General symptoms

Fainting

Fainting is defined as sudden brief (usually less than 1 minute) loss of consciousness not associated with a head injury. The medical term for fainting is “syncope.” The term for feeling like you are going to faint, but remaining conscious, is “presyncope.” There are innumerable causes of fainting, but most episodes are associated with decreased blood flow (oxygen and/or glucose) to the brain. This might be caused by low blood sugar (hypoglycemia—see page 162), slow heart rate (vasovagal or “vagal” reaction, in which the vagus nerve is overstimulated resulting in a slower heart rate: fright, anxiety, stomach irritation, bowel dilation, drugs, fatigue, prolonged standing in one position), nervous system dysfunction, rhythm disturbances of the heart (particularly in the elderly), transient ischemic attack (TIA) (see page 165), stroke, dehydration, heat exhaustion, hyperventilation, toxic exposure (e.g., carbon monoxide), anemia, coughing spell, seizure (see page 80), head trauma, subarachnoid hemorrhage (see page 196), breath holding (children), or bleeding. Medications can make a person weak or dizzy and can cause fainting. Some people become weak and faint after they eat. Fainting associated with exercise, particularly in young persons, should be thoroughly evaluated by a physician. Elderly men sometimes faint during or after urination (“micturition syncope”).

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 their legs 8 to 12 inches (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 them on their side. If they have fallen, examine them for injuries. A cool, moistened cloth wiped on their forehead, on their face, and behind their neck might make the victim feel better. Do not splash or pour water on their face. Do not slap the victim’s face.

After a victim suffers a fainting episode, they should be examined for any sign of serious illness or injury. If you do not suspect anything serious, have them lie still for a few minutes, and then sit for a few minutes. If the victim is alert and capable of purposeful swallowing, offer them cool sweetened liquids to drink—preferably one that contains electrolytes (see page 230)—to correct dehydration. When the victim feels normal, they may slowly regain an upright posture.

If a person feels like they are going to faint, but does not faint, they might experience symptoms of lightheadedness, dizziness, nausea, seeing flashing lights, sweating, and or weakness for a few minutes, but remain awake. This person should be observed as closely as someone who actually faints, because serious medical problems identical to those that cause fainting might become apparent.

Older patients are at a higher risk for having a fainting spell related to a heart attack (see page 57) or stroke (see page 165). They might have a history of heart disease or abnormal heart rhythm (irregular pulse, history of atrial fibrillation) or diuretic medication use. If any of these is present, if the fainting occurred while the patient was lying down, or if there is a family history of sudden death, a prompt formal medical assessment should be obtained.

A vagal reaction, as described earlier, is often preceded by warning signs of lightheadedness, a sensation of warmth, nausea, sweating, and “tunnel vision.” It most commonly occurs in persons who are standing. If a person suddenly loses consciousness, wakes up, and does not recall any of the warning signs of a vagal reaction, particularly if it occurred during exercise or when the person was sitting or supine, then suspicion is heightened for an abnormal heart rhythm that requires formal medical evaluation.

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 (be sure to take the person’s temperature); accompanied by certain associated symptoms, it might indicate a hypoactive or hyperactive 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 321), hyperthermia (see page 337), high-altitude illness (see page 347), infection, emotional depression (see page 316), anemia (pale membranes inside the eyelid, pale fingernail beds, sallow skin complexion), dehydration (see pages 229 and 341), or starvation. A diabetic who becomes fatigued might be suffering from high or low blood sugar (see page 162). 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 57).

If a person is suffering physical exhaustion, allow them 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—such as the legs during forced military-style marching or long-distance ultramarathon running—muscle tissue can be broken down. This is more common under conditions of environmental heat (see page 337). 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 (condition known as rhabdomyolysis or rhabdo). In this situation, remove the victim from environmental heat, place them at as near complete rest as possible, and encourage them to drink as much liquid as they can to correct dehydration and flush the pigment from their system (see pages 230 and 341).

Fever and chills

Fever is an elevation in body temperature sometimes 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 might need to be lowered if the elevation is extreme or prolonged.

Classic teaching is that normal body temperature is 98.6°F (37°C) measured orally, and 99.6°F (37.5°C) measured rectally. That has been challenged, stating that normal body temperature perhaps averages 97.9°F (36.6°C) measured orally. Furthermore, “normal” should be determined person by person because individuals vary. To convert degrees Fahrenheit (F) into degrees Centigrade (C, or Celsius), refer to temperature conversion chart found on page 501.

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.

The most accurate measure of a body temperature is by measuring the core body temperature (esophageal–usually only in the hospital setting, or rectal). Do not rely on skin temperature as a correlate for core body temperature. To take a temperature rectally (necessary in a case of suspected hypothermia, so long as it can be done in a location where the patient will not be exposed to the elements and become colder), the thermometer is gently placed—ideally lubricated with oil or petroleum jelly—1 inch (2.5 cm) into the rectum. It is held for at least 2 minutes and then extracted and read. Never leave a child or confused adult unattended with a thermometer in the mouth or rectum. To take a temperature by mouth, place the thermometer under the tongue, close the mouth, and take a reading after 3 to 4 minutes. Armpit (axillary) temperatures are far less reliable because they might underestimate the temperature elevation. However, a high temperature recorded from the armpit can be interpreted to mean that there is some elevation in body temperature. An armpit temperature might 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 approximate the equivalent rectal temperature.

Generally, 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 335), stroke (see page 165), 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 their body temperature is greater than 100.4°F (38°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. 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, they will be made more comfortable by lowering the fever with administration of aspirin, a nonsteroidal antiinflammatory drug (NSAID), 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, in order to prevent febrile seizures. 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 does not help much to reduce fever and can even be counterproductive if the child struggles or begins to shiver, both of which generate heat. 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 337 ), they will not benefit from and should not be given aspirin or acetaminophen. An NSAID 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 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; they will rarely suffer from being given a common antibiotic, such as amoxicillin or trimethoprim–sulfamethoxazole.

Chills might be 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” might actually occur during a temperature spike within a fever.