with 25 injuries per year
with 0.3 fatalities.17 By comparison,
dog bites average 4.7 million per year
and result in approximately 28 deaths
annually.12
After an animal bite, the site should
be swiftly evaluated for any blunt trauma,
crushing injury, or penetrating trauma re-
sulting in deeper neurovascular damage.
Wound management is paramount for in-
fection control and healing. The need for
rabies post-exposure prophylaxis, espe-
cially from bites from raccoons, skunks,
bats, and foxes, as well as tetanus vacci-
nation, should be considered.12
General precautions against crocodil-
ian attacks include being attentive with
small children and pets as they are con-
sidered prey, avoiding dawn, dusk, or
nighttime swimming, disposing food
scraps away from camping areas, and not
feeding crocodiles or alligators. If an en-
counter with a crocodilian does occur, you
should run as fast as possible in a straight
line to cover the most distance and away
from water as most fatalities tend to oc-
cur in the water secondary to drowning.
Once a bite has occurred, fight back and
gouge the eyes or nostrils which are sensi-
tive areas and can cause the crocodilian to
release its grip and allow escape.20
When traveling to bear country, safety
can be divided into four different parts:
avoiding an encounter, avoiding an at-
tack after an encounter, reducing injuries
Copyright © SLACK Incorporated

during an attack, and preventing bears
from preying on you. To avoid an en-
counter, be mindful of fresh bear signs
(eg, tracks, droppings, tree scratchings,
or carrion) and make noise such as regu-
lar conversation that allows the bear to
know that a human is present. Once a
close encounter with a bear has occurred,
allow the bear to fully visualize you as
human and not prey. Hiding may cause
the bear to come closer to inspect you.
Avoid inciting aggressive behavior in the
bear by speaking in a calm voice with no
sudden movements and avoid direct eye
contact by looking to the side or standing
sideways to the bear. The bear can outrun
you so do not consider running away or
climbing a tree. If physical contact does
occur, drop to the ground and protect the
head and neck in either fetal position or
prone and stay down until the bear has
left the area. The one exception is black
bears, where being submissive is not
advised and the recommendation is to
be aggressive by shouting and throwing
whatever objects are available. To avoid
becoming prey to bears, it is important to
consider avoiding anything that may at-
tract a bear to the campsite; this includes
bear-resistant food storage and garbage
and reducing food odors by cooking and
eating at least 100 yards from sleeping
area. A predatory bear is interested in
food and a victim to take from the camp
to eat later so responding quickly and
aggressively may save the victim’s life.
Some research has also shown the utility
of pepper spray on an aggressive bear.21
WOUND MANAGEMENT
The importance of appropriate wound
management is crucial. The goals are to
control the bleeding, minimize discom-
fort, infection risk, and loss of function,
and deliver the best care until definitive
care can be provided. In considering
wounds, it is important to distinguish
if they are clean, dirty, or contaminated
PEDIATRIC ANNALS • Vol. 50, No. 6, 2021
Healthy Baby/Healthy Child
wounds, which can increase the likeli-
hood for infection.22 The patient’s medi-
cal history or active medications can play
a role in wound outcomes. Determining
if or when the last tetanus vaccination
has been given can also dictate care, as
an unimmunized patient with a tetanus-
prone wound will require evacuation.
The mechanism of the sustained injury
will also be important as animal bites and
certain environments will contain spe-
cific bacteria and contaminants that can
increase infection risk. If possible, the
initial evaluation of the wound should be
done in a bloodless field with appropriate
lighting.
For patients who are actively bleed-
ing, direct pressure is the gold standard
for achieving hemostasis.22 Once the
bleeding has been controlled, pressure
dressings can be applied to maintain
hemorrhage control. Due to concern for
potential limb ischemia, tourniquets are
only used for life-threatening arterial
bleeds in extremities or if direct pressure
has failed to control bleeding. Tourni-
quets placed for less than 2 hours have
lower risk of medical complications;
however, most limbs can tolerate up to 6
hours of limb ischemia.22
Wounds should be irrigated with
potable water using a syringe and an
18-gauge needle. Tissue adhesives may
be used for most simple wounds; how-
ever, for contaminated wounds, delayed
primary closure is recommended.22 Last-
ly, a non-adherent dressing with topical
antibiotic ointment or petrolatum allows
for a moist environment which promotes
wound healing.
Prophylactic antibiotics are not rec-
ommended except for open fractures,
human bites, and mammalian bites to the
hand, and can significantly lower the risk
of infections. Amoxicillin/clavulanate
is often the first choice for infected ani-
mal bites and other skin and soft tissue
infections (SSTI).22 Second- and third-
generation cephalosporins as well as
moxifloxacin are all suitable alternatives
for SSTI in the patient who is allergic to
penicillin.22
Although typically mild injuries,
burns account for approximately 2%
to 8% of wilderness injuries.23 Scalds
are the most common in those younger
than age 5 years; however, burns second-
ary to flames or fire are the most com-
mon in all other age groups. First aid
typically consists of gently cleaning the
area, running cool water or cold com-
presses over the burns, and pain control
with acetaminophen/NSAIDs. Typically,
a petrolatum-impregnated gauze with
dressing can keep the wound moist for
optimal healing and protection. Impro-
vised dressings with aloe vera, honey,
and banana leaf have also been shown to
be reasonable alternatives in the wilder-
ness.23 Due to insensible losses and in-
travascular fluid leakage into soft tissues,
fluid therapy either via intravenous fluids
or oral rehydration will be important.
Immediate evacuation should be consid-
ered for inhalational injury or burns that
affect respiration, circumferential burns,
burns to distal extremities, face or mu-
cous membranes, large burns, or those
that have become secondarily infected.23
MUSCULOSKELETAL INJURIES
For any musculoskeletal injury, the
first step is gathering a quick history of
the mechanism of injury and the patient’s
pertinent past medical history. The next
step is a physical assessment of the in-
jury for any wounds, deformity, crepitus,
or swelling, and checking for intact dis-
tal circulation, sensation, and movement
(CSM) and range of motion. Typically
for sprains and strains, the treatment in-
cludes rest, ice, compression, elevation,
and stabilization (RICES):24
1. Resting the extremity for 24 to 48
hours will help to reduce inflammation
and pain.
e237
 Healthy Baby/Healthy Child
2. Ice/ibuprofen: applying either ice
or cold water to the injury for 10 minutes
on and 10 minutes off for the first 24 to
48 hours to help reduce pain and edema.
Ibuprofen or other NSAIDs combined
with acetaminophen may also help with
further pain control.25
3. Compression with an elastic ban-
dage reduces swelling but should not be
too tight to compromise blood flow.
4. Elevation of the extremity above
the heart increases venous return and
thus reduces swelling.
5. Stabilization of the joint with ei-
ther splinting or taping helps to protect
the joint from further injury. Remember
to keep splints simple, immobilize above
and below the injured joint, check CSM
before and after placement, pad well to
avoid voids, and place the joints in a
natural position.
For fractures, patients should be
treated with RICES and potential reduc-
tion of the fracture if it is severely angu-
lated or there is concern for loss of CSM.
Any open fracture is considered high
risk for infection, and treatment should
include high-pressure irrigation, moist
sterile dressings, splinting with the abil-
ity to see the site, and rapid evacuation.
The treatment of dislocations involves
either splinting or reduction depending
on CSM and assessment skills. If a frac-
ture cannot be ruled out, the dislocation
should be splinted and patient should be
evacuated.24
CONCLUSION
With the growing number of chil-
dren participating in outdoor activi-
ties, the likelihood of pediatric injury
stands to increase as well. Preparation
and prevention are the most effective
means of decreasing the potential mor-
bidity and mortality associated with
wilderness travel. Physicians can help
to facilitate these conversations with
parents and patients by educating them
e238
on safety concerns, basic first aid, and
available resources.
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