How to Treat Allergic Reactions in the Backcountry

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I took my first bite of the energy bar when I read the packaging at the same time: cashews. I am allergic to cashew nuts. We were two day hikes from the nearest road and far from a cell phone network. Luckily, I spit the stuff out before experiencing that itchy, anxious lump-in-throat sensation, which I sadly got to know, but the near miss reminded me to check my wilderness plan for allergic reactions.

Allergy symptoms vary widely, from hives or itchy eyes and sneezing on pollen-heavy days to real shortness of breath. Allergic reactions also often include rashes, vomiting or diarrhea, shortness of breath and wheezing, even dangerous swelling of the airways.

The most common allergy triggers are environmental—like stings, pollen, or contact with animals—or related to certain foods, like peanuts, tree nuts, or shellfish. Some food intolerances are on the rise: peanut allergies in children, for example, increased by more than 20 percent between 2010 and 2017. The rate of allergic reactions reported by students on NOLS expeditions between 2005 and 2019 tripled compared to the 20 years prior.

Bee stings are a common cause of allergic reactions in hikers. (Photo: © Philippe LEJEANVRE/Moment via Getty Images)

For most reactions, over-the-counter medications offer a first line of defense. Some medications are more sedating than others, which can be a real problem with outdoor activities. Medications can reduce or prevent some allergic symptoms (like annoying seasonal allergies) or provide effective first aid for minor reactions. Oral antihistamines such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) are a potent addition to almost any medication kit. Anti-allergy eye drops provide quick relief from scratchy, watery eyes and don’t take up much extra space or weight.

Anaphylaxis — a serious, life-threatening allergic reaction — manifests as severe shortness of breath or wheezing, airway obstruction such as swollen lips, tongue, and throat, or even low blood pressure and loss of consciousness. In the wild, anaphylactic reactions are rare, although it’s difficult to estimate how often. Over a 15-year period, during which Outward Bound enrolled over 40,000 students per year, the educational organization reported a total of 46 real-world cases of anaphylaxis. Most of these were related to insect bites, with a smaller number due to peanuts, tree nuts, or other causes.

Luckily, backcountry anaphylaxis can be effectively treated with adrenaline. Epi is a powerful, super fast-acting hormone that can reverse life-threatening airway or respiratory problems. Epi auto-injectors provide a quick injection with a pen-like device that is usually inserted into the outer thigh. Many non-medical professionals providing outdoor care (guides, rangers, etc.) have been trained to use and safely administer epinephrine, and anyone with a history of severe allergic reactions should have access to an auto-injector.

In resource-constrained environments, we might hesitate, wondering if it’s worth burning through the only Epi available or waiting to see how things go. First responders should play it safe. Epi works really well with few side effects. However, a few sneezes on a pollen-heavy day doesn’t justify stabbing yourself in the thigh with powerful drugs.

Those of us with food or environmental allergies won’t escape the occasional itchy eye or sore throat — but with proper preparation, we can avoid episodes that are terribly uncomfortable or worse. Carrying allergy medication and being aware of risky situations—whether potential contact with an objectionable food or increased likelihood of insect bites—reduces risk. If you have an epinephrine auto-injector somewhere in the bottom of your pack (or better yet, immediately accessible), let your companions know. They may end up saving the day for someone you meet in the backcountry, for yourself, or even for you.

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