1 CHAPTER 13 OBSTETRICS Pregnancy In women with regular menstrual cycles, a history of one or more missed cycles (periods) is suggestive of pregnancy. Associated symptoms include fatigue, nausea/vomiting, breast tenderness, frequent urination (caused by the enlarged uterus compressing the bladder), and вЂњquickeningвЂќ (first movements of a fetus felt in utero at 16-20 weeks). Calculate the EDC (estimated date of confinement) by adding 7 days to the first day of the last normal menses and subtracting 3 months. Signs Spider angiomata (branched capillaries on the skin, shaped like a spider) and blotchy or patchy palmar erythema (more than 50-60% of patients), regress after delivery. Striae gravidarum (stretch marks) develop in 50% of pregnant woman. Hyperpigmentation of nipples, areola, umbilicus, axillae, perineum and midline of lower abdomen (linea nigra). Breast enlargement due to increased hormone levels, which later causes release of colostrum (thin, yellowish fluid seeping from the nipple) and lactation. Other common signs and symptoms include lightheadedness, backache, dyspnea, urinary symptoms (frequency, urgency, and incontinence), hemorrhoids, heartburn, ankle swelling, varicose veins, abdominal cramping and constipation. Fetal heart tones can be heard via auscultation (bell side of stethoscope) at or beyond 18-20 weeks of gestation. Pregnancy tests can be used in the field. Most are nearly as accurate (97-99%) as a laboratory test on serum. Assessment: Palpation of fetal parts and the appreciation of fetal movement and heart tones are diagnostic. 2 Anatomy Placenta Transfer of gases Transport of nutrients Excretion of wastes Hormone production Protection Umbilical cord Connects placenta to fetus Two arteries One vein Amniotic Sac Membrane surrounding fetus Fluid originates from feral sources 500 - 1000 cc (after 20 weeks) Rupture produces watery discharge Terminology Antepartum - before delivery Postpartum - after delivery Prenatal - occurring before the birth Natal - connected with birth Gravida - number of pregnancies Para - number of pregnancies carried to full term Abortion - number of pregnancies that ended before full term Primigravida - woman who is pregnant for the first time Primipara - woman who has given birth to her first child Multiparous - woman who has given birth multiple times Gestation - period of time for intrauterine fetal development Fetal Growth Process End of third month Sex may be distinguished Heart is beating Every structure found at birth is present End of fifth month Fetal heart tones can be detected Fetal movement may be felt by mother 3 End of sixth month May be capable to survive if born prematurely Middle of tenth month Considered to have reached full term Expected date of confinement (EDC) Vaginal Delivery Symptom: When: Labor is defined as progressive dilation of the uterine cervix in association with repetitive uterine contractions resulting in complete dilation (10 cm) and effacement (thinning) of the cervical os. Normal labor is a continuous process. First stage: Onset of cervical changes and uterine contractions through full dilation and effacement of cervix Second Stage: Full cervical dilation and delivery of the infant Third Stage: Interval between the delivery of the infant and delivery of the placenta Fourth Stage: Recovery of the uterus after delivery of the placenta Supplies: 1% Lidocaine without epinephrine (approx. 20-30cc), sterile gloves (several pairs), gauzebandages and prep solution, 2-0, 3-0, and 4-0 absorbable suture (Vicryl or Chromic) for the repair, scissors or a scalpel to make the episiotomy incision, sterile (or clean) towels, suction device (bulb syringe), suture forceps, and needle holders 4 Procedure During the First Stage of Labor: 1. Assess motherвЂ™s gestational age by asking the date of the first day of her last normal menstrual period, subtracting 3 months and adding 7 days (40 weeks +/- 2 weeks). Palpate and measure the height of the uterine fundus (top) from the pubic bone. Up to about 36 weeks, this distance in centimeters approximates gestational age (i.e., 32 cm from pubic bone to top of fundus equals approx. 32 weeks gestational age). If not >36 weeks by dates or measurement, see Preterm Labor section. 2. Listen for fetal heart tones. Normal rate is approximately 160 beats/minute. Periodically reassess during labor. The rate normally decreases during contractions but should recover. 3. Encourage the mother to walk as gravity and motion will encourage cervical dilation. 4. Read this section and others related to birth (Episiotomy, Breech Delivery, etc.). 5. Periodically assess progression of labor by timing contractions. Eventual delivery is likely when contractions are <3 minute apart. 6. Check the birth canal with a sterile gloved hand once before birth to ensure the cervix is fully dilated and effaced. During the Second Stage of Labor: 1. As the cervix progresses to complete dilation, place the patient in the dorsal lithotomy position (patient is on her back with her thighs flexed on the abdomen). Women from some cultures may prefer to squat. 2. With each contraction the patient should be urged to push and the care provider should perform perineal massage. 3. As the fetal head crowns (i.e., distends the vaginal opening), consider an episiotomy if massage has failed to stretch the tissue adequately. An episiotomy facilitates delivery of a large infant, or one with shoulder dystocia. It is better to cut an episiotomy than to have the baby tear the perineal tissue into the rectum. See Episiotomy Procedure guide. 4. As crowning continues, it is very important to support the fetal head via a modified Ritgen maneuver. This is accomplished by placing one hand over the fetal head while the other exerts pressure through the perineum onto the fetal chin. Use a sterile towel to avoid contamination of this hand by the anus. 5. After the head is delivered, suction the nose and mouth with the bulb syringe. 6. Check the neck for the presence of a umbilical cord around it, which should be reduced if possible. If the cord is too tight, it should be doubly clamped and cut. 7. Place your hands on the chin and head, applying gentle downward pressure, delivering the anterior shoulder. Avoid injury to the brachial plexus; avoid excessive pressure on the neck. 8. Deliver the posterior shoulder by upward traction on the fetal head. 9. Delivery of the body should occur easily (see figure 3-8). 10. Cradle the fetus in your arms, suction once again and the umbilical cord is clamped and cut. If no clamps are available, suture may be used. 11. To avoid significant heat loss, dry the newborn completely and wrap in towels or blankets. 12. If the mother (or another person) can hold the baby safely, put the baby to the mother's breast. This will help the uterus contract. During the Third Stage of Labor: Soon after delivery of the infant, the placenta will follow. Placental delivery is iminent when the uterus rises in the abdomen, the umbilical cord lengthens, and a вЂњgushвЂќ of blood is noted. AVOID excessive traction on the umbilical cord to avoid uterine inversion (pulling the uterus вЂњinside-outвЂќ) which will cause profound blood loss and shock. Instead, wait up to 30 min. for spontaneous delivery of the placenta. 5 2. If spontaneous placental separation does not occur, remove the placenta manually. Pass a gloved hand into the uterine cavity and gently apply traction to the umbilical cord, using the side of the hand to develop a cleavage plane between the placenta and the uterine cavity. 3. Inspect the placenta to ensure it is complete. Inspect the cord for the presence of the expected two umbilical arteries and one umbilical vein. 4. After the delivery of the placenta, palpate the uterus to ensure that it has reduced in size and become firmly contracted. 5. Inspect the birth canal in a systematic fashion. Evaluate lacerations of the vagina and/or perineum and extensions of the episiotomy and repair if necessary (refer to Episiotomy section). Normal delivery, Crowning of the Head 5 6 7 During the Fourth Stage of Labor: 1. The likelihood of serious postpartum complications is greatest in the first hour or so after delivery. Palpate the uterus to ensure that it is firm. Repeat uterine palpation through the abdominal wall frequently during the immediate postpartum period to ascertain uterine tone. 2. Monitor pulse, blood pressure and the amount of vaginal bleeding every 15 minutes for the first hour, then every 30 min. for 3 hrs after delivery to identify excessive blood loss. 3. Manage pain with NSAIDS or low dose narcotics (i.e., Motrin 800 mg 1 tablet tid with food or Tylenol #3 1-2 tablets q 4-6 hrs). 4. Apply ice to the perineum for 20-30 minutes every 4-6 hrs to decreasing swelling after the delivery. What Not to Do: Do not contaminate the birth canal prior to birth. Do not allow the episiotomy to tear into the rectum. Do not forget to reduce umbilical cord. Do not forget to suction the babyвЂ™s nose and mouth. Do not forget to clamp and cut the umbilical cord. Do not forget to clean and dry the baby. Do not forget to deliver the placenta. Do not forget to repair an episiotomy and any tears. Do not forget to monitor the motherвЂ™s vital signs. Preterm Labor (PTL) Introduction: Preterm birth as a result of preterm labor is the most common cause of infant morbidity and mortality. Complications include respiratory distress syndrome (RDS), intraventicular hemorrhage (IVH), necrotizing enterocolitis, sepsis, and seizures. Long term morbidity associated with PTL and delivery includes chronic lung problems (bronchopulmonary dysplasia) and developmental abnormalities. Preterm labor is defined as regular uterine contractions occurring with a frequency of 10 minutes or less between 20 and 36 weeks gestation, with each contraction lasting at least 30 seconds. When contractions are accompanied by cervical effacement (thinning), dilation (opening), and/or descent of the fetus into the pelvis, it becomes increasingly difficult to stop labor. The cause of preterm labor is unknown but many factors have been associated with it and some include: dehydration, rupture of membranes, infections, uterine enlargement (twins), uterine distortion (fibroids), and placental abnormalities (previa and abruption), smoking and substance abuse. Approximately 10-15% of women will rupture the amniotic membrane around the fetus >1 hour prior to the onset of labor. This is called premature rupture of membranes, or PROM. After PROM, labor must begin promptly or infection will develop as bacteria ascend through the birth canal. Delivery should be completed within 24 hours of PROM to avoid infection in fetus and mother. One of the most important causes of early onset neonatal infection is group B streptococcus (GBS). 8 Symptoms: Menstrual-like cramps, low back pain, abdominal or pelvic pressure, painless uterine contractions, and increase or change in vaginal discharge (mucus, watery, light bloody discharge). Signs Palpable uterine contractions; palpable cervical dilation and effacement Lab: Urinalysis and a saline wet preparation to evaluate for bacterial vaginosis. Fern Test (amniotic fluid dries on a slide to resemble the leaves of a fern plant) to assess for PROM. Assessment: Assess for PTL risk factors, and treat those found. Differential Diagnosis Low back pain/spasm - palpate for back spasm; evaluate for associated neurological symptoms (leg tingling,radiation, etc.) Infection - evaluate for urinary tract infection (urinalysis, fever), GI infection (diarrhea, fever) and vaginosis (saline wet prep). Ureter/kidney stone - evaluate flank pain, fever; perform urinalysis True labor - verify dates of last menstrual period. PROM - history of vaginal gush or leak, positive Fern Test Constipation - history of infrequent bowel movements; retained fecal material Diarrhea - infection (above), food poisoning, and others. Treatment 1. Arrest labor: Magnesium sulfate, 4 gm loading dose over at least 5 minutes, followed by 2 gm/hour in a steady IV drip. Watch for magnesium toxicity with diminished reflexes and respiratory depression. Counteract with calcium gluconate 1 gm slow IV push over 2-3 minutes if magnesium toxicity is encountered. Alternates: Terbutaline 0.25 mg SQ, q 1-4 hours x 24 hours, total dose not to exceed 5 mg in 24 hours. May also be given po in 2.5 - 7.5 mg doses q 1.5 - 4 hours. Target maternal pulse rate is > 100 and < 120 BPM Indomethacin (Indocin) 50 mg po (or 100 mg PR), followed by 25 mg po q 4-6 hours for up to 48 hours. Watch for gastric bleeding, heartburn, nausea and asthma. Maternal: Significant hypertension (see Preeclampsia section), antepartum hemorrhage, cardiac disease. Fetal: Gestational age > 37 wks, fetal death, chorioamnionitis (intrauterine infection) 2. Prevent infection (PROM; PTL > 12 hours; history of UTI, vaginal infections in last 2 weeks): Primary: Penicillin 5 million units IV initially, then 2.5 million units q 4 hrs until delivered Alternates: Ampicillin 2 g IV q 4-6h or Rocephin may also be used, 1 gram IV q 12 hrs. For those patients who are penicillin allergic, clindamycin 600 mg q 6 h or 900 mg q 8 h or erythromycin 1-2 g q 6 h or vancomycin 500 mg q 6 h or 1000 mg q 12 h. 3. Help fetus mature: After postponing delivery, many fetuses less than 34 weeks gestation will benefit from administering steroids to the mother. The effect of the steroids on the fetus is to accelerate fetal lung maturity, lessening the risk of respiratory distress syndrome at birth. Dexamethasone 6 mg IM q 12 hours x 4 doses. 9 Relief of Shoulder [Dystocia] lock What: Shoulder dystocia is a labor complication caused by difficulty delivering the fetal shoulders. Improperly relieving the dystocia can result in unilateral or bilateral clavicular fractures. When: After delivery of the head, the fetus seems to try to withdraw back into the birth canal (the вЂњTurtle SignвЂќ). Further expulsion of the infant is prevented by impaction of the fetal shoulders within the maternal pelvis. Digital exam reveals that the anterior shoulder is stuck behind the pubic symphysis. In more severe cases, the posterior shoulder may be stuck at the level of the sacral promontory. What To Do: 1. Check for nuchal cord (the umbilicus wrapped around the baby's neck) and relieve it. 2. Suction the infantвЂ™s mouth to clear the airway of amniotic fluid and other debris. 3. Do not apply excessive downward traction on the head to get the baby out. This action can injure the nerves in the neck and shoulder (brachial plexus palsy) and must be avoided. While most of these nerve injuries heal spontaneously and completely, some do not. 4. Otherwise cut a generous episiotomy following proper technique (see Episiotomy Procedure in this chapter) unless a spontaneous perineal laceration has occurred, or if the perineum is very stretchy and offers no obstruction. 5. Initially apply gentle downward traction on the chest and back initially to try to free the shoulder. If this has no effect, do not exert increasing pressure. Try some alternative maneuvers to free the shoulder. 6. Place the mother in the MacRobertвЂ™s position, and apply gentle downward traction on the baby again. Maneuver involves flexing the motherвЂ™s thighs tightly against her abdomen. This can be done by the woman herself or by assistants. By performing this maneuver, the axis of the birth canal is straightened, allowing a little more room for the shoulders to slip through. 7. If the MacRobertвЂ™s maneuver fails have an assistant apply downward, suprapubic (above the bony pubic arch) pressure to drive the fetal shoulder downward, to clear the pubic bone. Again apply coordinated, gentle downward traction on the baby. 8. If pressure straight down is ineffective, have the assistant apply it in a more lateral direction. This tends to nudge the shoulder into a more oblique orientation, which usually provides more room for the shoulder. Again apply coordinated, gentle downward traction on the baby. 9. Often, the babyвЂ™s posterior arm has entered the hollow of the sacrum. Reach in posteriorly, identify the posterior shoulder, follow the humerus down to the elbow and identify the forearm. Grasping the fetal wrist, draw the arm gently across the chest and then sweep the arm up and out of the birth canal, freeing additional space and allowing the anterior shoulder to clear the pubic bone. Once again apply coordinated, gentle downward traction on the baby. 10. An electric light bulb cannot be removed by simply pulling it out- it must be unscrewed. This concept can be applied to shoulder dystocia problems. Rotate the posterior shoulder, allowing it to come up outside of the subpubic arch. At the same time, bring the stuck anterior shoulder into the hollow of the sacrum. Continue rotating the baby a full 360 degrees to rotate (unscrew) both shoulders out of the birth canal. Two variations on the unscrewing maneuver include: Rotating/shoving the shoulder towards the fetal chest (вЂњshoving scapulas saves shouldersвЂќ), which compresses the shoulder-to-shoulder diameter, and Rotating the anterior shoulder first rather than the posterior shoulder. The anterior shoulder may be easier to reach and simply moving it to an oblique position rather than the straight up and down position may relieve the obstruction. Applying fundal pressure in coordination with the other maneuvers may, at times, be helpful. Applied alone, it may aggravate the problem by further impacting the shoulder against the pubic symphysis. 10 12. If these measures fail, return to number 4 above and consider cutting or extending the episiotomy, then progress through these maneuvers again. Do not attempt a C-Section. Since the babyвЂ™s head is delivered, there should be no need to do so. Breech Delivery Breech presentation is an abnormality in which the buttocks or legs of the fetus, rather than the head, appear first in the birth canal. There are several breech variations, including buttocks first, one leg first or both legs first. вЂњFrank breechвЂќ means the buttocks are presenting and the legs are up along the fetal chestвЂ”the safest position for breech delivery. In any breech birth there are increased risks of umbilical cord prolapse and delivery of the feet through an incompletely dilated cervix, leading to arm or head entrapment. These risks are greatest when a foot is presenting (вЂњfootling breechвЂќ). When: Because of the risks of breech delivery, many breech babies are born by cesarean section (see Cesarean section template) in developed countries. In operational settings, cesarean section may not be available or may be more dangerous than performing a vaginal breech delivery. It is up to the care team to decide which option will be the safest mode of delivery for both mother and infant. What To Do: 1. The simplest breech delivery is a spontaneous breech. The mother pushes the baby out with normal bearing down efforts and the baby is simply supported until it is completely free of the birth canal. These babies essentially deliver themselves. This works best with smaller babies, mothers who have delivered in the past or frank breech presentation. 2. If a breech baby gets stuck halfway out or if you need to speed the delivery, perform an вЂњassisted breechвЂќ delivery. It is very helpful to have a second person assist you. 3. A generous episiotomy will give you more room to work, but may be unnecessary if the vulva is very stretchy and compliant. 4. Grasp the baby so that your thumbs are over the babyвЂ™s hips. Rotate the torso so the baby is face down in the birth canal. A towel can be wrapped around the lower body to provide a more stable grip. 5. Have your assistant apply suprapubic pressure to keep the fetal head flexed, expedite delivery and reduce the risk of spinal injury. 6. Exert gentle outward traction on the baby while rotating the baby clockwise and then counterclockwise a few degrees to free up the arms. 7. If the arms are trapped in the birth canal you may need to reach up along the side of the baby and sweep them one at a time, across the chest and out of the vagina. 8. It is important to keep your hands low on the babyвЂ™s hips. Grasping the baby above the hips could easily cause soft tissue injury to the abdominal organs including the kidneys. 9. During the delivery, always keep the baby at or below the horizontal plane or axis of the birth canal. If you bring the babyвЂ™s body above the horizontal axis, you risk injuring the babyвЂ™s spine. Only when the babyвЂ™s nose and mouth are visible at the introitus is it wise to bring the body up. 10. At this stage, the baby is still unable to breathe and the umbilical cord is likely occluded. Without rushing, move steadily toward a prompt delivery. Place a пЂЃnger in the babyвЂ™s mouth to control the delivery of the head. Try not to let the head вЂњpopвЂќ out of the birth canal. A slower, controlled delivery is less traumatic. What Not To Do: Do not assist too early. Only intervene if a breech baby gets stuck part way out of the pelvis. Do not place hands too high on the abdomen. Keep hands low on the babyвЂ™s hips. Do not raise baby above the horizontal plane until the nose and mouth are delivered. 11 ADVANCED Cesarean Section What: The delivery of a fetus by abdominal surgery (laparotomy) requiring an incision through the uterine wall (hysterotomy). When: Perform this procedure only when it is absolutely necessary, and is the only life saving measure for mother or infant! The decision to perform a C-Section must be based on the health and stability of the mother and fetus. Recognize that performing the procedure in the пЂЃeld as an untrained provider is extremely dangerous and will likely result in significant morbidity or mortality for both mother and infant. If a C-Section is anticipated, prepare equipment and read this material, since the procedure must often be performed emergently when vital signs become unstable. 12 The following are relative indications for cesarean delivery under field conditions: 1. Fetal Complications: a. Non-vertex (not head first) such as a transverse lie or breech presentation. Attempt vaginal delivery first. (See Breech Birth section). b. Multiple gestation: triplets or greater, twins in which the first twin is not head first (vertex). Attempt vaginal delivery of at least one fetus. (See Breech Birth section). c. Large Fetus: Attempt vaginal delivery first. d. Fetal distress: Fetal heart rate (<90 bpm) for more than 1 minute. 2. Placental Complications: a. Placenta Previa (placenta lies over cervical os) b. Placental Abruption (premature placental separation). c. Although these conditions cannot be diagnosed in the field, any large vaginal hemorrhage during labor, or hemorrhage accompanied by fetal distress should be reason to suspect them and consider C-Section. 3. Uterine Complications: a. Previous cesarean section with midline incision (classical). b. Other surgery (e.g., for fibroids) where the uterine cavity was entered. There is an increased risk for uterine rupture in this situation. C-Sections with low transverse incisions are much less risky. Attempt vaginal delivery first. 4. Vaginal Complications: a. Obstructive conditions (e.g., genital warts, cervical cancer). If noted, these conditions may hinder dilation of the cervical os and descent of the fetus through the birth canal. Attempt vaginal delivery first. b. Vaginal Infections (e.g., Group B Strep, genital herpes). Delivering the infant through the birth canal will greatly increase the babyвЂ™s risk of contracting these infections, which will likely be deadly. 5. Maternal Complications: Any medical condition that worsens during labor in which a delayed delivery would harm the mother (e.g., eclampsia). 6. Abnormal labor (failure to progress): Labor that does not progress (continued cervical changes and fetal descent) over several hours endangers the fetus by increasing the risk of cord compression and neurological damage. Episiotomy and Repair What: Incision of the perineum to enlarge the vaginal opening, and subsequent repair. When: At the time of delivery, perform an episiotomy when 3-4 cm of fetal scalp is visible at the vaginal opening. The most common practice is to repair the episiotomy after the delivery of the placenta. What You Need: 1% Lidocaine without epinephrine (approx. 20-30cc), sterile gloves, gauze bandages, prep solution, 2-0, 3-0, and 4-0 absorbable suture (Vicryl or Chromic) for the repair, scissors or a scalpel to make the episiotomy incision, suture forceps and needle holders. What to Do: Episiotomy: Indicated to assist in the delivery of a large infant or one with shoulder dystocia after perineal massage has failed to stretch the tissue adequately. It is better to cut an episiotomy than to have the baby tear the perineal tissue into the rectum. 1. If no anesthesia has been given, administer 5-10 cc of Lidocaine along the midline of the perineum and posterior vagina. Remember not to administer more than 50cc of Lidocaine total, and to aspirate prior to injecting. If the perineum is very thin and well stretched, anesthesia may not be necessary. Place the first two fingers into the posterior vagina between the fetal head and the vaginal wall, with one finger on either side of midline. 13 3. Cut between the fingers, through the vaginal wall and the perineum, but do not to incise the anal sphincter or its capsule. (Figure 3-12) 4. If pressure from the fetal head does not control bleeding, press a 4x4 bandage against the incised tissue to stop hemorrhage. 5. An alternate site for the episiotomy is the mediolateral position (approximately 4:30 on a clock face). Classifications of perineal episiotomies and lacerations First Degree: Extends only through the vaginal and perineal skin Second Degree: Extends deeply into the soft tissues of the perineum down to, but not including, the external anal sphincter Third Degree: Extends through the perineum and anal sphincter Fourth Degree: Extends through the perineum, anal sphincter, and rectal mucosa to expose the lumen of the rectum First Degree Episiotomy or Laceration Repair 1. Test the area to be sutured for residual sensation. If necessary, administer Lidocaine into the tissue as with typical wound repair. I2. If the edges of lacerated tissue are less than 1 cm apart and not bleeding, repair is not necessary. 3. Place the first stitch (2-0 or 3-0) 1 cm deep (proximal) to the end of the vaginal portion of the episiotomy (or laceration) and tie it. 4. Continue with locking, continuous sutures 1 cm from each wound edge, 1 cm apart and 0.5 cm deep through to the introitus or hymenal ring (or distal end of the laceration). Ensure the edges of the hymenal ring lay approximated. Do not cut the suture in episiotomy repair. 5. With another suture, sew a running subcuticular suture from the anal end of the skin wound back up toward the vagina to close the perineum. 6. Take the end of the suture back under the hymenal ring and tie it in the vagina. Second Degree Episiotomy Repair: 1. Repair vaginal wound as in First Degree Repair down to the hymenal ring. Do not cut the suture. 2. With another suture, sew 3 - 4 deep, interrupted stitches in the subcutaneous fascia, muscle and fat of the perineum. 3. Take the suture from the vagina under the hymenal ring and approximate the edges of the perineal fascia with continuous non-locking suture sewing toward the anus. 4. Sew a running subcuticular suture back up toward the vagina to close the perineum. 5. Take the end of the suture back under the hymenal ring and tie it in the vagina. 6. Do not suture any tear near the ureter without inserting a Foley catheter to avoid inadvertent urethral closure. Third and Fourth Degree Repair: 1. Reapproximate the rectal mucosa with interrupted, fine 4-0 sutures (usually two layers), taking care not to puncture the mucosa and to leave the ends of the suture in the tissue, not the rectal lumen. 2. Repair the torn ends of the doughnut-shaped anal sphincter with four well-spaced interrupted sutures that traverse through the capsule of the muscle. 3. Then repair the wound as in a second-degree laceration or an episiotomy (above). 14 Management after Episiotomy 1. Apply ice to the affected area tid to control swelling. 2. Relieve pain with Tylenol #3 1-2 tabs po every 3-4 hours. 3. Pain may be an indication of a large hematoma or perineal cellulitis. Examine these areas carefully if pain is severe or persistent. 4. Give stool softeners for approximately 7-14 days and direct increased intake of fiber and water. 5. Do not give enemas. What Not To Do: Do not fail to restore anatomical features. Do not use too many sutures. Do not fail to achieve hemostasis. 15 Preeclampsia/Eclampsia Preeclampsia is maternal hypertension accompanied by proteinuria or edema, seen from the 20th week of gestation through delivery. If these symptoms are complicated by seizures or coma, the mother has eclampsia. Hypertensive disorders are the most common medical complications of pregnancy. Symptoms Visual disturbances (usually irregular luminous patches in the visual fields after physical or mental labor), headaches, nausea, vomiting, epigastric pain and generalized edema, seizures or coma. Signs Mild Preeclampsia (1 of the following): 1. Blood pressure changes (measure on two occasions at least 6 hours apart): a. Systolic blood pressure (SBP) of 140 mm Hg or greater OR b. Diastolic BP (DBP) of 90 mm Hg or greater (< 110) OR Mean arterial BP (MAP) (calculated as 1/3 the difference between SBP and DBP, plus the DBP) of 105 mm Hg and/or an increase of 20 mm Hg over baseline 2. Proteinuria 2+ or > on a urine dipstick 3. Pathologic edema: generalized or involving the hands or face (Note: Moderate edema is a feature of approx. 70-80% of normal pregnancies). Weight gain greater than 4 pounds/week in the third trimester may be one of the first signs of preeclampsia. Severe Preeclampsia (1 of the following): 1. Blood pressure changes (measure on two occasions at least 6 hours apart): a. SBP of 160 mm Hg or greater OR b. DBP of 110 mm Hg or greater 2. Proteinuria 3+ OR 4+ on dipstick 3. Severe edema, including pulmonary edema 4. Evidence of end organ compromise (cerebral or visual disturbances) 5. Persistent abdominal pain with nausea and vomiting. May also see: a. Oliguria (< 400 ml in 24 hr). b. Decreased platelet count (thrombocytopenia <100,000) c. Hyperreflexia Eclampsia Convulsions (seizures) during pregnancy with history of preeclampsia, or without other explanation. 2. Hypertension. May also see weight gain, edema, proteinuria, visual disturbances, and right upper quadrant/epigastric pain. Treatment Mild Preeclampsia: 1. Observe for worsening signs of the disease. 2. If patientвЂ™s condition does not progress, discharge and follow on a twice weekly basis. 3. In a field or remote setting, manage aggressively with dexamethasone 6 mg IM q 12 hours for a total of 4 doses to prevent fetal respiratory distress syndrome and maternal thrombocytopenia, and to improve perinatal outcome in severe preeclampsia. 17 4. Give magnesium sulfate (to prevent seizures) by a controlled continuous infusion with a loading dose of 4-6 gm in 100 ml over 15-20 min. followed by a continuous infusion of 2-3 gm/hr. Toxic levels cause muscle weakness, respiratory paralysis, and cardiac arrest. Administer calcium gluconate 1 gm slow IV push over 2-3 minutes to counteract magnesium toxicity. Severe Preeclampsia: With SBP > 180 mm Hg or the DBP > 110 mm Hg, the possibility of intracerebral damage increases warranting antihypertensive medication. Give Hydralazine (Apresoline) 5-10 mg IV every 20 minutes as indicated, or labetalol 20 mg IV q 10 min with a max dose of 300 mg, to reduce BP. Monitoring BP q 5 minutes for at least 30 min. after giving the drug. Please note that some of the side effects with labetalol are maternal tachycardia, headache and flushing. Give magnesium sulfate as above. Eclampsia: 1. Give magnesium sulfate as above. 2. Provide oxygen and airway support as needed. 3. Evacuate. 4. If evacuation not feasible deliver the fetus after seizure activity has abated. 5. If magnesium sulfate is not available, consider cesarean section as only option to save both mother and fetus (see Cesarean Section procedure). 18 CHAPTER 14 Skin Disorders Introduction to Dermatology Classical Elements of the Clinical Approach to Dermatologic Disease Diagnosis and Disposition Type of Skin Lesion Primary Lesions Macule: A circumscribed area of change in normal skin color that is flat and less than 1 cm in diameter. Example: freckles. Patch: A circumscribed area of change in normal skin color that is flat and > 1 cm in diameter. Examples: cafГ©-au-lait spots, port-wine stains. Papule: A solid lesion, usually dome-shaped, <1 cm in diameter and elevated above the skin. Examples: verrucae, molluscum contagiosum. Nodule: A solid lesion, usually dome-shaped, > 1 cm in diameter and elevated above the skin. Examples: neurofibromas, xanthomas, and various benign and malignant growths. Plaque: An elevation above the skin surface occupying a relatively large surface area in comparison with its height. Frequently formed by a confluence of papules. Examples: lichen simplex chronicus and psoriasis. Vesicle: A circumscribed, thin walled, elevated lesion < 1 cm in diameter and containing fluid. Examples: herpes, dyshydrotic eczema, varicella, and contact dermatitis Bullae: A circumscribed, thin walled, elevated lesion > 1 cm in diameter and containing fluid. Examples: burns, frostbite, pemphigus. Comedone: Retained secretions of horny material within the pilosebaceous follicle. Examples: open (blackheads) and closed (whiteheads), the precursors of the papules, pustules, cysts and nodules of acne. Pustule: A circumscribed elevation containing pus. Examples: sterile lesions as in pustular psoriasis or bacterial as in acne and impetigo. Cyst: A circumscribed, thick walled, slightly elevated lesion extending into the deep dermis and subcutaneous fat. Examples: epidermal inclusion and pilar cysts. Wheal/Hive: A distinctive white to pink or pale, red, edematous, solid elevation formed by local, superficial, transient edema. They characteristically disappear yet may reappear within a period of hours. Examples: dermographism, insect bites, and urticaria. Telangiectasia: Blanchable (fades with fingertip pressure), small, superficial dilated capillaries. Examples: rosacea, lupus erythematosus and basal cell skin cancer. Purpura: Non-blanchable, purple area of the skin that may be flat/nonpalpable or raised/palpable. Examples: hemorrhagic lesions of some fevers. Secondary lesions represent evolution (natural) of the primary lesions. Atrophy: Thinning and wrinkling of the skin resembling cigarette paper Crusts (Scab): Dried serum, blood, or pus. Erosion: Loss of part or all of the epidermisthat will heal without scarring. Ulcer: Loss of epidermis and at least part of dermis that results in scarring. Excoriation: Linear or hollowed-out crusted area caused by scratching, rubbing, or picking. Lichenification: Thickening of the skin with accentuation of the skin lines. Scales: Accumulation of retained or hyperproliferative layers of the stratum corneum 19 Scar: Permanent fibrotic changes seen with healing after destruction of the dermis. Shape of Lesion a. Annular: Ring shaped, round or circular b. Nummular: Coin shaped c. Oval: Oblong d. Polycyclic: Rings within rings e. Polygonal: Geometric shaped f. Serpiginous: Snake-like Arrangement of the lesions in relationship to each other a. Grouped Arrangement i. Annular: Circular, round or like a ring ii. Arciform: Shaped in curves iii. Herpetiform: Like or in the shape of a herpetic lesion iv. Linear: Geometrically forming a straight line v. Reticulated: Net-like vi. Serpiginous: Shape or spread of lesion in the fashion of a snake b. Disseminated Arrangement: Diffuse involvement without clearly defined margins or scattered discre telesion. Distribution of Lesions a. Isolated single lesions b. Localized to specific body region c. Universal over the entire body surface d. Patterned i. Sun-exposed areas ii. Symmetrical iii. Follicular based iv. Flexure or extensor surfaces Assessment: Synthesize, integrate, and form a hypothesis by combining the history and the primary and secondary characteristics of the lesion(s) together with their shape, arrangement and distribution. Bacterial Skin Infections Disseminated Gonococcal Infection Gonococcemia is a systemic infection with Neisseria gonorrhoeae following the bloodborne spread (dissemination) of the gram-negative diplococci from infected sites (1% of untreated cases). Symptoms: Prodrome of fever and chills, anorexia, malaise during the 7 to 30 day incubation period. May have migratory polyarthritis. Signs Lesions: 1.0 -5.0 mm erythematous macules (2 to 20 lesions) that evolve to slightly tender, deep-seated, hemorrhagic pustules within 24-48 hrs; center may become necrotic; located on arms and hands more often than legs or feet, in regions near the joint spaces. Tenosynovitis of the extensors / flexors of the hands and feet is common. 20 Septic arthritis occurs with asym metrical, erythematous, hot, tender knee, elbow, ankle or metacarpophalangeal joints. Other organ systems may also be infected: hepatitis, carditis, meningitis, and others. Evaluate Lab: Gram stain of mucosal surfaces may yield gram-negative diplococci; culture mucosal sites (80-90% yield). Differential Diagnosis: Meningococcemia (CNS effects); other bacteremias; psoriatic arthritis (plaque lesions, multiple joints); systemic lupus erythematosus (multiple joints, multiple organ effects) Treatment: Primary: Ceftriaxone 1 gm IM or IV q 24 hrs Alternative: Ceftizoxime or cefotaxime 1 gm IV q 8 hrs, or spectinomycin 2 gm IM q 12 hrs After initial symptoms resolve, the uncomplicated patient should be treated for 1 week with oral cefuroxime axetil 500 mg bid, or amoxicillin 500mg with clavulanic acid tid, or ciprofloxacin 500 mg bid if patient is not pregnant. Meningococcemia Neisseria meningitides is a gram-negative coccus found in the nasopharynx of approximately 5 вЂ“ 15% of the general population. It invades the blood stream, causing acute meningococcal septicemia and meningitis. Transmission is through person-to-person inhalation of droplets of infectious nasopharyngeal secretions. Symptoms: Prodrome of spiking fever, chills, myalgia, arthralgia; rash, photophobia, headache Signs Abnormal vital signs: high fever, tachypnea, tachycardia, mild hypotension; rash: small, palpable, petechial lesions with irregular borders and pale gray, vesicular centers most commonly observed on the trunk and extremities (but may be seen anywhere, including the palms, soles and mucous membranes); posterior neck rigidity and tenderness with stretching; photophobia; altered consciousness; severely ill patients may display ecchymosis and coalescence of the purpuric lesions into bizarre shaped gray-to-black necrotic areas associated with disseminated intervascular coagulation. Lab: Gram stain scrapings from lesions to identify characteristic organism. Culture blood to identify organism. Differential Diagnosis: Rocky Mountain Spotted Fever, other rickettsial diseases, staphylococcal toxic shock syndrome, enteroviral infections and acute bacteremia. Treatment: Primary: Cefotaxime 2.0 gm IV q 4-6 hrs + vancomycin 1.0 gm q 6-12 hrs Alternate: Ceftriaxone 2 gm IV q 12 hrs + vancomycin 1.0 gm q 6-12 hrs Erysipelas Erysipelas is most commonly an acute, dermal and subcutaneously spreading cellulitis caused by Group A beta-hemolytic Streptococcus pyogenes or Staph. aureus. 21 It is characterized by an erythematous, warm, raised, tender area of the skin. Inoculation is through a break in the skin barrier (puncture, laceration,abrasion, surgical site) an underlying dermatosis (pitted keratolysis, tinea, or stasis dermatitis/ulcer), or through the middle ear or nasal mucosa in children. Symptoms: Prodrome of malaise, anorexia, fever and chills is occasionally observed. More common is the rapid development of high fever and chills. Signs The primary lesion is a bright erythematous, edematous, raised, warm, tender plaque with sharp, palpable leading margins. The distribution of lesion varies from the face to the lower extremities. Usually seen with an associated regional lymphadenopathy. Lab: WBC count for infection Differential Diagnosis: Early allergic or irritant contact dermatitis; fixed drug eruption; deep venous thrombosis; thrombophlebitis; rapidly progressive necrotizing fasciitis (a well-demarcated dusky purpuric lesion that is caused by thrombosis of the vessels, which is usually palpable). Treatment: Primary: Dicloxacillin 500 mg po q 6 hrs for early mild cases Or nafcillin or oxacillin 2.0 grams IV q 4 hrs for more severe cases Alternative: Erythromycin 500mg po q 6 hrs Staphylococcal Scalded Skin Syndrome Staphylococcal scalded skin syndrome is a fairly distinctive pediatric dermatosis caused by an epidermolytic (epidermis-destroying) toxin. The reason for the association with children appears to be related to the fact that most adults and children over the age of 10 can localize, metabolize, and excrete the toxin more efficiently. They may develop bolus impetigo instead, but will limit the hematogenous dissemination of the toxin. This condition is most common in children 5 years of age and younger. Symptoms: Prodrome: Fever, malaise, extreme irritability, and anorexia; irritable child with low-grade fever. Signs Generalized macular erythema, with fine, stippled, вЂњsandpaperвЂќ appearance, rapidly progressing to a tender scarlatiniform phase over 24-48 hrs; spreads from the intertriginous and perioral facial areas to the rest of the body. 22 The exfoliative phase is heralded by a characteristic perioral crusting that often cracks in a radial fashion. Within 48-72 hours, the upper epidermis may become wrinkled or slough off with light stroking of the skin (NikolskyвЂ™s sign). Shortly thereafter, flaccid bullae and desquamation of the upper layers of the epidermis are noted Unless subsequent infective processes are present, the entire skin will re-epithelialize with scarring with in 2 weeks. Lab: Staph aureus cultured only from colonized site of infection; umbilical stump, external ear canal, conjunctiva, or nasal mucosa. Diagnosis based on clinical criteria and verified by culture from a primary infection site. Differential Diagnosis - Erythema multiforme, drug-induced toxic epidermal necrosis, and pemphigus vulgaris. See related topics. Treatment: Primary: Supportive: Reliable home care, including cool baths or compresses and oral fluid replacement. Antibiotics: Dicloxacillin 30вЂ“50 mg/kg/day po in divided doses. In newborns and infants where extensive sloughing has occurred: IV oxacillin 200 mg/kg/day q 4 hrs. Apply mupirocin ointment or silver sulfadiazine (Silvadene) for more irritated and inflamed areas. Impetigo Contagiosa Impetigo is an acute, contagious, superficial infection caused by Staphylococcus aureus (bolus/ulcerative), or group A beta-hemolytic streptococci (vesiculopustular), or both. Although seen in all age groups, impetigo is most common in infants and children, occurring most frequently on the exposed parts of the body, especially the face, hands, neck and extremities. Predisposing factors include crowded living conditions, neglected minor wounds, and poor hygiene. Symptoms: Itching, weeping lesions Signs Lesions: 1вЂ“ 2 mm erythematous macules, which quickly develop into vesicles or bullae surrounded by a narrow halo of erythema. The vesicles rupture easily and release a thin, yellow, cloudy fluid which subsequently dries to a characteristic вЂњhoney crust.вЂќ Scattered, discrete lesions located most frequently on the exposed parts of the body, especially the face, hands, neck and extremities. Groups of lesions may have satellite autoinoculated lesions at the periphery . There may be associated regional lymphadenopathy. Lab: Gram stain of early vesicular lesions reveals gram-positive intracellular cocci in clusters or chains. Differential Diagnosis Varicella, herpes simplex, bullous tinea, allergic contact dermatitis (see appropriate topics in this book). Treatment Primary: Dicloxacillin 250-500 mg po qid x 10 days Alternative: Keflex (250 to 500 mg bid to tid); erythromycin (250 mg po qid) 23 Cutaneous Tuberculosis Cutaneous tuberculosis (TB) commonly represents skin manifestations of underlying pulmonary TB. It can also mean primary skin inoculation with TB, which is very rare. It is an acid-fast, aerobic, gram-positive bacterium with both human and bovine forms. Only about 1% of all TB patients will have skin lesions. Most cutaneous TB is indicative of systemic TB infection and can be the first sign of TB, especially in patients with HIV infection. Symptoms: Most are asymptomatic, some have a painless nodule progressing to painful ulcer, itching is uncommon. Signs Primary skin inoculation: Non-tender, well-circumscribed ulcer; non-tender lymphadenopathy (3-8 weeks later); these characteristics are the ulceroglandular complex Cutaneous manifestations of pulmonary TB: Variable presentations: boggy, indurated, erythematous skin and purulent ulcerations overlying infected subcutaneous tissue and enlarged lymph nodes (scrofuloderma); brown-red papules, soft and applejelly like, most common on the face, ears, buttocks and breasts (lupus vulgaris); discrete, blue-red to brown, tiny papules, some capped with minute vesicles, which burst to leave a crust and may affect all body parts, but the trunk, thighs, buttocks and genitalia are predisposed Differential Diagnosis Primary Skin Inoculation - primary syphilis, tularemia, cat scratch disease, sporotrichosis, and others. Cutaneous Manifestations of Pulmonary TB: extensive list including tertiary syphilis, deep fungal infections, chronic granulomatous disease, leishmaniasis, sarcoidosis, squamous cell carcinoma, and many others Treatment Primary: There are at least 13 different agents to choose from. Many organisms are multi-drug resistant. See Respiratory: TB section for details. Medications: Some medications can be toxic, so periodic blood tests are necessary during treatment. Leprosy (HansenвЂ™s disease) An inflammatory disease caused by infection with Mycobacterium leprae. It may be localized to the skin only or may involve internal organs. Infection of cutaneous nerves is very common. Leprosy is endemic in India, sub-Saharan Africa, South and Central America, the Pacific Islands and the Philippines. India, Myanmar and Nepal account for 70% of all the cases in the world. It is found in the Southeastern US and Hawaii. Most patients in the United States have a history of exposure to armadillos, a natural host for M. leprae. Symptoms: Hypopigmented or reddish skin lesions with decreased or no sensation. Signs: Circular patches and plaques with variable color including erythema, hyperpigmentation, or hypopigmentation; tissue swelling with nodules or ulcerations; lesions are common on the face, ears, and extremities. 24 Differential Diagnosis Tinea corporis, mycosis fungoides, cutaneous TB, other causes of erythema nodosum (GI infections, drug reactions, sarcoidosis, others). Treatment Dapsone, rifampin and clofazimine in combination as per specific protocols. Treatment lasts 6-12 months or longer. The relapse rate is very low (0.1% per year on the average). Prevention: Isolate known patients until therapy is instituted. Viral Skin Infections Ecthyma Contagiosum Ecthyma contagiosum infections (Milker's nodules, human orf) are caused by a genus of parapoxviruses which normally infect animals and only cause human infections when one handles infected livestock or works in infested areas. Symptoms One usually reports a history of contact with ungulates (sheep, goats, yaks), or cattle. After a 5 to 7 day incubation period one notes pruritus in an abraded area. This lesion enlarges and becomes painful. One may note systemic complaints of fever and chills on occasion. Signs In MilkerвЂ™s nodule primary lesion is a deep erythematous papule (or small group of papules that enlarges) gradually into a firm, smooth, hemispherical nodule varying in size up to 2 cm in diameter. In human orf infections (HO) there are six classic clinical stages of the usually solitary lesion that last approximately 1 week; erythematous papular stage, targetoid plaque with central crusting, tender nodular, acute weeping nodular stage, regenerative stage, and regressive stage that heals without scaring. The most common location is the dorsum of the index finger on the dominant hand due to handling the livestock or items within the livestock area. Other exposed skin sites of the arm, face, and leg are also at risk of infection. Diagnosis based on clinical morphologic criteria and history of exposure to infected bovine or ungulate livestock or livestock areas. Differential Diagnosis Erysipelas, erysipeloid, atypical mycobacterium, bacillary angiomatosis, cat-scratch disease, leishmaniasis, pyogenic granuloma. Treatment Primary: Symptomatic treatment for pain and pruritus. Alternative: Antibiotic for secondary wound infections. 25 Herpes Zoster (Shingles) Herpes zoster is an acute, localized, recurrence of the varicella-zoster virus (VZV) most commonly seen in patients over the age of 50. Less than 10% of cases are under the age of 20. Symptoms A prodrome of pain, tenderness, itching, burning, and/or tingling in a dermatomal distribution precedes the eruption by 2-7 days. Intense pain in the dermatome usually persists throughout the eruption and resolves slowly (post herpetic neuralgia). Constitutional symptoms of headache, fever and chills occur in approximately 5% of patients. Signs Erythematous papules or plaques, followed by umbilicated vesicles and bullae that commonly evolve to pustules (progression over 48-72 hours) and crust over by 7-10 days; new lesions may continue to appear for up to 1 week; lesions typically cluster in the distribution of a dermatome. Lab: Tzanck smear of vesicle (undersurface of the vesicle or bullae has the highest yield) with multinucleated giant epidermal cells. Differential Diagnosis Pain can be intense and may resemble that of cardiac disease, an acute abdomen or vertebral disk herniation. The eruption of zoster can resemble allergic contact dermatitis, irritant contact dermatitis or a localized bacterial infection. Treatment Primary: High dose oral acyclovir 800 mg po 5 times a day x 7 days. Molluscum Contagiosum Molluscum contagiosum is endemic in school age children through casual contact and spread of the poxvirus. Lesions are discrete, umbilicated, pearly, red papules. Involvement of the diaper area, trunk, face, and axilla is common. 26 In the adult population, molluscum contagiosum is usually transmitted sexually, and may resolve spontaneously after several months or may reappear. HIV infected patients may have hundreds of small (2-3 mm) papules or develop giant 1-2 cm lesions. Symptoms Asymptomatic, slow growing papules; commonly irritated by trauma or scratching, which can cause local spreading and/or secondary infection. Signs Sharply circumscribed single or multiple superficial, pearly, dome-shaped papules with a characteristic umbilication seen easily with a hand-held lens. They initially present as pinpoint papules, increase slowly to 2-3 mm in size , and are often found in the genital region. Treatment Primary: Treatment depends on location on body. Facial lesions should be treated less aggressively to decrease the risk of scarring. Retinoid gel 0.01%-0.25% applied to affected area q hs will cause a minor irritation to the lesion and works well for the face, as does potassium hydroxide topically. Apply to lesion daily until cleared. Alternative: Curettage, followed by imiquimod 5% cream applied to the lesion each day until cleared. Warts (including Venereal Warts) The common wart is a benign growth in the epidermis seen in 7-10 % of the population. It is caused by the human papilloma virus (HPV) and commonly presents as papules and plaques in school age children. Some HPV strains have been associated with malignant transformation. Symptoms: Usually slow growing; commonly irritated with minor trauma or excoriations Signs Verruca vulgaris: Appear predominately on the dorsal aspect of the hands and periungual region of the nail, but may occur anywhere. They vary from solitary isolated lesions to vast numbers in any given individual. The normal progression of the primary lesion is from a small, round, discrete, flesh colored papule to a larger yellowish tan to black lesion that measures from several millimeters to a couple centimeters. 27 The surface of the lesion commonly takes on a rough finely papillomatous (verruciform) surface with many characteristic вЂњreddish-black seedsвЂќ (thrombosed capillary loops). Verruca plana: Appear predominately as smooth, flesh-colored to slightly tan, elevated papules, 2 to 5 mm in diameter, with a round or polygonal base on the face, neck, arms, and legs. In the bearded area of men and on the legs and axilla of women, irritation from shaving tends to cause the warts to spread in linear arrays (Koebner effect) Verruca plantaris: Appear initially as small, shiny, skin colored, sharply marginated papules that evolve to plaques with a rough hyperkeratotic surface. They commonly present over the weight bearing points of the foot and therefore are commonly tender to palpation. They may be distinguished from calluses by noting the loss of the normal dermography (skin lines) that calluses usually retain. (see Podiatry: Plantar Warts). Venereal Wart / Condyloma Acuminatum: Appear initially as tiny, pinpoint, flesh-toned, papules that may grow rapidly to cauliflower-like masses in any region of the anogenital area and the oral mucosa. Differential Diagnosis Verruca vulgaris - seborrheic keratosis, lichen planus, simple callus, molluscum contagiosum, carcinoma with verrucous (wart-like) appearance Verruca plana - simple callus, foreign body, lichen planus, carcinoma with verrucous (wart-like) appearance Venereal warts - condyloma lata (syphilis), intraepithelial neoplasm (BowenвЂ™s disease), invasive squamous cell skin cancer, molluscum contagiosum, lichen planus, skin tag Treatment Verruca vulgaris: Trim warts; apply liquid nitrogen to the lesion (for 5 seconds, slowly thaw, repeat x 1); or apply 40% salicylic acid to area once daily after trimming lesions; apply duct tape if unable to keep acid on lesion; may need to treat for weeks until dermography (skin lines) returns. Verruca plana: Trim warts; apply liquid nitrogen to the lesion for 5 seconds, slowly thaw, repeat x 1; or apply 40% salicylic acid, retinoic acid, or cimetidine to the lesions as described above Venereal Warts: Apply podophyllin (10-25%), imiquimod cream to the lesions as described above; or apply liquid nitrogen as above. 28 Superficial Fungal Infections Dermatophyte (Tinea) Infections Ringworm - Tinea corporis Jock itch - Tinea cruris AthleteвЂ™s foot - Tinea pedis Some Dandruff - Tinea capitis Finger/Toenails - Tinea unguium Dandruff of Beard - Tinea barbae/faciale Palms and Soles - Tinea manuum Dermatophyte infections are superficial, caused by fungi that invade only dead outer layers of the skin or its appendages (stratum corneum, nails, hair). Microsporum, Trichophyton and Epidermophyton are the genera most commonly involved. Transmission of dermatophyte infections may be grouped into 3 main categories: from animals, from the environment, and from one another. Infections are seen worldwide. Symptoms: Rash, itching and flaking; severe cases: Painful, pruritic blisters. Signs Tinea corporis: Scaling, sharply demarcated plaque (with or without vesicles or pustules) with central clearing and peripheral enlargement producing an annular configuration, commonly on forearm and neck. Tinea pedis: Various patterns: Slightly erythematous plague on the plantar surface of the foot; dry, superficial, white scale is observed in an arciform pattern; moist patch of erythema, small fissures and erosions usually localized to the third and fourth interdigital spaces and the lateral sole. Tinea unguium (onychomycosis): Whitish/yellow/brown, thick, dry, subungual (under nail) accumulation of friable keratin debris; the great toe is commonly affected first. Tinea capitis: 3 main groups: Focal patch of alopecia with minimal scale and erythema; вЂњBlack dotвЂќ appearance of broken of hair shafts also seen with minimal scale and erythema; kerion- a boggy, purulent, inflamed group of pustules that is often tender to touch and heals with severe scarring. Tinea cruris: Similar to Tinea corporis but restricted to the intertriginous area of the groin. Tinea barbae: Similar to Tinea corporis but restricted to the facial area. Tinea manuum: Similar to Tinea corporis but restricted to the hands and feet. Lab: KOH preparation for characteristic fungal hyphae. Differential Diagnosis Pityriasis rosea, discoid eczema, and psoriasis. Diagnosis requires a KOH preparation Treatment Primary: Lac-Hydrin and Clotrimazole topically bid for 2-4 weeks for tinea pedis and onychomycosis. Lac-Hydrin decreases the dryness and increases the barrier properties of the skin. Griseofulvin 500 mg bid with fatty meals (aids absorption) for 2 weeks for tinea corporis to 2 to 3 months for tinea capitis. Not effective against candidiasis or tinea versicolor. Clotrimazole topical preparations (cream and solution) are effective against most fungal infections when applied bid/tid to affected areas and washed off before reapplication. Alternate: Itraconazole and terbinafine are not recommended in the field due to the inability to properly evaluate side effects. A more effective treatment of onychomycosis is prevention and topical ciclopirox nail lacquer (Penlac). Note: Nystatin treats only candidal infections not dermatophytes 29 Pityriasis (Tinea) Versicolor Pityriasis versicolor (tinea versicolor) is a chronic, asymptomatic fungal infection caused by Pityrosporum orbicularis, a normal resident of the skin. The fine scales of this lesion are teeming with hyphae and spores that transmit the disease. Factors that predispose to infection include warm humid climate, genetic predisposition, high plasma cortisol levels (i.e., patients taking corticosteroids), serious underlying disease or immunocompromise, pregnancy. Symptoms: Asymptomatic to slightly pruritic depigmentation of skin. Signs White, tan, brown, or pink coalescing macules and patches with a fine scale; found most commonly on the upper torso and neck (or face in children). Lab: KOH prep of scales reveals numerous short, straight or ring-shaped hyphae. Differential Diagnosis Allergic contact or irritant dermatitis, various tinea, post inflammatory changes (hyper- or hypopigmentation), vitiligo (familial, autoimmune hypopigmentation, with only cosmetic effects). Treatment Primary: Ketoconazole 400 mg po with orange juice to aid in absorption, wait one hour, exercise, leave sweat on body till the morning, then wash with selenium sulfide suspension. Repeat in one week Alternative: Fluconazole 200 mg po as above. CELLULITIS: A superficial bacterial infection of the skin and skin structures. Common in tropic regions. Signs & Symptoms: Skin is red, hot and tender to the touch. Patient may have a mild/moderate fever. No abscess is palpated in the SubQ tissue. Treatment: Keflex, 250-500 mg every 6 hours. Alternative include: Cipro, 500 mg b.i.d. or Rocephin, 1 gram IV or IM every 24 hours. Warms soaks may help decrease symptoms. Evacuate if symptoms do not improve within 24 hours of initiating treatment, if any high fever develops or if rash continues to spread despite treatment. 30 Skin Cancer (Basal & Squamous Cell Carcinoma, Malignant Melanoma) Basal Cell Carcinoma (BCC) BCC is by far the most common cancer in the world, with over 700,000 cases each year in the U.S. alone. Early detection and treatment are paramount in order to avoid extensive tissue destruction, damage to adjacent structures, and complex surgery and reconstruction. The good news is that this cancer is virtually 100% curable if approached early and properly. Metastasis is very rare. Sun exposure and fair complexion, light-colored hair and eyes are the main risk factors for skin cancer. Symptoms: Very slow-growing, small, pearly or waxy papule, usually in a sun-exposed area. Sometimes the presenting complaint is that of a sore that will not heal. There may be a history of trauma preceding the lesion. Signs Waxy or pearly papule (2-3mm diameter) that can grow to several cm over time; peripheral telangiectasias (small, dilated blood vessels); superficial erosion; some lesions are lat scars, usually without a history of trauma; sun-exposed areas are the most common sites: ears, periauricular skin, eyelids and periocular skin, nose, cheeks, temples, forehead, upper chest and back, and arms and forearms; can occur even in protected areas like the axilla, so skin exams should be thorough and complete. Differential Diagnosis - benign lichenoid keratosis, intradermal nevus, neuroпЂЃbroma, irritated seborrheic keratosis, amelanotic melanoma, tricholemmoma. Differentiating these conditions in the field is nearly impossible, since they require expert microscopic evaluation of a biopsy. Treatment: Freeze or store tumor in formaldehyde if possible for later study. Prevention: Education about aggressive sun precautions is vital: avoid the sun during hours when the individualвЂ™s shadow is shorter than their height; wear long sleeves, pants and broad-brimmed hats (brim > 4 inches wide); apply sunscreen of SPF 30 or greater (with special attention to the nose, ears and lips). Squamous Cell Carcinoma (SCC) SCC is the second most common skin cancer, affecting over 100,000 Americans each year. The risk of metastasis is very real in invasive SCCs, especially on the lip or ear. Rates of metastasis range from about 1-5 %. Subjective: Symptoms KAs grow rapidly, while SCCs usually are slow growing and much more common in sun-exposed areas; usually painless lesion; history of chronic sun exposure is common, as is an inability to tan, with many severe sunburns. Signs Red, scaly (hyperkeratotic) papules are most characteristic for SCC. Size varies from a few mm to several cm. SCC in situ can occur on the glans penis or within the foreskin, and usually has a soft, red, velvety appearance, without hyperkeratosis (BowenвЂ™s disease), since it arises from mucosa. 32 It is associated with a genital wart virus (HPV type 16) and can appear similar to genital warts, with dark flat- topped verrucous papules. Cervical and penile cancers are known to be caused by a genital wart virus. KA has a distinctive appearance, similar to that of a volcano, with a central core of keratin surrounded by domed, rolled borders, usually ranging in size from 1-3 cm. Metastatic SCC often presents with palpable lymphadenopathy. Differential Diagnosis - BCC, ulcers, chronic ulcerative herpes, benign adnexal tumors, contact dermatitis, BowenвЂ™s disease. Differentiating some of these conditions in the пЂЃeld is nearly impossible, requiring expert microscopic evaluation of a biopsy. Treatment: Evacuate and refer to dermatology. If evacuation is not possible in the foreseeable future (1-2 monthsвЂ”relatively slow growing tumor), perform full thickness excisions with wide margins (5 mm) all around the tumor. Freeze or store tumor in formaldehyde if possible for later study. Prevention: Education about aggressive sun precautions is vital: avoid the sun during hours when the individualвЂ™s shadow is shorter than their height; wear long sleeves, pants and broad-brimmed hats (brim > 4 inches wide); apply sunscreen of SPF 30 or greater (with special attention to the nose, ears and lips). Malignant Melanoma Incidence of malignant melanoma is rising faster than all other cancers in the United States. The lifetime risk for developing melanoma in U.S citizens is currently 1 in 75 and rising, up from about 1in 250 twenty years ago. About 70,000 people in the U.S. develop melanoma each year, and about 7,000 die. The 5-year survival rate is about 83% (double what it was 50 years ago), but since melanoma is becoming more common, the death rate is still rising (3 per 100,000/year). Melanoma is a killer, but is 100% curable with early detection and surgery. Acral locations (hands and feet) are at risk for acral lentiginous melanoma. The nail beds and nail matrix (which is just proximal to the cuticle and between the skin and the bone of the distal phalanx) are also at risk, so have a high index of suspicion for pigmentation changes in these areas. Amelanotic melanomas are difficult to diagnose because they do not have much pigment and can look nothing like the above description. Amelanotic melanomas can be flesh-colored or hypopigmented papules or plaques and are often thought to be some other entity when they are biopsied. Symptoms High-risk history: family history of melanoma, childhood history of sunburns, personal history of many atypical nevi. Signs Use the mnemonic ABCD for lesion: вЂњAвЂќвЂ“asymmetry, вЂњBвЂќвЂ“ border irregularity, вЂњCвЂќвЂ“color variegation or change вЂњDвЂќвЂ“ diameter greater than 6mm. 33 The earliest of these is probably color variegation, and the colors red, white or blue are most worrisome. Irregular areas which are very dark, or which become very light in color are also bad signs. Asymmetry and border irregularity come from uncontrolled growth of abnormal melanocytes at the edges of the lesion. Notched, grooved or scalloped borders are suspicious, and are usually apparent in a lesion of 6mm diameter or more. Early melanomas tend to be flat with nodular components indicating that the cancer is progressing, and a higher risk for metastasis. Lymphadenopathy may suggest metastasis. Differential Diagnosis: Seborrheic keratosis, pigmented basal cell carcinoma, atypical nevus, solar lentigo. Treatment: extreme care Seborrheic Keratosis Seborrheic keratosis is a very common pigmented, benign tumor that typically presents on the torso after the age of 30. Symptoms Strong hereditary predisposition; slightly more common in males; rarely pruritic or painful unless irritated or secondarily infected after trauma. Signs Lesion: 1 mm to 3 cm, round to oval, slightly elevated, вЂњstuck-onвЂќ appearing, papule or plaque with variable pigmentary change; surface of lesion commonly has вЂњwartyвЂќ (verrucoid) appearance as it matures and grows; face, trunk and extremities are common sites. Differential Diagnosis: Early lesions: actinic keratosis, nevus. Later lesions: malignant melanoma, pigmented basal cell carcinoma. Differentiating these conditions in the пЂЃeld can be very difпЂЃcult without expert microscopic evaluation of a biopsy. Treatment: None is required for this benign lesion Contact Dermatitis The two main categories are allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD). The main difference is that an allergen will only cause problems such as dermatitis in those sensitized to it. Both ACD and ICD can be acute or chronic. Plants such as poison oak can leave linear streaks of itchy, red papules and vesicles, corresponding to the leafy contact made with the skin. 34 Nickel is the most common ACD causative agent, often affecting the earlobes, from earrings, or the belly, from a belt buckle. Neomycin is a very common cause of ACD (sensitizing almost 10% of all people exposed to it). Beware of products containing neomycin, such as Neosporin ointment. Some cases of detergent ICD arise from overly vigorous cleansing due to the mistaken notion that there is a fungal infection or some type of infestation. Symptoms Various skin reactions including wheals, erythema, hives, edema, papules, vesicles and others, depending on the product and level of sensitization. Geometric or linear arrangements implicate a contactant substance. Differential Diagnosis - other dermatitides such as atopic, seborrheic, xerotic, and stasis dermatitis, as well as tinea, impetigo, erysipelas, cellulitis, or even BowenвЂ™s disease (carcinoma in situ). (See appropriate sections of this book). Treatment: 1. AVOIDANCE IS KEY! Protective clothing can help, but a change of occupation, hobby or substances used may be necessary. 2. Topical steroids are very useful, in higher potencies (fluocinonide or triamcinolone ointment), in order to calm the skin while identifying offending agent. 3. For exudative, weeping areas, a soothing astringent (drying) treatment such as Domeboro compresses bid/tid can help. Minimize wet-dry cycles and avoid over-cleansing the skin. In generalized cases, bathe just every other day, with lukewarm water for less than 5 minutes. Use only a mild cleanser like Cetaphil lotion or Dove Sensitive Skin soap. Avoid scrubbing the affected areas. 4. Bland emollients like white petrolatum (Vaseline) or Crisco vegetable shortening will help to moisturize and protect. 5. Oral antihistamines like Atarax (hydroxyzine) in doses of 25-50 mg tid/qid, or up to 100mg at bedtime can alleviate much of the itch. The antipruritic effects of Atarax last 24 hours and the drowsiness usually only lasts 8-10 hours, a decided advantage over Benadryl. 6. Oral steroids can be needed in the most severe cases, used in a tapering fashion for 3 weeks, starting at 60 mg each morning for a week, then 40 mg for a week, then 20 mg for the last week. Reserve oral steroids for the most widespread or bothersome cases. Three weeks of treatment is very important in order to outlast the hypersensitivity reaction in the skin. COMMON SKIN CONDITIONS CUTANEOUS CANDIDIAS LUPUS 35 ACNE FUNGAL NAIL INFECTION SKIN HEMANGIOMA HIVES RUBEOLA PSORIASIS VITILIGO SHINGLES STASIS DERMATITIS CARBUNCLE 36 SUBCUTANEOUS CYST Surgically removed encapsulated cyst. If a portion of the cyst is left behind, there is a good chance it will return. 36 CHAPTER 14 Sexually Transmitted Diseases (STD) CHAPTER 14 Sexually Transmitted Diseases (STD) Consider evaluating for HIV antibody in 4-6 weeks when STDs ar treated Urethral Discharges Gonorrhea and chlamydia both present with urethral discharges. Patients are often co-infected with both. Neisseria gonorrhoeae causes gonorrhea and appears on Gram's stain as a clump of gram- negative intracellular diplococci. Asymptomatic infection can occur especially in the cervix, rectum and oropharynx. Disseminated gonorrhea presents with infectious arthritis, tenosynovitis, and a characteristic gunmetal blue skin lesion surrounded by a red halo, usually on the extremities (arthritis-dermatitis syndrome). The incubation period is 2-14 days after exposu Consider evaluating for HIV antibody in 4-6 weeks when STDs ar treated Urethral Discharges Gonorrhea and chlamydia both present with urethral discharges. Patients are often co-infected with both. Neisseria gonorrhoeae causes gonorrhea and appears on Gram's stain as a clump of gram- negative intracellular diplococci. Asymptomatic infection can occur especially in the cervix, rectum and oropharynx. Disseminated gonorrhea presents with infectious arthritis, tenosynovitis, and a characteristic gunmetal blue skin lesion surrounded by a red halo, usually on the extremities (arthritis-dermatitis syndrome). The incubation period is 2-14 days after exposure. Most nonspecific or non-gonococcal urethritis (NGU) and cervicitis is caused by Chlamydia trachomatis, but Ureaplasma, genital Mycoplasma, Trichomonas and Herpes simplex are also implicated. These are some of the most common sexually transmitted diseases in the U.S. and a leading cause of female infertility. Infant eye and lung infections are consequent to maternal genital infection with Chlamydia. Incubation period is 7-12 days after exposure. A thick mucus discharge with pain on urination and genital ulcer should suggest Herpes simplex. Incubation period is 2-12 days after exposure. Symptoms Male: Acute (< 3 days): Dysuria with discharge/without discharge- usually NGU Chronic (>10 days) urethral stricture Female: Acute (< 3 days): Dysuria or frequent urination, vaginal discharge, pain with intercourse, lower pelvic pain Chronic (>10 days): PID, infertility Either: Sub acute (3-10 days): Painful joints, gun metal blue skin lesions (GC), tenosynovitis Focused History: Have you had unprotected sex with a new partner in the past 6 weeks? (incubation period 2 weeks for GC; longer for NGU) Signs Inspection: Acute (< 3 days): Purulent yellow to green discharge (both GC and chlamydia), mucoid /scant discharge (more consistent with NGU), if oropharyngeal exposure, see red tonsils with exudate (GC), Sub acute (3-10 days): Infection of periurethral glands, epididymitis, if disseminated GC: red, tender swollen joints and tendon insertions, fever to 102ВєF. Palpation: Pelvic exam may show cervical movement tenderness Lab: Gram stain: Urethral discharge shows gram-negative intracellular diplococci (low diagnostic sensitivity in females), or many polymorphonuclear neutrophils but no organisms (NGU), pregnancy test (drug selection). Differential Diagnosis Other causes of dysuria include: Trichomonas - malodorous discharge in females Vaginal candidiasis - pruritus, white curd-like discharge Herpes simplex - presence of mucoid discharge with skin ulcer Urinary tract infection - usually frequency, urgency; sometimes hematuria 38 The arthritis-dermatitis syndrome of disseminated gonorrhea may resemble: Meningococcemia - GC rash on extremities has distinctive bluish lesions surrounded by erythema Lyme disease - E. migrans rash has larger, red lesions Treatment: Ceftriaxone 125 mg IM single dose AND azithromycin 1 gram po single dose Cefixime 400 mg po single dose + doxycycline 100 mg po bid x 7 days ciprofloxacin 500 mg po azithromycin 1 gm po single dose + ceftriaxone 125 mg IM single dose + erythromycin 500 mg qid x 7 days Azithromycin 2 gm in single dose (poor gastrointestinal tolerance) alone. Pregnant patient: Use ceftriaxone or cefixime in a single dose AND erythromycin 500 mg po qid for 14 days. Do not use doxycycline in pregnant or nursing females. Genital Ulcers Genital ulcers have a wide variety of sexually transmitted causes. Chancroid, caused by Hemophilus ducreyi, has been associated with an increased risk for HIV transmission and may co-exist with other causes of genital ulcer (such as herpes infection). The incubation period is 3-7 days. Granuloma inguinale (caused by gram-negative Calymmatobacterium granulomatis) causes beefy red granulomas that progress slowly but can cover the genitalia and heal slowly with scarring. Patients can spread lesions to other areas through autoinoculation. Incubation period is 1-12 weeks. Lymphogranuloma venereum (LGV), caused by variants of Chlamydia trachomatis, starts as a painless vesicle or nodule that then ulcerates and heals. Days to weeks later, regional lymph nodes become inflamed and tender. Suppuration, scarring, systemic infection, chronic elephantiasis and rectal strictures have been seen in untreated infection. Caused by Treponema pallidum, syphilis is known as the вЂњgreat imitatorвЂќ. Left untreated, up to 1/3 of patients will develop tertiary syphilis (CNS infection, aortic aneurysm, gummas of the skin, bone and visceral organs). Syphilis is curable in all stages but treatment may yield a Jarisch-Herxheimer reaction with fever, rigors and intensification of the lesions 2-24 hours after initiating treatment. Incubation period of primary stage syphilis is 10 days to 3 months. Herpes is caused by Herpes simplex (HSV) type 1 and 2, both of which can cause genital ulcers. HSV 1 is usually milder and often associated with oral sores, вЂњfever blisterвЂќ, keratoconjunctivitis and encephalitis. HSV 2 causes a more severe initial episode (fever, exudative pharyngitis, toxic appearance, multiple genital lesions), and then recurs as a localized cluster of vesicles that ulcerate painfully. HSV2 is associated with aseptic meningitis and radiculitis. Symptoms Painless ulcer: Syphilis, LGV, granuloma inguinale (Donovanosis) Painful ulcer: Herpes simplex, chancroid, phagedenic ulcer (an otherwise painless ulcer secondarily infected with bacteria) Constitutional: Acute (1-3 days): Fever (in LGV and 1st episode HSV) Specific: Acute (1-3 days): Generally starts as papule that ulcerates, HSV: Paresthesias can precede outbreak, syphilis: rash including palms and soles Chronic (>1 month): LGV may be very chronic, HSV often recurs 39 Signs Inspection HSV: Acute (1-3 days): Vesicles in clusters, 1st time may have fever Sub acute (3-10 days): Shallow painful ulcer (often multiple) Chronic (>1 month): In AIDS patients- huge non-healing ulcers Chancroid: Acute (1-3 days): Papules Sub acute (3-10 days): Painful, shaggy edged, deep ulcers; suppurative regional adenopathy Chronic (>1 month): Phimosis Granuloma Inguinale: Acute (1-3 days): Bright red, painless, satiny-surface, raised plaque, often in folds between scrotum or labia and thighs Sub acute (3-10 days): The border of the ulcer shows rolled edge LGV: Acute (1-3 days): Painless vesicle or nodule that ulcerates and heals; may have fever Sub acute (3-10 days): Groove sign (lymph node adheres above and below inguinal ligament) Chronic (>1 month): Chronic elephantiasis of genitals, rectal strictures, rectal fistula Syphilis: Acute (1-3 days): Painless ulcer with rolled border (chancre) heals without Rx in 3-6 weeks Chronic (>1 month): Secondary syphilis: (see generalized 2-4 weeks after chancre, rash including palms and soles; can also see flat genital warts, loss of hair, patches on the mucous membranes Tertiary or late (5-20 years) syphilis: gummas (tumor like masses in skin/bone/viscera) neurologic abnormalities- вЂњneurosyphilisвЂќ: posterior column findings such as slapped foot gait, loss of deep tendon reflexes, loss of position sense or hot/cold sense); also develop abnormal pupillary reflexes, dementia Auscultation: Syphilis: In late syphilis may hear aortic regurgitation murmur Palpation: Most patients with genital ulcers develop tender regional adenopathy Lab: GramвЂ™s stain pus from bubo (enlarged fluctuant node): large numbers of small gram negative coccobacilli in a вЂњschool of fishвЂќ pattern (chancroid); Giemsa stain edge of tissue scraping from edge of ulcer: intracytoplasmic bacilli in the macrophages (Donovan bodies) (Granuloma Inguinale); Giemsa stain of tissue scraping at base of the ulcer (Tzanck smear): observe for multinucleated giant cells (herpes); RPR (syphilis): may be negative during early stage, and should be repeated in 4-6 weeks. The first symptom of primary syphilis is often a small , round, firm ulcer called a chancre ("shanker") at the place where the bacteria entered your body. mia via hematocrit; perform pregnancy test Differential diagnosis: For many of these etiologies of AUB, physical findings will be minimal and limited: Bladder Pubic symphisis 40 Chlamydia Mode of Transmission Oral / Anal / Vaginal Sex with an infected person Symptoms: Considered a silent disease with no apparent symptoms up to 2weeks from Infection Those who do have symptoms may have an abnormal discharge (mucus or pus) from the vagina or penis or experience pain while urinating. These early symptoms may be very mild. TESTING: Swab test is obtained by briefly placing a swab in the opening of the urethra at the tip of the penis; this causes brief discomfort and a burning sensation TREATMENT: Antibiotics like Zithromax or Doxycycline Chancroid Treatment: Primary: Antibiotics: Ceftriaxone 250 mg IM single dose, needle aspirate fluctuant nodes to avoid rupture Alternatives: Azithromycin 1 gm po single dose, erythromycin 500 mg po qid x 7 days or ciprofloxacin 500 mg po bid for 3 days Lymphogranuloma venereum (LGV) Treatment: Primary: Antibiotics: Azithromycin 500 mg po qd x 7 days or 1 gm po each week for 4 doses; drain fluctuant buboes by needle aspiration, avoid incision and drainage which can cause sinus tracts. Alternatives: Doxycycline 100 mg po x 21-30 days, ceftriaxone 1 gm IM qd x 14 days, ciprofloxacin 750mg po qd x 21 days or erythromycin 1000 mg po bid x 21 days. No Improvement/Deterioration: Drug resistant strains have been seen. Expect to see a treatment response by seven days but prolonged therapy is needed to avoid relapse. Granuloma inguinale Treatment: Primary: Azithromycin 500 mg po qd x 7 days or 1 gm po each week for 4 doses Alternatives: Doxycycline 100 mg po x 21-30 days, ceftriaxone 1 gm IM qd x 14 days, ciprofloxacin 750 mg po qd x 21 days or erythromycin 1 gm po bid x 21 days No Improvement/Deterioration: Drug resistant strains have been seen. Expect to see a treatment response by seven days but prolonged therapy is needed to avoid relapse. Herpes simplex Treatment: Primary: Acyclovir 400 mg q 8 hours x 10-14 days if initial episode, for 5 days if recurrence Alternative: Valacyclovir 1000 mg q 12 hours x 10 days (use 500 mg po qd for 5 days for recurrence), Famciclovir 250 mg po q 8 hours x 5-10 days (use 125 mg bid for 3-5 days for recurrence) 41 Vaginal Trichomonas Trichomonas vaginalis, a sexually transmitted fungus, is a common cause of abnormal vaginal discharge. The asymptomatic carrier rate in women is 10%. Sexual partners should be treated. Symptoms: Yellow-green discharge (may be frothy and malodorous but not usually fishy); vulvovaginal irritation and burning; dysuria. Signs: Characteristic discharge not always present; vulva may be edematous and inflamed; redness of the cervix (вЂњstrawberry cervixвЂќ); tender vagina; no abdominal pain. Lab: Vaginal pH: should be > 4.7 (test with urine dipstick); motile, flagellated trichomonads on wet prep. Differential Diagnosis Bacterial vaginosis, gonorrhea or chlamydial infection, atrophic vaginitis, candida vaginitis Treatment Primary: Metronidazole 2 gm po X 1 or metronidazole 500 mg po bid x 7 days (95% cure rate) Highly recommend GC/Chlamydia cultures - co-infection is common. HIV The highlight of the 20th century has been the pandemic of HIV/AIDS. This disease has spread across all the continents, countries & races breaking all natural or manmade barriers. The human immunodeficiency virus (HIV) infects cells of the immune system,destroying or impairing their function, leading to "immune deficiency." The immune system is considered deficient when it can no longer fulfill its role of fighting infection and disease. Infections associated with severe immunodeficiency are known as "opportunistic infections," because they take advantage of a weakened immune system. The term AIDS applies to the most advanced stages of HIV infection, defined by the occurrence of any of more than 20 opportunistic infections or HIV-related cancers. How quickly does a person infected with HIV develop AIDS? The length of time can vary widely between individuals. 42 Left untreated, the majority of people infected with HIV will develop signs of HIV-related illness within 5-10 years. Antiretroviral therapy (ART) can slow the disease progression by decreasing an infected personвЂ™s viral load. Acute HIV syndrome 50вЂ“70% of persons with HIV infection experience an acute clinical syndrome approximately 3вЂ“6 weeks after primary infection. Usually persists for 1 to several weeks Symptoms & Signs General symptoms Fever Pharyngitis Lymphadenopathy (70% of cases) Headache/retro-orbital pain Arthralgias/myalgias Lethargy/malaise Weight loss Anorexia Mucocutaneous ulceration Nausea Vomiting Diarrhea Neurologic Meningitis Encephalitis Peripheral neuropathy Myelopathy Dermatologic Erythematous maculopapular rash Symptomatic disease Symptoms can develop at any time during the course of HIV infection. More severe and life-threatening complications of HIV infection occur in patients with a CD4+ T-cell count <200/ОјL. Persistent generalized lymphadenopathy Fever persisting for >1 month Involuntary weight loss of >10% of baseline Diarrhea for >1 month in absence of explainable cause HIV encephalopathy (AIDS dementia complex) Aseptic meningitis Myelopathy Peripheral neuropathy Myopathy 43 Secondary infectious diseases Pneumocystis carinii pneumonia (m.c 80%) Candida albicans (oral thrush, esophagitis) Mycobacterium avium intracellulare (localized or disseminated infection) Mycobacterium tuberculosis Cryptococcus neoformans (meningitis, disseminated disease) Toxoplasma gondii (encephalitis, intracerebral mass lesion) Herpes simplex virus (severe mucocutaneous lesions, esophagitis) Diarrhea due to Cryptosporidium species or Isospora belli Bacterial pathogens (especially in pediatric cases) KAPOSIвЂ™S SARCOMA 45 Secondary neoplasms KaposiвЂ™s sarcoma (cutaneous and visceral, more fulminant course than in nonвЂ“HIV-infected patients) Lymphoid neoplasms (especially B cell lymphomas of brain, marrow, GI tract) Organ-specific disease What are antiretroviral drugs? Antiretroviral drugs are used in the treatment and prevention of HIV infection. They fight HIV by stopping or interfering with the reproduction of the virus in the body. Standard antiretroviral therapy (ART) consists of the use of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. In health care settings, transmission of HIV can be prevented through primary prevention measures such as standard precautions, blood safety, injection safety, and safe waste disposal, as well as secondary prevention measures, such as post-exposure prophylaxis for occupational or certain nonoccupational exposures to HIV such as in health-care settings, post-rape, and in case of condom breakage. 31 anti retroviral drugs (ARVs) approved by the U.S. Food and Drug Administration (FDA) to treat HIV infection. These treatments do not cure people of HIV or AIDS. Rather, they suppress the virus, even to undetectable levels, but they do not completely eliminate HIV from the body. By suppressing the amount of virus in the body, people infected with HIV can now lead longer and healthier lives. However, they can still transmit the virus and must continuously take antiretroviral drugs in order to maintain their health quality. 46 CHAPTER 15 Gynecology Female Pelvic Examination When: As indicated per differential diagnosis, which primarily is for abdominal and pelvic complaints. IMPORTANT DETAILS Most females in the U.S. have one pelvic examination per year from the age of 18 to assess for gynecologic malignancies or benign conditions such as uterine fibroids. For females this examination is the most sensitive and fraught with concern. Discussion before and after the exam what will happen and what was found. It is necessary to discuss each part of the exam prior to its performance вЂ“ prior to touching or moving any structure The exam should be performed expeditiously yet thoroughly. A female chaperone is absolutely necessary for male examiners Keep the patient as covered as possible. If the examination targets the vulva ask the patient to undress only from the waist down. Cover the abdomen with a sheet or drape. As soon as the exam is done, allow the patient to dress. What You Need: For all exams: Good light source вЂ“ preferably a mobile light, non-sterile gloves, water-soluble lubricant, vaginal speculum of the correct size (small for patients who are virginal, medium Graves are appropriate for most sexually active females and for parous women. Obesity may necessitate a large Graves due to redundant tissue in the vagina). A speculum may be improvised out of two spoons joined by a rubber band, or two bent spoons. On certain exams: Culture medium for gonorrhea and chlamydia testing, large cotton-tipped swabs, pH paper, screening test for fecal occult blood, set-up for wet mount and KOH prep (see Lab Procedures). What To Do: Position the patient in low lithotomy. The head may be elevated 30-60В° to allow the patient visual access to the exam. If a lithotomy table with stirrups is not available, the patient may flex her knees to her chest or an exam table can be improvised with a litter, litter stands, IV poles and small battle dressings. External Genitalia Examination: Prior to touching the perineum inspect it visually. Observe for symmetry, bulges, rashes or lesions If asymmetry or mass is noted these areas should be palpated to confirm mass, induration or other abnormality. Vaginal Examination: Select the appropriate sized speculum. Speculum may be lubricated with warm water prior to insertion. Remember to discuss the examination with the patient. Ask the patient to consciously relax the muscles at the opening of the vagina. 47 Gentle downward pressure with the tip of the speculum or with the finger may help the patient relax, although many times this is not necessary. Place the speculum at the opening of the vagina and gently push it in and downwards until the vaginal apex is reached. Insert the speculum obliquely through the introitus and then rotated to the horizontal plane. Always control the speculum blades, holding them shut with one hand until the blades are opened as the vaginal apex is reached. Observe the vaginal sidewalls and the cervix. Inspect vaginal discharge for quantity, color, consistency and odor. Evaluate the cervix for erosion, lesion, infection, laceration, polyps, ulceration and tumors. ADVANCED To perform cervical cultures for gonorrhea and chlamydia, place each swab into the cervical os and allow to sit for 20-30 seconds. Replace in culture tube. Assess vaginal pH by obtaining a sample of vaginal discharge from the sidewall or from any pooled discharge in the posterior fornix using a small cotton swab. Touch the cotton swab to the pH paper and look for color change. Obtain discharge samples for KOH and wet mount with a similar technique. Blood or cervical mucus will be basic (high pH) and will give false readings, so avoid these while sampling. Bulging of the bladder and/or rectum into the vagina may be seen in patients with pelvic relaxation. Women who have had children vaginally will have some relaxation of the rectovaginal and vesicovaginal septum. The cervix may descend into the vagina with Valsalva. Rectovaginal Examination: Always change gloves (so no blood is carried to the rectum) and obtain a large dollop of lubricant prior to rectovaginal examination. Ask the patient to relax the anal sphincter. The middle finger is inserted into the rectum and the index finger into the vagina. It is helpful to have the patient bear down as the rectal finger is inserted slowly. The rectovaginal septum can be felt between the index and middle finger. Palpate the posterior aspect of the uterus, uterosacral ligaments and posterior cul-de-sac along with the anorectal area. Note masses, nodularity and pain. A simple rectal examination is the only way to assess the pelvis in an infant or child. Test a sample of fecal material for occult blood. What Not To Do: Do not be insensitive, unprofessional or humorous with the patient during the exam. Do not perform routine pelvic exams during pregnancy. Most women will not require such exams unless there is a strong suspicion of vaginal pathology. The exam may introduce harmful organisms into the vagina or otherwise endanger the fetus. Do not perform the exam in stages. Do a complete exam the first time and allow the patient to get dressed. Do not perform an occult blood test with gloves that have been used to examine the vagina. The test will likely be falsely positive. Abnormal Uterine Bleeding Introduction: Abnormal uterine bleeding (AUB) is symptom that can have a variety of etiologies, ranging from simple to life-threatening illnesses. The work-up of abnormal uterine bleeding is systematic and will usually lead to diagnosis. AUB is characterized by changes in the interval and duration of menstrual flow. 48 The normal menstrual interval is 28 days with a range of 21-35 days. The normal duration of the menstrual flow is 2-7 days with average blood loss < 80 cc. AUB can present as vaginal hemorrhage, which is the primary focus of this section. Symptoms Significant change in menstrual pattern or amount of bleeding. Acute, excessive menstrual blood loss can lead to symptomatic anemia, if so, patient will complain of fatigue, orthostatic changes, and heart palpitations. Excessive blood loss may be described as вЂњgushingвЂќ; large clots may be passed; pregnant patients may complain of associated early pregnancy symptoms such as nausea and vomiting, breast tenderness and missing last menstrual cycle. Signs May have large amounts of blood issuing from the vagina; the cervix may be obscured with blood; uterus may be misshapen by a uterine fibroid, a common cause of heavy menses; patients with acute anemia will have heart rate and blood pressure changes based on the volume of blood loss. Lab: Assess aneUterus Rectum Cervix Pregnancy - always rule out first Anatomic abnormalities - uterine fibroids, uterine and cervical polyps and large ovarian cysts may secrete estrogen, which disrupts normal menstrual function. Uterine fibroids are a common cause of AUB in women from ages 30 through menopause. After menopause, most fibroids become asymptomatic. A postmenopausal woman with AUB and an enlarged irregular uterus has cancer until proven otherwise. Infection - cervicitis and endometritis, pelvic inflammatory disease Cancer and pre-cancerous lesions - post-coital bleeding is a presenting symptom of cervical cancer. Postmenopausal bleeding is a primary presenting symptom of uterine carcinoma and endometrial hyperplasia/ dysplasia. Ovarian cancer may present with bleeding due to estrogen secretion by the tumor. Endocrine disorders - disorders of prolactin secretion, hyper and hypothyroidism, adrenal dysfunction. This category includes anovulation which results in irregular/heavy and occasional absent menses. Hematologic - suspect coagulopathies in a young, newly menstruating female with abnormally heavy flow Treatment Significant vaginal hemorrhage: 1. Stabilize patient (ABCs, etc.); monitor vital signs closely and transfuse if necessary 2. Maintain patient on bed rest 49 3. If evacuation delayed, give oral contraceptive pill qid (estrogen can stabilize the uterine lining) anticipate nausea and treat with oral or IV antiemetic. 4. Give antibiotics (see below) liberally for: febrile patient (start immediately), tender uterus (suspect infection of the uterine lining), foul-smelling discharge. Minor menstrual irregularities: 1. If HCG negative and HCT and physical examination are normal, treatment may be delayed until appropriate consultative services are available. 2. NSAIDs (ibuprofen 800 mg po tid or Naprosyn 500 mg po bid) may reduce blood flow. 3. Oral contraceptive pills are the most effective way to control menstrual irregularities (see Contraception section on CD-ROM). Antibiotic regimens: Primary: Ampicillin/sulbactam 3 gm IV q 4-6 hours Alternate: Cefotetan 1-2 gm IV q 12 hours or piperacillin 3-4 gm IV q 4 hours, or ticarcillin/clavulanate 3.1 gm IV q 6 hours, or gentamicin 1.5 mg/kg load then 1.0 mg/kg IV q 8 hours and clindamycin 900 mg IV q 6 hours (if patient remains febrile after 48 hours, add ampicillin 2 gm IV q 6 hours). Empiric: If IV therapy is not available, treat the patient as per oral PID protocol with IM ceftriaxone 250 mg and 1 gm of oral azithromycin or 100 mg doxycycline po bid. OB/GYN expert as needed for continued or recurrent symptoms. Pelvic Pain, Acute Introduction: Internal gynecologic pathology is a common cause of pelvic and abdominal pain. Acute pain may be secondary to an ectopic pregnancy, a ruptured ovarian cyst, torsion of the ovary, pelvic inflammatory disease or a non-GYN cause such as appendicitis. All of these situations require close observation for possible surgical intervention or transfer to an acute care facility. Symptoms Abrupt onset of abdominal/pelvic pain. Character of pain and other symptoms vary depending on the cause. Ruptured ovarian cyst: acute lower pelvic pain, often mid-cycle (day 12-16); occasional postcoital onset of pain due to disruption of cyst during intercourse; should not have associated fever; may present acutely and improve over 8-12 hours; minimal blood loss. Torsion of the ovary: intermittent severe pelvic pain initially localized in right or left lower quadrant then becoming more diffuse as the ovary necroses. The ovary will often torse and de-torse prior to a final torsion so the patient will describe this same pain lasting for shorter intervals prior to the event that brings the patient in for care. Not initially associated with fever; pain often radiates down inner thigh on affected side; hematologically stable. Fever and elevated white blood cell count are seen if the ovary has become necrotic (prolonged torsion - usually greater than 8 hours although no good data is available on exact time). Ectopic pregnancy: late, short or missed menses; suddenly worsening abdominal pain which may radiate to a shoulder due to irritation of the diaphragm; circulatory collapse due to internal bleeding; history of vaginal bleeding, infertility, prior PID or pelvic surgery to include infertility procedures; increased risk if prior ectopic pregnancy. Pelvic Infection: See PID section. 50 Signs Ruptured ovarian cyst: tender adnexa, normal ovaries after rupture. Fullness in posterior cul-de-sac may suggest blood in pelvis. Localized guarding but no rebound until rupture, no abnormal vaginal discharge, normal uterine exam, afebrile, normal vitals. Torsion of the ovary: Very tender mass in right or left lower quadrant; rebound and guarding; afebrile early with normal WBC, but both elevated later; nausea and vomiting; rare anorexia; NO leg numbness or weakness to accompany pain (consider disc herniation if present); hemodynamically stable. Ectopic pregnancy: If ruptured: acute abdomen with peritonitis; nausea and vomiting; hemodynamically unstable with tachycardia, hypotension and anxiety; slightly enlarged, tender uterus with severe cervical motion tenderness. If not ruptured: unilateral, palpable, tender mass without peritonitis; early ectopic will not be palpable and may have intermittent, severe, cramping pain; mild spotting through a closed cervical os (open os with significant vaginal bleeding is a miscarriage). Pelvic Infection: Lower abdominal tenderness, bilateral adnexal tenderness (see PID section). NOTE: Perform rectal examination with Hemocult for blood. Change gloves before rectal/ Hemocult exam if the patient is having vaginal bleeding. Positive Hemocult does not occur with the above diagnoses without co-existing GI disease. Lab: WBC count (elevated in later torsion and in PID), urine HCG (ectopic), CBC (anemia due to hemorrhage), stool Hemocult (guaiac), cervical cultures for gonorrhea, type blood Differential Diagnosis (see Symptom: Abdominal Pain and GI chapter) Appendicitis- frequently confused with gynecological acute pathology. Appendicitis begins in the epigastrium, migrates to the periumbilical region and then settles in the right lower quadrant (RLQ) after 6 to 8 hours, with rebound tenderness and RLQ tenderness to palpation (most common finding). Anorexia, nausea and vomiting are common. Prodromal symptoms include indigestion and irregularity of the bowels. The WBC count is often NOT elevated until the patient has had symptoms for over 24 hours. Diverticulitis- pain due to infected diverticulum is usually left lower quadrant. Past history includes diarrhea and bloody stools, low-grade fever, elevated WBC counts and age over 40. Severe Constipation- acute cramping pain; anorexia and nausea or vomiting; common in the second and third trimesters; treatment with fluids and fiber will be sufficient for many pregnant women. Acute constipation can indicate underlying disease. Inflammatory Bowel Disease or Irritable Bowel Syndrome- abdominal pain rarely sudden in onset; will have a past history of intermittent symptoms including diarrhea and bloody stools. Plan 1. Stabilize patient (airway, breathing, circulation, etc). 2. Start 2 large bore IVs and initiate fluid resuscitation for unstable patients (see Shock: Fluid Resuscitation). 3. If PID, then treat per PID section (antibiotics and bedrest). 4. Initiate transfer/evacuation if patient has: possible ovarian torsion, ectopic pregnancy or is hemodynamically unstable. 5. If the patientвЂ™s diagnosis is consistent with ruptured ovarian cyst and she is hemodynamically stable, she can be placed on bedrest. Repeat vital signs and physical examination q 4 hours. She should improve and be ambulatory in 6-12 hours, NSAIDs may be given, as well as mild narcotics (should only be necessary for the 1st 12-24 hours, if at all. If a significant narcotic need exists beyond 12 hours the patient should be evacuated). If you are unable to evacuate the patient immediately, institute bedrest and fluid resuscitation with lactated RingerвЂ™s or normal saline. Blood transfusion may be life saving and should be given if patient has failed resuscitation with crystalloid or is otherwise showing signs of inadequate tissue perfusion. Type and crossmatched vs. type specific vs. O negative depending on urgency and availability 51 Pelvic Pain, Chronic Defined as pelvic pain of greater than 6 months duration, chronic pelvic pain is usually multifactorial in etiology. Primary Dysmenorrhea - a major cause of chronic pelvic pain and the easiest to diagnose. Dysmenorrhea (painful menstruation) is classified as primary when there is no underlying organic cause other than prostaglandin release from the uterus itself during the time of menstruation. Symptoms: Once a womanвЂ™s cycles become ovulatory, anywhere from 6 months to 2 years after the start of her periods, she can experience dysmenorrhea and most do. Age of onset is therefore 6-24 months after the start of menstruation. The pain ranges from very mild to quite severe. It is described as cramping in nature and is felt in the sacral area, low pelvis and inner thigh area. Usually starts and ends with menstruation. The patient feels well throughout the remainder of her cycle. Some will have a day or two of premenstrual pain. Many young women will вЂњgrow out ofвЂќ their primary dysmenorrhea. May have associated nausea, vomiting and diarrhea (due to excessive prostaglandin release from the uterus). Some may be severely fatigued, pale and ill appearing. Occasionally vasovagal loss of consciousness may occur -usually with the early years of menstruation only. Fever is not present; anorexia is rare other than with the first day of a severe menstrual cycle. Diagnosis: Based on history. Treatment: Involves prostaglandin release suppression with NSAIDs and/or hormonal suppression of ovulation with birth control pills. Birth control pills are very effective at decreasing menstrual pain and should be prescribed to all who fail NSAIDs. They may have endometriosis. Endometriosis - Very common cause (60-70%) of chronic pelvic pain in premenopausal women. Caused by the presence of functional ectopic endometrial glands, which may be located in the ovaries, uterus, uterosacral ligaments or any area within the pelvis. The usual age of onset is in between age 30 and 40. Symptoms: Dysmenorrhea (pain with menstruation) will occur in most women with endometriosis. Worsening from the normal minor menstrual discomfort Start at least a week prior to the onset of menstruation and may last a few days after blood flow stops. Pain often radiates to the rectum and inner thighs. Pain with intercourse (dyspareunia) It is not uncommon for women with endometriosis to have daily pelvic pain 52 Pelvic Examination: Palpating the uterus and ovaries often reproduces the pain. The pain may be reproduced with deep abdominal palpation but this is not a reliable finding. As endometriosis can cause scarring in the pelvis, one can find that the uterus and ovaries are immobile due to adhesions. Endometriosis can also cause ovarian cysts. Often the examination is unremarkable other than in the fact that you can reproduce the patientвЂ™s pain. This is because very small areas of endometriosis can cause great pain. Treatment: Many women are not diagnosed for years and so treatment is delayed. Ibuprofen 800 mg po tid or Naprosyn 500 mg po bid should be helpful. Birth control pills suppress ovulation, which will decrease the activity of the endometriosis implants. Patient with any history consistent with the above review it is best to start NSAIDs, birth control pills and refer to Gynecology as surgery (laparoscopy) gives the definitive diagnosis and often alleviates symptoms. Mittelschmerz - ovulatory pain. Some women have midcycle pain due to either distension of the ovarian capsule or spillage of the ovarian contents at the time of ovulation. This pain usually coincides with the 12th-16th day of the menstrual cycle (count the first day of bleeding as day #1). Women will sometimes have a small amount of vaginal bleeding during this time. Symptoms: Gradual or rapid onset of pelvic pain that will usually peak in 24 hours and then remit. Occasionally the pain will be acute in onset and more painful then usual. This may be a ruptured ovarian cyst. The most significant piece of history is the timing of the pain- Mittelschmerz will usually be on the 12th-16th day. Pelvic Examination: Only significant for generalized lower pelvic discomfort that is mild to moderate in nature. The ovary will sometimes be enlarged (a woman ovulates from only one side each month so the pain is often lateralizing and changes sides month-to-month). Diagnosis: If the pain occurs only during midcycle it is Mittleschmerz. Pain that occurs frequently throughout the month will fall into another category. Treatment: NSAIDs such as ibuprofen 800 mg po tid will help to alleviate discomfort. Primary treatment is ovulatory suppression with birth control pills. Irritable Bowel Syndrome (IBS) - may be the source of 50% of cases of chronic pelvic pain or may occur in conjunction with diseases such as endometriosis. 53 IBS is a disease of abnormal bowel motility triggered by situational stress and certain substances (lactose). Studies show that patients with IBS have increased colonic contractions particularly in response to meals. The discomfort that occurs is often left lower quadrant and lower abdominal causing many women to interpret their symptoms as related to the uterus and/or ovaries. Symptoms: Colicky abdominal pain with a sensation of rectal fullness and bloating. Pain is often relieved with bowel movement and exacerbated by meals. The symptoms wax and wane in a cyclic fashion, sometimes lasting for months. The cycles often parallel physical or emotional stress. Abdominal pain is usually accompanied by diarrhea and/or constipation but occasionally may be the only complaint. Physical Examination: In patients with IBS the uterus and ovaries should be WNL unless a coexisting gynecological problem exists. Treatment: Involves behavior and dietary modifications. Diagnostic Tests 1. Urine culture, cervical cultures to rule out gonorrhea and chlamydia. 2. The patient should chart the days of menstruation. She should note pain on a scale of 1-10 and any other accompanying symptoms, including physical and psychological symptoms. 3.If available, radiographs of the pelvis and lumbo-sacral spine can identify other potential explanations of chronic pelvic pain. Treatment Warm compresses, rest and warm baths can be helpful for many types of chronic pain. Relaxation and meditation have helped many women deal with and decrease pain. Bacterial Vaginosis Introduction: Bacterial vaginosis is caused by a vaginal overgrowth of several indigenous bacterial species. Symptoms Symptoms are localized to the vagina rather than throughout the pelvis: a gray-yellowish, thin vaginal discharge with a foul-fishy odor made worse after intercourse; vulvar burning and irritation; pain during and after intercourse due to vaginal irritation. Signs Pelvic exam: Thin, homogenous, gray or greenish-yellow discharge adherent to side walls of the vagina; pooled fluid in the posterior vaginal cul-de-sac; normal vaginal epithelium; amine (fishy) odor to discharge; erythema of external genitalia; normal uterus and ovaries. Lab: Examine discharge, prepare wet mount/KOH slides (see Lab Procedures), test pH with urine dipstick. 54 Consider STD and pregnancy evaluation. Diagnosis based on the discharge having three of the following four characteristics: pH greater than 4.7; Thin yellow-white discharge present on vulva and vagina; Wet prep reveals clue cells Candida Vaginitis/Vulvitis Introduction: Candida vaginitis and vulvitis are inflammatory conditions caused by Candida yeast. Symptoms Vulvar and vaginal itching are the most common complaints; thick, curdy white discharge - increased from baseline; external irritation and occasionally dysuria and pain with intercourse; no systemic symptoms (i.e., fever or abdominal pain) unless there is another illness; no foul-smelling vaginal discharge. Signs Thick, white, curdy discharge adherent to side walls of the vagina (may look like cottage cheese or be thick and white/yellow) Later signs include erythema and edema of the vulva/vagina (perineal rash with red, shiny appearance); fissures of the vulva; self-inflicted scratches of the vulva; swelling and redness of the labia; abdominal exam will be benign. Lab: KOH (potassium hydroxide) wet-mount examination yields yeast hyphae in 50-80% of patients Vaginal pH: will be < 4.7 in patient with candida (test with urine dipstick). Differential Diagnosis: Bacterial vaginosis, trichomonas, gonorrhea or chlamydial infection, atrophic vaginitis (see Vaginal Discharge Table and STD chapter). Treatment Various intravaginal azole agents used for 3-7 days (miconazole, clotrimazole are most common) Alternative: Oral fluconazole 150 mg X 1 Pelvic Inflammatory Disease Introduction: Pelvic Inflammatory Disease (PID) results from organisms spreading directly from the cervix to the endometrium (uterine lining) and then to the Fallopian tubes. Symptoms: Lower abdominal pain with or without signs of peritoneal irritation; severe and continuous pain in both lower quadrants, increased by movement and intercourse (dyspareunia); abnormal vaginal bleeding in 15-35%; fever in less than 50%; onset of symptoms likely within 7 days of onset of menses. Signs Lower abdominal tenderness, bilateral adnexal tenderness, cervical motion tenderness; also fever >101В°F, mucopurulent cervicitis. Lab: Cervical culture positive for gonorrhea (chocolate bar), WBC count > 10,500; Gram stain of cervical discharge with gram-negative intracellular diplococci and >10 WBC/hpf. 55 Minimum criteria for clinical diagnosis of PID: Lower abdominal tenderness, bilateral adnexal tenderness, cervical motion tenderness Treatment 1. Ceftriaxone 250 mg IM plus doxycycline 100 mg po q 12 hours X 14 days or cefoxitin 2 gm IM plus probenecid 1 gm po plus doxycycline 100 mg po q 12 hours X 14 days. 2. Tetracycline 500 mg po qid X 10-14 days may be substituted for doxycycline. 3. Pregnant patients or those with GI intolerance to doxy/tetracycline may use erythromycin 500 mg po qid X 10 days. 4. Azithromycin 1 gm x 1 day may be substituted for doxy/tetracycline or erythromycin. 5. Strict rest is mandatory during the first 72 hours of therapy. Family members should facilitate patient compliance. 6. Treat partners after patient provides identity. 7. Due to the significant consequences of PID, it is better to treat the patient at risk that has only uterine tenderness or lower pelvic discomfort. BartholinвЂ™s Gland Cyst/Abscess Introduction: The mucus-secreting BartholinвЂ™s glands drain by way of a 2 cm duct into the vaginal vestibule immediately outside the hymenal ring at about the 4:00 and 8:00 position. Blockage of the duct causes secretion accumulation and cyst formation in the gland itself. Symptoms: Pain with walking, tight clothing or intercourse; mass presents right or left outside of the vagina. Signs: Tender, cystic mass in the area of the BartholinвЂ™s duct and gland; warm, red overlying skin; purulent drainage from duct. A chronic duct obstruction will often be asymptomatic and an incidental finding on pelvic exam (no treatment required). Lab: Gram stain may disclose gonococci or clue cells. Culture gonorrhea from exudate. Treatment 1. Antibiotics (per pelvic inflammatory disease protocol): ceftriaxone 250 mg IM and doxycycline 100 mg po bid x 10-14 days. 2. Incision & drainage 3. Pain control with ibuprofen 800 mg tid (or other NSAID). Occasionally patient will need a mild narcotic for the first 24-48 hours (Tylenol #3 or Percocet). ADVANCED Incision and Drainage of BartholinвЂ™s Gland Abscess When: When the BartholinвЂ™s cyst becomes an abscess. What You Need: Sterile prep and drape, local anesthetic agent such as 1% lidocaine (with or without epinephrine), 5 cc syringe, 18 gauge needle to draw up the lidocaine, 22-26-gauge needle for injection, scalpel with 15 or 11 blade, Kelly clamp or other instrument to insert into abscess and break up any loculations or adhesions, Foley catheter (if available), suture with needle (if available). 56 What To Do: 1. Discuss and describe procedure with the patient. Keep her informed as you move along. 2. Give dose of antibiotics as above. 3. Gather materials and set up surgical site 4. Fill 5 cc syringe with lidocaine using 18-gauge needle; replace 18 gauge with smaller gauge needle for injection. 5. Protect yourself вЂ“ abscess may spray when opened and decompressed (mask, gloves, gown if you have one). 6. Place patient in low lithotomy position (patient lies on her back with her buttocks at the end of the table and her feet supported in stirrups). If table with stirrups not available then patient may lie on table or bed with feet drawn up to buttocks and ankles together in midline. It may help to place a pillow underneath the buttocks. 7. Apply sterile prep and drape 8. Inject anesthesia (3-5 cc of lidocaine should be sufficient) in triangular pattern around abscess. Wait 5 minutes. 9. Test for numbness by pinching skin lightly with Adson forceps or other sharp object. Inject 2-3 cc more anesthetic if necessary. 10. Identify incision site вЂ“ inside the vaginal mucosa outside the hymenal ring near the usual duct opening 11. Make a vertical incision in the vaginal mucosa approximately 1 cm long. It must enter the abscess cavity. If pus is not draining out you are not there yet. Gradually deepen the incision until reaching the abscess. 12. Insert Kelly clamp into the abscess to a depth of 2-3 cm if possible, and break up any loculations or adhesions. Allow the abscess to drain. 13. Evacuate patient to a gynecologist for definitive care. If evacuation not possible, proceed with the following steps. 14. Cut a 15cm length of Iodoform gauze and loosely pack the cavity with it. This will keep the incision open and allowing continuous drainage over the next few days. Have the patient return in 24 hours for reassessment. 15. If the abscess recurs, marsupialize the gland. Open the cyst again as in before, then suture the everted edges of the gland to the vaginal mucosa. This allows for continuous drainage and a permanent open path Do not open abscess through normal skin. Enter via the vaginal mucosa. Do not make too large or deep an incision. Do not attempt marsupialization of the gland unless evacuation is not available to a trained gynecologist. Headache Introduction: There are virtually hundreds of conditions that can cause headaches. Therefore a good examination of HEENT, neck, and the nervous system is crucial. Symptoms: Head pain, which can vary in severity, and be accompanied by virtually any symptoms; fever, rash, neck stiffness; loss of consciousness or altered mental status. Migraine: Pounding/throbbing pain, usually but not always unilateral, moderate to severe in intensity, often with nausea/vomiting, often with light or noise sensitivity; routine activities make it worse, patient wants to lie down in a quiet, dark room; builds up over minutes to hours and lasts hours to days; some patients have an вЂњauraвЂќ, such as пЂ‚ashing lights; women affected more than men. 57 Tension-type: Global, squeezing headache; less severe than migraine; can last hours to weeks; no nausea or aversion to light and sound. Cluster: Less common, but affect young men predominantly; severe, short-lived unilateral headaches, usually around the eye, lasting at most a few hours; can occur many times in a day and even wake the patient at night; may want to pace the halls (compare to migraine). Signs Possible tachycardia and hypertension; fever in infection or some CNS trauma; neck stiffness in meningitis; neck tenderness in tension-type headache; abnormal neurological examination (including mental status examination [MMSE is adequate]; see Appendix) suggests signiпЂЃcant CNS or PNS; papilledema suggests intracranial swelling; neurological exam may change over time, indicating a worsening condition. Lab: WBC for infection. Treatment 1. Meningitis should be treated as soon as suspected. (See Neurology: Meningitis) 2. First or worst headache needs emergent evacuation (CT, MRI and/or spinal tap may be needed). 3. Treat source of secondary headache, such as sinusitis, if recognized. 4. Treat primary headache symptomatically. Some patients need all three methods. a. Behavioral/nonpharmacologic: Ensure patients sleep regularly, get aerobic exercise, manage stress constructively and eat a healthy diet. Avoid caffeine or analgesic withdrawal. b. Prophylactic medications (oral): Inderal 40 вЂ“ 160 mg/d, Pamelor 25 вЂ“ 75 mg q hs, Neurontin 300 mg tid, or Depakote 500 mg bid. Start at a low dose and increase every 2 weeks to effect. Ask women about pregnancy before prescribing. c. Abortive or acute therapy: (1) Pain relief: 2 вЂ“ 3 adult aspirin tablets, or 1000 mg Tylenol, or 800 mg Motrin with food, or 500 mg Naprosyn with food works for most headaches. Caffeine in coffee or cola sometimes helps. Midrin (2 initially, then 1 q 1 h to max of 5 in 12 h) is a combination medication with acetaminophen. Fiorinal and Fioricet (1-2 po q 6 h prn) each have caffeine and a mild barbiturate as well as aspirin or Tylenol respectively. IM Toradol 60 mg is an option for nausea. The вЂњTriptansвЂќ, such as sumatriptan (Imitrex) 50 вЂ“ 100mg po, 20 mg in a nasal spray, or 6 mg in a sq auto-injector or rizatriptan (Maxalt) 5 вЂ“10mg po are the most effective migraine medications, but nothing works for everyone. Narcotics are rarely needed. Beware that overuse of analgesic medications can produce rebound headaches. (2) Nausea or vomiting: Reglan 10 mg po q 8 h prn or Compazine 5-10 mg IM q 3-4 hrs, max 40 mg/ day. 58 Cancer Screening As recommended by the American Cancer Society, if youвЂ™re a woman over age 20, you should have a Pap smear taken every year or two; after three normal tests, have a Pap smear every 3 years from then on. Practice breast self-examination monthly. Any suspicious change should be checked out with a doctor. Mammography is a yearly screening procedure recommended for women after age 40 (with high risk) or age 50. After age 50, tests for colorectal cancer (digital rectal exam and occult blood test) are advisable on an annual basis. In addition, sigmoidoscopy every 5 years or colonoscopy every 10 years is recommended. Your skin should be examined annually for any suspicious moles or other lesions. Breast Self-Examination Most women will have lumps in their breasts at some time during their lives. Regular self-examination of your breasts improves your chances of avoiding serious consequences. Self-examination should be done monthly, just after the menstrual period, when the breasts have fewer hormone-related lumps. Self- examination is an absolute necessity for a woman with naturally lumpy breasts. If there is a new lump or change in an existing lump, seek immediate medical care. To do a self-exam, examine your breasts in the mirror, first with your arms at your sides and then with both arms over your head. The breasts should look the same. Watch for any change in shape or size, or for dimpling of the skin. Occasionally a lump that is difficult to feel will be quite obvious just by looking. Next, while lying flat, examine the left breast using the inner fingertips of the right hand and pressing the breast tissue against chest wall. Don't pinch the tissue. Your left arm should be behind your head when you examine the inner half of the left breast and down by your side when you examine the outer half. Don't neglect the part of the breast underneath the nipple, plus the part that extends away from the breast toward the underarm. A small pillow under the left shoulder may help. Repeat this process on the opposite side. Many doctors recommend repeating the self-examination in the shower, where smooth, slightly soapy skin can make lumps easier to detect. 59 Breast self-examination is a supplement to other screening techniques for breast cancer. Mammography is strongly recommended yearly after age 50, or after age 40 for women with a history of breast cancer in their family. An annual examination by a health care worker is also of benefit. These guidelines are based upon current technology. It is very likely that the diagnostic value of these and newer tests will continue to improve, while the associated cost, risk, and discomfort will diminish. INFORMATION ON DISEASES, SYMPTOMS AND CONDITIONS Vaginal Discharge and/or Itching Normal vaginal secretions are thin, clear, and painless. Abnormal vaginal discharge is common, however, and could have many causes. Bacteria, common viruses, and other microbes can infect the vagina and cause discharge. Laboratory tests allowing microscopic evaluation of vaginal fluid are required for a correct diagnosis. A variety of effective drugs are available for treating vaginal infections. Bacterial vaginosis is the most common cause of vaginal symptoms among women of childbearing age. The primary symptom is an abnormal vaginal discharge with a fishy odor. Trichomoniasis is a very common vaginal infection caused by a single-celled protozoan parasite. Symptoms in women include a heavy, yellow-greenish vaginal discharge, discomfort during intercourse, and painful urination. A woman and her partner both need to be treated to eliminate this infection. Vulvovaginal candidiasis, sometimes referred to as candidal vaginitis, monilial infection, or vaginal yeast infection, is a common cause of vaginal itching, burning and irritation. Candidiasis is caused by an overabundance or overgrowth of yeast cells (primarily Candida albicans) that normally colonize in the vagina. Associated with symptomatic candidiasis in women, including pregnancy, diabetes mellitus, and the use of oral contraceptives or antibiotics. 60 The discharge is typically described as cottage-cheese-like in nature, although it may vary from watery to thick in consistency. Non-infectious irritation or allergic symptoms can be caused by spermicides, vaginal hygiene products, detergents, and fabric softeners. Tampon Reactions Symptoms of toxic shock syndrome can be hard to recognize because they mimic the flu. Sudden high fever, vomiting, diarrhea, dizziness, fainting, or a rash that looks like sunburn during your menstrual period or a few days after. Bleeding Between Menstrual Periods The interval between two menstrual periods is usually free of bleeding or spotting. Women using an intrauterine birth control device are particularly likely to have occasional spotting. Taking birth control pills may also cause spotting between periods. Such spotting is probably not a cause for concern. Bleeding along with abdominal pain may be a sign of a pregnancy developing outside the uterus (ectopic pregnancy), which requires immediate surgery. It may also be a sign of a uterine miscarriage. However, some women may have some bleeding throughout a normal pregnancy. Difficult Menstrual Periods Adverse mood changes with fluid retention and bloating are very common in the days just prior to a menstrual period. Such problems are difficult to treat and are a result of normal hormonal variations during the menstrual cycle. Salt tends to hold fluid in tissues. If you can reduce the salt in your diet and increase your water intake (to вЂњwashвЂќ out the salt), you may have less swelling and less fluid retention. For menstrual cramps use ibuprofen or naproxen. Most products designed for menstrual cramps now have ibuprofen as the main ingredient. Menopause During menopause, the ovarian production of female hormones decreases. Most women can tell if they are approaching menopause because their menstrual periods start changing. Menstrual periods usually become lighter and irregular, then stop altogether. Some menopausal symptoms mentioned below can start long before menstrual periods become irregular. Some women report the symptoms as early as their mid-30s. Hot flashes, sudden feelings of intense heat lasting two or three minutes, are an annoying symptom of menopause. They can happen anytime during the day but are most common in the evening or at night. For most women, hot flashes gradually decrease over about two years and eventually disappear altogether. Staying cool is the key to treating hot flashes. Sleep is often affected by menopause, whether it is interrupted by hot flashes or there is difficulty falling asleep. Many women also have mood swings during menopause. Irritability may be triggered by sleep deprivation. Vaginal dryness and frequent urinary tract infections may occur after menopause. Urine leakage may become a problem as muscle support for the bladder and urethra weakens. vaginal creams help with vaginal dryness. 62 After menopause, a few women are aggravated to find they have trouble remembering things or concentrating. These symptoms may be caused by changes in estrogen levels. Not getting enough sleep or having sleep disrupted may also contribute to memory and concentration problems. Hormone replacement therapy (HRT) has been prescribed for menopause- related changes and to reduce the risk of osteoporosis that may develop in the years following menopause because of estrogen depletion. HRT also has some risks.. There are at least two major health conditions that can develop in the years after menopause because of the decrease in hormone production that occurs: coronary artery disease and osteoporosis. Osteoporosis A number of research projects involving experimental preventive measures have been reported in the current medical literature. Some of this research may prove to be helpful in reducing the risk of osteoporosis, or perhaps preventing it altogether: (1) in women, administering estrogen before bone loss becomes severe to prevent the progress of the disease; (2) exercising to prevent bone loss; (3) taking calcium supplements and vitamin D, with magnesium, in order to limit excessive bone loss; and (4) for both men and women, giving up smoking and alcohol. Regular exercise and adequate dietary calcium are important to prevent osteoporosis. Physical activity will help keep bones strong. Menopausal women should take in about 1500 mg of calcium per day, about as much as in a quart of skim milk, with 400 IU of vitamin D. You can use a calcium supplement if you cannot get enough from dairy products. Management of Recurrent Urinary Tract Infection The best-known symptoms of bladder infection are pain or burning on urination, frequent and urgent urination, and blood in the urine. Bladder infection is far more common in women than it is in men. The female urethra, the tube leading from the bladder to the outside of the body, is only about one-half inch long in women, a short distance that makes it easy for bacteria to travel upward to reach the bladder. Most bacteria that cause bladder infections come from the rectal area, and sometimes bladder infection is related to sexual activity. Breast Problems: Mastitis Mastitis is inflammation of the breast most commonly presenting as a cellulitis of the subcutaneous tissues in a lactating breast (1-3% of breastfeeding women). The causative organisms, S. Aureus, E. Coli and streptococcus (rarely), are easily treated with antibiotics. One of the risk factors for mastitis is plugging or obstruction of one of the milk ducts which drain to the nipple. Obstruction can be secondary to delayed infant feedings, which can lead to engorgement, and tight clothing (poorly fitting brassieres and underwires that dig in). Other risk factors include cracked nipples, maternal stress and fatigue. Do not let mastitis interrupt breastfeeding. The infected breast will worsen if the baby does not empty it, and the infection cannot be transmitted to the infant through the milk. 63 Untreated or delayed and inappropriate treatment can lead to breast abscesses and stop lactation in the affected breast, which deprives the infant of its food source. Symptoms: Localized pain, redness, swelling, warmth in one breast; fever; chills; body aches; fatigue; headache; occasionally nausea and vomiting. Signs Fever - often greater than 101В°F Pink, wedge-shaped area on the breast. Patient appears in mild to moderate distress. Palpation: Tender, occasionally indurated, warm area. There SHOULD NOT be a palpable, fluctuant mass - that is a sign of abscess. Differential Diagnosis: Plugged Duct - Tender lump in the breast of a mother who is otherwise well. Caused by partial obstruction of a duct. Infection is not present but MAY RESULT if the duct remains blocked. See end of this section for treatment. Breast Engorgement - Gradual onset in the immediate postpartum period (peak on days 2-4) of bilateral breast swelling and warmth. Pain is generalized. Fever may occur but is rarely over 101В°F. The breasts feel better after they are emptied. Caused by inadequate emptying of the breasts. Breast Abscess - Painful, fluctuant mass. 10-15% of women who delay treatment of mastitis will develop a breast abscess. Should be suspected if a patient on antibiotics for mastitis does not improve after 72 hours of antibiotic therapy. Breast Cancer - Very rare. Unilateral, unchanging lump or mass that persists despite treatment for engorgement. Plugged duct or persistent mastitis must be evaluated by appropriate radiological and surgical approaches, if possible. Treatment for Mastitis Primary: 1. Ensure infant nurses on both breasts, starting on the unaffected side. Even after feeding the affected breast may need to be more thoroughly emptied by manual expression or pumping. 2. Put mother on bedrest. Maternal fatigue and stress are risk factors for recurrent mastitis. The baby should be right next to the mother either in the same bed or readily available in a nearby crib to facilitate frequent emptying of the breast. 3. Ensure mother completes full course of therapy: a. Dicloxacillin or cephalexin 500 mg po q 6 hrs x 10 days b. Patients allergic to penicillin: clindamycin 300 mg po q 6 hours x 10 days or erythromycin 500 mg po q 6 hours x 10 days c. If patient does not improve after 48 hours of rest and therapy, switch to Augmentin (amoxicillin/ clavulanate) bid if 875/125 mg or tid if 500/125 mg. 4. Apply ice packs or warm packs to the breast (whichever the mother prefers). Hot packs provide drainage and pain relief. 5. Ensure mother drinks plenty of fluids. 6. Give ibuprofen or acetaminophen for pain relief. 7. Advise mother to wear a support bra or other supportive clothing that does not cause painful pressure on the breast. 64 Alternate: Patients who are intolerant of oral medications may need IV therapy. You may use nafcillin or oxacillin 2.0 gm q 4 hrs IV or cefazolin 1.0 gm IV q 8 hours. Penicillin allergic patients can be given clindamycin 300 mg IV q 6 hrs. Primitive: If antibiotics are not available, initiate rest, hydration and MOST IMPORTANTLY, drainage (nursing) of the affected breast. Mastitis will recur in at least 50% of women not treated with antibiotics, and the breast abscess rate will be high. If the patient remains febrile after 72 hours: 1. If possible, transfer the patient immediately. If not, then see below. 2. If non-compliant, administer ceftriaxone 1 gm IM. See if the patient would also take one gram of oral azithromycin. Follow-up in 24 hrs and repeat the ceftriaxone. 3. If compliant add clindamycin IV as above. 4. Find an experienced person in the community who can stay with the patient and assist with breastfeeding and manual expression. Treatment for Plugged Duct: Massage the area, gently pressing toward the nipple. Warm compresses help. The most important intervention is frequent feeding on the affected side. Consecutive feedings should be started on the affected side to facilitate flow from the obstruction. Because different lobes of the breast are drained better with different nursing positions, place the infant with its chin pointing toward the blocked duct. If the mother is separated from her infant for any reason the breast should be emptied by handexpression or by using an effective breast pump. Be sure to follow the mother closely as mastitis can occur. NOTE: Plugged ducts will last only for short periods of time (a few days). Any lump that persists for many days must be evaluated for malignancy. Treatment for Engorgement: Frequent breastfeeding is the most effective treatment. If the nipples are engorged it may be difficult for the baby to latch on. Relieve nipple engorgement by applying warm compresses before the feeding, gently express some milk to soften the breast, or lean the breasts into a large bowl of warm water (or take a warm shower) just before the feeding to facilitate milk release and soften the nipples. After the feeding, apply cold compresses, or cool cabbage leaves to the breast for 20 minutes leaving the nipple exposed. Use standard doses of acetaminophen and/or ibuprofen for pain relief. Support the breasts with a good-fitting brassiere. Do not bind the breasts as this will increase the engorgement. Breast Abscess Incision and Drainage Procedure When: A breast abscess is causing systemic symptoms that are unresponsive to less invasive therapy. The abscess will be a fluctuant breast mass related to non-resolving or worsening mastitis (see Mastitis section). The condition is rare, except when antibiotic treatment has been delayed or discontinued too early. Needle aspiration of a recurrent abscess should be attempted twice before incision and drainage is required. What You Need: Sterile prep and drape, 18 and 24-26 gauge needles, 5 cc and 10cc syringes, alcohol prep pads, local anesthetic agent such as 1% lidocaine with epinephrine, 2x2 and 4x4 dressings, scalpel with #15 blade (but any blade will work), sterile irrigation if available, gloves, and a small Penrose drain What To Do: Needle Aspiration: Anesthetize skin and subcutaneous tissues over fluctuant area using 5cc syringe and 24-26 gauge needle. Insert 18 gauge needle attached to 10cc syringe into the abscess, aspirating as you advance the needle. Drain as much pus as possible once the cavity is entered. Then remove needle and cover puncture site with a small dressing. 65 Incision and Drainage of Abscess: Anesthetize the skin and subcutaneous tissues over the fluctuant mass. If possible, choose your incision point close to but not in the areola (allow room for an infant to nurse without contacting the incision). Make the incision parallel to the edge of the areola and over the fluctuant area. Try not to make transverse incisions- they leave an unacceptable scar. Circumareolar incisions will heal with a better cosmetic result. Keep the incision small, only large enough to allow entrance of your 5th digit. Do not cut deeply into the breast tissue, but start superficially and advance carefully. Make your incision deeper until the cavity is just reached and pus begins to drain. Insert your 5th digit into the wound to break up any loculations and to ensure complete drainage. Irrigate the wound, and if possible place a Penrose drain, pack with 2x2 dressings and cover with 4x4 dressings. Follow-up care: Remain at bedrest, continue warm soaks and hydrate well. Continue antibiotic therapy with Augmentin (amoxicillin/clavulanate) po bid if 875/125 mg or tid if 500/125 mg for 10 days after resolution of the abscess. Engorgement of the breast will interfere with healing. Feed infant or empty the affected breast on a regular basis, every 2-2 1вЃ„2 hours. The milk is clean as long as the abscess drains to the outside (through the skin). Nursing can continue when the abscess is surgically drained as long as the incision and drainage tube are far enough from the areola. If the drain is too near the areola for the infant to nurse, the breast still must be emptied by manual expression or pumping. Milk may drain from the incision during breastfeeding. Apply pressure over the incision while breastfeeding to minimize leakage. If the patient cannot do this herself, her spouse or another person may hold light pressure over the incision. What Not To Do: Do not make incision any deeper than necessary. Do not make the incision too close to the areola to avoid compromising breastfeeding. Do not allow the skin to close over the incision until the abscess has healed from the inside out to the surface. 67 CHAPTER 16 Male Genital Problems Genital Inflammation Balanitis: Inflammation of the glans penis and foreskin occurs primarily in the uncircumcised male but is rare in the circumcised male. The glans will look wet, red and may have multiple small red bumps and a whitish material on the surface consistent with yeast. The shaft of the penis just under the skin and on the surface of the erectile bodies contains numerous large veins that can develop clots. They will appear as dark, hard, raised bumps that follow the course of the vein. Lymph channels can also become hard cords, but will be more clear or lack color. These conditions probably result from overly vigorous intercourse. FournierвЂ™s Gangrene: This condition is life threatening and is most likely to occur in the severely injured patient with poor circulation or diabetes. It presents as a rapidly spreading skin inflammation with development of necrotic/purplish tissue. Candidal Infection: Most cases will present as balanitis. Occasionally, the patient will present with a red scrotum with satellite red lesions. The rash will be itchy, painful and tender. Cellulitis: Patients will have diffusely red and painful scrotal or penile skin. The skin may be weeping, thickened and have pustules. When the skin lacks pustules, it is important to determine if the skin changes are a reaction to underlying inflammation such as epididymo-orchitis or torsion of the testis. In the latter cases, the testis and epididymis are markedly tender. The patient can usually differentiate testis pain from skin pain. Contact Dermatitis: Contact with chemicals and even some ointment may cause a profound inflammation of the scrotal skin. The skin may have the appearance and tenderness of cellulitis. History of exposure is extremely important. Signs: Swelling, tenderness and redness; purulent discharge in the case of severe phimosis; swollen lymph nodes. Lab: Urinalysis for presence of glucose, leukocytes, blood or nitrite; KOH prep of the weepy material on the skin may show the presence of yeast elements such as budding yeast or strands called hyphae. Differential Diagnosis Sexually transmitted disease lesions are usually much more focal than these inflammatory conditions. Treatment Phimosis: Keep the penis clean with soap and water several times per day. Broad-spectrum antibiotics such as ciprofloxin 500 mg po bid or Keflex 500 mg po qid x 1 week may be used if purulent discharge is noted from the meatus. If the phimosis is symptomatic and severe, perform a dorsal slit (procedure below) and refer for circumcision later. Paraphimosis: Try to reduce the foreskin by pushing the glans in and pulling the edematous skin forward. Balanitis: Wash the penis several times a day and apply antifungal cream such as Nystatin, Mycolog or Lotrimin bid. If a wet prep shows no yeast elements, can give Flagyl 500 mg po bid x 1 week. Thrombosis of Penile Vein and Sclerosing Lymphangitis: Refrain from any sexual activity. Use NSAIDs such as ibuprofen. 68 FournierвЂ™s Gangrene: Perform emergent aggressive surgical debridement. Broad-spectrum IV antibiotics such as ampicillin 2 gm q 8 h, gentamicin 5 mg/kg qd and Flagyl 500 mg q 6 h are usually warranted. Candidal Fungal Infection: Keep skin dry and antifungal medications such as Nystatin, Mycolog or Lotrimin bid for 1 week or single dose fluconazole 150 mg po. See ID: Candidiasis section for more information. Cellulitis: Treat with dicloxacillin 500 mg po q 6 h or Keflex 500 mg po q 6 h for mild cases. For severe cases, treat with oxacillin 2 gm IV q 4 h or vancomycin 1 gm IV q 12 h. Contact Dermatitis: For mild, treat with topical 1% hydrocortisone and oral diphenhydramine (Benadryl). In severe cases, add prednisone 50 mg po qd and wean by 10 mg /day over 5 days. If there is a question of infection, treat for cellulitis also. Alternative: Yeast infections can be treated with alkaline washes to the glans penis, if no oral agent is available. Dissolving a few sodium bicarbonate tablets in a small container of water can make an alkaline solution, which can be directly applied to the skin. General: If the patient has balanitis, phimosis or paraphimosis and has not been circumcised, he should have it done electively. Dorsal Slit Procedure Essential: If the patient has severe phimosis where the foreskin has scarred down to a small hole and the patient is having significant pain and discharge from the penis, the foreskin needs to be incised (dorsal slit). Similarly, if paraphimosis is severe, excessive circumferential swelling may compromise blood flow in the penis, which can be relieved with a dorsal slit. ADVANCED 1. Attempt non-surgical reduction with anti-inflammatory medications, ice water and lubricants. Evacuate patient to a trained provider for this procedure if possible. If there are signs of systemic infection (fever, nausea, fatigue, etc.), and prompt evacuation is not available, perform a dorsal slit. 2. Assemble equipment: 1% lidocaine (w/o Epi), needle and syringe, clamp, forceps, scalpel or surgical scissors, needle driver, 4-0 suture, prep solution, alcohol. 3. Prep the penis as with any surgical procedure (sterile scrub, Betadine, drape), and attempt to clean between the head and the foreskin, especially on the dorsal side. 4. Use 1% lidocaine and a small needle (25-26 gauge) infiltrate the skin about mid-shaft and extend the wheal at least halfway around the shaft of the penis. 5. Confirm the top of the penis (dorsal side) is numb with forceps or needle. 6. Use a straight clamp to crush the skin from the phimotic area back to the glans (head). Make sure the jaw stays between the glans and the foreskin. Do NOT pass the jaw into the meatus. The glans will still have sensation and the patient should be able to tell you if the meatus is being cannulated. 7. Leave the clamp on for 5 minutes to compromise blood flow in the area to be incised. 8. Remove the clamp and use a scissors to cut the crushed skin where the clamp had been. Do not incise the glans. 9. This should expose the glans. Control bleeding with figure 8 stitches using 4-0 non-absorbable sutures. 10. Clean the penis with sterile prep solution between the head and foreskin, then wipe prep solution away with alcohol. Allow to air dry and apply a sterile dressing leaving the meatus clear. 11. Monitor the patient, as this maneuver is only temporary and the slit can contract. He should have elective circumcision later. 69 Testis/Scrotal Mass Testis masses are alarming to the patient since they may represent cancer. Testis cancer is quite curable in its early stages. However, the cancer can grow rapidly so early detection and referral is necessary to avoid treatment delays. Symptoms: Testicular pain, enlarged scrotum or testis. Increased risk of benign tumors with history of trauma and vasectomy. Signs Tender testis; palpable mass in testis, spermatic cord or epididymis; mass may appear smooth and spherical, be located on the surface or deep in the testis, enlarge with standing, transilluminate with a bright flashlight. Lab: Urinalysis: Nitrite and leukoesterase positive urine suggest infection. Differential Diagnosis Solid, non-transilluminating mass that is >4 millimeter size, located below the testicular surface and inseparable from the testis must be considered to be cancer until proven otherwise. Transilluminating smooth spherical masses are benign and are hydrocele (around the testis), spermatocele or loculated hydrocele (above the testis). Rarely it can be a cyst adenoma. Small 1-4 mm size nodules on the surface of the testis are benign. вЂњWormyвЂќ mass above the left testis that gets smaller when patient shifts from the standing to the supine position are varicoceles. Right-sided varicoceles need elective referrals. Other masses in the scrotum, either on the cord, in the scrotal skin or in the midline area near the penis are almost always benign. Painful area behind the testis is usually an indication of epididymitis (see Epididymitis section). If the pain in the scrotum is severe, refer to sections on epididymitis and torsion. Treatment Give 2-week course of NSAIDs (e.g., Naprosyn 375 mg po bid or ibuprofen 800 mg po tid with food). If epididymitis is suspected or cannot be eliminated, add doxycycline 100 mg po bid x 14 days. Elevate scrotum with comfortable athletic supporter and decrease activity. Avoid sun exposure if on doxycycline. Prostatitis Introduction: Prostatitis is used liberally to describe voiding problems and pain associated with the prostate. Symptoms: Obstructive symptoms include slow start, low flow and dribbling; irritative symptoms include frequency (> q 2 hours) and/or urgency; pain in the head of the penis or under the scrotum; low back pain; fever. Signs: Tender prostate with/without tender pelvic floor or coccyx (palpate 360В° on rectal exam); distended bladder Lab: Urinalysis: heme and leukoesterase positive urine (infection). 70 Differential Diagnosis Irritative voiding symptoms with or without fever - urinary tract infection until proven otherwise, distal ureteral stone, urethral stricture, bladder neck dysfunction, bladder or prostate cancer, foreign body in bladder, overflow incontinence. Obstructive voiding - enlarged prostate, urethral stricture, and neurologic disease of the spine or peripheral nerves. Painful prostate - urinary tract infection, bladder neck dysfunction/prostatodynia/pelvic floor dysfunction, musculoskeletal pain, coccydynia, seminal vesiculitis Treatment: Infection 1. If the patient is lethargic and febrile, begin high dose IV ampicillin 1-2 gm IV q 6-8h and gentamicin 5 mg/ kg IV qd. If penicillin allergic, use IV fluoroquinolones (Levaquin 250 mg IV q day or Cipro 400 mg IV bid) or vancomycin 1 gm IV bid and gentamicin 5 mg per kg IV qd. Hydrate aggressively. When the patient is afebrile, switch to oral fluoroquinolone (see UTI section) for a total of 30 days. 2. If the patient is alert and manifesting either low-grade fever or no fever, treat with fluoroquinolones (see UTI section). 3. Treat any male suspected of having an infection for 30 days regardless of the location of symptoms (kidney, prostate or scrotum). Infected urine can easily reflux into prostatic ducts, therefore assume the prostate is infected. 4. If symptoms persist and urinalysis continues to be abnormal without improvement after 3-5 days, suspect bacterial resistance and change antibiotics. 5. If a bladder is palpated, attempt to pass a Foley catheter. Inability to pass catheter suggests a stricture. If patientвЂ™s symptoms worsen, consider suprapubic aspiration . 6. If the entire pelvic floor is tender, pain is not from prostate alone. Treat for musculoskeletal pain with NSAIDs. Alternative Antibiotics: Septra DS po tid until fever resolves, followed by Septra DS po bid x 30 days, Augmentin 500 mg po bid x 30 days, or Keflex 500 mg po qid x 30 days. Doxycycline or Vibramycin are not as effective since they are bacterio-static, and should only be used (100 mg po bid) if there is no other alternative. Nitrofurantoin has minimal tissue penetration and should not be used in prostatitis. Treatment: No Infection Primary: 1. Treat initially with a course of antibiotics, with or without alpha-blockers. Levaquin 500 mg po qd has broad coverage for both C. trachomatis and urinary pathogens. Treat for 30 days. Alpha blockers include the following: Hytrin (terazosin) 1-5 mg po q hs (start at low dose and titrate up over several weeks) Cardura (doxazosin) 1-4 mg po q hs (start at low dose and titrate up over several weeks) Flomax (tamsulosin) 1 po q d (No titration necessary) Minipress 1-5 mg PO q hs 71 2. Patients who complain of frequency should be given bladder antispasmodics with caution since they can cause urinary retention. Hyoscyamine 1 po bid prn, Ditropan 5 mg po TID prn, Elavil 10-25 mg po qd, or Flavoxate 1 po bid can all be used. 72 Testis Torsion Introduction: Rapid identification and treatment of torsion is necessary to preserve testis function. Such patients require tacking or fixation of the opposite testis to the scrotal skin since it is also at risk. Loss of both testes not only results in sterility but loss of testosterone, which requires lifelong supplementation for normal body function. Salvage of the affected testis can be achieved if reduced in 4 hours. Symptoms Acute (< 2 hr): Severe scrotal pain, onset can be at night while asleep, may have prior history of scrotal pain lasting less than 1 day, may have nausea/vomiting, testis is extremely painful, spermatic cord may be tender Sub-acute (2-48 hr): Scrotal pain increases over several hours. After 24 hours, some of the pain may start to subside Chronic (>48 hr): History of acute onset of pain. Testis pain is improved but not gone. Signs : Extreme, diffuse tenderness of the entire testis; edema; vomiting. Lab: Urinalysis: Strongly heme or leukoesterase positive sample suggests kidney stone or infection. Differential Diagnosis Orchitis - fatigue, muscle aches, sore throat or other flu-like symptoms with gradual onset and normal spermatic cord. Mumps orchitis is extremely rare with modern vaccinations. Severe epididymo-orchitis - voiding symptoms with leukoesterase and nitrite positive urine. Testis tumor - considered when there is a mass with mild to moderate pain 73 Torsion of the appendix testis/epididymis - point tenderness on the superior portion of the testis/epididymis with the remaining testis being non-tender. Ruptured testis - history of trauma Spermatic cord torsion - tender testis with a non-palpable vas deferens. Kidney stone - especially if lodged just below the kidney will present with scrotal pain, but a nontender, normal scrotal exam. Severe flank pain Incarcerated hernia - most of the discomfort will be above the testis. A hydrocele may be present, making it difficult to examine the testis. If omentum is in the hernia, there may not be any bowel symptoms. Treatment Manual detorsion, with or without injection of the spermatic cord with local anesthesia. Torsion may be 180-720В° (2 full twists). Attempt to detorse the testis first by rotating the testis outward (like opening a book). If the pain worsens or does not improve, rotate the other direction. The torsion may be 2 full twists. If the testis hangs lower but pain persists, continue untwisting the cord. If lidocaine is available, inject into the cord using a long needle or spinal needle in the spermatic cord. TECHNIQUE This can be accomplished by straddling the cord on the affected side between two fingers just as the cord crosses over the pubic bone lateral and superior to the penis. Make multiple passes through the cord and down to the pubic bone injecting a total of 10 cc of 1% lidocaine local anesthetic. This should numb the testis. This may relieve the pain, causing the cremasteric muscles to relax and may result in spontaneous de-torsion. If the pain is gone, check the testis for descent to the normal position and if the testis has become less tense. Also try to palpate the vas deferens posteriorly. This tube is about the consistency and size of uncooked spaghetti and is located behind and is easily separable from the bulk of the spermatic cord. If the tube is in its normal location, spermatic cord torsion is unlikely. You can use the vas deferens as a guide to untwist the cord. The vas deferens should lie posteriorly to the cord. Palpate the vas high in the scrotum and try to follow it down. If unable to detorse the testis, treat with narcotics and empirically with antibiotics (Cipro 500 mg po bid or Keflex 500 mg po qid or Septra DS 1 po bid) until pain has resolved. Most pain from a dead testis will improve after 48 hours. Increasing pain would suggest the presence of infection or testis tumor or rupture of testis (suspect if there is a history of blunt trauma). Epididymitis Introduction: It can become painful from either mechanical or infectious irritation. Symptoms: Pain in the scrotum behind the testis with tenderness of the epididymis, and without pain In the testis. Signs Marked swelling of the hemi-scrotum, urethral discharge, frequent and urgent urination, fever. Use penlight or otoscope to transilluminate the scrotum to differentiate swelling due to a mass vs. fluid (bright, diffuse glow; seen with spermatocele or hydrocele). 74 Lab: Urinalysis: nitrite and leukoesterase positive urine (infection). Do urine culture if available and dipstick is positive. Gram stain urethral discharge to screen for gonorrhea and chlamydia. Differential Diagnosis Pain and tenderness in other areas of the scrotum, such as the cord or groin, of equal or greater severity would suggest other causes of the pain such as hernia, varicocele, musculoskeletal pain or entrapped nerve. An abnormal testis on physical exam may suggest tumor, appendix testis, viral orchitis, testis trauma or testis torsion. Recurrent symptoms lasting less than 1 day are much more suggestive of intermittent testicular torsion. Treatment : 1. Scrotal support/elevation, bedrest. 2. NSAIDs such as ibuprofen 800 mg po tid with food. 3. If the urine is nitrite and leukoesterase positive, treat with antibiotics. a. If a fever is present and there is no urethral discharge, give: Levaquin 500 mg po bid x 10 days or Septra DS 1 po bid x 30 days. In severe cases ampicillin 1 gm IV q6h plus gentamicin (loading dose of 1.5 mg/kg followed by 1 mg/ kg IV q8h) or Rocephin 5 mg/kg IV qd (ceftriaxone 500 mg to 1gm IV bid) should be given until fever resolves, then convert to oral antibiotics (above). If there is a urethral discharge and no fever, give ceftriaxone 250 mg IM (or Cipro 500 mg po or Floxin 400 mg po) single dose to treat gonorrhea, and follow with 7-10 days of doxycycline 100 mg po bid (or Floxin 400 mg po qd or Levaquin 500 mg po qd). If both fever and urethral discharge are present, treat for disseminated gonorrhea: ceftriaxone 1 gm IV qd (or spectinomycin 2 gm IV q 12 hours) until symptoms improve, followed by Cipro 500 mg po bid (or Levaquin 500 mg po qd) for 7 more days. If neither fever nor discharge are present, empirically treat for chlamydia: doxycycline 100 mg po bid for 7-10 days (or Floxin 400 mg po qd for 7-10 days or Levaquin 500 mg po qd for 775 CHAPTER 17 Bacterial Infections Anthrax Introduction: Anthrax is an acute bacterial (spore-forming Bacillus anthracis) infection transmitted through broken skin or mucous membranes, inhalation, or ingestion (rare). Fatally infects herbivores (sheep, cattle, horses, pigs, goats, water buffalo, elephants, zebras or antelopes) that shed the bacilli into the environment. Spores remain viable in contaminated soil for years. Dried skins, hides, wool, bone or bone products can transmit infection. Veterinarians, farmers, tannery, wool workers are occupationally exposed. There are three forms of disease, dictated by entry site; 95% of cases are cutaneous. Less common gastrointestinal and pulmonary anthrax infections are generally fatal within days. Symptoms Cutaneous anthrax: Acute (< 1 week): Local pruritus, papule with vesicles Sub-acute (1-2 weeks): Ulcer that dries to a black painless eschar, brawny edema, regional adenopathy Chronic (> 2 weeks): Without treatment, 80% resolve over 6 weeks. Pulmonary anthrax (acute symptoms only): Fever; URI-like cough and chest discomfort; 36-48 hours after infection may observe stridor; respiratory distress; shock and death. Gastrointestinal anthrax (acute symptoms only): Neck swelling, fever, painful swallowing, nausea, vomiting, severe abdominal pain, gastrointestinal hemorrhage and death. Objective: Cutaneous anthrax: Acute(< 1 week): Papule with vesicles forms an ulcer Sub acute (1-2 weeks): Non-tender ulcer with black eschar, edema (can persist) Chronic (>2 weeks): Eschar loosens and separates Pulmonary anthrax: Rapid respiratory rate; neck and chest edema Gastrointestinal anthrax: Acute(< 1 week): Edema of oropharyngeal tissues Sub acute (1-2 weeks): Oropharyngeal/tonsillar ulcers; may see bloody ascites Auscultation: Pulmonary anthrax: Rhonchi or rales; hypotension Palpation: Cutaneous anthrax: Acute(< 1 week): Regional adenopathy Pulmonary anthrax: Neck and chest edema Gastrointestinal anthrax: Tender abdomen Pulmonary: Percussion: localized dullness Lab: Boxcar-shaped, gram-positive rods on Gram stain of skin lesion fluid, or blood/sputum (late in course) (see Color Plates Picture 13). Differential Diagnosis: Cutaneous anthrax: Staphylococcal boil - does not ulcerate or turn blackish; usually pus-filled and painful. Scrub typhus - вЂњtache noireвЂќ lesion is blackish; usually patient is febrile, often with a generalized petechial rash. Spider bite - brown recluse spider bite turns blackish with necrotic changes; usually painful lesion. Cutaneous plague and tularemia - usually more vivid, painful skin lesions. Pulmonary anthrax: Influenza - initial symptoms are similar, but no hemorrhagic mediastinitis or death within 24 hours of onset. Mediastinitis - usually seen post-operatively (thoracic surgery), with histoplasmosis or after esophageal perforation. 76 Gastrointestinal anthrax: Severe gastroenteritis - early similar symptoms, but no progression to hematemesis, bloody stools, occasionally bloody ascites, shock and frequent death in 2-5 days. Treatment: Even if left untreated, 80% of cutaneous anthrax remains localized. However, 20% of skin cases and all other forms of anthrax may die from untreated infection. Primary: Cutaneous: Penicillin V 30 mg/kg in four doses/day x 5-7 days and Cipro 750 mg bid for 60 days Pulmonary: Ciprofloxacin IV 400 mg q12hours x 7-10 days Gastrointestinal: Ciprofloxacin 750 mg po bid x 60 days Alternative: Cutaneous: Levofloxacin 500 mg po q d x 60 days Pulmonary/Gastrointestinal: Doxycycline 100 mg q12hour or penicillin G 4 MU q4hours IV for 710 days Empiric (presumed exposure): Pulmonary: Ciprofloxacin 500 mg po bid for 6 weeks, and vaccination DO NOT NECROPSY any animal showing this sign. The chronic form is characterized by localized, subcutaneous, edematous swelling of the ventral neck, thorax and shoulders. In horses the disease is acute, with signs of fever, chills, colic, anorexia, and swelling of the animalвЂ™s ventrum, with death in 2-3 days. Swine may die acutely without showing signs, or having a rapid swelling of the throat. Bartonellosis (Cat Scratch Disease, Trench Fever, Oroya Fever) Introduction: There are several Bartonella bacterial species that cause different illnesses. Bartonella bacil- liformis causes Oroya fever, a febrile anemia and chronic skin eruption (verruga peruana) in a limited area of mountain communities in Peru, Ecuador and Colombia. It is thought to be transmitted by the bite of a sand fly. Bartonella quintana, transmitted by body lice, causes trench fever, a febrile illness that which can recur years later. Bartonella henselae is inoculated by cat scratch or bite and causes lymphadenitis and variable fever 310 days after cat exposure. Symptoms S. American Bartonella (Oroya fever): Fever, which can persist up to 6 weeks; pallor; weakness; chills; muscle/joint aches. After 2-20 weeks, crops of painless, red, 2-4 mm skin lesions can be seen, mainly on head and extremities. Trench fever: Headache; fever (episodic fever of 3-5 days duration - can have fever relapses up to 10 years later); back/leg ache; shin pain; transient rash (maculopapular). Cat scratch disease: Papule at inoculation site; regional adenopathy that can suppurate; nodes subside in 2-5 months without treatment. Signs Oroya fever: Fever (up to 105В°F) begins early and may persist for weeks, skin pallor and slight jaundice. After several weeks, crops of persistent, 2-4 mm, red to purple skin nodules appear on the exposed parts of the body. Trench fever: Fever (up to 105В°F) lasting 4-5 days, recurs in paroxysms for 3-6 weeks. In the immunocompromised, crops of crusted red-purple papules appear. 77 Cat scratch disease: Variable fever >101В°F is accompanied by crusted papule or pustule at inoculation site. Later: tender, fluctuant, regional adenopathy develops, which may last about 3 months Lab: The Oroya fever organism can be seen on a peripheral blood smear inside red blood cells. Differential Diagnosis: KaposiвЂ™s sarcoma (KS) - trench fever skin lesions (immunocompromised patients) and Verruga peruana may resemble disseminated KS, a malignancy seen in immunocompromised hosts with HIV and in elderly men who live in the Mediterranean area. Chronic febrile illnesses of the tropics, including Salmonella, malaria, tuberculosis, or brucellosis, may co-exist with Oroya fever or mimic it. Oroya fever is differentiated by severe anemia and the presence of bacteria in the red blood cells on blood smear. The suppurative adenopathy associated with a skin lesion of cat scratch can mimic cutaneous plague, tularemia, toxoplasmosis, and sporotrichosis infection. Exposure to cat injury helps differentiate. Treatment Primary: Oroya fever: Chloramphenicol 2-4 g/d po in divided doses x 7 days Verruga Peruana: Rifampin 10 mg/kg/day po x 14-21 days Salmonella is a frequent life-threatening secondary infection, and is often suggested by splenomegaly. Infection during pregnancy can result in fetal death or abortion. Trench fever: Aspirin prn, doxycycline 100 mg po qd x 15 days Cat scratch disease: Azithromycin 500 mg po day 1, then 250 mg po qd x 4 days; analgesics Brucellosis A bacterial infection acquired by ingesting raw milk, unpasteurized cheese or by direct contact with secretions or birth products of infected animals (cattle, goats, buffalo, camels, reindeer, caribou, yaks, coyotes, deer or swine). Average incubation period is 2 weeks, but can take up to several months. Symptoms Acute (1-7days): PM fever > 100В°F; profuse, malodorous sweating; flu-like symptoms and a peculiar taste in mouth Sub-acute (1-2 weeks): Fever, weight loss, arthralgias and myalgias Chronic (weeks to months): Recurrent undulant fever if not treated, arthralgias or arthritis, constipation, depression and back pain. Focused History: ExposureвЂ“ Have you had any raw milk or cheese? Have you come in contact with cattle, goats, buffalo, camels, reindeer, caribou, yaks, coyotes, deer or swine? FeverвЂ“ Do you have a fever? (up to 104В°F). Signs Inspection: Temperatures to 104В°F Palpation: Acute (1-7 days): Generalized adenopathy Sub-acute (1-2 weeks): Hepatomegaly (>50%), splenomegaly (30%) Differential Diagnosis: Enteric fever, nonpulmonary tuberculosis, or non-falciparum malaria (with chronic relapses of fever), may have similar symptoms. Treatment Primary: Doxycycline 100mg po bid x 6 weeks with gentamicin 5mg/kg q 24 hours IV x 14 days (danger of renal insufficiency) 78 Alternate: Doxycycline 100 mg po bid and rifampin 900 mg qd, but twice as high relapse rate Ehrlichiosis: Ehrlichiosis is a tick-borne bacterial illness. Symptoms Headache, fever, rash, myalgias. Signs Temperature over 101В°F; rash in 30% (most commonly involving the trunk; not associated with site of tick bite). Differential Diagnosis: Many infections present similarly, but fever and headache (especially in a patient with exposure to ticks) should prompt the consideration of ehrlichiosis. Rocky Mountain Spotted Fever and meningitis have substantial clinical overlap. NOTE: Serology testing of blood is available at many hospitals. Treatment: Doxycycline 100 mg bid for x 7-10 days. Treatment often results in rapid clinical improvement Plague: a highly fatal illness, is usually transmitted by a bite from a rodent flea or by contact with infected wild rodents (rats, squirrels, chipmunks, prairie dogs), rabbits, or domestic cats. The current plague vaccine does not protect against pneumonic plague, which can spread by droplet inhalation. The incubation period is 1-7 days. This rare disease has foci in the western USA, South America, Asia and Africa. The bubonic form (90-95% of cases) has a very rapid onset associated with a toxic state characterized by enlarged and very tender lymph nodes (buboes). The other forms of plague, pneumonic (progression of 5% of bubonic cases) and septicemic (5-10% of cases) are rapidly toxic and nearly always fatal if untreated. Symptoms Constitutional: Acute (< 2 hr): Sudden onset fever, chills, headache, myalgias, lethargy Specific: Sub-acute (24-48 hr): Cough, if pneumonic form; buboes* (85% cases), diarrhea (septicemic plague), abdominal pain Chronic (>48 hr): Bloody, frothy sputum; buboes suppurate *Tender, swollen lymph nodes with red, edematous overlying skin, often in inguinal and axillary regions. Signs Inspection: Acute (< 48 hrs): Fever to 104В°F; a skin lesion at site of flea bite (25%); lethargy; tachycardia 110-140; hypotension; toxic appearance; Pneumonic: respiratory distress, tachypnea Chronic (>2 weeks): Can see meningeal signs: Plague meningitis is particularly associated with axillary buboes. Auscultation: Sub-acute (up to one week): Rales if pneumonic Palpation: Acute (< 48 hrs): Buboes Sub-acute (up to one week): Buboes may start to recede, also could suppurate. Lab: Gram's stain of bubo needle aspirate (usually need to inject and withdraw some saline to get sample) or sputum may show gram-negative coccobacillus with a bipolar (safety pin) staining appearance. In severely septicemic patients this may even be seen with a Gram's stain of blood. CXR: Can be normal but rapidly progress to diffuse pneumonitis (increased markings throughout lung fields). 79 Differential Diagnosis: Tularemia, enteric fever, rickettsial infection, acute lymphadenitis, dengue, typhus and Hantavirus. Treatment Primary: Gentamicin 2 mg/kg load then 1.7 mg/kg q 8 hours IV (adjust lower if kidney dysfunction as noted on urinalysis) Alternative: Doxycycline 200 mg first day then 100 mg bid x 10-14 days NOTE: If meningitis develops, use ciprofloxacin 750 mg po bid or chloramphenicol 50 mg/kg/day x10-14 days. Rat Bite Fever: Caused by infection with Streptobacillus moniliformis or Spirillum minor, rat-bite fever is transmitted by the bite of a rodent and has worldwide distribution. Symptoms Fever, chills, headache, myalgias, arthralgias and rash [incubation period is 3-10 days[ Signs: The rash can be maculopapular, morbilliform or petechial, and erupts over the palms, soles and extremities. Lab: Culture of blood, joint fluid or pus may demonstrate organism. Differential Diagnosis: Other potential causes of fever/rash are varied, and include measles, meningococcemia, Rocky Mountain Spotted Fever and secondary syphilis. Treatment: For moderately to severely ill patients, use procaine penicillin G 600,000 units IM or IV penicillin every 12 hours. For mildly ill patients, amoxicillin 500 mg po tid x 14 days is probably adequate. For penicillin-allergic patients, tetracycline 500 mg po every 6 hours or doxycycline 100 mg po every 12 hours may be given. Acute Rheumatic Fever: (ARF) typically occurs approximately 19 days after untreated streptococcal pharyngitis in 1-3% persons. Symptoms: Fever; migratory polyarthralgias in knees, ankles, elbows or wrists; rash which can wax and wane over months; subcutaneous nodules and chorea. Signs Inspection: Fever to 102В°F (up to 21 days); rapid respiratory rate (if carditis); E. marginatum rash (irregularly edged, transient, lacy, macular rash [pink rimmed with internal blanching] found on the trunk and extremities) which waxes and wanes for months; chorea (short, abrupt, non-purposeful movements, which often disappear during sleep and grimacing). Palpation: Migratory large joint inflammation (arthritis); 10% have subcutaneous nodules on extensor elbows and forearms which last up to 4 weeks. Auscultation: In carditis: bibasilar rales, aortic insufficiency or mitral regurgitation murmurs, pericardial friction rub, S3 gallop. In carditis, CXR may show cardiomegaly. EKG may have prolonged PR interval. 80 Diagnosis Based on clinical observation and application of the Jones criteria for diagnosis: 2 major criteria, OR 1 major and 2 minor criteria AND evidence for prior streptococcal infections (prior scarlet fever, + throat culture) Major Criteria: Carditis, polyarthritis, subcutaneous nodules, and chorea, E. marginatum rash Minor Criteria: Fever, arthralgias prior rheumatic fever, heart block seen on EKG Differential Diagnosis Polyarthritis is often the main presenting symptom. The differential diagnosis should include: Gonococcal arthritis - sexual exposure; dysuria; urethral discharge; characteristic gun metal blue skin lesion Subacute bacterial endocarditis - diagnose with blood cultures (if available); usually few joints involved; may see embolic skin lesions Lyme disease - fever less frequent; fewer joints involved; history of tick bite ReiterвЂ™s syndrome - fever is unusual; prior history of sexually transmitted disease or acute diarrheal illness; characteristic skin lesions (painless, superficial erosions) in genital area/soles of feet Carditis: Viral myocarditis - unlikely to see joint symptoms or the E. marginatum rash Pericarditis - may see diffuse ST segment elevations Treatment Primary: Benzathine penicillin 1.2 MU IM (600,000 U in children) or oral penicillin 250 mg po qid x 10 days Salicylates: 4-8 grams aspirin per day x 3-4 weeks Alternative: Erythromycin x 10 days or azithromycin x 5 days can be used in patients allergic to penicillin. Other NSAIDs may be used in place of aspirin Streptococcal Infections Streptococcal Pharyngitis and Scarlet fever: Introduction: Streptococci are gram positive bacteria. Some species are pathogenic in humans, responsible for illnesses ranging in severity from mild upper respiratory infections to life-threatening necrotizing fasciitis. Fulminant necrotizing fasciitis due to group A streptococcus may begin at a site of trivial trauma (for example a paper cut, abrasion on a cinder block), with rapid progression over 2472 hours and 20-70% mortality even with ICU care. This is a deep-seated, fast moving infection that destroys fascia, fat, muscle and other tissue but may spare the skin. It often involves the extremities. Streptococcal infection of muscle (myositis) often is from blood infection, not associated with trauma. It may involve a single muscle group and be associated with compartment syndrome Symptoms Initial flu-like symptoms with fever to 104В°F, extreme pain and erythema at infection site. Signs Inspection: Acute (< 24 hr): Ill-appearing, fever as high as 105oF, SBP <110, increased heart rate, abrupt onset red/swollen affected area, confusion/mental status changes common. 81 red/swollen area spreads locally, color turns to blue/purple with bullae, may see gangrene by day 4-5. Lab: Gram stain of fluid or tissue (blood, throat, wound and debrided tissue) for gram-positive cocci in chains (see Color Plates Picture 26). CXR to assess for early ARDS development. Chronic (>7 days): Earlier signs continue, clear demarcation at site of involvement Palpation: Acute (< 24 hr): Tenderness >inflammatory change, area warm to touch; may see capillary leak syndrome with generalized edema (the вЂњMichelin manвЂќ look), in myositis find changes c/w compartment syndrome of affected area. Sub-acute/Chronic: Continuation of earlier signs, other physical findings related to multi-organ system failure in severe cases Differential Diagnosis: Necrotizing fasciitis - due to Clostridia; crepitus on physical exam or gas on X-ray. Cellulitis or lymphangitis - deep streptococcal infection is much more painful and purpuric. Treatment 1. Immediately for surgical and intensive care support. 2. If medical help is delayed or not possible, give antibiotics. IV Penicillin 24 MU/day (4 MU q 4 hrs) and Clindamycin 900 mg q 8 hrs for 10-14 days. Clindamycin decreases streptococcal toxin production. Intravenous immunoglobulin (IVIG) 150 mg/kg/day for 5 days given early may decrease mortality. 3. Aggressively debride deep-seated infection. External findings are often the вЂњtip of the icebergвЂќ regarding tissue involvement. (see Procedure: Wound Debridement) 4. Oxygen, IV fluids (LR or NS) and other treatment as in ARDS section. Consider adding ceftriaxone or ciprofloxacin. Tetanus Introduction: Clostridium tetani bacteria are introduced into the body through contaminated open wounds, burns, frostbite, needles, or unclean cutting/dressing of the umbilical cord. The tetanus toxin (tetanospasmin) causes acute central nervous system intoxication. Case fatality rate is 10-90%. The incubation period is 3-30 days There are four subtypes described for tetanus: generalized, localized, cephalic and neonatal. Symptoms Neonatal cases: Weakness, irritability, trouble nursing, unable to suck Specific: Acute (1-7days): Pain at wound site, local muscle spasticity Sub-acute (7-14 days): Trismus (lockjaw), painful tetanic spasm, glottic or respiratory muscle spasm, urinary retention, constipation, rigid abdominal wall muscles, trouble swallowing Chronic (>2 weeks): Slow recovery phase (4 weeks) Signs Inspection: Acute (1-7 days): Afebrile; localized muscle spasticity, localized pain at inoculation site, neonatal cases: unable to nurse, with stiff muscles or spasming Sub-acute (7-14 days): Afebrile, tetanic spasm (stimulus induced) trismus (lockjaw), opisthotonos (arched back spasm), glottic/respiratory muscle spasm, cyanosis/asphyxia, profuse sweating Palpation: Sub-acute (7-14 days): Abdominal muscle wall rigidity Percussion: Acute (1-7 days): Brisk local deep tendon reflexes 82 Differential Diagnosis Meningoencephalitis - usually associated with fever; true seizures and mental status changes not seen in tetanus. Strychnine poisoning - mimics tetanus; abdominal wall muscle rigidity more often seen in tetanus; ask about an ingestion history Hypocalcemic tetany - involves extremities; rare to see lockjaw; tapping on facial nerve (over parotid) can induce facial muscle spasm in low calcium states (ChvostekвЂ™s sign) Generalized seizures - associated with loss of consciousness, no trismus Phenothiazine toxicity - drug history; can see torticollis (not in tetanus); relieved with Benadryl (not in tetanus) Treatment 1. Maintain airway (ET tube can stimulate spasm so may need early tracheostomy for respiratory difficulty) 2. Medications: a. Tetanus (human) immune globulin (HTIG, Hyper-tet) 500 IU intramuscularly or injected directly into wound b. Tetanus immunization 0.5 ml IM at site away from HTIG administration. d. Diazepam titrated for effect 5-10 mg q 2-4 hours to control muscle spasms (lorazepam or midazolam are also effective) e. Metronidazole 30 mg/kg/day divided in q 6 hour dosing for 7-10 days (average about 500 mg q 6 hrs IV); can also be given 1 gm per rectum q 8 hrs 3. Nursing: Keep patient in a quiet, darkened room; avoid unnecessary touching; use Foley catheter for urinary retention. Alternate Antibiotics: Penicillin G 4 million units IV q 6 hrs for 10 days or doxycycline 100 mg q 12 hrs IV Tularemia Introduction: Francisella tularensis is a small gram-negative bacillus that can enter the body by ingestion (eating undercooked meat, drinking contaminated water), inoculation (bites, skinning/ trapping animals), inhalation or contamination. This organism can penetrate unbroken skin. It is common in rabbits, opossums, beavers, water rats, raccoons, muskrats and feral cats. It is transmitted by ticks, and less commonly by deer flies. Symptoms Constitutional: Acute (< 2 hr): Fever 101-104В°F, chills, malaise, anorexia, fatigue Sub-acute (2-48 hr): Fever Chronic (>48 hr): Fever, if untreated, can last up to 30 days; chronic debilitation for months. Specific: Acute (< 2 hr): Tender adenopathy; oculoglandular: tearing, photophobia; pharyngeal: severe sore throat; typhoidal: dry cough; pneumonic: Dry cough Sub-acute (2-48 hr): All: rash (35%); ulcer (skin); typhoidal: abdominal pain, diarrhea; pneumonic: pleurisy, rare hemoptysis; Chronic (>48 hr): Suppuration of lymph nodes Signs Inspection: Acute (< 2 hr): Fever to 104В°F; relative bradycardia. Ulceroglandular form: papule; pharyngeal form: exudative pharyngitis; oculoglandular form: purulent conjunctivitis, eyelid edema Sub-acute (2-48 hr): sometimes develops membrane or oral ulcer; rash (35%): acneiform, E. Nodosum, E. multiforme, urticaria, Diffuse maculopapular Chronic (>48 hr): Ulcer (skin) 84 Auscultation: Sub-acute (2-48 hr): Pneumonic form: rales Palpation: Acute (< 2 hr): Swollen localized lymphadenopathy Sub acute (2-48 hr): Fluctuant regional lymph nodes, typhoidal form: hepatosplenomegaly Percussion: Acute (< 2 hr); Sub acute (2-48 hr) Typhoidal form: Enlarged liver and spleen; pneumonic form: Signs of consolidation (dullness to percussion), egophony. Differential Diagnosis: Meningococcal infection - rapidly progressive; petechial to purpuric rash; often with meningeal signs; no tick or animal exposure Rickettsial infection - febrile illness with rash after tick bite; not likely to have suppurative lymphadenopathy or skin ulcers Cat scratch disease - can be confused with ulceroglandular tularemia, history of cat scratch and lack of risk factors for tularemia Sporotrichosis - history of thorn/cactus/plant related injury to body; lymphangitis seen commonly with sporotrichosis while it is less common with oculoglandular tularemia Syphilis - sexual contact; genital ulcer, which is painless; patient often afebrile Lymphogranuloma venereum - sexually transmitted infection; can cause regional and generalized adenopathy with genital ulcer; less likely to have ulcer elsewhere on body Other less likely possibilities are cutaneous tuberculosis, plague and anthrax. Treatment Gentamicin 5 mg/kg/day divided q 8 hrs IV or IM for 7-10 days. Due to risk of renal toxicity, ensure adequate hydration and urine output. If in doubt, use alternate drug. Alternative: Tetracycline 500 mg q 6 hrs until fever breaks, then 250 mg qid for 5-7 days (higher relapse than gentamicin) Typhoid Fever: caused by Salmonella typhi. The incubation period is 1-3 weeks after exposure. Symptoms Acute (3-7days): Fever, flu-like symptoms, chills, weakness, anorexia, myalgias, Sore throat, nonproductive cough, constipation, diarrhea (5-10%), abdominal discomfort Chronic (>3 weeks): If fever> 4 weeks, consider metastatic focus. Abdominal pain, abdominal perforation, lower GI bleed Signs Acute (3-7 days) Inspection: Stepladder temperatures to 104В°F (usually in afternoon/night), relative bradycardia in 25%; moderately ill appearing; rose spots (2-3 mm pink to red papules on chest/abdomen that fade with pressure) in fair skinned persons, furry tongue; (thick white to brown coating that spares edges) Palpation: Abdominal distension; mild, diffuse abdominal tenderness. Sub-acute (1-3 weeks): Palpation: splenomegaly (50%), Percussion: liver can be slightly enlarged 2-3 cm below costal margin. Lab: Urine culture is positive after one week, blood culture may be positive for first 2 weeks, and stool culture is positive for weeks 3-5. Other clues from stool include fecal leukocytes (may suggest an invasive gastroenteritis). Blood smear may demonstrate low white blood count and anemia. 85 Differential Diagnosis Nontyphoidal Salmonella - infections are generally milder, without rose spots. Tuberculosis - generally chronic, lower grade fever; night sweats; cough; hemoptysis; abnormal CXR. Hepatitis - more often see jaundice, dark urine, gastrointestinal symptoms, malaise and fatigue Leptospirosis - remarkable conjunctival injection; has similar fever pattern; history of exposure to contaminated fresh water Malaria - nocturnal fever pattern typical; thick and thin blood smears will help detect the malaria parasite Amebic liver abscess - may see more tenderness in hepatic region Brucellosis - chronic febrile illness with relative bradycardia, splenomegaly; animal exposure, occupation may help differentiate Treatment: Antibiotics prolong Salmonella excretion in the stool and should not be given unless patient is febrile. Ceftriaxone 1 gm q 12 hrs IV or IM x 14 days (recent study suggests that a 5 day course may be as effective), azithromycin 1 gm load on day 1 then 500 mg po days 2-6 86 CHAPTER 18 Mycobacterial Infections Tuberculosis Mycobacterium tuberculosis, M. Bovis and others cause tuberculosis (TB), a chronic pulmonary infection that is seen worldwide. Infection is spread by airborne particles. Clinical disease (TB) develops in only about 10% of those infected. Others have latent tuberculosis infection (LTBI), since they do not have evidence of active disease. Symptoms: Chronic productive cough (bloody), chest pain, fever, chills, night sweats, anorexia, weight loss, fatigue. Signs Vital Signs: Normal to low-grade fever, weight loss Percussion: Unilateral, localized dullness over the upper lung fields Auscultation: Decreased breath sounds or rales corresponding to percussed dullness (upper lung fields) CXR: consolidation or cavitary lesion in upper lung fields; purified protein derivative (PPD) skin testing to document tuberculosis infection. NOTE: PPD may be negative in persons with active infections. Differential Diagnosis Chronic cough - chronic bronchitis or COPD not associated with progressive weight loss or night sweats Lung cancer - usually seen in patient with smoking history Fungal pneumonias (histoplasmosis, blastomycosis, paracoccidioidomycosis) - chronic pulmonary symptoms are rare and usually seen in smokers in endemic areas. Treatment Primary: Base the selection of antimycobacterial drugs on knowledge of local resistance patterns. Usually, 3-4 drugs are initiated. The most common regimen is isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and either ethambutol (EMB) or streptomycin (SM). In cases of sensitive tuberculosis, these drugs are given for 8 weeks, followed by a 6-month course of INH and RIF only. Medicines may be given 2, 3 or 7 times each week. Use directly observed therapy (DOT) to assure compliance. Treat PPD positive contacts without active disease (LTBI) with isoniazid, 300 mg/day for 9-12 months. Children under 5 years of age who are contacts of an active pulmonary case should receive isoniazid, 10-20 mg/kg (300 mg maximum) even if initial PPD is negative. If the PPD remains negative on retesting after three months, INH may be stopped. Alternative: Alternate regimens are usually based on results of susceptibility testing. NOTE: Multidrug resistant tuberculosis (MDR-TB) is defined as any M. tuberculosis that is resistant to both INH and RIF. 87 PPD skin testing is done as follows: 1. Placement of PPD: inject 5 IU (0.1 mL) intradermally into flexor surface of LEFT forearm (so you will remember where to look for reaction). 2. Interpretation of PPD reaction: a. Measure diameter (in mm) of INDURATION or swelling (not redness) of reaction, when viewed in cross-section at 48-72 hours. b. >5mm is positive in HIV patients, and in close or household contacts of a patient with an active TB infection. c. >10mm is positive for those personnel exposed to people at high-risk for having TB. This standard applies to medical personnel and team members. d. >15mm is positive for personnel with no risk factors for exposure. This standard applies to most Americans. Nontuberculous mycobacterial (NTM) Nontuberculous mycobacterial (NTM) or mycobacteria other than tuberculosis (MOTT) infectious diseases include lymphadenitis caused by Mycobacterium avium complex (MAC) and M. scrofulaceum; skin and soft tissue infection secondary to M. fortuitum, M. abscessus, M. marinum, and M. ulcerans; and pulmonary disease, most commonly secondary to MAC or M. kansasii. Lymphadenitis in children age 1-5 years is most commonly caused by M. avium complex. Pulmonary syndromes are usually chronic, often occurring in persons with other underlying pulmonary disease. Symptoms Lymphadenitis (painless enlargement of the lymph nodes of the neck), usually unilaterally; skin and soft tissue infections - edema, erythema; pulmonary infection - chronic, productive cough with fever and weight loss; accompanied by malaise, night sweats and hemoptysis. Signs Lymphadenitis: Enlarged, unilateral nodes of the neck (usually anterior cervical chain) that may spontaneously form sinus tracts and drain. No overlying erythema. Individual nodes are difficult to identify. Normal vitals. вЂњSwimming pool or fish tank granulomaвЂќ caused by M. marinum starts as a papule (usually on extremity) that slowly enlarges and ulcerates. These lesions are associated with water or fish exposure. Introduction of the organism is likely via an abrasion or puncture. Pulmonary disease: Presents similar to tuberculosis (see ID: TB). Perform PPD testing to rule out tuberculosis. CXR may reveal thin-walled cavities and more pleural thickening than tuberculosis. Differential Diagnosis Lymphadenitis - cat scratch disease (kitten exposure, pain), lymphoma, tuberculous lymphadenitis (also called scrofula; positive PPD or TB exposure) Skin and soft tissue infection - nocardiosis (no water exposure), sporotrichosis (exposure to soil, organic gardening materials), leishmaniasis (endemic area, sandfly exposure) Pulmonary disease - TB; see Respiratory: Pneumonia, COPD 88 Treatment Primary: Lymphadenitis (due to MAC or M. scrofulaceum) - excisional surgery without antimicrobial drugs. Cutaneous lesions (due to M. marinum) - doxycycline 100 mg bid or trimethoprim/sulfamethoxazole, 160/800 mg bid for 3 months. Excisional therapy is also an option. NOTES: Disseminated M. avium complex (DMAC) is another NTM disease that is virtually restricted to persons with late stage AIDS. This infection presents as a chronic febrile wasting syndrome with associated anemia and MAC bacteremia. 89 CHAPTER 19 Fungal Infections Candidiasis (Thrush) Candida albicans is a yeast normally found in the mouth, intestines, and vagina. Overgrowth of this yeast can cause skin or mucosal diseases including oropharyngeal candidiasis (thrush), intertrigo (disease limited to moist skin folds), esophagitis, and vaginitis (see GYN section). In adults, disease commonly occurs in diabetics, the immunocompromised, and after antibiotic treatment for other disorders. Inhaled and oral corticosteroid preparations also increase risk. Disseminated, life-threatening infection can also occur in severely immunocompromised persons. Symptoms Oral thrush: Usually asymptomatic; may cause mouth discomfort or difficulty swallowing. Esophageal thrush: Painful or difficult swallowing. Intertrigo: Local burning-like pain, often with pruritus. Vaginal thrush: Itching, dyspareunia (pain with intercourse) and change in the odor or consistency of vaginal discharge. Signs Inspection: Oral/esophageal: white plaques, which are scraped to reveal an erythematous base and are seen on any oral mucosal surface except the tongue. Cutaneous (intertrigo or vulvar): erythematous, shiny rash with small вЂњsatelliteвЂќ lesions at its periphery. Candidal vaginitis is associated with a curd-like vaginal discharge Candidal vaginitis). Lab: Potassium hydroxide (KOH) wet mount of scrapings or discharge reveals typical yeast, usually with pseudohyphae and/or hyphae. Differential Diagnosis Oropharyngeal candidiasis - particulate debris secondary to poor oral hygiene (debris is usually easily removed) Esophageal candidiasis - esophagitis due to herpes simplex, cytomegalovirus, aphthous ulcers, and toxins Candidal vaginitis - trichomoniasis, bacterial vaginosis (can be differentiated with wet mount) Treatment Oropharyngeal candidiasis - nystatin solution, 400,000-600,000 units qid po as a swish and swallow x 7 - 14 days. Esophageal candidiasis - fluconazole, 200 mg/day po or IV x 14 days. Intertrigo - nystatin powder or clotrimazole or miconazole cream twice daily until resolved. Candidal vaginitis вЂ“ see GYN Problems section. Alternative: Oropharyngeal candidiasis - clotrimazole troches (lozenges), 10 mg 5/day, oral fluconazole, 50-200 mg/day, itraconazole, 100-200 mg/day, or ketoconazole, 200 mg/day. Esophageal candidiasis itraconazole 100-200 mg/day, or intravenous amphotericin B, 0.3-0.5 mg/kg/day, in refractory cases. 90 NOTE: Oral candidiasis (thrush) in a young adult should always raise the suspicion of immunocompromise, especially undiagnosed HIV infection. Blastomycosis (North American Blastomycosis, Gilchrist Disease) Blastomyces dermatitidis is a yeast-like fungus that causes a spectrum of disease including asymptomatic infection, acute and chronic pulmonary infection and disseminated infection of the skin, bone, GU tract, and rarely, the CNS. This infection is seen most often in central and southeast US in areas near rivers or streams. Approximately 1/2 of exposed persons will develop symptomatic disease. The incubation period is 3045 days. Most individuals seeking care for this infection have progressive pulmonary disease or cutaneous lesions. Symptoms Acute pulmonary infection: fever, cough, and pleuritic chest pain Chronic pulmonary disease : presents with similar symptoms over a longer course. Skin lesions are typically painless or slightly tender. ) Signs Pulmonary infection: associated with diffuse auscultatory findings and fever. Chronic pulmonary disease can also include hemoptysis, weight loss, and skin lesions. Skin lesions are most often located on the face, scalp, neck, and extremities. These begin as red papules or nodules that enlarge and then ulcerate or become verrucous. Associated adenopathy is uncommon. Lab: Large (8-15 mm), thick-walled, broad-based, budding yeast cells may be visible on Gram stain of sputum or lesion. Differential Diagnosis Acute pulmonary infection - influenza, bacterial pneumonia Chronic pulmonary infection - tuberculosis, lung cancer, other fungal pneumonias Skin lesions - squamous cell carcinoma, mycosis fungoides Treatment IV amphotericin B is required in life-threatening infections, all central nervous system infections, infections in immunocompromised patients and in pregnant patients. Itraconazole can be used in all other infections at a dose of 200-400 mg/day po, usually for 6-12 months. Alternative: Ketoconazole 400-800 mg/ day or fluconazole 400-800 mg/ po day Coccidioidomycosis (Valley Fever, Desert Rheumatism) Coccidioides immitis is a dimorphic fungus that causes disease ranging from self-limited pulmonary infection to chronic meningitis. Incubation period is 7-21 days. More than 60% of all infections are asymptomatic. Most symptomatic infections take the form of acute pulmonary disease. Untreated, acute infection resolves in 95% of patients. About 1% of those infected develop chronic pulmonary disease or disseminated infection to the meninges, skin, bone, or soft tissue. 91 It occurs in the southwest deserts of the US and northern Mexico, and a few pockets of in Central and South America. It has frequently been reported in service members training at Fort Irwin, California. Symptoms Cough (usually dry), fever, pleuritic chest pain, malaise, headache, anorexia, myalgia and often rash; severe disease may present with a sepsis-like syndrome. Large joint pain may occur after asymptomatic infection (desert rheumatism). Meningitis presents with chronic headache, memory loss, lethargy, or confusion. Signs Vital signs: Fever and tachypnea Inspection: Various rashes: Diffuse, faint erythematous rash lasting less than one week; or erythema multiforme (painless, diffuse rash consisting of rings and disks); or erythema nodosum (painful red nodules usually occurring on the shins). Auscultation: Diffuse ausculatory findings (abnormal breath sounds). Ophthalmoscope: Patients with meningitis may have papilledema on funduscopy. Lab: Eosinophils may be seen on blood smear. Gram stain or KOH of sputum for spherules (10-80 Вµm round structures with 2-5 Вµm round endospores inside) Differential Diagnosis Acute pulmonary disease - influenza, вЂњatypicalвЂќ pneumonia, histoplasmosis, blastomycosis Meningitis - tuberculosis, syphilis, cryptococcosis (see respective topics); and CNS tumors (see Neurology: Seizure Disorders and Epilepsy) Treatment Primary: Amphotericin B 0.5-1 mg/kg IV daily should be used in acute life-threatening infection. This can be followed with fluconazole 400-800 mg/day to complete 3-6 months of therapy. Meningeal infection is treated with fluconazole, 400-800 mg daily for life. All other forms of coccidioidomycosis are treated with long-term fluconazole. Alternative: Itraconazole (400-600 mg/day) may be used in non-meningeal infections. Some authorities add intrathecal amphotericin B in the initial therapy of meningeal disease. Histoplasmosis (DarlingвЂ™s Disease) Histoplasma capsulatum is a dimorphic fungus that can cause disease ranging from asymptom- atic pulmonary infection to life-threatening disseminated infection. Acute infection occurs 3-21 days after exposure. Most infection is asymptomatic or self-limiting pulmonary disease. Severity is dependent on patientвЂ™s immunity and intensity of exposure. Chronic pulmonary disease, mediastinitis and disseminated disease are rare. Found worldwide, this infection is most common in the central US (Mississippi and Ohio River basins). Risk Factors: Outbreaks may occur with the removal of debris containing contaminated bird or bat droppings. 92 Symptoms Acute (days): Malaise, fever, chills, anorexia, myalgias, cough, pleuritic chest pain. Chronic (months): cough Signs Inspection: Fever, weight loss; hypotension and shock in immunocompromised patient (sepsis) Auscultation: coarse breath sounds, pleural friction rub Palpation: hepatomegaly and/or splenomegaly may be seen in disseminated infection CXR: Hilar or mediastinal lymphadenopathy with or without patchy infiltrates. Treatment Primary: Itraconazole 200 mg daily for 6-12 weeks, can be given in those cases that do not spontaneously improve/resolve. For severe infection, including acute or chronic pulmonary disease, disseminated disease or meningitis, give amphotericin B 0.7-1 mg/kg IV daily. This therapy can be changed to intraconazole 200 mg once or twice daily, for 6-24 months when clinically stable or continued for 3-4 months (35 mg/kg total amphotericin B). Alternative: Ketoconazole 200-800 mg/day can be used as an alternative to itraconazole. NOTES: Lung granulomas, and hilar and splenic calcifications are commonly seen on CXR of persons who have had acute pulmonary histoplasmosis in the past. Outside the endemic area however, lung granulomas and hilar calcifications more commonly represent inactive tuberculosis. Paracoccidioidomycosis (South American Blastomycosis) Paracoccidioides brasiliensis is a dimorphic fungus that typically causes chronic, progressive, pulmonary disease in rural male workers. Incubation may be prolonged up to 15 years. Symptoms: Chronic, productive cough, +/- bloody sputum; shortness of breath; weight loss; painful mouth or nose ulcers; hoarseness. Signs Vital signs: Normal Inspection: Ulcerative lesions of the face, mouth, larynx, or pharynx Auscultation: Rales or decreased breath sounds in the middle or lower lung fields Treatment Primary: Itraconazole 100-400 mg/day x 3-6 months. Alternative: Sulfadiazine 4 gm/day for weeks to months, based on clinical response, then 2 gm/day for 3-5 years. Other sulfa-based antibiotics can be used. Amphotericin B can be used in life-threatening and unresponsive infections. Ketoconazole 200-400 mg/day and fluconazole 600 mg/day have also been used. NOTE: Paracoccidioidomycosis has a less common juvenile form which causes acute, progressive, disseminated infection similar to acute disseminated histoplasmosis seen with AIDS and in younger individuals. 93 CHAPTER 20 INFECTIOUS DISEASES REVIEW Since the epidemiology and treatment recommendations change over time, as new antibiotics are developed and resistance to older ones evolves, more current information is available at the Centers for Disease Control and Prevention website at: http://www.cdc.gov/. SEXUALLY TRANSMITTED DISEASES Over 30 microorganisms can be sexually transmitted with many having similar symptoms. Despite this complexity, initial management (with subsequent referral) can be accomplished in many settings with a minimum of resources. The following clinical syndromes associated with sexually transmitted diseases will be discussed in this section: f Urethral discharge (urethritis) f Painful testicle (epididymitis) L Genital ulcer L Genital warts f Lymphogranuloma venereum (LGV) m Pruritis (itching) M Vaginal discharge Л† Lower abdominal pain In evaluating patients at risk for STDs, remember that many of these diseases can be asymptomatic and the patient may not suspect he/she has infection. However, asymptomatic patients can also transmit disease to others. Urethral Discharge (Urethritis) Urethritis is characterized by a discharge from the urethra and burning with urination. It is usually caused by one of two bacteria: Neisseria gonorrhoeae (which causes gonorrhea) and Chlamydia trachomatis (which causes chlamydia), both of which infect and irritate the urethra. The usual incubation period for gonorrhea is 3-5 days and the discharge is yellow or green. The incubation period for chlamydia is longer, 1-5 weeks (usually 10-16 days), and the discharge is less profuse, less purulent (often white or watery) and less painful. About 20% of men with gonorrhea also contract chlamydia at the same time. Examination of a Gram-stain of the discharge may disclose gram-negative diplococci inside of white blood cells, diagnostic of gonorrhea and the patient should be treated for both gonorrhea and chlamydia. If the Gram stain of the exudate does not disclose white cells with gram-negative intracellular diplococci, the patient should be treated for chlamydia. If no microscope is available, it is difficult to distinguish gonococcal urethritis from chlamydial urethritis with surety and the patient should be treated for both. Younger women may occasionally develop urethritis caused by C. trachomatis. These women do not have a urethral discharge, but have pain with urination due to the urethral inflammation. However, a urinary tract infection is more common cause of painful urination. Painful Testicle (Epididymitis) The epididymis, which stores sperm and is located on the posterior side of the testicle, may become infected by C. trachomatis (most commonly) or N. gonorrhoeae. 94 Epididymitis must be differentiated from acute testicular torsion (twisting of the testicle inside the scrotal skin, which can lead to loss of blood supply to the testicle.) Examination of a patient with epididymitis shows tenderness of the epididymis and possible swelling. In men with sexually transmitted epididymitis, there will usually be symptoms or signs of urethritis, but this may not be prominent (particularly in men with chlamydia). Genital Ulcer Erosions of the skin (ulcers) may be caused by Herpes simplex virus (genital herpes), Treponema pallidum (syphilis) and Haemophilus ducreyi (chancroid). Erosions may be caused by trauma (during sex or in zippers) or less commonly by reactions to medications (particularly tetracyclines). The most common disease is genital herpes, whose incubation period is five to10 days. Initially, small, painful, grouped blisters occur which, over several days, break open into shallow ulcerations. Painful, swollen, lymph nodes in the groin may accompany the blisters and ulcers. Over ensuing days, the ulcers crust and heal; the entire process takes about 21 days for initial attacks. Subsequent attacks may occur and last seven to 10 days. Women with initial attacks may have accompanying erosions of the cervix. The primary stage of syphilis is characterized by one to four painless smooth ulcers which appear about 21 days following infection. Small, minimally tender lymph nodes in the groin may occur. Without treatment, the ulcers heal after two to six weeks As the ulcers are healing, or several weeks afterward, the secondary stage of syphilis occurs and is characterized by a skin rash consisting of small flat patches, often most noticeable on the palms and soles; patients may have a low-grade fever. Without treatment, the rash will resolve after about two to six weeks, but may return. Without treatment at this stage, patients may develop tertiary syphilis in one to 30 years, characterized by neurologic (stroke, dementia) or cardiac (heart valve disease) abnormalities. Chancroid is characterized by one to four very painful ulcers which often appear quite ragged. Painful enlargement of the lymph nodes in the groin occurs in half of patients. Genital Warts Genital warts occur several weeks following infection with human papilloma virus (HPV). HPV warts look like warts elsewhere on the body, but differentiation from other causes of skin growths is not always easy. Lymphogranuloma Venereum (LGV) LGV is a systemic disease of venereal origin caused by a virus-like organism. The infectious agent is a Bedsonia organism closely related to that of psittacosis. After an incubation period averaging one to four weeks, a small painless genital lesion occurs in about one fourth of patients. The lesion is an inconspicuous bump, blister, or shallow ulcer that heals within a few days and typically goes unnoticed by the patient. The earliest clinical signs are fever up to 1030F (39.40C), chills, headache, malaise, coughing, and muscle and joint pain. 95 Shortly after the onset of these symptoms, the patient becomes aware of a painful swelling in one or both groin areas. The inguinal bubo is common in males. Early in the course of regional node involvement, one can feel one or more enlarged discrete movable tender nodes. These eventually become matted together into an oval-shaped mass. As the disease progresses, some of these matted nodes undergo softening. Because there are nodes in different stages of evolution, the mass becomes large and lobulated with alternating areas of softening and hardness. The overlying skin becomes swollen, sometimes bluish-red in color, and fixed to the underlying mass. When pus forms and breakdown occurs, multiple fistulous tracts may open to the skin surface. Pruritus (Itching) Pruritus may be caused by pubic lice (crabs) and scabies; both are parasites and in both cases, pruritus is caused by sensitization to the organism. The pruritus caused by lice is limited to the genital area while that due to scabies often occurs elsewhere on the body where the mite Adult lice and their eggs (nits) in egg casings may be seen with the naked eye clinging to pubic hairs, or adult lice may be in the crusts of skin scabs formed from scratching; a magnifying lens helps visualize adults and eggs. Sarcoptes mites burrow under the skin, forming linear tracks and nodules (which house the mite); common locations are the groin, finger webs and axilla. Diagnosis of lice depends upon seeing the lice or their eggs; diagnosis of scabies depends upon seeing typical nodules. Pubic lice are treated by: lindane shampoo (1%), (not recommended for pregnant or nursing women, or children <2 years of age);or, permethrin creme rinse (1%) or pyrethrins with piperonylbutoxide. Scabies is treated by: permethrin cream (5%); or, lindane (1%), applied to the body from the neck down and washed off after 8 hours. Carefully read and follow directions when using any of these preparations. They are toxic substances and are dangerous if misused. For both diseases, bedding and clothing should be machine washed and machine dried using a hot cycle. Ironing clothes also kills the parasites. Vaginal Discharge Vaginal discharge is a common symptom that can be normal or a symptom of various infections. Normal vaginal secretions vary with hormonal balance and the menses cycle. Normal secretions are painless, clear, and thin, but can be quite profuse at some times of the month. Some infections present with a vaginal discharge. Trichomonas causes a white, frothy discharge with itching. Monilia, or a yeast infection, is characterized by a white, cheesy discharge resembling cottage cheese. Nonspecific vaginitis is due to a range of bacteria, and can have differing presentations. Some infections, such as chlamydia and gonorhhea in women, may have no symptoms. 96 Lower Abdominal Pain Lower abdominal pain is characteristic of pelvic inflammatory disease (PID), in which microorganisms ascend through the cervix into the uterus and fallopian tubes. The most common organisms involved are N. gonorrhoeae and C. trachomatis. Other causes of lower abdominal pain, i.e. appendicitis, should always be considered before making a diagnosis of PID. Appendicitis is a medical emergency that is life threatening if untreated. PID is characterized by acute or gradual onset of pain in the lower abdomen. HUMAN IMMUNODEFICIENCY VIRUS INFECTION/ ACQUIRED IMMUNODEFICIENCY SYNDROME (HIV/AIDS) Incubation Period: The time from HIV infection to seroconversion (a positive result on an HIV antibody laboratory test on blood or oral fluid) is a few weeks to a few months. The interval between HIV infection and diagnosis of AIDS varies greatly with todayвЂ™s treatment; the range in adults is from about two to 15 years. AIDS is caused by a retrovirus, known as human immunodeficiency virus (HIV). Tests for HIV antibodies are in widespread use and confirmed positive test results indicate infection by the virus. HIV is transmitted sexually and through contact with blood such as when injecting illicit drugs or in tattooing. HIV also may be transmitted through transfusions of blood or blood components, medical contact with blood (as in surgery or in treating open wounds), and prenatally from HIV infected mothers to their infants. Tthe more common manifestations include severe immunosuppression (as measured by a decline in the T-helper lymphocyte count to below 200 cells per ml of blood), wasting syndrome (loss of more than 10% of body weight), Pneumocystis carinii pneumonia (PCP), tuberculosis (TB), bacterial pneumonias, cytomegalovirus retinitis, Kaposi's sarcoma, cryptococcal meningitis, candidiasis of the esophagus, toxoplasmosis of the central nervous Adenoviruses Many adenoviruses cause febrile syndromes commonly associated with upper and lower airway diseases such as pharyngitis, bronchitis, and pneumonia . Over 49 adenoviruses have been described as etiologic agents of acute respiratory distress syndrome (ARDS) but only a few are major respiratory pathogens. These agents are extremely contagious, resulting in epidemic outbreaks worldwide in crowded quarters such as recruit training sites. Symptoms Fever, headache, prostration, coryza (nasal mucous membrane inflammation and discharge), sore throat and cough after short (1-5 days) incubation period; usually occurs with constitutional symptoms of malaise, chills, anorexia; persists for 2-5 days then spontaneously resolves. Signs Vitals: fever up to 102В°F Inspection: Follicular, erythematous, or exudative pharynx/tonsils; swollen, tender cervical lymph nodes; conjunctivitis. Auscultation: Possible rales 97 Lab: Monospot to rule out mononucleosis Differential Diagnosis Pneumonia - may be indistinguishable from viral ARD or ARDS (see Respiratory: Pneumonia). Pharyngitis - ulcerative pharyngitis is associated with the enteroviruses; palatal petechiae, red beefy uvula, and scarlatiniform rashes are often associated with Group A streptococcal pharyngitis. Influenza - typically results in more systemic disease, including sustained fever, malaise, and myalgia accompanying respiratory manifestations in adults Infectious Mononucleosis - persistent illness for several weeks suggests Infectious Mononucleosis Treatment: There is no specific therapy. Arboviral Encephalitis Arthropod-borne viruses (arboviruses), including Japanese encephalitis (JE), West Nile (WN), tickborne encephalitis (TBE), St. Louis encephalitis (SLE), Kunjin, and Murray Valley encephalitis (MVE) flaviviruses have been associated with sporadic fatal meningoencephalitis in humans. Japanese encephalitis is the most common and one of the most dangerous arboviral encephalitides (inflammation of the brain tissue), with over 50,000 cases reported annually. 25% of individuals with JE die from the disease and 50% are left with permanent neurologic or psychiatric sequelae. Symptoms Sudden fever, headache, vomiting, and dizziness; rapid progression of mental status changesвЂ” disorientation, focal neurologic signs, seizures, stupor and coma; followed usually by recovery, or death (1-60% mortality) or severe sequelae. Signs Neurological: Use Glasgow coma scale (GCS) to track progression of mental status changesVitals: Fever and respiratory insufficiency. Inspection: Transient weakness, diminished sensorium, hyperactive deep tendon reflexes, sensory disturbances; limb paralysis (JE, TBE), paresis of the shoulder girdle or arms (TBE); tremors, abnormal move- ments, and cranial nerve abnormalities (gaze paralysis, speech disorders) (JE). Palpation: Nuchal (neck) rigidity may be present Definitive diagnosis may require lumbar puncture, CT, EEG and other advanced testing. Differential Diagnosis Herpes simplex encephalitis - focal, non-motor changes (personality, speech, temporal seizures) Other Herpesviruses or HIV - Infectious Mononucleosis and HIV sections Rabies, TB, meningitis Subdural hematoma and other trauma Treatment: There is no drug treatment for arboviruses. ANTHRAX (CUTANEOUS) Incubation Period: Within 7 days (usually 2 to 5 days). 98 Cover skin lesion until lesion is free of anthrax bacilli. Anthrax is an acute, infectious bacterial disease that is caused by Bacillus anthracis. When anthrax appears as a skin disease, it may look like an ordinary vesicle, boil, or carbuncle. However, the surrounding skin may become swollen. If the skin lesion ruptures, serous (straw-colored) fluid escapes, revealing a black eschar or scab at the base of the ulcer. There may be severe systemic symptoms such as fever or prostration. It is difficult to distinguish anthrax from an ordinary boil. Someone with a severe skin reaction surrounding a boil plus other bodily symptoms should be treated with antibiotics. CHICKENPOX (VARICELLA) Incubation period: 14 to 21 days. Isolation period: For 1 week after rash appears or until all lesions become crusted. Chicken pox is a highly contagious viral disease that produces a typical rash. It is usually a disease of children and typically occurs in the late winter and early spring. The virus is spread by airborne respiratory secretions as well as by direct contact. It is communicable from a few days before the rash appears until all vesicles have crusted. Individuals normally have it one time and will not be infected again as adults. However, if one did not have it as a child, one can get it as an adult. The disease begins with a running nose, tearing eyes, slight fever to about 101oF (38.3oC), occasional sore throat, loss of appetite, decreased energy, and restlessness. Within 24 hours an eruption appears, mostly on the trunk and face, and occasionally on the arms and legs. The skin lesions arise in crops of vesicles (clear fluid-filled blisters on a slightly raised red base), may become pus-filled, and crust in a few days. As healing occurs, the crusts or scabs fall off. CHOLERA Incubation Period: 12 hours to 5 days (usually 1 to 3 days). Cholera is an acute disease characterized by profuse watery diarrhea, often with vomiting and prostration. It is caused by intestinal infection with certain strains of the bacterium Vibrio cholerae. In severe cases, it causes profound and sometimes fatal dehydration. Cholera is usually acquired by exposure to unclean water sources or by eating seafood exposed to such water sources. Cholera is not transmitted through direct contact with an infected person, though it is readily transmitted through any fecal contamination from an infected person. The symptoms of cholera usually begin within one to three days after exposure. Diarrhea may be the only symptom in mild cases. In more severe cases, patients have profuse watery diarrhea, vomiting, and prostration or collapse. Typical stools are almost clear water with shreds of mucus, and are described as rice-water stools. The diarrhea may be continuous, leading to tremendous loss of body fluids and dehydration. Cholera is an officially notifiable disease. 99 DENGUE FEVER (BREAKBONE FEVER) Incubation Period: 3 to 15 days (usually 4 to 6 days). Isolation Period: 5 days after onset or until fever abates, in a screened room or under a bednet. Dengue fever is an acute viral disease that is transmitted by the bite of an infective Aedes mosquito. Aedes aegypti, a highly domesticated urban mosquito, is the principal vector. For the virus to be transmitted, the following sequence of events must take place: Гђ female mosquitoes feed on the blood of an infected person from 1 to 2 days before the person's illness began to 5 days after onset of illness P the virus develops in the mosquito tissues for 8 to 12 days \ the female mosquito transfers the virus to susceptible persons when it feeds Dengue fever is characterized by a sudden onset of fever, which may rise to 102o to 105oF (38.8-40.5oC), headache, eye pain, backache, bone and joint pain, weakness, and malaise. Nausea and vomiting are common. Some patients have a blotchy rash, flushing, conjunctivitis, taste aberrations, loss of appetite, and abdominal pain. Fever and associated symptoms may last for 3 to 5 days, followed by complete recovery. The decline in fever may be followed 1 to 3 days later by another rise in temperature and associated symptoms (saddleback fever). A second rash, varying in form, may appear with the first decline in temperature. Mild to severe bleeding may occur from the nose, gums, gastrointestinal tract, and skin. DIPHTHERIA Incubation Period: 2 to 5 days. Isolation Period: 14 days after onset. Diphtheria is a serious acute infectious disease that is caused by the Corynebacterium diphtheriae bacillus. The bacteria grow in the throat, nose, or windpipe and give off a toxin (poison) that causes an illness of the entire body. Prevented by diphtheria toxoid injection with booster doses every ten years. Early symptoms of diphtheria include: overall body discomfort, restlessness, weakness, loss of appetite, headache, and chills. Sore throat with fever to 103oF (39.4oC), prostration, vomiting, and convulsions may develop in some cases. Dirty gray patches of an adherent membrane form in the back of the throat and in the windpipe itself. These patches resemble dead skin and when brushed, come away with difficulty leaving tiny bleeding points in the uncovered mucous membrane. There may be a bloody nasal discharge and a вЂњcroupyвЂќ cough. GASTROENTERITIS/DIARRHEAL ILLNESSES Diarrheal disease is often due to inflammation of the intestines and may be referred to as gastroenteritis, colitis or dysentery. 100 Gastroenteritis is inflammation of the stomach and intestines. Inflammation of the large bowel is referred to as colitis. Dysentery usually presents with bloody diarrhea and is often of bacterial origin. These terms are often used interchangeably. Specific causes of diarrhea and some special treatments are outlined below: Viruses - Many viruses present as intestinal illness. Usually, there is little or no fever. The onset of illness lasts several hours and is usually over within two or three days. The vomitus and stools are typically watery without blood or mucus. The patient often feels reasonably well in between bouts of diarrhea and vomiting. Bacteria - Salmonella, shigella, campylobacter, yersinia, and cholera are some of the bacterial causes of dysentery. Clinically these infections can resemble viral gastrointestinal illness, although blood or mucus in the stool is more typical. Shigella may present with seizures. Salmonella may be carried in undercooked poultry, powdered eggs, powdered milk, or other food, as well as by livestock and pets. Pets may also be a source for campylobacter and yersinia. Diagnosis requires stool examination and culture. Toxin induced food poisoning - Although staphylococcal organisms are bacteria, it is the toxin they produce that is responsible for the symptoms of food poisoning. Undercooked poultry and poorly refrigerated foods such as pastries, custards, and mayonnaise are typical sources. Symptoms usually begin rapidly and violently within one to six hours after eating contaminated food. Profuse vomiting, diarrhea, abdominal cramps, and prostration occur. Campyolobacter difficille colitis - Referred to as C. diff. colitis, is another form of toxin producing colitis, and commonly follows antibiotic therapy. Antibiotics destroy normal gut flora which allows this organism to take over and multiply, producing bloody or non-bloody diarrhea. History of antibiotic use, severity of symptoms, and prolonged illness can be clues to diagnosis. Stool cultures are required to detect the toxin, and medical advice and referral are necessary. Amebic dysentery - The only known human infectious cause of amebic dysentery is via the parasite Entamaeba histolytica. Amoebiasis tends to be a chronic diarrheal illness that may produce an acute colitis which is indistinguishable from bacterial dysentery. Diagnosis requires laboratory identification of the amoeba in the feces. Fever is usual. Abcesses may form in the liver or elsewhere, which may prove fatal in exceptional cases. Other - Chronic forms of diarrheal illness can be non-ifectious such as ulcerative colitis, regional enteritis, functional/spastic colon, and malabsorption syndromes. Hantavirus Hantaviruses infect rodents worldwide and aerosolization of rodent excreta (especially urine) is responsible for transmitting infection. There are many hantaviruses, Sin Nombre virus, mainly found in the western U.S. and Canada, causes Hantavirus Pulmonary syndrome (HPS). The incubation period is generally 1 to 4 weeks. Symptoms Constitutional: Acute (1-4 days): High fever, chills, myalgias, headache; Sub-acute (5-14 days): Low grade fever, apprehension; Chronic (> 2 weeks): Fatigue and lethargy Specific: Acute (1-4 days): Abdominal pain, flushed face; Sub acute (5-14 days): Low urine output, back pain; Chronic (> 2 weeks): Diuresis, renal concentrating defect Signs Acute (1-4 days): Toxic appearance, fever to 104В°F, conjunctival injection, flushed face/neck/ upper torso (blanches with pressure), dermatographism (drawing on skin leaves an exaggerated mark); 101 Sub-acute (5-14 days): Temperature up to 101В°F, truncal and axillary fold petechiae, lowered blood pressure, low urine output up to day 7, profound diuresis thereafter(up to liters/day) Inspection: Acute (1-4 days): Increased respiratory rate, accessory muscle use for breathing, Fever to 104В° F Auscultation: Acute (1-4 days): Lungs often normal, tachycardia, mild hypotension; Sub acute (5-14 days): Diffuse вЂњVelcroвЂќ rales LAB: Urine is dilute (specific gravity 1.010) with proteinuria, hematuria, occasional red and white blood cell casts; may see elevated white blood count, thrombocytopenia, increased hematocrit (up to 55-65% in severe infection). Pulse oximetry may demonstrate hypoxia even if CXR is normal in HPS. CXR may show bilateral whiteout, pleural effusion, increased vascular markings; may see elevated white blood count, thrombocytopenia, increased hematocrit (up to 55-65% in severe infection). Differential Diagnosis Leptospirosis - pulmonary hemorrhage presentation of leptospirosis (as seen in Hawaii) may present similarly to HPS. Travel history, conjunctival redness and skin contact with standing fresh water all suggest leptospirosis. Hemorrhagic fever virus - more prominent bleeding (HFRS can have bleeding, but late in course) and rash seen with some types. Typhus - responds to doxycycline, presents with a rash, lowered white blood cell count, and tache noire for some types. Also consider plague, tularemia. Treatment Avoid excess fluids; consider blood transfusion and Trendelenburg position for shock; give O2. For HFRS, ribavirin IV 2 gram loading dose, then 1 gram q 6 hours for 4 days, then 500mg q 8 hours for 6 days. General: This infection has high mortality. Most deaths occur within the first 48 hrs. HEPATITIS, VIRAL Hepatitis is an inflammation of the liver that results in acute and chronic forms of disease. Many agents cause hepatitis including viruses, drugs, alcohol, and other non-viral infectious diseases. It is important to exclude non-viral causes of hepatitis since their treatment differs. Hepatitis A and E virus transmission mainly occurs by a fecal-oral route via person-to-person transmission and foodborne outbreaks. Hepatitis B, hepatitis C, and the hepatitis delta agents are transmitted by percutaneous and mucous membrane exposures to infectious blood and other body fluids. The most frequent symptoms of acute viral hepatitis are fatigue, muscle pains, nausea, and absence of appetite, which typically develop 1 to 2 weeks before the onset of jaundice. [ yellowing of the skin or eyes, dark brown urine and/or clay-colored stools.] Headaches, joint pains, vomiting, and right-upper-quadrant tenderness are also common. Chronic hepatitis is defined as an inflammation of the liver lasting longer than 6 months. It may be asymptomatic for years. Over time it can develop into serious liver disease or liver cancer. Patients who are chronic carriers can spread the disease to others. Hepatitis A and E are not known to cause chronic hepatitis. Hepatitis B plus or minus the hepatitis delta agent, and hepatitis C typically cause chronic hepatitis. HEPATITIS A (HAV) (Infectious hepatitis, epidemic jaundice) Incubation Period: 15 to 50 days, depending on dose; average 28. 102 Hepatitis A virus (HAV) is transmitted mainly by the fecal-oral route, most commonly by direct personto-person contact. Acute hepatitis A may be symptomatic or asymptomatic. Severity of illness varies and most commonly presents as a mild flu-like illness lasting 1 to 2 weeks. Because clinical signs and symptoms are similar to those of other types of viral hepatitis, serologic detection of specific antibody responses to HAV is necessary to confirm the diagnosis. HEPATITIS B (HBV) (Serum hepatitis, Australia antigen hepatitis) Incubation Period: 45 to 160 days, average 120 days. Hepatitis B virus (HBV) is transmitted primarily by percutaneous and mucous membrane exposures to blood and other infectious body fluids. The course of acute hepatitis B is usually divided into an incubation period, pre-icteric, icteric, and convalescent phases. The preicteric phase, typically lasting less than a 1 week, is characterized by the gradual onset of malaise, nausea, right-upper-quadrant pain, and lack of appetite. Fever may be absent or mild. With the onset of the icteric phase, symptoms worsen and dark urine and jaundice appear. This phase may last a few days to several months. Itching and pale stools usually occur after the onset of jaundice. Weight loss of 2 to 10 kilograms is typical. No specific therapy exists for acute hepatitis B. DELTA HEPATITIS (HDV) (Viral hepatitis D, Hepatitis delta virus, Delta agent hepatitis, Deltaassociated hepatitis) Incubation Period: About 2 to 8 weeks as a superinfection; requires HBV as a coinfection. Isolation Period: Same as that for HBV. (See above). Hepatitis delta agent (HDA) is an incomplete virus requiring the helper function of HBV to replicate. Therefore, HDA causes hepatitis but only in conjunction with HBV. HDA can be acquired mainly via sexual transmission as a coinfection with HBV or as a superinfection of chronic HBV carriers. No specific therapy exists for acute Hepatitis D. HEPATITIS C (HCV) (Formerly called post transfusion non-A non-B hepatitis) Incubation Period: 2 weeks to 26 weeks, average 6 to 7 weeks. Isolation Period: None. Groups at high risk include injection-drug users, hemophiliacs, hemodialysis patients, persons with high-risk sexual behaviors, or those with sexual or household exposure to HCV carriers, and health care workers. HCV may present asymptomatically. Because clinical signs and symptoms are similar to those of other types of viral hepatitis, specific serologic tests for antibodies to HCV are required to establish a diagnosis of hepatitis C. HEPATITIS E (HEV) (Enterically transmitted or epidemic non-A non-B hepatitis, fecal-oral non-A non- B hepatitis) Incubation Period: 15 to 64 days; mean incubation ranges of 26 to 42 days have been reported. Isolation Period: 103 Hepatitis E is a self-limited, acute disease similar to hepatitis A in that it only presents acutely (no chronic state exists) and it is transmitted via the fecal oral route. INFLUENZA (FLU) Incubation period: 1 to 3 days. Isolation period: None. Influenza is an acute respiratory illness caused by influenza type A or B viruses. Typical manifestations include fever, cough, sore throat and coryza, accompanied by headache, muscle and joint aches and extreme fatigue. Influenza is easily transmitted by airborne spread. The most severe symptoms typically occur over 2 - 4 days and frequently require bedrest. Immunization with influenza vaccine is the primary method of prevention. Persons at highest risk who should be immunized include: N persons age 65 yrs or older and those any age who have certain chronic health conditions Г health care providers and household contacts of persons at high risk Q military personnel to prevent disruption of activities during epidemics Г students living in dormitories because of close living conditions LEGIONNAIRESвЂ™ DISEASE (LEGIONELLOSIS) Incubation period: 2-14 days Isolation period: None.. Legionnaires' disease is a common type of pneumonia caused by Legionella bacteria. Symptoms often include fever, shortness of breath, cough, chest discomfort, weakness, headache, confusion, and diarrhea. Illness can range from gradual malaise, muscle aches, loss of appetite, and low grade fever to explosive high fever and respiratory failure developing within 24 hrs. The illness can be quite serious and up to 15% of cases end in death. Legionnaires' disease is not spread from person-to-person. Most illnesses occur as a result of inhalation of aerosols or mists containing Legionella within water droplets. such as from air handling systems Only a small proportion of those exposed to contaminated aerosols during outbreaks develop illness. Antimicrobial treatment, given early in the course of illness, can substantially reduce the risk of serious complications. Antibiotics such as fluoroquinolones (ciprofloxacin), erythromycin, or azithromycin are used for treatment. MALARIA Incubation period: 7-28 days. Malaria transmission occurs on every continent in subtropical and tropical regions. Disease in humans is caused by one of four parasites called Plasmodium (falciparum, vivax, ovale and malariae). Plasmodium falciparum causes the most severe infections, and greatest number of deaths. P. falciparum has developed resistance to chloroquine, a drug widely used to both prevent and treat malaria in many areas. P. vivax has developed resistance to chloroquine on the island of Papua New Guinea. 104 Infection results from a bite from an infected female Anopheles mosquito which injects parasites when it takes a blood meal; these enter human liver cells. After one to two weeks of development, blood stage parasites burst from liver cells, enter the blood, and invade red blood cells. Asexual reproduction occurs in red blood cells, forming many more parasites. The red blood cells rupture releasing more parasites, which then infect more red blood cells. This continuous cycle causes symptoms of malaria illness and destruction of red blood cells. MEASLES (RUBEOLA) Incubation Period: 8 to 13 days, sometimes more. Isolation Period: From diagnosis until 7 days after the rash appears. In the U.S. measles is largely prevented by vaccination Measles, an acute viral disease, is among the most contagious of all communicable diseases. The virus is found in secretions of the nose, mouth, throat, and lungs of infected persons. Many adults have had the disease in childhood, and one attack provides lifelong immunity. Complications include diarrhea, pneumonia, ear infection, and inflammation of the brain (encephalitis). In unvaccinated populations in developing countries measles is a leading cause of pediatric deaths. Symptoms begin within 2 wks of exposure. Onset is sudden with a general overall feeling of illness, sneezing, runny nose, headache, sore throat, cough, soreness of the eyes, dislike of bright light, and a rise in temperature to about 102oF (38.8oC). Copious tears, swollen lids, and bloodshot eyes may be present. During this early stage the disease is most contagious. On the second and third day symptoms become more marked and the face gets a puffy look. On the inner side of the cheeks, where the back teeth meet, tiny whitish spots (KoplikвЂ™s spots) may be seen. The patient now should be isolated, if not already done. After 3 - 5 days of the disease, the typical measles rash appears. The rash of a reddish hue with slightly raised irregular blotch patches starts on the forehead and behind the ears, and gradually spreads to the face, body, and limbs. The rash remains about 4 - 5 days, then fades in the same sequence that it appeared. This is followed by a fine peeling of the skin. As the rash disappears, the patient becomes non-infectious and the temperature drops to normal. MEASLES, GERMAN (RUBELLA) Incubation Period: 12 to 23 days (rash 14 to 17 days after exposure). Isolation Period: 7 days after onset of rash. German Measles usually called three-day measles In the week preceding rash, older children and adults may have low-grade fever, malaise, symptoms of upper respiratory infection, and swelling and tenderness of lymph nodes in the neck, especially behind the ears. A pink rash, which begins on the face and moves to the trunk, lasts about 3 days. There may be a general feeling of bodily discomfort, headache, symptoms of a common cold, eye soreness, stiffness of joints, and a slight fever, about 102oF (38.8o C). Rubella vaccine is a live attenuated vaccine commonly given in combination with the measles and mumps vaccines (MMR). 105 MENINGOCOCCAL DISEASE Incubation Period: 1 to 10 days, most commonly less than 4 days. Isolation Period: Routine isolation for the first 24 hrs of therapy and prophylaxis of household contacts as described below. Infections caused by the gram-negative bacterial pathogen Neisseria meningitidis. Fever, headache, and stiff neck are the most common symptoms Alteration in mental status may also occur, and patients may have a rash. Onset of rash may be quite abrupt and the patient appear quite toxic. The rash itself may be petechial (pink dots), purpuric (look like diffuse bruises or blueberry muffin), or macular (larger pink rash difficult to distinguish from other viral rashes). Meningeal inflammation may be manifested by Kernig's sign and/or Brudzinski's sign. Kernig's sign is resistance to passive extension of the leg when the hip is flexed while supine. Brudzinski's sign is spontaneous flexion of hips and knees with passive flexion of the neck. MONONUCLEOSIS, INFECTIOUS Incubation period: 21 to 42 days. Isolation period: None. Infectious mononucleosis is an acute viral disease, caused by Epstein-Barr virus (EBV), and characterized by fever, sore throat (often with exudative pharyngitis), and lymphadenopathy. The first symptoms are similar to any upper respiratory infection: with fever, chills, headache, cough, and general malaise. After two to three days, swollen lymph glands may appear on the sides and back of the neck, in the armpits, and the groin. Enlargement of the spleen is noted in 50% of young adults, and jaundice (yellow color) of the skin and eyes in about 4%. The diagnosis is aided by finding lymphocytosis of greater than 50% with 10% or more atypical lymphocytes on a peripheral blood smear. It is serologically confirmed by heterophile and EpsteinBarr virus blood tests. Treatment: There is no specific treatment for infectious mononucleosis except bed rest during the acute phase. Bed rest should be extended in cases with prolonged fever. Robust exercise should be avoided by any cases with abdominal pain or tenderness, which may be associated with enlargement of the spleen, to reduce the possibilities of rupture. MUMPS (EPIDEMIC PAROTITIS) Incubation Period: 12 to 26 days. Isolation Period: 9 days from onset of parotitis (swelling of salivary glands). Acute, contagious, viral disease identified by tenderness and swelling of one or more of the salivary glands. Usually the parotid glands are affected. The virus may be spread by direct or indirect contact with nose and throat discharges from an infected person. 106 One attack usually gives immunity for life. The disease begins with malaise, headache, a slight rise in temperature, and possibly nausea. In severe cases the temperature may reach 104oF (40oC) and last as long as a week. On the second day the swelling usually begins on one side of the jaw or cheek and increases greatly. In a couple of days, there is considerable enlargement at the side of the neck, posterior part of the cheek, and underneath the side of the jawbone. The patient complains of pain and stiffness on moving the lower jaw. The opposite side of the face usually becomes affected in a few days, though infection may occur unilaterally. The swelling lasts about 10 days. In young adult males, the infection may spread to one or both testicles to produce a painful inflammation and swelling called orchitis. Some degree of testicular atrophy is common, but sterility is rare. Treatment Bed rest with strict isolation nursing technique. Analgesics-antipyretics such as acetaminophen relieve pain caused by salivary gland inflammation and reduce fever. Warm or cold packs applied to the inflamed areas may relieve discomfort. Fluids should be encouraged with a soft diet. PLAGUE Incubation Period: 2 to 6 days. Isolation period: Until declared free from infection by a physician. An acute, sometimes fulminating disease caused by the Gram-negative bacillus, Yersinia pestis. Plague is primarily a disease of rodents and is most often transmitted to humans by the bite of BUBONIC PLAGUE Most common form, is usually acquired by the bite of an infected rodent flea. The disease may also be transmitted by direct contact with tissues or body fluids of an infected animal. The onset of illness is usually heralded by fever, intense headache, fatigue, and profound weakness. The fever often rises to 102o F (38.9o C) or higher on the first day of illness, then fluctuates. The pulse is rapid, sweating and chills may occur, and the patient may experience extreme thirst. The patient often becomes anxious or agitated, and delirium and convulsions may develop. The characteristic buboes (swollen, extremely tender lymph nodes) usually develop on the second or third day of illness, most often in the inguinal (groin) area, in the axillary (armpit) area and in the cervical (neck) region. The affected glands often swell to a size of 2 or more inches (5 cm) in diameter and are surrounded by edema of the soft tissues. The overlying skin is usually reddened, warm, and extremely painful. PNEUMONIC PLAGUE Primary pneumonic plague, spread by respiratory droplets exhaled by coughing, talking, or sneezing, is the least common, but most serious form of the disease. 107 Fatal, unless the patient is treated early with the appropriate antibiotic regimen (within 18-24 hours after onset of symptoms). Symptoms are as described above with the additional problems of cough, rapid respirations, difficulty in breathing, and cyanosis that may occur as the pneumonia advances. The sputum may be scant and blood-tinged, or may be profuse, watery, and bloody. SEPTICEMIC PLAGUE Primary septicemic plague (infection of the bloodstream) occurs in 10% or less of all cases. It usually arises from direct handling of infected tissue and fluids of infected animals. Septicemia secondary to bubonic or pneumonic plague is not uncommon The patient is rapidly prostrated and may develop irreversible septic shock. Clotting problems as evidenced by bleeding are common. If not treated promptly, death often occurs in 2 to 4 days, frequently preceded by delirium, stupor, and coma. POLIOMYELITIS Incubation Period: Commonly 7 to 14 days, with a range from 3 to 35 days. Poliomyelitis is an acute viral disease that occurs chiefly in children. It is spread by respiratory and fecal routes. Today polio is wholly preventable with two types of vaccine available: the injectable Salk vaccine (IPV) and the oral Sabin vaccine (OPV). RABIES (HYDROPHOBIA) Incubation Period: 10 days to more than 12 months (usually under 4 months). Patients bitten about the head and those with extensive bites may have shorter incubation periods. Isolation Period: Duration of the illness. Rabies is an acute infectious viral disease that is almost always fatal. When a rabid mammal bites a human or other animals, its saliva transmits the infection into the wound where it spreads to the central nervous system. Human rabies may begin with fever, nausea, headache, loss of appetite, and sore throat. The body temperature may rise to 1030F (39.40C). At the bite wound, there may be a tingling or burning feeling. As the infection progresses, extensive portions of the brain and central nervous system become involved. Paralysis and muscle spasms occur, with spasms of muscles in the mouth and throat that control swallowing. The term hydrophobia (fear of water) derives from the patientвЂ™s inability to drink, regardless of thirst. Patients become very weak and their mental outlook changes. They become apprehensive, irrational, even maniacal. They may suffer from widespread muscular twitching and convulsive seizures provoked by any stimulus, especially by attempts to drink or even air currents. Thick ropy saliva may drip from the lips. Eventually there are breathing difficulties, coma, and general paralysis. Tetanus toxoid or prophylactic antibiotics may be indicated depending upon the patientвЂ™s vaccine history and the extent of the bite. 108 RHEUMATIC FEVER Incubation Period: 7-14 days. Isolation Period: None. Evidence of a recent strep throat infection is of course supportive. A positive throat culture, a rapid antigen detection test and/or elevated or rising ASO (strep antibody) titers would be tests which would be supportive, were one to have access to such studies. symptoms: b migratory joint pains or heart problems such as chest discomfort that suggest swelling, 0 a new murmur, rapid heart rate, skin nodules migratory rash fever RELAPSING FEVER (TICK-AND LOUSE-BORNE RELAPSING FEVER) Incubation Period: 5 to 15 days (usually 8 days). Isolation Period: None. Relapsing fever is an acute infectious disease caused by spirochetes of the genus Borrelia. It is transmitted by lice and ticks. The disease is characterized by rapid onset of fever, chills, dizziness, headache, muscle and joint pains, vomiting, and at times delirium. The fever remains high for two to nine days, then ends suddenly by crisis, in which there is a further rise in fever accompanied by rigors, followed by a rapid fall in body temperature and drenching sweats. This is followed by several days of fair health without symptoms, after which a relapse usually occurs, plus jaundice in some cases. There may be three, four, or more recurrent attacks, each decreasing in severity, as immunity develops. SCARLET FEVER Incubation period: 1-4 days. Isolation period: None. Scarlet fever consists of a streptococcal infection, usually a strep throat, accompanied by a characteristic rash. The symptoms of scarlet fever include those of a strep throat: mild to severe sore throat (sometimes asymptomatic), fever, chills, malaise, abdominal complaints/vomiting. The throat may look normal or erythematous with a purulent exudate over the tonsils. Enlarged, tender anterior cervical lymph nodes may be palpable accompanying the infection. The scarlet fever rash typically has a sandpaper-like quality and begins on the first or second day of illness. It spreads over the trunk to the extremities but spares the palms and soles. The rash may also be accentuated in areas of the skin folds (PastiaвЂ™s lines). The tongue may have a strawberry-like appearance (strawberry tongue). The rash usually subsides within a week and is often followed within several days by desquamation of the palms and soles. It is one of few rashes affecting the palms of the hands and soles of the feet. 109 Treatment: intramuscular benzathine penicillin G or a complete 10 day course of oral penicillin V, or erythromycin for those with penicillin allergy. SHINGLES Herpes Zoster Same virus that causes chicken pox. The rash of shingles follows a dermatome pattern and is typically quite painful. TETANUS (LOCKJAW) Incubation Period: 3 - 21 days or more (depending on character, location, and extent of wound). Isolation Period: None. Tetanus can be prevented with vaccine вЂ“ current vaccination is critical. Tetanus is caused by a toxin produced by the bacillus Clostridium tetani, a bacterium that grows in the absence of air at the site of an injury. Tetanus bacteria commonly enter the body through wounds contaminated by debris or foreign bodies. Early symptoms are aches and pains in the muscles, general fatigue, and headache. Soon the characteristic signs appear - stiffness of the neck and jaw that gradually extends to the muscles of the back and the extremities. The jaw may become clenched tightly (lockjaw). The body is held rigidly straight or arched so that the patientвЂ™s back may touch the bed only with his head and heels. TUBERCULOSIS Incubation Period: Variable, from 10 weeks to years. Isolation period: Isolation should be discontinued only after the patient has been evaluated, treated, and declared noninfectious by a physician. Tuberculosis (TB) is an infectious disease caused by bacteria called Mycobacterium tuberculosis. TB can attack any part of the body, but most commonly causes lung disease. Bacteria are expelled into the air by a person with active TB and patients are most infectious when they have a cough. Persons with human immunodeficiency virus (HIV) infection or other immune suppressing conditions(transplant recipients); persons with other medical conditions such as diabetes, silicosis, and malnutrition; or those in the extremes of ages (infants and elderly). General symptoms include a persistent cough, weight loss, fever, night sweats, chills, loss of appetite, and fatigue. The most reliable signs of TB are a cough that persists for more than 2 weeks, often with blood tinged sputum, and chest pain. TB therapy consists of several drugs, which must be taken for an extended period, usually for at least 6 months. Some of the drugs used include isoniazid, pyridoxine and rifampin. Susceptibility to TB drugs should be tested. 110 TYPHOID FEVER (ENTERIC FEVER) Incubation Period: Usually 1-3 wks, depending upon size of infectious dose and vaccine status. Isolation Period: Isolation not required. Typhoid fever is caused by the bacterium Salmonella typhi. A high fever with a slow pulse rate, lasting more than a week, plus headache and abdominal pain, may be presenting signs. Onset of fever is gradual and may rise in a stepwise fashion over 2 - 3 days, peaking at 103-104oF (38.8 - 40oC). Chills, mental cloudiness, malaise, constipation, abdominal pain, nausea, and loss of appetite may present early on. Diarrhea and vomiting are less common. One-third will have a dry cough. Within the first week, a sparse rash may appear on the chest and/or abdomen which typically consists of a few red, flat, nontender lesions ("rose spots"), 1-2 mm in diameter. The abdomen may be slightly distended with a varying degree of tenderness. Bleeding and perforation of the bowels are two of the most common complications of typhoid fever; typically occurring 2-3 weeks after the onset of the illness. TYPHUS FEVER Incubation period: 10 to 20 days. Isolation period: Until declared free from infection by a physician. Typhus fever is a term applied to several worldwide forms of disease that are caused by obligate intracellular bacteria of the family Rickettsiaceae. Each form of this disease is characterized by sudden onset of nonspecific symptoms that often include fever, headache, chills, muscle aches, joint pains, and rash. Malaise may progress to prostration. Anorexia, cough, and photophobia (pain from bright lights) may also occur. Each species of rickettsia is transmitted via a particular arthropod vector, including ticks, lice, fleas, and mites. Humans who engage in activities that bring them in close contact with vectors, reservoirs, or both, are at increased risk for these zoonotic diseases. The most serious of the typhus fevers is Rocky Mountain spotted fever (RMSF). This disease is carried by a tickborne vector and is the most commonly encountered rickettsia in the United States. Persons who have frequent outdoor exposures to ticks, including campers, hikers, fisherman, and hunters, are at increased risk for infection. Other tickborne typhus fevers are named for the geographic region where they are found. Louse-borne typhus is transmitted within populations living at high altitudes or cold climates where pediculosis is common and bathing and laundering of clothing are infrequent. The disruption of community services, such as electricity and water supplies, that often accompanies armed conflict and natural disasters, provides a potential setting for epidemics. Brill-Zinsser disease occurs as a milder recurrence (recrudescence) among persons who have been inadequately treated in the past for their louse-borne typhus (or among those who have recovered from louse-borne typhus whose immune status has diminished). Fleaborne typhus has a worldwide distribution but is uncommonly reported in the U.S. It is prevalent among populations that live in close association with rodents and their fleas. Persons who have occupational exposure to rodents (e.g., agricultural workers) are at risk. 111 Miteborne typhus (scrub typhus) is widespread throughout Asia and the Pacific Islands. Edge or scrub vegetation provides habitat for rodent hosts of vector mites, and human populations that frequent these areas, including military personnel and agricultural workers, have increased risk. UNDULENT FEVER (BRUCELLOSIS, MALTA FEVER OR MEDITERRANEAN FEVER) Incubation period: Less than 5 days to several months, most cases occur 2 - 8 wks after exposure. Isolation period: Unless the patient has a draining wound, no special precautions are required. Brucellosis is acquired by direct contact with secretions and excretions of infected animals and by ingestion of the milk of cows, sheep, or goats or the products of their milk (butter and cheese) containing the Brucella organisms. The disease is characterized by an acute febrile stage and by a chronic stage with relapses of fever, weakness, sweats, and general aches and pains. WHOOPING COUGH (PERTUSSIS) Incubation Period: 7 to 14 days. Isolation Period: For 4 weeks (after the cough begins.) Whooping cough is a highly communicable bacterial disease that is caused by the bacillus Bordetella pertussis. The coughing spasms often result in vomiting and are associated with the typical вЂњwhoop.вЂќ The disease is spread by the patientвЂ™s respiratory secretions through coughing, sneezing, and close contact. The characteristic whooping type of cough reaches its worst stage about two or three weeks after symptoms begin. YAWS Incubation Period: 9 to 90 days; generally 21 to 42 days. Isolation Period: None. Avoid intimate contact and contamination of the environment prior to treatment and until 48 to 72 hrs after penicillin treatment. Yaws is a highly infectious, nonvenereal, bacterial tropical disease caused by Treponema pallidum, subspecies pertenue, a species of spirochete similar to that of syphilis. Yaws is limited to tropical and remote regions of Africa, South America, the Caribbean, Southeast Asia and Indonesia. I About a month after a person becomes infected, the first symptom appears as a painless inflamed raspberry-red elevation of the skin. This is called the "mother yaw" that enlarges and forms an ulcer in its center. The primary lesion may heal in a few weeks or persist for months if left untreated. Two to eight weeks after the appearance of the "mother yaw," open oozing sores occur on the face, scalp, trunk, hands, or feet. The patient may show a slight rise in temperature, general malaise, headache, and pains in bones and joints. 113 CHAPTER 21 Neurologic Disorders Seizure Disorders and Epilepsy A seizure is an uncommon event that can be caused by many different ailments and processes. Not all convulsions become an epileptic condition, and most are brief and self-limited. Once a вЂњdiagnosisвЂќ of epilepsy is documented, it will follow the patient for the rest of their life and greatly impact their employability, insurability, driving status and many other areas. Symptoms: Abrupt onset of abnormal muscle activity, or prodrome of confusion, dГ©jГ vu, peculiar behavior, automatisms, or other psychic phenomena preceding onset. Signs Sudden onset of loss of consciousness, followed by abnormal motor activity such as tonicrigidity, clonic rhythmic movements of the limbs, urinary incontinence, frothing at the mouth, and biting the tongue and mouth; may last seconds to minutes, and is usually followed by a period of weakness, somnolence and confusion (postictal state); will spontaneously stop without any intervention after a few minutes. Differential Diagnosis - the differential diagnosis of a convulsive event is extensive: idiopathic epilepsy, alcohol or drug associated seizures, post concussive syndrome, convulsive syncope, heat stroke, infectious (meningitis), brain mass lesions, nerve gas exposure and metabolic abnormalities. Treatment: Symptomatic treatment initially. 1. Remove the patient from an area where he could injure himself or others. Keep sharp and breakable objects away from the patient. Pad objects if possible to avoid injury. 2. Do not put anything in the patientвЂ™s mouth. Never put your figers in the patientвЂ™s mouth. 3. MEDICATIONS ARE RARELY INDICATED FOR A FIRST TIME SEIZURE. 4. After the seizure, evacuate the patient to an appropriate treatment facility for a neurological examination and further evaluation. For recurrent seizures: 1. If the seizure lasts more than 10 minutes, immediate medical intervention is indicated. 2. Begin an IV access line. 3. EEG monitoring if available. 4. Give 5 to 10 mg IV Valium. 5. If this does not stop the seizure, consider Dilantin 1000 mg IV as an infusion over 30 minutes, not to exceed 50 mg/min. When giving Dilantin as an infusion, do not mix it with D5W because it will precipitate. Clear the IV tubing with normal saline first. 6. If this does not stop the seizure, consider Phenobarbital 10 mg/kg IV over 10 minutes. May be repeated one time. Must have a secure airway and closely monitor breathing. 7. If this does not stop the seizure, general anesthesia or barbiturate coma may be required. Advanced care will be required. 8. Transport to the nearest MTF for further evaluation and disposition. Use Dilantin 300 mg po or IV qd y as these drugs may cause respiratory suppression. 114 If IV unavailable, Phenobarbital may be given IM. Do not give Dilantin or Valium IM. NOTES: If seizure lasts more than ten minutes, there is the possibility of Status Epilepticus. These seizures must be stopped ASAP. This is a life-threatening event and may produce significant brain injury if the patient survives. Emergency medical assistance and intervention must be rapidly sought Meningitis Meningitis is an acute, life-threatening infection of the lining of the brain and spinal cord. It can be caused by a virus, bacteria, fungus, parasite, or more complex organism. Bacterial meningitis is rapidly progressive and should be considered an emergency. Aseptic meningitis (normally caused by viruses) has a slower course. . Symptoms: Fever, stiff neck, headache, photophobia, malaise; later: delirium, coma, seizures, nausea, vomiting, dizziness Signs Fever to 104В°F; cervical meningismus (stiff neck, painful to move); prostration; toxic appearance; positive KernigвЂ™s sign (inability to completely extend the knees straight вЂ“ stretches spinal cord); positive Brudzinski sign (forward flexion of the head produces flexion at hip and knee вЂ“ stretches spinal cord); rash (may indicate activation of the clotting cascadeвЂ”hemorrhagic fevers; or petechial with meningococcus). Chronic infection: deafness. NOTE: Do complete neurological examination, including Glasgow Coma Scale, looking for alterations of mental status or ambulation, and focal neurological deficits. Perform a thorough examination for possible sources of infection, such as middle ear, sinus, lungs, urinary tract, and wounds. Lab: WBC count or blood smear (may show leukocytosis in bacterial meningitis), urinalysis; RPR, blood cultures; chest X-ray Differential Diagnosis: If in doubt, treat for bacterial meningitis. Meningitis comes in many forms that are infectious, the most common including bacterial and viral. Fungal forms also may occur in immuno-compromised patients. Other more rare forms include tuberculous, parasitic, spirochetal. Rickettsial infection - usually no leukocytosis; no meningeal signs; вЂњtache noireвЂќ lesion (ulcer covered with black, adherent crust). Leptospirosis - look for conjunctival discharge; history of exposure to water which might be contaminated with animal urine Cerebral malaria - no meningeal signs; positive blood smear; thrombocytopenia Malignancy - variable symptoms based on lesion location. Severe viral or bacterial sepsis with headache, high fever, but without meningeal seeding. Brain abscess - focal neurologic пЂЃndings; low-grade temperatures; no neck stiffness or tenderness Subdural/Epidural hematoma - history of trauma with rapid or progressive development of symptoms. Subarachnoid hemorrhage - often low-grade temperature; acute onset preceded by severe head aches; focal neurologic findings. Stroke - variable symptoms based on lesion location. 115 Treatment: 1. Begin antibiotics as soon as possible if bacterial meningitis is suspected (time to antibiotic administration is correlated with outcome). Empiric Choices: Penicillin: 24 million units/day in 6 divided doses, ampicillin: 12 gm/day in 6 divided doses, vancomycin: 2 gm/day in 2 divided doses, ceftriaxone: 6 gm/day in 3 divided doses. 2. Evacuate immediately. 3. Airway support and oxygen. Intubate as needed. 4. Fluid hydration with IV NS or LR. 5. Control fever with Tylenol. 6. If viral meningitis is suspected (slower onset, less severe symptoms), give acyclovir 12.5 mg/kg/day IV divided tid x 10 days. 7. Consider steroids (Decadron 0.4 mg/kg q 12 hour for 4 doses), with first dose prior to starting antibiotics, if bacterial meningitis is likely present (based on an acute presentation). BellвЂ™s Palsy (Idiopathic Facial Nerve Palsy) BellвЂ™s palsy is a common peripheral mononeuropathy involving the seventh cranial nerve. It usually follows a benign course, has no obvious underlying cause and is a condition from which nearly all patients recover fully. Symptoms: Abrupt onset of ear pain followed by weakness in muscles of facial expression, slurred speech and drooling when drinking; diminished or altered taste, increased sensitivity to sound on the involved side; evolves over 1-2 days; bilateral involvement and numbness are rare. Signs: Unilateral weakness (paresis) of the entire face, slurred speech and drooling Differential Diagnosis: Bilateral involvement can occur, but is rare and suggests more serious disease such as sarcoidosis, Lyme disease or Guillain-Barre syndrome. Idiopathic neuropathy Herpes zoster - simultaneous characteristic vesicular eruptions in the ear canal or on the face. Lyme disease - a history of tick bite and characteristic rash (erythema migrans). Sarcoidosis - paralysis of additional parts of the nervous system. Guillain-Barre - absence of reflexes are typical of Guillain-Barre. Myasthenia gravis - weakness of additional muscles (especially the eye muscles, causing double vision). Peripheral Nerve System (PNS) Lesion - weakness of the forehead corrugator muscles and absence of involve- ment in other parts of the nervous system suggest a more serious disorder such as a peripheral nerve problem from a central lesion in the cerebrum or brainstem. Treatment: 1. Protect the eye from exposure keratitis (dryness, erythema, poor vision) and foreign bodies by wearing eyeglasses when outdoors and taping or patching the eye during sleep. 2. Instill artificial tears several times throughout the day and viscous artificial tears (if available) at bedtime will help keep the eye surface lubricated and free of debris. 3. Prednisone 60mg/day po with taper over 10 вЂ“ 14 days for severe cases. Most young adults will make a full recovery with no treatments. 4. For herpes zoster, give Acyclovir 800 mg po five times a day x 5 days. 116 Examining the peripheral nerves Whenever a patient has injured a limb, especially if he has a penetrating wound, test the function of its nerves and tendons before you anaesthetize him. Test the most distal point supplied by each nerve. The following tests are so quick that you can do them all in a few seconds. Always record your results. It will then be certain that paralysis is not the result of treatment. QUICK TESTS FOR PERIPHERAL NERVES Record both power and sensation when you first see a patient, and after each subsequent examination. AXILLARY (CIRCUMFLEX) NERVE This arises from the posterior cord of the bachial plexus, and winds round the neck of a patientвЂ™s humerus to supply his deltoid and the skin over the lower part of this muscle. It is injured in dislocations of the shoulder. Ask the patient to abduct his arm. Put the palm of your hand over his deltoid. Even a flicker of contraction shows that his deltoid is working. Test sensation with a pin on the outer part of his shoulder, over the insertion of his deltoid. If his axillary nerve has been injured, there will be a small patch of anaesthesia. MUSCULOCUTANEOUS NERVE If this nerve has been injured there will be anaesthesia along the outer side of his forearm, and he will be almost unable to flex his arm. SCIATIC NERVE This is sometimes injured by pelvic fractures. Test its peroneal and tibial branches as described below. Test the sensation of the dorsum of his foot. SOME QUICK TESTS FOR PERIPHERAL NERVES. Test the function of an injured patientвЂ™s nerves and tendons before you anaesthetize or refer him. COMMON PERONEAL BRANCH OF SCIATIC NERVE Paralysis causes foot drop. Can he walk on his heels with his forefoot raised? Test for anaesthesia in the distribution of his deep peroneal nerve in the web between his big and second toe. His common peroneal nerve can be injured by Thomas splints, badly applied skin traction, or blows to the neck of his fibula. TIBIAL BRANCH OF SCIATIC NERVE Ask him to plantar flex his ankle, or stand on tip toe. 118 CHAPTER 23 Toxicology Poisoning: General Almost anything in sufficient quantity can be toxic, even substances that are essential to life such as water and oxygen. A poison is any substance that even in small quantities produces harmful physiologic or psychological effects. Poisonings are responsible for 10% of all emergency department visits, 9% of all ambulance patient transports, and 5%-10% of all medical admissions to hospitals. Poisons enter the body through a variety of different routes - ingestion, inhalation, injection, and surface or dermal absorption. The toxic effects of ingested poisons may be immediate when inhaled or injected, or delayed when absorbed through the skin or ingested. Because most substances are absorbed through the small intestine, it may take several hours for the poison to enter the bloodstream. Alcohol, which is absorbed in the stomach, is a notable exception. Use the mnemonic: AEIOUTIPS to recall other causes of altered mental status: A - Alcohol and other toxins/drugs, E - Endocrine (hypothyroidism); I - Insulin, too much (hypoglycemia), or Insulin, too little (hyperglycemia); O - Opiates (heroin, morphine, etc.) and Oxygen, too little (hypoxia); U - Uremia (kidney failure); T - Trauma (head injury, shock)/Temperature (hyper/hypothermia); I - Infection (meningitis, encephalitis); P - Psychiatric (pseudocoma); S - Space-occupying lesion (epidural/subdural hematoma), Stroke, Subarachnoid hemorrhage, Shock. When treating a poisoned/intoxicated patient, the medical practitioner should protect himself. If the patient has been poisoned by a hazardous material, this substance may also pose a risk to the practitioner . Patients who are intoxicated may behave irrationally or violently. Symptoms An accurate history is the most important component of the workup. If poisoning was suicidal in nature or involved the use of illicit drugs, history from patient is often inaccurate or intentionally misleading. Obtain history from family members and obtain description of the scene from persons who initially found the patient. Determine which drugs (legal and illicit) or toxins to which the patient may have had access. In the event of ingestion, determine what was ingested, when it was ingested, and whether the patient vomited. In cases of possible occupational exposure, identify the patientвЂ™s job and the types of toxins to which he/she may have been exposed. 119 Symptoms: hr) Constitutional recovery Acute (< 2 hr) Nausea/vomiting Sub-acute (2-48 hr) Signs/symptoms of Chronic (>48 Death or organ failure +/symptoms are of common chronic organ system damage Location: Three organ systems are most likely to produce immediate morbidity and mortality. Respiratory Difficulty breathing, Shortness of Recovery or chronic shortness of breath breath on exertion shortness of breath, chronic cough, etcвЂ¦ Cardiovascular Fainting/near fainting, Postural hypotension, Recovery or symptoms of palpitations, chest pain shortness of breath on exertion CHF CNS Hallucinations, difficulty concentratingNumbness/tingling/ Recovery or symptoms of, visual disturbances pain, long term visual visual disturbances painful sensations, disturbances learning disabilities, chronic headaches Signs Focus of the initial physical examination should be on ruling out life/limb/sight threatening conditions. In poisonings these involve the respiratory, cardiovascular, and central nervous systems. Inspection: Should reveal spontaneous conversation, gait, posture, general appearance, affect (depressed, agitated, happy) and appearance of the skin (needle track marks or other evidence of drug use, evidence of trauma, discoloration). Vital signs can indicate type and severity of systemic effects. Monitor cardiac function. Perform a basic neuro examination with a focus on mental status (assess for agitation, mania, depression, etc., as well as basic orientation) and eyes (pupil size, equality, and reactivity, nystagmus, visual acuity, and extraocular muscles). Observe gait if possible and perform tests of cerebellar function (i.e.,finger-tonose, rapidly alternating hand movements, heel-to-shin, Romberg). Signs hr) Respiratory Acute(< 2 hr) Dyspnea, wheezing, Sub acute (2-48 hr) Shortness of Chronic (>48 Recovery or COPD, stridor, apnea, breath on exertion restrictive lung disease, hypo/hyperventilation, emphysema, etcвЂ¦ Cardiovascular Hypo/hypertension, Signs of ischemia/ Recovery or signs of infarction, postural recurrent tachy/bradyarrhythmias chronic CV disease, hypotension, early CHF tachy/bradyarrhytmia CNS Stroke, seizures, altered Paralysis, seizures Recovery or persisting mental status to include persistent altered mental persistent mental somnolence/depression status retardation, paralysis, recurrent seizures, coma, agitation/ vegetative state 120 Pulse oximetry (WARNING: Pulse oximetry may be normal in carbon monoxide poisoning, cyanide poisoning initially, methemoglobinemia, and other conditions causing inadequate oxygenation of the tissues). The presence of a normal pulse oximetry reading does not always indicate adequate oxygenation. EKG (arrhythmias). Lab: urinalysis, blood glucose. Drug testing Differential Diagnosis: See AEIOU-TIPS discussion in Introduction. Treatment 1. Secure airway. If patient is hypoxic and/or hypoventilating apply oxygen and assist respirations. 2. Start an IV in all presumed poisoned patients for drug access. Fluid resuscitate as needed to support blood pressure. 3. Treat arrhythmias per ACLS. 4. Decontamination procedures: Decontaminate skin and mucous membranes as required with mild soap and water. Remove patient from any further exposure to toxic vapors/fumes. Give syrup of Ipecac (if within 20 minutes of ingestion), gastric lavage, and/or activated charcoal to minimize toxins in the GI tract (see below). NOTE: Inducing diarrhea is NOT effective and is likely to make the patient worse (dehydration, electrolyte imbalance). Syrup of ipecac - effective in some cases if administered within 20 minutes of ingestion. 1. Administration: a. In patients 1-12 years old, give 15 ml followed by 2-3 glasses of water. b. In patients over 12 years, give 30 ml followed by 2-3 glasses of water. b. May be repeated in 20 minutes if vomiting does not occur. 2. Complications: Mallory-Weiss tear of the esophagus, causing bleeding; pneumomediastinum (air trapped in chest cavity outside the lungs); diaphragmatic or gastric rupture; and/or aspiration pneumonitis 3. Contraindications: Patient < 1 year old, altered level of consciousness (aspiration), ingestion of caustic substances, loss of gag reflex, seizures, pregnancy, acute myocardial infarction, ingestion of: acids, alkalis, ammonia, petroleum distillates, non-toxic agents, rapidly acting central nervous system agents, or hydrocarbons. Gastric lavage - may provide opportunity for immediate recovery of a portion of gastric contents. 1. Administration: A. Use large-bore orogastric tube rather than a smaller nasogastric tube (Size 36-40 French for adults, size 24-28 French for children). B. Never insert large orogastric tubes nasally (may fracture/amputate nasal turbinate and/or cause serious bleeding). 2. Complications: Agitation, tracheal intubation, esophageal perforation, aspiration pneumonitis, pediatric fluid and electrolyte imbalances. 3. Contraindications: Altered levels of consciousness (relative contraindication if the airway is protected), low-viscosity hydrocarbons or caustic agent ingestion. Activated charcoal 1. Administration a. Administering 20-30 minutes before gastric lavage may double the effectiveness of lavage. b. Do not administer until after vomiting if ipecac has already been given. c. Form slurry of 1-2 g/kg body weight (30-100 g for adults, 15-30 g for children), and administered orally or by gastric tube. 2. INDICATIONS/ CONTRAINDICATIONS: a. Safe and effective treatment in most toxic ingestions. b. Do not use for strong acid, strong alkali. c. Not effective for cyanide, iron or alcohol 121 Venomous Snake Bite Venomous snakes cause injuries and deaths worldwide in all temperate and tropical climates, but they are a particular problem in Australia, which has 40% of the worldвЂ™s neurotoxic snakes and about 23% of all venomous snakes. In North America, poisonous snakes cause only 14-20 deaths per year. The risk of death is greatest in the very young, the very old, those with medical problems involving the cardiovascular and respiratory systems and those who sustain multiple bites. Only about 1/5 of snake bites in the U.S. are inflicted by venomous snakes and not all bites by poisonous snakes result in envenomation. Rattlesnakes fail to inject venom in up to 20% of bites. Because snakes either hibernate or are inactive during winter, the peak snakebite season in temperate climates is April-October. In the United States the great majority of poisonous snakebites are caused by pit vipers (Crotalidae), specifically rattlesnakes, copperheads and cottonmouth snakes. Eastern and western diamondback rattlesnakes, although causing only about 10% of all snakebites in the U.S., are responsible for 95% of all snakebite deaths in the U.S. The other poisonous species of snakes in North America (not pit vipers) are the Eastern and Texas coral snakes. They are members of the Elapidae family, along with cobras, kraits, and mambas. Sea snakes belong to the Hydrophidae family. Symptoms Variable depending on type of snake, amount of venom injected, age of victim and other factors. Crotalidae: Acute (2 hr) Sub-acute (2-48 hr) Chronic (>48 hr) Rapid onset Persistent severe Either improving or organ of severe pain at bite site, pain, HA, thirst, dizziness, system failure (renal, severe HA, marked thirst. chills, nausea. Excessive perspiration disseminated hemorrhage, Little/no immediate pain Hydrophidae: Muscle aches/ Pruritus, fever, myalgia,at bite site pains/stiffness and pain on arthritis suggests serum passive movement of arm, sickness secondary to thigh, neck, trunk muscles antivenin admin. Respiratory Onset of anaphylaxis may be Elapidae/Hydrophidae: breathing, shortness of delayed > 2 hr. Respiratory paralysis may be breath. Elapidae/ SOB/ bronchospasm occur. prolonged (up to 7 days) Hydrophidae: Severe Elapidae/Hydrophidae: envenomation may cause respiratory paralysis/arrest respiratory paralysis/arrest possible Cardiovascular If anaphylaxis: Fainting/ Palpitations, shock symptoms Usually no long term effects near fainting, shock symptoms, severe envenomation may cause arrest GI Nausea/Vomiting Nausea/Vomiting Usually no long Neuro term effects Elapidae/Hydrophidae: Blurred vision Elapidae/Hydrophidae: Elapidae/Hydrophidae: Paresthesias (numbness of Recovery or possible lips/soles of feet) long-term numbness, burning/ tingling sensation 122 Soft Tissue Crotalidae: Usually two Crotalidae: Significant Crotalidae: Usually no long fang punctures at site of swelling, tissue necrosis, term morbidity, rapid onset of petechiae, ecchymosis, compartment syndrome, tissue swelling bullaeвЂ“ local & poss. diffuse necrosis, в†“ROM may occur Lab: Hematocrit, urinalysis and 12-lead EKG to assess renal and cardiac complica- tions. Blood transfusion: type and crossmatch as required. Non-venomous snakebite; venomous bite from animal other than a snake; other sources of intoxication. Treatment Goals: rapid transport to hospital-level care, delay progress of envenomation and alleviate early symptoms. Primary 1. Ensure airway is patent and adequate -- if not, secure airway. If hypoxic and/or hypoventilating, apply O2 and assist respirations, prevent aspiration (lay the patient on their side), intubate as required. 2. Start an IV in all snakebitten patients (in an unbitten extremity). Fluid resuscitation to support blood pressure and maintain urine output (see below). Drink water as tolerated but otherwise NPO. NO ALCOHOL! Be prepared for shock. 3. Monitor vital signs with pulse oximetry and cardiac monitoring if available. Treat arrhythmias per ACLS guidelines вЂ“ NOTE: Muscle breakdown may release significant potassium, so consider hyperkalemia if arrhythmias occur. 4. Limit the systemic spread of the venom thru methods described below: a. Keep the patient as calm and inactive as possible. Reassure. Give benzodiazepam (e.g., Valium 5 mg) po as needed. b. Gently clean around the bite site to remove any venom from the skin. c. Immobilize the bitten limb in a dependant position. d. Suctioning the bite site (NOT with mouth) within minutes after bite is reasonable if remote from hospital care. Do not incise over the puncture site. The use of suction is controversial but all agree: never use the mouth to apply suction. A syringe is a good alternative to other suction devices. e. Do not apply tourniquets, ligatures, or constricting bands unless the snake is primarily neurotoxic (Australian elapid, sea snake, krait, cobra or other neurotoxic species). Neurotoxic bites only: apply a constricting band approximately 1 in. wide 2-4 inches above the bite and loose enough to admit a finger. Alternatively, wrap the bitten extremity with an elastic bandage or place it in an air splint. Another method: Place a thick pad over the area of the bite and hold it in place with a tight wrap, wrapping from distal to proximal. If more than 30 minutes after the bite, do not apply a constricting band. Do NOT treat pit viper bites with these methods. Always check for a pulse after applying вЂ“ this is not a tourniquet! f. Measure the circumference of a bitten extremity 10 cm proximal to the bite. Track this measurement and pulses over time. 5. Remove all jewelry from bitten extremity. 6. Insert Foley catheter, record urine output and monitor fluid balance. Check urine for myoglobin (positive for blood on urine dipstick but no RBCs on microscopic exam) and blood. Avoid overhydration (rales, wheezing, orthopnea, respiratory distress, and distended jugular veins). Cautiously hydrate to maintain urine output > 30-50 cc/hr (adults). Administer furosemide (Lasix) up to 100 mg to promote urine output as needed. Give low dose dopamine (2.5 kg/minute) by continuous infusion if necessary to maintain urine output. Give adult victims with myoglobinuria and decreased urine output 25 grams of Mannitol and 100 mEq (generally two ampules) sodium bicarbonate added to 1 liter 5% dextrose and infused over 4 hours to prevent myoglobinuric nephropathy. 7. Treat pain with acetaminophen and opiates as required. Avoid NSAIDs, which interfere with platelet function 123 8, Treat nausea/vomiting with Compazine (give slowly if administering by IV - this can cause/worsen hypotension). 9. Give tetanus toxoid as required. Arguably this may overload the system and an alternative would be tetanus antitoxin 10. DO NOT cauterize, incise, or amputate the bite site. DO NOT apply electric shock or pack bitten limb in ice. These methods have been proven undocumented and unreliable. Anecdotal stories were probably dry bites. 11. If the snake can be SAFELY killed, bring in for identification. Avoid handling the snake. Be sure it is dead. WARNING вЂ“ dead snakes can still reflexively bite! 12. Give antivenin, which is the only proven therapy for snakebite, only if it is specific for the snake involved (monovalent), or if the envenomation is severe (polyvalent). See (and follow) package insert for antivenin-specific instructions. The administration of any type of antivenin has a risk of allergic reaction and serum sickness that can be life-threatening. DO NOT administer antivenin unless the specific criteria for administration are met. Remember: death from snakebite is rare and snakebite without envenomation is common. Inappropriate administration of antivenin can kill a patient who would otherwise have survived without permanent sequelae. In the U.S. even when the offending snake is venomous, and envenomation has occurred (e.g., copperhead), antivenin administration is often not necessary. 13. Be prepared to treat anaphylaxis after giving antivenin with epinephrine 0.3 cc 1:1000 IM and diphen- hydramine 50 mg IM. If patient rapidly becomes hypotensive and/or develops acute severe respiratory distress it may necessary to give 1mg (10cc) 1:10000 epinephrine slowly by IV. NOTES: 1. Snakebites on the extremities can produce extensive swelling that may (but rarely does) lead to the development of a compartment syndrome (pain on passive stretching and active flexing of the involved muscle groups, distal paresthesias, pulselessness, tense overlying tissues). Doing a fasciotomy in a patient with a venom-induced bleeding disorder and local tissue necrosis may cause significant, even life-threatening, bleeding and/or infection. An aggressive surgical approach is more likely to cause harm than good, so delay fasciotomy (see Procedures: Compartment Syndrome Management) as long as feasible. 2. Early, prophylactic, broad-spectrum antibiotic therapy (second-generation cephalosporin вЂ“ Keflex/Ancef) is reasonable but not generally recommended. If suction by mouth has been done, prophylax with erythromycin. Treat infection, if it develops as appropriate. NOTE: Redness, swelling, pain, and increased warmth in the surrounding tissue occur in both envenomation and infection. Alternate: Support the airway, maintain adequate oxygenation, ventilation, urine output and blood pressure until specific, neutralizing, antivenin can be administered. There is no good evidence supporting that any first aid measures aside from those describe herein. 3. Maintaining airway and urine output will save most patients. An overly aggressive surgical approach and resorting to various unproven therapies will cause more harm than good. 4. In the proper circumstances, assume snakebite with envenomation and observe patient for 4-6 hours for development of signs/symptoms. If no signs/symptoms after 6 hours, consider bite w/o envenomation. NOTES: Snake identificationвЂ“Pit vipers: вЂњpitвЂќ located below each nostril; triangular-shaped head; elliptical, not round, pupils; hollow fangs; single, not double row of scales on the ventral (belly) side distal to the anal plate; rattlesnakes usually have a rattle. Coral snakes in U.S. - encircling colored bands of black, red and yellow/white, with the latter bands touching вЂњred on yellow, kill a fellow; red on black, venom lackвЂќ); no long fangs; small mouth makes it difficult for them to bite anything larger than finger. 125 127 128 CHAPTER 28 VENAMOUS REPTILES GUIDELINES AND CONSIDERATIONS: вЂў There are five venomous snake families: 1) Crotalidae. Uses hemotoxic venom. Includes all pit vipers (rattlesnake, copperhead, cottonmouth, etc.) 2) Colubridae. Uses hemotoxic venom. Back fanged snakes. Limits ability to envenomate humans. 3) Elipidae. Uses neurotoxic venom. Includes cobras, mambas, kraits and coral snakes. 4) Viperdae. Uses hemotoxic venom. True vipers. Includes puff adders, vipers and desert adders. 5) Hydrophidae. Uses neurotoxic venom. Sea snakes. вЂў The majority of snakebite victims survive. вЂў Not all bites from poisonous snakes involve injection of venom: Up to 50% of cobra bites and 30% of rattlesnake bites are вЂ�dry strikesвЂ™, meaning no venom is injected. вЂў Operators should be familiar with the types of venomous snakes found in their area of operation, and the recommended field treatment of bites. NOTE 1: All snake venoms (and some large breed lizards) contain components that are neurotoxic and hemotoxic. You will see neurotoxic reactions to primary hemotoxic venoms and hemotoxic reactions to primary neurotoxic venoms. NOTE 2: Bites from large breed lizards (Gila Monster, Komodo Dragon, Monitor, etc) carry a high incidence of infection. Debride aggressively and administer antibiotics. WARNING: Snakebite is a true emergency, requiring fast action and emergency evacuation of the victim. HEMOTOXIC ENVENOMATIONS: Most common with pit vipers (rattlesnakes, copperheads, cottonmouth moccasins, Fer-de-Lance and Bushmaster) and old world vipers. Signs & Symptoms: Swelling and blistering at bite site; muscle fasciculation, weakness and syncope; nausea & vomiting; chills, hypotension, lymphangitis, and respiratory distress may occur; GI and GU bleeding may occur; Bite site tends to ooze blood constantly. Moderate to severe pain at the bite site, starting within a few seconds of the bite; perioral numbness and tingling; metallic taste in the mouth may occur. NEUROTOXIC ENVENOMATIONS: Most common in bites from Elapids (cobras, coral snakes, kraits), sea snakes, and most snakes found in Australia. Signs & Symptoms: Mild pain or painless bite site; Numbness or tingling of bite site; perioral numbness and metallic taste in mouth may occur. Muscle weakness, uncoordination, fasciculationвЂ™s; difficulty in swallowing and speaking may occur; Visual disturbances, ptosis, respiratory distress, hypotension and convulsions may occur. Respiratory paralysis may occur. NOTE: Neurotoxic symptoms may take hours to appear and then progress rapidly. Treatment: 1. Extractor Pump: The extractor pump (NSN 6545-01-281-1237) is known to be effective in pit viper envenomations and is likely to be effective in elapid envenomations, removing up to 30% of the injected venom load. It should be applied to the bite site as soon as possible after the bite (Pump is most effective if applied within 3 minutes). Empty the bell of the pump as it fills with fluid, and reapply. Continue for 30-60 minutes. If a suction device is not available, a syringe with an enlarged tip can be used. NOTE 1: No incisions should be made. NOTE 2: Mouth or rubber bulb suction is NOT a substitute for an extractor pump. Compression/Immobilization (Used for neurotoxic-predominant bites): Apply an ace wrap and splint to the bitten extremity. Wrap proximal to distal and slightly tight. Wrap so the extractor pump/bite site is accessible. Do not remove wrap until at a medical facility. 129 NOTE 3. Proximal Constriction Band (Used for hemotoxic-predominant bites): Use a 1вЂќ wide penrose drain or similar wide band. Place above the bite site, just tight enough to indent the skin (should be loose enough to slip one finger between the band and skin). Check proximal pulses frequently. If the band becomes too tight as a result of swelling, place a second band above the first before releasing the first band. Once a constriction band has been placed, do not remove until at a medical facility. NOTE: This is not a tourniquet! вЂў Venomous snakes found in the United States include rattlesnakes, copperheads, cottonmouths/water moccasins, and coral snakes. вЂў It has been estimated that 7,000вЂ“8,000 people per year receive venomous bites in the United States, and about 5 of those people die. вЂў Rattlesnakes are the largest of the venomous snakes in the United States. вЂў They can accurately strike at up to one-third their body length. Rattlesnakes use their rattles or tails as a warning when they feel threatened. Rattlesnake Timber Rattlesnake Western Diamond Back Range and habitat вЂў Western diamondback rattlesnake (Crotalus atrox), responsible for the majority of venomous snakebites in North America, coiled in defensive posture with rattle erect вЂў Most species live near open, rocky areas. Rocks offer them cover from predators, plentiful prey (e.g. rodents, lizards, insects, etc. that live amidst the rocks), and open basking areas. вЂў Snakes prefer a temperature range between 80 and 90В°F (26-32В°C), but can survive from brief exposure to temperatures as low as 4В°F (-16В°C), and surviving for several days in temperatures as low as 37В°F (3В°C). 130 Effects of a rattlesnake bite вЂў Rattlesnakes are a group of venomous snakes of the genera Crotalus and Sistrurus of the subfamily Crotalinae ("pit vipers"). вЂў There are 32 known species of rattlesnake, with between 65-70 subspecies, all native to the Americas, ranging from southern Alberta and southern British Columbia in Canada to Central Argentina. вЂў All rattlesnakes possess a set of fangs with which they inject large quantities of hemotoxic venom. вЂў The venom travels through the bloodstream, destroying tissue and causing swelling, internal bleeding, and intense pain. вЂў Some species, such as the and the Mojave Rattlesnake, additionally possess a neurotoxic component in their venom that causes paralysis and other nervous symptoms. вЂў Rattlesnakes are the leading cause of snakebite injuries in North America. However, rattlesnakes rarely bite unless provoked or threatened; and if treated promptly, the bites are rarely fatal. Venom вЂў Most species of rattlesnakes can control how much venom to inject and have hemotoxic venom, destroying tissue, causing necrosis and coagulopathy (disrupted blood clotting). вЂў In the U.S., the Tiger rattlesnake (C. tigris) and some varieties of the Mojave rattlesnake (C. scutulatus) also have a presynaptic neurotoxic venom component known as Mojave Type A toxin, which can cause severe paralysis. вЂў Although it has a comparatively low venom yield, the venom toxicity of C. tigris is considered to be the highest of all rattlesnake venoms, and the highest of all snakes in the Western Hemisphere. C. scutulatus is also widely regarded as producing one of the most toxic snake venoms in the Americas. вЂў Rattlesnake venom is a mixture of 5-15 enzymes, various metal ions, biogenic amines, lipids, free amino acids, proteins, and polypeptides. вЂў It contains components designed to immobilize and disable the prey, as well as digestive enzymes which break down tissue to prepare for later ingestion. The venom is very stable, and retains its toxicity for many years in storage. Hibernation вЂў вЂў Some rattlesnake species hibernate in the colder winter months. They often gather together for hibernation in very large numbers (sometimes over 1,000 snakes), huddling together inside underground "rattlesnake dens" or hibernacula. вЂў Rattlesnakes often return to the same den, year after year, sometimes traveling several miles to get there. 131 Rattlesnake bites are painful when they occur. Symptoms usually begin right away and may include: Bleeding Breathing difficulty Weakness Blurred vision Eyelid drooping Weak pulse Low blood pressure Nausea and vomiting Tiredness Numbness Pain at site of bite Thirst Paralysis Rapid pulse Tissue damage Skin color changes Swelling 132 Copperheads вЂў Copperheads vary in color from reddish to golden tan. вЂў The colored bands on their body are typically hourglass-shaped. Most adults are 18вЂ“36 inches long. Rattlesnakes may be found sunning themselves near logs, boulders, or open areas. These snakes may be found in most work habitats including the mountains, prairies, deserts, and beaches. вЂў They are not usually aggressive, but will often freeze when frightened. вЂў Copperheads are often found in forests, rocky areas, swamps, or near sources of water like rivers. Cottonmouths/Water Moccasins Results of a cottonmouth strike 133 вЂў Cottonmouth snakes average 50вЂ“55 inches long. вЂў The adult snakeвЂ™s skin is dark tan, brown, or nearly black, with vague black or dark brown crossbands. вЂў Juveniles have a bold crossbanded pattern of brown or orange with a yellow tail. вЂў Cottonmouths are frequently found in or around water. They do not scare easily and will defend themselves when threatened. U.S. Geographic Region: Wetland areas, rivers, lakes, etc., in the southeastern states. Cottonmouth and copperhead bites are painful right when they occur. Symptoms, which usually begin right away, may include: вЂў вЂў вЂў вЂў вЂў вЂў Bleeding Breathing difficulty Low blood pressure Nausea and vomiting Numbness and tingling Pain at site of bite вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Shock Skin color changes Swelling Thirst Tiredness Tissue damage Weakness Weak pulse Scarlet King Snake Note that the head does NOT have a blake nose 134 Western Coral Snake Micrurus fulvius Months after a coral snake bite Venomous; 20-35 inches (508 to 890 mm) пЃ¬ Sandhills, wooded & wiregrass areas in sandy soil are home to this rare, small, secretive snake, which spends most of its life underground. пЃ¬ It burrows in sand, leaf litter, and under loose boards, tin, or logs. пЃ¬ Coral Snake always has a bulbous black and yellow head, and the red bands are bordered with yellow. The more common nonvenomous look-alikes have red on their heads, and the red bands are bordered with black. Coral snakes are related to cobras and sea snakes. Coral snakes are not pit vipers, and do not have triangular shaped heads or cat's eye pupils. Although the venom is extremely toxic, this snake is quite docile and is unlikely to bite unless handled or stepped on. U.S. Geographic Region: Wooded, sandy, or marshy areas of the Southern United States. Symptoms Signs or symptoms associated with a snake bite may vary depending on the type of snake, but may include: вЂў A pair of puncture marks at the wound вЂў Redness and swelling around the bite вЂў Severe pain at the site of the bite вЂў Nausea and vomiting вЂў Labored breathing (in extreme cases, breathing may stop altogether) вЂў Disturbed vision вЂў Increased salivation and sweating вЂў Numbness or tingling around your face and/or limbs Preventing Snake Bites вЂў Do not try to handle any snake. вЂў Stay away from tall grass and piles of leaves when possible. вЂў Avoid climbing on rocks or piles of wood where a snake may be hiding. вЂў Be aware that snakes tend to be active at night and in warm weather. вЂў Wear boots and long pants when working outdoors. вЂў Wear leather gloves when handling brush and debris. 135 First Aid вЂў Seek medical attention as soon as possible (dial 911 or call local Emergency Medical Services.) вЂў Try to remember the color and shape of the snake, which can help with treatment of the snake bite. вЂў Keep still and calm. This can slow down the spread of venom. вЂў Inform your supervisor. вЂў Apply first aid if you cannot get to the hospital right away. вЂў Lay or sit down with the bite below the level of the heart. вЂў Wash the bite with soap and water. вЂў Cover the bite with a clean, dry dressing. Do NOT do any of the following: вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Do not pick up the snake or try to trap it. Do not wait for symptoms to appear if bitten, seek immediate medical attention. Do not apply a tourniquet. Do not slash the wound with a knife. Do not suck out the venom. Do not apply ice or immerse the wound in water. Do not drink alcohol as a painkiller. Do not drink caffeinated beverages. Antivenin вЂў Antivenin, often referred to as antivenom, is commonly used to treat the effects of local and systemic pit viper envenomations вЂў Because antivenin is derived from animal antibodies, people generally display an allergic response during infusion, known as serum sickness. вЂў When a bite occurs the amount of venom injected is under voluntary control by the snake. вЂў Approximately 20% of bites result in no envenomation at all. A lack of burning pain and edema 3вЃ„8 in (1 cm) away from the fang marks after 1 hour suggests that either no or minimal envenomation occurred. A lack of edema or erythema in the area of the bite after 8 hours indicates a lack of envenomation for most rattlesnake bites. Gila Monster or Mexican Beaded Lizard Report on envenomation by a Gila monster (Heloderma suspectum) with a discussion of venom apparatus, clinical findings, and treatment. Source 137 Reptile Research and Breeding Facility, Cincinnati, OH 45238, USA. Abstract вЂў Human envenomations by Heloderma species are a rare but clinically important medical problem. We report a case of an adult male bitten on the left hand by a 50-cm male, captive specimen of Heloderma suspectum (Gila monster). вЂў Immediate signs and symptoms included pain at the bite site radiating into the arm and axilla and swelling of the hand and forearm. вЂў Systemic complaints of nausea, diaphoresis, and dizziness (without a decrease in blood pressure) lasted approximately 1 hour, and laboratory studies were normal. вЂў The patient's course was uneventful except for persistent hyperesthesia, which eventually abated. вЂў Two types of helodermatid bites produce distinct clinical pictures. вЂў The chewing bite potentially causes more envenomation than the slashing bite. вЂў The venom contains a number of protein and nonprotein components including serotonin, a bradykinin-releasing substance, protease, hyaluronidase, helodermin, and gilatoxin. вЂў The clinical presentation of a helodermatid bite can include pain, edema, hypotension, nausea, vomiting, weakness, and diaphoresis. вЂў No antivenin is commercially available. Treatment is supportive. 138 CHAPTER 29 ARACHNID AND ARTHROPOD BITES AND STINGS NOTE: This list is not inclusive. Investigate those types that are specific to your operation location and consult with a qualified medical officer for specific treatment. BLACK WIDOW SPIDER ENVENOMATION Signs & Symptoms: вЂў Pinprick sensation followed by minimal swelling and erythema; вЂў Fang marks may be noted; Sometimes the bite is not felt. вЂў Dull crampy pain may develop at sign of bite and later spread to entire body. вЂў Generally, the pain is spread to the chest from upper extremity bites and to the abdomen from lower extremity bites. вЂў Abdominal cramping may be severe and mimic appendicitis. вЂў Other symptoms include dizziness, restlessness, nausea, vomiting, diaphoresis, and cramping in all muscle groups. вЂў The patient may become hypertensive. Treatment: 1. 2. 3. 4. 5. Ice application to the area. IV access in unaffected extremity. Monitor airway, breathing and circulation. If significant symptoms, consider immediate evacuation. IV Diazepam can be given to control muscle cramping. 139 BROWN RECLUSE SPIDER BITE Signs & Symptoms: Initial burning at site of bite, most notably within 3-4 hrs. White area then forms from local vasoconstriction followed a central blister with surrounding erythema. The blister then darkens as necrosis appears. Patient may exhibit or complain of fever, rash, chills, nausea, vomiting, malaise and weakness. Treatment: вЂў Clean area with soap and water. вЂў Transport as needed. Chagas disease or American trypanosomiasis A tropical parasitic disease caused by the flagellate protozoan Trypanosoma cruzi T. cruzi is commonly transmitted to humans and other mammals by an insect vector, the blood-sucking "kissing bugs" Symptom: Acute stage: mild and usually produce no more than local swelling at the site of infection. The initial acute phase is responsive to antiparasitic treatments, with 60вЂ“90% cure rates. 140 After 4вЂ“8 weeks, individuals with active infections enter the chronic phase of Chagas disease, which is asymptomatic for 60вЂ“80% of chronically infected individuals through their lifetime. Treatment: The currently available antiparasitic treatments for Chagas disease are benznidazole and nifurtimox, which can cause temporary side effects in many patients including skin disorders, brain toxicity, and digestive system irritation. End stage Chagas disease is achieved by a devastating invasion of the Autonomic Nervous System, especially the Parasympathetic influence of the Vagus Nerve. The acute phase lasts for the first few weeks or months of infection. It usually occurs unnoticed because it is symptom-free or exhibits only mild symptoms that are not unique to Chagas disease. These can include fever, fatigue, body aches, headache, rash, loss of appetite, diarrhea, and vomiting. The signs on physical examination can include mild enlargement of the liver or spleen, swollen glands, and local swelling (a chagoma) where the parasite entered the body. The primary wildlife reservoirs for Trypanosoma cruzi in the United States include opossums, raccoons, armadillos, squirrels, woodrats, and mice The most recognized marker of acute Chagas disease is called RomaГ±a's sign, which includes swelling of the eyelids on the side of the face near the bite wound or where the bug feces were deposited or accidentally rubbed into the eye. Of individuals with chronic Chagas disease, 60вЂ“80% will never develop symptoms (called indeterminate chronic Chagas disease), while the remaining 20вЂ“40% will develop life-threatening heart and/or digestive disorders during their lifetime (called determinate chronic Chagas disease). In 10% of individuals, the disease progresses directly from the acute form to a symptomatic clinical form of chronic Chagas disease There are two approaches to treating Chagas disease, antiparasitic treatment, to kill the parasite; and symptomatic treatment, to manage the symptoms and signs of the infection. Antiparasitic treatment is most effective . Drugs of choice include azole or nitro derivatives, such as benznidazole or nifurtimox. Both agents are limited in their capacity to effect parasitologic cure (a complete elimination of T. cruzi from the body), especially in chronically infected patients, and resistance to these drugs has been reported Chronic stage: The disease cannot be cured in this phase Chronic heart disease caused by Chagas disease is now a common reason for heart transplantation surgery. Until recently, however, Chagas disease was considered a contraindication for the procedure. , since the heart damage could recur as the parasite was expected to seize the opportunity provided by the immunosuppression that follows surgery. 142 SCORPION ENVENOMATION Scorpions have two eyes on top of the head Two to five pairs of eyes along the front corner of the head Scorpions donвЂ™t see well and must rely on their pectines for sense of touch to find prey and for navigation. They have a well developed sense of hearing Scorpions range in size from ВЅ inch to 7 ВЅ in length Usually tan with flat bodies that enable them to hide in small cracks, under rocks and in bark Average litter is 13 to 47 Scorpions fluoresce under an ultraviolet light Scorpions have adapted to desert living with extra layers of fats on their exoskeleton that minimizes water loss. Scorpions do drink water but they derive most of their water from food Scorpions have been known to survive 4 to 5 months without food Scorpions are most active at nighttime temperatures are above 70 degrees. Less active during winter and the hottest part of the summer during daylight hours Signs & Symptoms: Local erythema and swelling may or may not be present. There can be increased sensitivity to the area, along with numbness and weakness. Multiple symptoms may develop to include anxiety, restlessness, muscle spasm, nausea, vomiting, excessive salivation, sweating, itching of the nose and throat, hyperthermia, blurred vision, pseudoseizures, hypertension, hemiplegia, syncope, cardiac arrhythmias, or respiratory distress. Symptoms can occur over 24 hrs, or respiratory arrest can occur within 30 min. NOTE: The less dangerous the species, the more local the reaction will be. The more dangerous the species, the less the local reaction will be. Treatment: 1. Ice application to the area. 2. IV access in unaffected extremity. 3. Monitor airway, breathing and circulation. 4. Arrange for immediate evacuation if possible. 5. IV Diazepam can be given to control seizures and muscle spasm. 143 Whipscorpions Live under logs, rocks, bark Active at night Mastigoproctus giganteus (Vinegaroon) Can pinch Sprays vinegar when surprised 84% acetic acid Can blister human skin Tarantulas Large, wandering predatory spiders About 30 U.S.species Relatively docile Rarely bite Bite produces local pain, edema, lymph node swelling Flick irritating abdominal hairs if bothered 144 Hobo Spider (Tegenaria agrestis) Found in the Pacific northwest of the US They are aggressive because it bite with minor provocation. Live in moist dark areas (woodpiles/basements). They are brown with grey markings, have 7 вЂ“ 14mm body length and 27 вЂ“ 45mm leg span вЂў вЂў вЂў вЂў Present similar to that of brown recluse spider. Initial bite is painless ! delay presentation Induration may occur with surrounding erythema, followed by blistering, rupture, and necrosis. HA is the most common systemic symptom, but N/V and fatigue can occur. вЂў Aplastic anemia and death are rare complications. 146 CHAPTER 30 BEES, WASPS, HORNETS AND ANTS 50% of 2006 sting patients experiencing allergic reaction had NO previous warning symptoms! Hymenoptera: Most important venomous insect known to humans More fatalities result from stings by these insects. Three major subgroups: Apidae includes honeybee and bumblebee Vespidae & includes yellow jackets, hornets and wasps Formicidae ants Most of all allergic reaction reported yearly occur from vespid stings. Female bee is capable of stinging only once. (Male bees have no stinger). Vespid have ability to perform multiple sting Hymenoptera Venom Contain several components. Histamine is only a minor component within the venom. 50% of the venom consist of Melittin. Melittin is a known membrane-active polpeptide that can cause degranulation of basophils and mast cells. Yellow jackets venom is perhaps the most potent sensitizer. Venom: Local Reaction Urticarial lesion contiguous with the sting site. Severe local reaction may involve one or more neighboring joints. If the sting involve the mouth or throat, it can produce airway obstruction. Toxic Reaction Multiple stings (Africanized bees) can lead to systemic toxic reaction. Symptoms may resemble anaphylaxis, but these pts can also develop N/V/D. They may also have HA, fever, drowsiness, involuntary muscle spasms, edema without urticaria, and convulsions. Signs & Symptoms: Initially will experience burning pain later followed with itching. If allergic, symptoms of anaphylactic reaction may develop. 147 Locally reaction includes redness and swelling at site of bite. Systemic reaction occurs due to an allergic response: wheezing, urticaria, abdominal cramps, generalized edema, nausea, vomiting, dizziness, hypotension, confusion, and anaphylactic type reaction. Treatment: 1. Local Reaction: a. If stinger is present: remove by scraping. b. Wash site with soap and water. c. Apply cold compress. Оґ. Antihistamines may be useful if not contraindicated Ants (Formicidae) 5 known species of fire ants (Solenopsis) (S. aurea, S. geminata, S. xyloni, S. invicta, and S. richteri) вЂў Fire ants swarm when provoked and they may attack in numbers. вЂў Fire ants sting simultaneously in response to an alarm pheromone released вЂў Fire ants sting result in a papule that becomes a sterile pustule in 6 to 24 hrs. вЂў Pustule can lead to localized necrosis scarring secondary infection. вЂў Systemic reaction (urticaria / angioedema) can also occur. вЂў Treatment includes: вЂў вЂў local wound care. Usual treatment for anaphylaxis should be initiated if there is evidence of systemic reaction. 148 CHAPTER 31 POISONOUS PLANTS Many native and exotic plants are poisonous to humans when ingested or if there is skin contact with plant chemicals. However, the most common problems with poisonous plants arise from contact with the sap oil of several ever-present native plants that cause an allergic skin reactionвЂ”poison ivy, poison oak, and poison sumac. Poison ivy, poison oak, and poison sumac release an oil, urushiol, when the leaf or other plant parts are bruised, damaged, or burned. When the oil gets on the skin an allergic reaction, referred to as contact dermatitis, occurs in most exposed people as an itchy red rash with bumps or blisters. When exposed to 50 micrograms of urushiol, an amount that is less than one grain of table salt, 80 to 90 percent of adults will develop a rash. The rash, depending upon where it occurs and how broadly it is spread, may significantly impede or prevent a person from working. Although over-the-counter topical medications may relieve symptoms for most people, immediate medical attention may be required for severe reactions, particularly when exposed to the smoke from burning these poisonous plants. Burning these poisonous plants can be very dangerous because the allergens can be inhaled, causing lung irritation. Outdoor workers may be exposed to poisonous plants. Outdoor workers at risk include farmers, foresters, landscapers, groundskeepers, gardeners, painters, roofers, pavers, construction workers, laborers, mechanics, and any other workers who spend time outside. Forestry workers and firefighters who battle forest fires are at additional risk because they could potentially develop rashes and lung irritation from contact with damaged or burning poisonous plants. It is important for employers to train their workers about their risk of exposure to poisonous plants, how they can prevent exposures and protect themselves, and what they should do if they come in contact with these plants. 149 Plant Identification The old saying "Leaves of three, Let it be!" is a helpful reminder for identifying poison ivy and oak, but not poison sumac which usually has clusters of 7-13 leaves. Even poison ivy and poison oak may have more than three leaves and their form may vary greatly depending upon the exact species encountered, the local environment, and the season. Being able to identify local varieties of these poisonous plants throughout the seasons and differentiating them from common nonpoisonous look-alikes are the major keys to avoiding exposure. Poison Ivy Eastern poison ivy is typically a hairy, ropelike vine with three shiny green (or red in the fall) leaves budding from one small stem Western poison ivy is typically a low shrub with three leaves that does not form a climbing vine вЂў May have yellow or green flowers and white to green-yellow or amber berries Poison Oak Typically a shrub with leaves of three, similar to poison ivy вЂў вЂў Pacific poison oak may be vine-like May have yellow or green flowers and clusters of green-yellow or white berries Poison Sumac вЂў Woody shrub that has stems that contain 7-13 leaves arranged in pairs вЂў May have glossy, pale yellow, or cream-colored berries Exposure Workers may become exposed to urushiol through: вЂў Direct contact with the plant вЂў Indirect contact, such as touching tools, livestock, or clothing that have urushiol on them вЂў Inhalation of particles containing urushiol from burning plants Symptoms Signs or symptoms associated with dermal contact with poisonous plants may include: вЂў Red rash within a few days of contact вЂў Possible bumps, patches, streaking, or weeping blisters (blister fluids are not contagious) вЂў Swelling вЂў Itching First Aid Anyone who has come in contact with poisonous plants should: вЂў Immediately rinse skin with rubbing alcohol, specialized poison plant washes, degreasing soap (such as dishwashing soap) or detergent, and lots of water. вЂў Rinse frequently so that wash solutions do not dry on the skin and further spread the urushiol. вЂў Apply wet compresses, calamine lotion, or hydrocortisone cream to the skin to reduce itching and blistering. вЂў Follow the directions on any creams and lotions. Do not apply to broken skin, such as open blisters. вЂў Oatmeal baths may relieve itching. вЂў An antihistamine such as diphenhydramine (Benadryl) can be taken to help relieve itching. вЂў Follow directions on the package. вЂў Drowsiness may occur. 150 вЂў If children come in contact with work clothing contaminated with urushiol, a pediatrician should be contacted to determine appropriate dosage. вЂў In severe cases or if the rash is on the face or genitals, seek professional medical attention. вЂў Call 911 or go to a hospital emergency room if the worker is suffering a severe allergic reaction, such as swelling or difficulty breathing, or has had a severe reaction in the past. Common Poisonous Plants and Plant Parts Vegetation helps sustain life. We eat many plants, herbs and so forth in our daily diet. But, we must remember to be choosy. Some plants, trees or shrubs are potential killers of man. Some part of the ornamental plants or flowers in your yard may contain deadly poison. Many poisonous plants are so common and seemingly innocuous you do not suspect their toxic qualities. For example, who would expect that the beautiful oleander bush-grown indoors and outdoors all over the country-contains a deadly heart stimulant, similar to the drug digitalis? It is easy to be deceived by plantsвЂ¦one part may be edible while another is poisonous. The following chart lists some of the more common poisonous plants. PLANT Hyacinth, Narcissus, Daffodil Oleander PART Bulbs Nausea, vomiting, diarrhea. May be fatal. Leaves, branches Extremely poisonous. Affects the heart, produces severe digestive upset and has caused death. Dieffenbachia (Dumb Cane), All parts Elephant Ear Rosary Pea, Castor Bean SYMPTOMS Seeds Intense burning and irritation of the mouth and tongue. Death can occur if base of the tongue swells enough to block the air passage of the throat. Fatal. A single Rosary Pea seed has caused death. One or two Castor Bean seeds are near the lethal dose for adults. FLOWER GARDEN PLANTS Larkspur Young plant, seeds Digestive upset, nervous excitement, depression. May be fatal. Monkshood Fleshy roots Digestive upset and nervous excitement. Autumn Crocus, Star of Bethlehem Lily-of-the-Valley Iris Foxglove Bleeding Heart Bulbs Leaves, flowers Underground stems 151 Vomiting and nervous excitement. Irregular heart beat and pulse, usually accompanied by digestive upset and mental confusion. Severe-but not usually serious-digestive upset . Leaves Large amounts cause dangerously irregular heartbeat and pulse, usually digestive upset and mental confusion. May be fatal. Foliage, roots May be poisonous in large amounts. Has proved fatal to cattle. VEGETABLE GARDEN PLANTS Rhubarb Leaf blade Fatal. Large amounts of raw or cooked leaves can cause convulsions, coma, followed rapidly by death. ORNAMENTAL PLANTS Daphne Berries Fatal. A few berries can kill a child. Wisteria Seeds, pods Mild to severe digestive upset. Many children are poisoned by this plant. Golden Chain Jasmine Bean-like capsules in which the seeds Severe poisoning. Excitement, staggering, are suspended convulsions and coma. May be fatal Berries Lantana Camara (Red Sage) Green berries Yew Berries, foliage Fatal. Digestive disturbance and nervous symptoms. Fatal. Affects lungs, kidneys, heart and nervous system. Grows in the southern U.S. And in moderate climates. Fatal. Foliage more toxic than berries. Death is usually sudden without warning symptoms. TREES AND SHRUBS Wild and cultivated cherries Twigs, foliage Oaks Elderberry Black Locust Foliage, acorns Fatal. Contains a compound that releases cyanide when eaten. Gasping, excitement and prostration are common symptoms. Affects kidneys gradually. Symptoms appear only after several days or weeks. Takes a large amount for poisoning. Children have been poisoned by using pieces of the All parts, pithy stems for blowguns. Nausea and digestive especially roots upset. Bark, sprouts, foliage Children have suffered nausea, weakness and depression after chewing the bark and seeds. 152 PLANTS IN WOODED AREAS Jack-in-the-Pulpit Like Dumb Cane, contains small needle-like crystals All parts, of calcium oxalate that cause intense irritation and especially roots burning of the mouth and tongue. Moonseed Berries Blue, purple color, resembling wild grapes. May be fatal. Mayapple Apple, foliage, roots Contains at least 16 active toxic principles, primarily in the roots. Children often eat the apple with no ill effects, but several apples may cause diarrhea. Mistletoe Berries Fatal. Both children and adults have died from eating the berries. PLANTS IN SWAMP OR MOIST AREAS Water Hemlock All parts Fatal. Violent and painful convulsions. A number of people have died from hemlock. PLANTS IN FIELDS Buttercups All parts Irritant juices may severely injure the digestive system. Nightshade Poison Hemlock All parts, Fatal. Intense digestive disturbance and nervous especially the symptoms. unripened berry All parts Jimson Weed (Thorn Apple) All parts Fatal. Resembles a large wild carrot. Abnormal thirst, distorted sight, delirium, incoherence and coma. Common cause of poisoning. Has proved fatal. 154 CHAPTER 32 Poisonous Marine Animals NOTE: This section does not address all the many creatures that can envenomate humans, but does include the noteworthy ones. Jelly Fish Stings Photo courtesy of Wikimedia Jellyfish Most jellyfish stings are mild and donвЂ™t require treatment or can be treated yourself. However, seek medical assistance (dial 999) if there are severe symptoms, such as difficulty breathing, chest pain, or if a large or sensitive area of the body, such as the face or genitals, has been stung. Get the Person Out of the Water Applying shaving cream to the affected area will help prevent the spread of toxins. Use a razor blade, credit card or shell to remove any nematocysts (small poisonous sacs) that are stuck to the skin Stop Stinging [don't use vinegar or alcohol to wash the affected area because it can make the pain worse.The use of other substances, such as alcohol and baking soda, should also be avoided.] For a jellyfish sting in non-tropical waters: вЂў Wash the area with seawater to deactivate stinging cells. For a sting in tropical waters -- especially from box jellyfish: вЂў Rinse immediately with vinegar. Do not use fresh or tap water, which can reactivate stinging cells. вЂў Continue until you can get medical help. For a jellyfish sting in non-tropical waters: вЂў Wash the area with seawater to deactivate stinging cells. For a sting in tropical waters -- especially from box jellyfish: вЂў Rinse immediately with vinegar. Do not use fresh or tap water, which can reactivate stinging cells. 155 The American Heart Association and the American Red Cross have recommended the following: Rinse the area with vinegar for at least 30 seconds. If vinegar is not available, a solution of baking soda can be used. This will deactivate the stinging cells. вЂў Next, soak the area in hot water for at least 20 minutes if possible. Cold packs can be used instead if the area canвЂ™t be soaked in hot water вЂў Use mild hydrocortisone cream or oral antihistamine to relieve itching and swelling. NOTE: Rinse the area with vinegar for at least 30 seconds. These treatments are based on research done in the Indo-Pacific areas, however, and may not be effective in the oceans of the North Atlantic . Some experts therefore recommend a hot water rinse and lidocaine applied to the area if available. If this is not possible, then removing the stinging cells and rinsing in seawater would also be an option. Aftercare вЂў After a jellyfish sting, any pain and swelling can be treated with painkillers, such as paracetamol and ibuprofen. For less severe sting: вЂў Use ice packs or over-the-counter pain relievers for welts. вЂў Clean open sores 3 times a day and apply antibiotic ointment. Bandage if needed. For a severe reaction: вЂў The person may be hospitalized for several days. вЂў Anti-venom will be administered for box jellyfish stings. SEA URCHIN вЂў If there are signs that you or someone you're with has had a severe allergic reaction (anaphylaxis), dial 999 to request an ambulance. вЂў The small, venomous organs (pedicellariae) can be removed by applying a small amount of shaving cream to the affected area and using a razor blade to gently scrape them out. вЂў вЂў Any large spines should be carefully removed from the wound using tweezers. Scrub the wound using soap and water and then rinse it with fresh water. Do not close the wound with tape. 157 Aftercare вЂў Pain and swelling can be treated with painkillers, such as ibuprofen. вЂў If the skin is red and badly inflamed, a topical antibiotic cream or ointment should be applied three times a day. Stingrays Stingrays are common in tropical and temperate areas. They hide in the ocean floor sand with eyes and tail exposed. Most attacks from stingrays occur from swimmers or divers stepping on them. The tail will whip up in self-defense and impale the diver/swimmerвЂ™s leg with a barbed spine. вЂў The wound area has a blue rim and is typically swollen, painful, and pale. Generalized reactions can include: 1. 2. 3. 4. fainting nausea, vomiting Frequent urination sweating 5. 6. 7. respiratory difficulty cardiovascular collapse No antivenin is available. 158 вЂў вЂў вЂў вЂў вЂў Alert a lifeguard and dial 999 to request an ambulance if you're stung by a stingray. There's no antidote to stingray venom immersing the affected area in hot water (as hot as can be tolerated) for 30-90 minutes use pain-numbing medication (Lidocaine) you'll usually be given antibiotics because there's a high risk of the wound being contaminated by bacteria in the sting and the seawater, which could lead to an infection. вЂў The wound will initially be left open before being closed with stitches after about 48 hours if it hasn't become infected. Coral This porous, rock-like formation found in water often has sharp edges. Usually cuts from coral are self-limiting and have only a mild skin reaction. Unfortunately, they usually take a long while to heal. Some coral can sting (coelenterate family). One of the deadliest poisons known was found recently in coral (genus Palythoa). 159 If it is introduced into a deep cut in the body, it may be fatal. No antidote is known. Divers should wear dive suits to protect them from coral cuts, especially in surging waves. Coral treatment 1. Control bleeding. 2. Promptly clean with hydrogen peroxide or 10% povidone-iodine solution and debride the wound.Remove all foreign particles. 3. Cover with a clean dressing. 4. Administer tetanus prophylaxis. 5. Topical antibiotic ointment. 6. Manage pain Do NOT use narcotics in cases of RESPIRTORY DISTRESS or FAILURE. 7. Evacuate to medical treatment facility if symptoms are severe. Octopi вЂў The octopus is an underwater chameleon, changing colors often in the water trying to conceal itself from its enemies. вЂў Most species of octopi found in the U.S. are harmless to humans. Octopi can envenomate by biting and injecting venom from salivary glands. вЂў An octopus bite consists of two small punctures, surrounded by swollen, red and painful tissue. вЂў Bleeding may be severe due to anticoagulant effects of the venom. вЂў The blue ringed octopus found in Australian and Indo-Pacific waters is often deadly. It injects a neuromuscular blocker called maculotoxin that may cause paralysis, vomiting, respiratory difficulty, visual disturbances and cardiovascular collapse. No antivenin is available. Paralysis may last 4-12 hours (with mechanical ventilation). 160 Octopi Treatment 1. 2. 3. 4. Control local bleeding with pressure Clean and debride wound. Cover with clean dressing. If blue-ringed octopus is suspected: a. Apply pressure bandage and immobilize the bitten extremity. Place extremity lower than the heart. b. Be prepared to administer CPR and ventilate patient c. Immediately evacuate patient to medical treatment facility for intensive care. 5. Administer tetanus prophylaxis. Cone Shells вЂў The cone shell is widely distributed throughout the world. вЂў Venom is contained in darts inside the proboscis, which extrudes out of the narrow end but can reach most of the shell. вЂў A stinging or burning sensation begins at the site of the sting; followed by numbness and tingling that spread from the wound to the rest of the body. Involvement of the mouth and lips is severe. вЂў Generalized symptoms include: 1. muscular paralysis 2. difficulty swallowing or talking 3. visual disturbances and respiratory distress. 4. A cone shell sting should be viewed as severe as snakebite 5. Cone shell victims will probably experience paralysis or paresis of skeletal muscle with our without myalgia. 6. Symptoms develop within minutes and can last up to 24 hours. 7. No antivenin is available and mortality reaches 25%. Cone Shell Treatment 1. Place patient supine. 2. Apply pressure bandage to wound and place injury site at a level below the heart. Keep the patient from moving. 3. Immediately transport patient to medical treatment facility for intensive care. Be prepared to ventilate patient and administer CPR. Treat symptoms with supportive care as they present. 4. Avoid any analgesics that cause respiratory depression (narcotics). 5. Administer tetanus prophylaxis 161 SEA SNAKES вЂў Sea snakes are air-breathing reptiles that swim underwater for great distances (over 100 miles from land). вЂў вЂў вЂў вЂў They inhabit the Pacific and Indian Oceans and the Red Sea. The neurotoxin venom of a sea snake is 2-10 times more potent than that of a cobra. Bites are usually not painful, and only about 25% cause envenomization. There is a latent period of 10 minutes to several hours after the bite before generalized symptoms develop: 1. muscle aches and stiffness 2. thick tongue sensation 3. progressive paralysis 4. nausea and vomiting 5. difficulty with speech and swallowing 6. respiratory distress and failure 7. and smoky colored urine from myoglobinuria (which may progress to kidney failure). 8. antivenin is available TREATMENT вЂў Lidocaine may be used in the wound for pain relief, but NEVER use epinephrine. вЂў Explore the wound and clean out any remaining spines or barbs. вЂў Immobilize the affected extremity. вЂў Administer tetanus and antibiotic prophylaxis (tetracycline 250 mg po qid, and neomycin or bacitracin topically). вЂў Keep victim still. вЂў Apply pressure dressing to bite site and place bite in a position below the heart. вЂў Transport patient immediately to medical treatment facility for antivenin treatment and intensive care. вЂў Be prepared to ventilate patient and perform CPR. NOTE: Antivenins are available from Commonwealth Serum Lab; 45 Poplar Rd, Parkville; Melbourne, Victoria, Australia. Telephone: 011-61-3-389-1911. Telex: AA-32789. 162 Poisonous Spiney Fish If you're stung it's important to get first aid and medical attention immediately. To control the pain, the affected area should be immersed in hot water (as hot as can be tolerated) for 30-90 minutes. You can use simple painkillers, such as acetaminophen, to relieve remaining pain Any large spines should be carefully removed from the wound using tweezers (avoid touching the spines with your bare hands). Clean the wound using soap and water and then rinse it with fresh water. Do not cover the wound. A severe allergic reaction (anaphylaxis) will need to be treated in hospital immediately. Aftercare вЂў If there is itching, hydrocortisone cream can be applied 2-3 times a day. вЂў However, this should be stopped immediately if there are any signs of infection (severe inflammation and redness). вЂў Pain and inflammation can also be treated with painkillers, such as acetaminophen and ibuprofen. вЂў If an infection develops, a course of antibiotics may be prescribed. They should be taken for a minimum of five days after the signs of infection have disappeared. GENERAL INFORMATION FOR FIRST RESPONDERS 1. Remove the victim from the water. 2. Spray the sting area with vinegar; remain on the skin for 5 minutes 3. Wash the area with seawater. (Avoid fresh water or alcohol, which cause stinging cells to discharge) 4. Remove tentacles with a gloved hand or forceps. 5. Area should not be rubbed with sand. 6. Spray the sting area with vinegar again. 7. Dust the area with talcum powder or cover with shaving cream, and then gently scrape off with a knife or safety razor. 8. Wash with sea water and apply a steroid cream. STINGS (Sea Urchins, Cone Shells, Stingray, Bony Fish) Sea Urchins Signs &Symptoms: Pain. Small, possibly discolored puncture wounds in area of contact. The spines generally break off in the wound causing more problems with infection that with a toxic reaction. Burning pain and discoloration. Usually no systemic symptoms. 164 CHAPTER 33 WEAPONS OF MASS DESTRUCTION CHEMICAL WARFARE AGENTS: Divided into two categories: 1. Casualty Agents and Incapacitating Agents. Casualty Agents (Choking, Nerve, Blood, and Blister) have the ability to cause severe and permanent injury, or even death. 2. Incapacitating Agents (vomiting and tearing agents) are usually not lethal, produce no CHOKING AGENTS Phosgene (CG): вЂў A colorless fog-like gas that characterized by the smell of new-mown hay or green corn. Protective Measures: Protective mask. Persistency: Will dissipate within 20 min in open terrain, but may persist for up to 10 hrs in shaded areas, low terrain and in temperatures below 68В° F. Signs & Symptoms: вЂў Eye irritation, throat, lung irritation, cough and dyspnea. вЂў Most deaths will occur within 24 hrs. NERVE AGENTS Signs & Symptoms: вЂў Difficulty breathing, drooling, nausea, vomiting, cramps, involuntary defecation and urination, twitching, seizures, staggering, headache, drowsiness, coma, constricted pupils. вЂў Very small skin dosages sometimes causes local sweating and tremor with little other effects. Treatment: See Nerve Agent Exposure Treatment. Tabun (GA): A colorless to brownish liquid that emits a colorless vapor. Tabun is odorless in pure concentration, but emits a fruity odor in impure concentrations. Persistency: Persists 1-2 days under average conditions Sarin (GB): A colorless liquid, which emits a colorless vapor. Sarin is odorless in pure concentrations and has a slightly fruity odor in impure concentrations. Soman (GD): A colorless liquid that emits a colorless vapor. Soman has a fruity odor in pure concentrations and a camphor (Vicks Vapor RubВ®, mothballs, or strong pine pitch) odor in impure concentrations. NOTE: This agent вЂ�agesвЂ™ rapidly, resulting in an irreversible agent-AChE (acetylcholinsterase) bond. Use of pyridostigmine bromide (PB) tabs prior to exposure to this agent can вЂ�preserveвЂ™ functional. Persistency: Persists for 1-2 days under average conditions. Treatment: See Nerve Agent Exposure Treatment. V-Agents: A colorless to amber liquid, which emits a colorless vapor. V-Agents are odorless when in pure concentration. Persists for long periods of time under average weather conditions. 165 Treatment: вЂў (MARK 1) 2 mg of atropine and 600 mg of 2-PAM chloride. WARNING: Seizures associated with exposure to nerve agents indicate serious and possible lethal exposure. Seizures due to nerve agent exposure must be treated aggressively and prevented if possible. LIQUID EXPOSURE (Liquid on Skin): LONG TERM CARE OF THE NERVE AGENT CASUALTY: 1. Continue giving atropine injectors every 5 minutes as long as symptoms are present or until IV atropine is available. 2. Suction and ventilate the patient as needed. 3. When possible, safely remove chemical protective gear and perform complete evaluation of the patient. 4. If hypoxia is NOT present, give 1-2 mg (0.02-0.05 mg/Kg) of atropine IV every 10-15 minutes until signs of atropinization occur (secretions stop, muscle fasciculationвЂ™s stop, and patient become easy to ventilate) CAUTION: DO NOT use pupil dilation as a sign of endpoint of atropine therapy: It is unreliable in nerve-agent poisoning. 5. If hypoxia is present or cannot be ruled out, continue giving atropine 2 mg (0.02-0.05 mg/Kg) IM every 10-15 minutes until signs of atropinization occur. 6. Administer pralidoxime: a) If 3 Mark 1вЂ™s have been given (600 mg of pralidoxime each, total of 1800 mg), then begin an IV drip of 10-20 mg/Kg per hour of pralidoxime, to a max dose of 500 mg/hour. b) If no Mark 1вЂ™s have been given or the 2-PAM injectors were not used: Administer an initial IV bolus of 1-2 grams of pralidoxime (25-50 Mg/Kg, max of 2 grams) IVPB over 15-20 minutes, then begin an IV drip at 10-20 mg/Kg per hour as above. П‡) Continue the pralidoxime drip for 12 hours, or as directed by medical control. 7. If signs of nerve agent poisoning reoccur, treat with atropine and pralidoxime as above. 8. Symptoms may reoccur up to 24 hours after exposure/treatment. DECONTAMINATION: 1. Bleach slurry or dilute alkali solutions (equipment). 2. In confined areas use steam and ammonia or hot, soapy water (equipment). 3. Warm soapy water for skin decontamination if the above are not available. BLOOD AGENTS Hydrogen Cyanide (AC): A colorless gas that emits an odor of bitter almonds. Persistency: Quickly dissipates into the air. Signs & Symptoms: Irritation to the eyes and skin, low levels cause weakness, headache, disorientation, nausea and vomiting. Increased dosages result in loss of consciousness. Treatment: Complex, multi-step process. Requires specialized medications, advanced level of care. If patient is still alive after exposure Decontamination: Aeration under confined conditions. For complete decontamination, use caustic soda with steam. Cyanogen Chloride: A colorless gas with a sharp and peppery odor. Persistency: Rapidly disperses, vapor may linger in jungle and forest for some time under suitable weather conditions. 166 Signs & Symptoms: Highly irritating to the eyes and upper respiratory tract. Low levels cause weakness, headache, disorientation, nausea and vomiting. Increased levels causes loss of consciousness. Treatment: Treat ABCвЂ™s, oxygen and evacuate. Decontamination: Same as AC. BLISTER AGENTS Distilled Mustard (HD): An amber-brownish liquid that produces low-lying colorless vapor with a garlic-like odor. Persistency: 1-2 days under average weather conditions. A week to several months under cold conditions Signs & Symptoms: Conjunctivitis or inflammation of the eyes, redness of the skin followed by blistering or ulceration, inflammation of the nose, throat, trachea, bronchia and lung tissue. Vapors will cause temporary blindness. Symptoms may be delayed 4-6 hrs after exposure.Treatment: Strong bleach solutions and caustic soda. Decontamination: Strong bleach solutions and caustic soda for terrain. Live steam for buildings and substructures. Levinstein Mustard (H): An amber- brownish liquid, which produces a low-lying colorless vapor with a sulfur odor. Persistency: 1-2 days under average weather conditions. A week to several months under cold conditions. Signs & Symptoms: Symptoms may be delayed up to 12 hrs after exposure. Skin lesions. Irritation to the nose and throat, hoarseness, loss of voice and persistent cough. Ingestion may cause diarrhea, nausea and vomiting. Treatment: Same as HD. Nitrogen Mustard (HN-1, HN-2, HN-3): A pale-to-amber liquid, which produces a colorless vapor. HN-1 emits a fishy or musty odor. In low concentrations, H-2 emits a soft soap odor and in high concentrations a fruity odor. HN-3 is odorless. Persistency: HN-1 and HN-2 persists up to a day or two in moderate climate and less in dry arid conditions. HN-3 persists considerably longer than HN-1 and HN-2. May last for up to a week under cold conditions. Signs & Symptoms: Irritation to the eyes, nose and throat. Hoarseness, loss of voice and persistent cough. Ingestion may cause diarrhea, nausea and vomiting. Cumulative poison with symptoms delayed up to 12 hrs after exposure. Treatment: Same as HD. Decontamination: Same as HD. Phosgene Oxime (CX): May be crystalline solid or clear liquid. The crystalline solid is colorless, while the clear liquid has a sharp penetrating and disagreeable odor or pepperish smell. Persistency: Liquid form 1-2 days under average weather conditions. A week to several months under cold conditions. Crystalline form may lasts for several months in dry, arid and cold conditions. Signs & Symptoms: Symptoms: Red circle from area of contact. Causes immediate pain from prickly sensation to severe bee sting. Irritates the mucus membranes of the eyes and nose. Effects are instantaneous. Treatment: No treatment available. Decontamination: Flush with warm water to dissolve the agent. Bleaches and strong oxidizers will break down the compound. Use strong alkali solutions (sodium hydroxide) with live steam to decontaminate large ground and structural areas. 167 BIOLOGICAL AGENTS GUIDELINES AND CONSIDERATIONS вЂў Biological warfare agents are difficult to detect, but relatively easy to protect against. Most biological agents capable of being weaponized require inhalation of the agent for infection вЂў Immunizations against specific biowarfare agents may be required. Keep immunizations current. вЂў Avoid water that hasnвЂ™t been properly purified and food from the local area if possible. вЂў Decontamination for most biowarfare agents is done with 5% sodium hypochlorite solution (Clorox bleach out of the bottle is 5% hypochlorite) for equipment, and 0.5% hypochlorite solution for skin (dilute the Clorox solution 1:10 with water). Allow the solution to dry on the equipment and skin. NOTE: For most biological agents, washing with warm soapy water is just as effective for skin decontamination as a bleach solution is. NUCLEAR CONTAMINATION :Nuclear/radiation exposure can be divided into several different categories. The patient themselves DO NOT become radioactive from exposure to radiation NOTE: In some cases, patients can become contaminated with dust or other material that has radioactive material in it. Once this is removed, the patient is cared for in the normal manner. GUIDELINES AND CONSIDERATIONS Prevention of exposure depends on the type of threat in the area. In all cases, remember that radiation protection is dependent on: 1) TIME OF EXPOSURE, 2) DISTANCE FROM THE SOURCE, and 3) SHIELDING. вЂў For a fixed radiation source that is not in particulate form: It is best to limit exposure during rescue. Move the patient as rapidly as possible, keeping as far away from the radiation source as possible. вЂў For a particulate radiation source with external contamination (dust/debris containing radioactive material is on the patient): Wear a chemical protective mask with war filters in place to prevent inhalation of dust. Wear an overgarment that can be discarded after leaving the contaminated area. Decontaminate the patient by removing all clothing and washing off any dust. вЂў For a patient with internal contamination (radioactive material either ingested or driven into wounds): Wear protective clothing as noted above. Once out of the contaminated area, Decontaminate the patient as above. Debride the wounds to remove any particulate matter, if possible. Cover the wounds and Evac the patient, making sure the next echelon of medical care knows that an internally contaminated patient is on the way. Patients who have inhaled, or ingested radioactive material should be evacuated to the next echelon of care. 168 CHAPTER 34 MEDICAL EMERGENCIES CHEST PAIN: All non-traumatic chest pain must be evaluated to rule out cardiac ischemia. A thorough history of events is needed, including onset of pain, severity, and duration of pain. Other history includes association with activity, previous history of cardiac problems, hypertension, diabetes, hypercholesterolemia, smoking and family history of cardiac disease. GUIDELINES AND CONSIDERATIONS CHEST PAIN OF CARDIAC ORIGIN: Determining if chest pain is due to cardiac ischemia or not is a difficult process, often requiring considerable clinical skill and experience. Classically, chest pain of cardiac origin has the following characteristics: вЂў Dull and diffuse pain, often described as a вЂ�weightвЂ™ on the chest, a heavy sensation or a squeezing sensation. The pain can radiate to the left arm (or less commonly, right arm), neck or jaw. NOTE: A sharp, well-localized chest pain is less likely to be cardiac in origin if the pain is reproduced by palpation at the painful area; by taking a deep breath; or twisting the torso. вЂў Chest pain of cardiac origin is frequently accompanied by associated symptoms, such as shortness of breath, diaphoresis, nausea, dizziness, feelings of dread, and verbal denial. вЂў Patients with a history of cardiac chest pain (angina) can be asked if this pain is similar to their previous episodes of angina. Angina usually lasts less than 5 minutes. Any angina- like pain that has lasted longer than 5-10 minutes must be treated as a possible heart attack. вЂў Asking the patient to rate their pain on a scale of 1-10 (1= no pain, 10= worst pain they have ever had) is a simple method of following the success of any treatments. вЂў DonвЂ™t be overconfident: Cardiac chest pain can be a subtle, difficult diagnosis, even under ideal conditions. Patients with diabetes are especially prone to having unusual presentations of cardiac pain. When in doubt, treat for a cardiac event, and evacuate the patient as soon as possible. MANAGEMENT OF SUSPECTED ISCHEMIC CHEST PAIN 1. Place patient at rest to reduce anxiety 2. Administer 100% Oxygen, place on cardiac monitor, if available. 3. Initiate IV with normal saline 4. Obtain vital signs 5. Give 325 mg of aspirin PO if patient is not allergic, and no recent GI bleeding or stroke. 6. Nitroglycerin 0.4 mg sublingually every 5 minutes X3. Do not give if systolic BP below 100. Check BP after every dose, and just before giving next dose. Record any changes in intensity of pain associated with administration of nitroglycerin. 7. Morphine Sulfate, 4mg bolus then titrate every 2-4 minutes by 2mg until pain relief. NOTE: If resuscitative equipment is available and individual is ACLS qualified, refer to specific cardiac algorithms for further direction. See pages 94-112. 169 PULSELESS ELECTRICAL ACTIVITY (PEA): PEA may be a result of trauma necessitating a thorough evaluation of potential causes and rapid correction. Consider the following: CONDITION 1. HYPOVOLEMIA 2. HYPOXIA Ventilation with 100% O2 CLUES History, flat neck veins Cyanosis, pulse oximetry MANAGEMENT Volume expansion Airway establishment 3. CARDIAC History of MOI; No pulse with CPR Pericardiocentesis TAMPONADE Neck vein distention, hypotension, Low pulse pressure;, change from tachycardia to bradycardia as a terminal event. 4. TENSION PEUMOTHORAX 5. HYPOTHERMIA Algorithm No pulse with CPR, neck vein distention, tracheal deviation. History of cold exposure Needle decompression See hypothermia DIABETES: There are two life threatening diabetic conditions that the pararescueman needs to be aware of: Hypoglycemia and Hyperglycemia. Diagnosis and treatment is extremely limited in the field environment. HYPOGLYCEMIA (INSULIN SHOCK): Extremely low levels of circulating glucose. Often a result of excess insulin or inadequate glucose intake to meet metabolic needs. Signs & Symptoms: Weak rapid pulse, cold clammy skin, weakness/uncoordination, headache, irritability, may appear intoxicated, decreased level of consciousness. Treatment: 1. Maintain ABCs 2. Establish IV with normal saline 3. If patient is unconscious, administer 50 ccвЂ™s of 50% Dextrose solution IV, if available (consult medical control if possible) 4. If patient is conscious, administer PO sugar solution or dextrose paste if available. 5. If patient is unconscious and IV Dextrose is unavailable, insert NG tube and administer sugar slurry via the NG tube. HYPERGLYCEMIA (DIABETIC COMA / DIABETIC KETOACIDOSIS): Elevated levels of circulating glucose often the result of concurrent disease; excessive intake of glucose; decreased effective insulin or excessive alcohol consumption. Signs & Symptoms: Polyuria, polydypsia, nausea and vomiting, tachycardia, deep, rapid respirations, warm, dry skin, fruity odor on breath, decreased level of consciousness, hypotension. Dry mouth, intense thirst, and abdominal pain. Treatment: 1. Maintain ABCs 2. Establish IV with normal saline (Note: If medical control is not available, infuse normal saline 1 liter bolus, followed by infusion of 500 cc/hr not to exceed a total of 2 liters. 3. Administer 100& oxygen. 4. If patient is a known diabetic, and unconscious, 50% Dextrose may be given under physician direction. 5. If patient is unconscious, administer naloxone 2mg IV (may repeat X1 in 5 minutes if no result) 6. Insulin, if available, is only to be given under direct medical control 170 COMA: In general only two mechanisms produce coma: 1) structural lesions that depress consciousness by destroying or encroaching on the ascending reticular activating system (RAS) in the brain stem and 2) toxic metabolic states that involve the presence of circulating toxins or metabolites or the lack of metabolic substrate (i.e., glucose or oxygen). Preserved pupillary response suggest that the origin is toxic, whereas unresponsive or asymmetrical pupillary responses point to a structural cause. Treatment: In general, treatment is directed at support of patientвЂ™s vital functions, prevention of further deterioration and treatment of reversible causes. 1. If respirations are slow or shallow or if cerebral edema is suspected, hyperventilate at 24-30 breaths/ minute with 100% oxygen. 2. If no gag reflex, intubate. 3. Establish IV with normal saline or start saline lock. 4. If hypoglycemia is suspected, refer to hypoglycemia treatment (above). 5. Naloxone 2mg IV, repeat X1 in 5 minutes if no response 6. If medical control is available, thiamine 50-100 mg IV may be considered. This should be given prior to any dextrose. SEIZURES: A temporary alteration in behavior or consciousness caused by abnormal electrical activity in the brain. May result from multiple factors: stroke, head trauma, hypoxia, infection, hypoglycemia and drug overdose. Aim of treatment is to address correctable causes and reduce or eliminate additional seizure activity. MOST SEIZURES ARE SELF-LIMITING and will stop once underlying causes are corrected. If seizure activity persists for greater than 3-5 minutes, intervention may be required. NOTE 1: If a patient has multiple seizures without fully recovering between episodes, intervention is required. After a seizure has stopped, it is normal for the patient to be drowsy, incoherent and/or disoriented. This is referred to as the postictal period. The patient will usually recover from this within 15-20 minutes. NOTE 2: If the patient has another seizure before the end of the postictal period, then treatment for the seizure is needed. Treatment: 1. Prevent patient from sustaining physical injury. NOTE: Do not restrain patient nor should objects be forced between the patientвЂ™s teeth to maintain an airway. 2. Place in a lateral recumbent position to allow drainage of oral secretions and facilitate suctioning if needed. 3. Supplemental oxygen should be administered with a non-rebreather mask. 4. Consider intubation during flaccid period if there is no gag reflex. Provide 100% oxygen and ventilation support. 5. Establish IV access with normal saline and secure with tape and elastic bandage. 6. If hypoglycemia is suspected, administer 50% Dextrose, if available (only under physician direction.). 7. If prolonged seizure activity or repeated episodes, give Diazepam 5mg IV and repeat every 5-10 minutes until seizure stops. Do not exceed 20 mg of diazepam. ASTHMA: A reversible obstruction to airflow caused by bronchial smooth muscle contraction, hypersecretion of mucus resulting in bronchial plugging and inflammatory changes in the bronchial walls. Signs & Symptoms: Obvious respiratory distress with rapid and loud respirations, audible wheezing may be present. In severe cases hypoxic signs may be present (i.e., lethargy, exhaustion, agitation, and confusion). Other severe signs include: diaphoresis and pallor, abdominal and intercostal retractions, inability to speak, tachycardia greater than 120, tachypnea greater than 30, pulseless paradoxus greater than 20 mm Hg and altered mental status. Treatment: 1. Assure ABCs 2. Administer 100% oxygen via non-rebreather mask. 3. Establish an IV with normal saline, run at 250 cc/hr and monitor closely for S&S of pulmonary edema. 4. Epinephrine 1:1000 administer .01cc/lb subcutaneuosly and repeat every 5 minutes for 3 doses. 171 5. Do not exceed 0.3cc per dose (by physician direction only). 6. Administer Albuterol via nebulizer, 0.5ml in normal saline for a total volume of 3cc, repeat treatment every 15-10 minutes X3, under the direction of a physician. 7. Albuterol metered-dose inhaler (MDI) can be used instead of the nebulizer as noted in #5 above. 8. Dose is 2 puffs every 10-15 minutes x 3. NOTE: If available, albuterol is the preferred treatment for asthma, as versus giving epinephrine. Use epinephrine if albuterol is not available. Solu-Medrol or Decadron may be given for severe asthma attacks, however this should only be done under direct medical control. INFECTIOUS DIARRHEA: Defined as watery stool, associated with bloody stool, mucus, and/or fever. Treatment: 1. Encourage oral clear fluids, electrolyte replacement if available. 2. If tilt positive, Establish an IV with normal saline, and give 2 liter bolus of saline, then run 250 cc/hr. Do not exceed 3 liters. 3. Phenergan 12.5 mg IV if significant abdominal cramping or nausea and vomiting. 4. Imodium 2mg caps initially, then 2mg after each lose stool, not exceed 10 mg/24hrs. NOTE: Do not give Imodium unless ciprofloxin is given first. 5. Ciprofloxin 500 mg bid X 5 days. STOOL GUIAC TESTING: The presence of obvious blood in the stool (bloody diarrhea) is usually indicative of infectious diarrhea. In some cases, blood in the stool may not be obvious. In cases of diarrhea, testing the stool with a guiac card may show the presence of occult (hidden) blood. In cases of diarrhea with a positive stool guiac, treat as infectious diarrhea. This test can also be used to detect small amounts of blood in the stool of trauma victims. Procedure: 1. Place a small sample of stool on the front of the guiac card. Close the cover. 2. Open the back side of the card and put 1-2 drops of guiac developer on the card. 3. Place a drop of the developer on the вЂ�controlвЂ™ section of the card. 4. Any blue color, or a color that resembles the color of the вЂ�control positiveвЂ™ part of the card is a positive stool guiac, indicating the presence of occult blood. 173 CHAPTER 35 PHARMACOLOGY What went wrong with Antibiotic Usage? Treating trivial infections / viral Infections with Antibiotics has become routine affair. Many use Antibiotics without knowing the Basic principles of Antibiotic therapy. Many Medical practioners are under pressure for short term solutions. Commercial interests of Pharmaceutical industry pushing the Antibiotics, more so Broad spectrum and Newer Generation antibiotics. as every Industry has become profit oriented. Poverty encourages drug resitance due to under utilization of appropriate Antibiotics. Why we Need Antibiotic Policy вЂў Reduce the Antimicrobial resistance вЂў Initiate best efforts in the hospital area as many resistance Bacteria are generated in Hospital areas and in particular critical care areas. вЂў Initiate good hygienic practices so these bacteria do not spread to others вЂў Practice best efforts, these resistance strains do not spill into critically ill patients in the Hospital вЂў To prevent spill into Society, as they present as community associated infections.. вЂў Antibiotics should not be used casually вЂў Policy emphasizes, avoiding the use of powerful Antibiotics in the Initial treatments. вЂў We should create awareness that we are sparing the powerful Broad spectrum Drugs for later treatment вЂў To many drugs creates complex problems in drug resitance. вЂў The clinicians should optimize the duration of empherical treatment. GUIDELINES AND CONSIDERATIONS: The key to drug use is using caution. Familiarity with adverse drug effects and preparedness to deal with those effects are also paramount to safe use. The following factors can influence the therapeutic effects of medications: вЂў Age вЂў Body Weight вЂўTime of administration вЂў Pathological state вЂў Sex вЂў Route of administration вЂў Rate of inactivation and excretion вЂў Genetic factors вЂў Tolerance вЂў Drug interaction Allergy and Hypersensitivity: Hypersensitivity reactions can vary in their presentation. Antibiotics are the most common cause, however, any medication may be at fault. Allergic reaction to any antigen, e.g. snake envenomation, insect stings, pollens, etc., can cause similar symptoms. Reactions may include, but are not limited to: вЂў Allergic rhinitis, urticaria (hives), reactive airway/asthma or profound hypotension. вЂў Local reactions may include GI distress and/or dermal presentation, e.g. nausea, vomiting, cramps, diarrhea, pruritic skin, hives, local rash. вЂў Life threatening reactions (such as anaphylaxis) can occur in seconds to minutes and may include: вЂўвЂў Tightness in the chest and wheezing вЂўвЂў Skin changes: diffuse redness, hives and flushing 174 вЂўвЂў Angioedema or swelling of the periorbital and perioral area вЂўвЂў Rapidly progressive respiratory distress due to laryngeal edema, bronchospasm and fluid accumulation in the lungs. вЂўвЂў Hypotension/overt signs of shock OBSERVE THE FOLLOWING: 1. Medications are not always indicated. You must weigh the benefits against the potential adverse patient and mission effects. 2. All medications have potential adverse effects and many patients have a history of adverse reactions to various medications. In a conscious patient obtain a drug history. In an unconscious patient search for identification/warning tags denoting medication sensitivities. 3. Recommended doses will be followed. 4. When using IV medication, have a reliable IV fluid line running and inject the medication into the rubber fitting in the IV line. 5. When injecting through a saline lock, flush the lock with 10 cc of normal saline after administering the medication. 6. In addition to medication, your patient will require maintenance fluids, electrolytes, and nutritional balance. 7. CAUTION: Be prepared for anaphylactic reactions at all times. GENERAL RULES: вЂў Sterile technique: Alcohol cleaning of injection port or skin. вЂў Always aspirate before injecting medication to make sure you are not in a vessel or to insure proper placement in a vein for IV medication. вЂў For IVs: Mark on tape the date, time, and needle size. вЂў CAUTION: Be prepared for immediate hypersensitivity reactions and anaphylactic shock reactions at all times. ROUTES OF ADMINISTRATION: вЂў Oral: Give adequate fluids 175 вЂў Subcutaneous (SQ or SubQ) injection: Gently grasp skin over injection site and pull skin away from underlying muscle, forming a mound. Insert the needle at a 450 angle. Aspirate before injection. вЂў Intramuscular (IM) injection: Hold needle at 90 degrees to the skin, insert deep into the muscle, aspirate to make sure you are not in the vein or artery, and inject. вЂў Intravenous (IV) injection: Inject slowly into the tubing of an actively running, reliable IV. You may "piggy back" (run one IV into the tubing of another) a medication. IV injection through the port of a saline lock should be followed by at saline flush of 5-10 ccвЂ™s. 176 MEASUREMENT OF DOSAGES: вЂў Grain (gr): Measure of weight (apothecary system). вЂў Gram (gm): Measure of weight (metric system) equals to 1,000 milligrams (mg). вЂў Liter (l) and Cubic Centimeter (cc): Measures of volume. вЂў Milligrams per milliliter (mg/ml) and milligrams per cubic centimeter (mg/cc): Units of concentration. вЂў Milligrams per Kilogram (mg/Kg): Most commonly used with pediatric medications вЂў Units (u): An arbitrary measure of an active ingredient, e.g., penicillin, established to determine the effective dosage of medication. ANAPHYLAXIS PROTOCOL Signs/Symptoms of Anaphylaxis Present? вЂў 100% Oxygen by mask вЂў Support Ventilation as needed вЂў Start IV NS вЂў Evaluate severity of symptoms: вЂў Urticaria вЂў Rhinitis вЂў Mild Angioedema вЂў Bronchospasm вЂў Early Laryngeal вЂў Edema вЂў BP less than 100 вЂў Laryngeal Edema вЂў Respiratory Failure вЂў Shock вЂў Cardiovascular Collapse 177 Epinephrine, 1:1,000 0.3 SC Repeat in 5 min вЂў if no improvement Epinephrine,,1:1,000 0.3-0.5 cc SC Repeat in 5 min вЂў if no improvement Epinephrine 1:10,000 0.5-1.5 cc IV* Repeat in 5 min if вЂў no improvement Benadryl, 25-50 mg PO or IM Zantac, 50 mg IM or 150 mg PO Zantac, 50 mg IV or IM Observe for 24 hours SoluMedrol, 125 mg IM or IV Benadryl, 50 mg PO or IM Benadryl, 50-75 mg IV** Zantac, 50 mg IV SoluMedrol, 125 mg IM or IV NOTE 1: *If unable to obtain IV access consider sublingual injection (injection into the plexus of veins under the tongue) of epinephrine as a temporary measure while establishing an IV. May also be given by ET Tube (dilute to 1:10,000 and follow with 5-10cc of saline to flush). NOTE 2: **May give IM if no IV access. CAUTION: SxS of anaphylaxis may reoccur 12-24 hours after the original reaction. Keep the patient under close observation at all times for the first 24 hours following initial reaction. If symptoms reoccur, treat via the above protocol. Patients with moderate or severe reactions should be evacuated as soon as possible, with close observation while awaiting evacuation. Caution: In the treatment of anaphylactic shock, IV epinephrine must be given very slowly, preferably at least 5 minutes per dose. Rapid bolus IV injection can cause myocardial ischemia and potentially fatal cardiac arrythmias. Caution: IV epinephrine must be injected SLOWLY: Give dose over at least 5 minutes. 179 VITAMINS VITAMINS AND MINERALS вЂў Organic substances required for normal cell function, growth, and development. There are 13 essential vitamins. 1. Fat-Soluble Vitamins: Fat-soluble vitamins are those that bind to fat in the stomach and are then stored in the body for later use. We are less likely to become deficient in these vitamins (A, D, E, and K), but more likely to build up to toxic levels, usually due to extreme overconsumption or overzealous supplement use. 2. Water-Soluble Vitamins: The rest of the vitamins are water-soluble, meaning they can be absorbed directly by cells. When in excess, these vitamins are flushed out of our system with each bathroom break. The water-soluble vitamins вЂ” biotin, vitamin C, niacin, folic acid, pantothenic acid, and the four B complex vitamins вЂ” need to be restored more frequently, but the body can tolerate higher doses. 3. Minerals: Minerals are inorganic substances. TheyвЂ™re also necessary for normal body function and development. There are two groups of minerals: macrominerals (which the body needs in large doses) and trace minerals (only a pinch required). RDA: Recommended Dietary Allowances, or RDAs, represent the average daily dietary intake of each vitamin and mineral a person needs to stay healthy and steer clear of deficiencies. The values, which are all backed by scientific data, are broken down by age and gender. AI: For those vitamins for which an RDA has not yet been set (usually due to lack of scientific data), or adequate intake level, is used in place. UL: The tolerable upper intake level (UL) is the maximum amount of daily vitamin or mineral dosage that is likely to be safe for the average person. Stay under the UL radar (especially when using supplements) to prevent toxicities. вЂў вЂў Vitamins or minerals that are needed in larger doses are expressed in units of milligrams (mg). Trace minerals and vitamins are expressed in micrograms (mcg). Biotin (a.k.a. Vitamin B7 or Vitamin H): вЂў Like the rest of the water-soluble B-complex vitamins, biotin plays a huge role in cell growth and food metabolism. вЂў Deficiency of this vitamin is extremely rare, but overdoing it on raw egg whites has been known to prevent biotin absorption RDA: 30 mcg Sources: Cooked salmon (4-5 mcg per 3 ounces) whole grains (0.02-6 mcg per slice of bread), eggs (13-25 mcg per large egg), or avocados (2-6 mcg per avocado) Calcium: вЂў вЂў A macromineral crucial for the healthy development of bones and teeth. Calcium also offers a helping hand in muscle function, blood clotting, nerve signaling, hormone secretion, and blood pressure . вЂў Requires:Vitamin D and Magnesium for assimilation. RDA: 1,000 mg 180 Sources: Milk (300 mg per cup), yogurt (300 mg per cup), cheddar cheese (303 mg per 1.5 ounces), tofu (258 mg per ВЅ cup), bok choy (79 mg per ВЅ cup), spinach (115 mg per ВЅ cup), and rhubarb (174 mg per ВЅ cup). Threshold: 2,500mg Choline: вЂў Choline, another water-soluble B vitamin, is a building block of the neurotransmitter acetylcholine, which is essential for the nerve and brain activities that control memory and muscle movement. Choline also helps turn the food we eat and our stored energy into fuel . вЂў Vegetarians, vegans, pregnant women, and endurance athletes are at greater risk for choline deficiency, which is linked to fatty liver disease, atherosclerosis, neurological disorders, and impaired fetal development . вЂў Extremely high doses, more than 10 grams per day, can cause vomiting, increased sweating and salivation, and a fishy body order . RDA: Men = 550 mg; Women = 425mg Sources: Eggs (126 mg per egg), milk (38 mg per cup), cooked broccoli and Brussels sprouts (both 62 mg per cup), beef (67 mg per 3 ounces), and milk chocolate (20 mg per 1.5 ounce bar). Threshold: 3,500 mg Chromium: вЂў Though this trace mineral is thought to enhance insulin activity and the breakdown of the sugars that we eat, itвЂ™s only needed in small amounts and is not considered вЂњessentialвЂќ вЂў Overconsumption of chromium supplements could cause kidney damage. RDA: 35 mcg; Women = 25 mcg Sources: broccoli (22 mcg per cup), grape juice (7.5 mcg per cup), and whole-wheat products like whole-wheat frozen waffles (6.7 mcg per waffle) or whole-wheat English muffins (3.6 mcg per muffin). Threshold: Not determined Copper: вЂў Essential trace element and antioxidant. вЂў Frontline in the creation of red blood cells, copper is also important for proper energy metabolism, immunity, and nervous system function . вЂў Copper deficiencies may manifest as anemia, a low white blood cell count, and bone deterioration . RDA: 900 mcg Sources: liver (4,049 mcg per ounce), oysters (670 mcg per medium oyster), crabmeat (634 per 3 ounces), nuts (cashews, for example, offer 629 mcg per ounce), raw mushrooms (344 mcg per cup), and semisweet chocolate (198 mcg per ounce). Threshold: 10,000 mcg Fluoride: вЂў This non-essential trace mineral helps keep teeth cavity-free and bones less breakable . RDA: Men = 4 mg; Women = 3 mg Sources: Food sources include grape juice (0.05-0.64 mg per cup), canned sardines (0.2-0.4 mg per 3.5 ounces), and chicken (0.06-0.10 mg per 3.5 ounces). Threshold: 10 mg 181 Folic Acid (a.k.a. folate or folacin): вЂў Folic acid is such a key part of our diet that the U.S. government decided to fortify most commercial flour with this water-soluble vitamin. вЂў Vital for pregnant women to ensure the babyвЂ™s proper development, helping prevent birth defects in the brain and spine . вЂў Folic acid also helps create most all cells in the body and may reduce the risk of heart disease and colon cancer. RDA: 400 mcg Sources: fortified grains and cereals (200-400 mcg per cup), asparagus (134 mcg per 6 spears), spinach (132 mcg per half cup), orange juice (83 mcg per cup), and lentils (179 per half cup). Threshold: 1,000 mcg Iodine: вЂў This essential trace mineral is a crucial component of thyroid hormones, which maintain our basal metabolic rate (BMR). вЂў Iodine also helps to regulate body temperature, nerve and muscle function, and plays a role in the bodyвЂ™s growth and development . вЂў Too little iodine can lead to thyroid dysfunction, developmental abnormalities, and even goiters, a swelling of the thyroid gland . вЂў Iodine is found in most table salt вЂў Excess of iodine can cause hyperthyroidism, goiters, and in severe cases, GI discomfort and burning of the mouth, throat, and stomach, though rare. RDA: 150 mcg Sources: cod (99 mcg per 3 ounces), shrimp (35 mcg per 3 ounces), canned tuna (17 mcg per half can), milk (56 mcg per cup), baked potatoes (60 mcg per medium potato), and (small amounts of) seaweed (more than than 4,500 mcg per Вј ounce!). Threshold: 1,100 mcg Iron: вЂў A large componenet of hemoglobin, a component of red blood cells, and myoglobin (hemoglobinвЂ™s counterpart in muscles) bring oxygen to all the cells that need it. вЂў Iron is also important in the production of amino acids, collagen, neurotransmitters, and hormones . вЂў Since this mineral is more easily absorbed from red meat and poultry, vegetarians and vegans may want to consider iron supplements, or at least consume more iron-rich fruits and leafy green vegetables. вЂў Acute overdose of iron can be lethal, and general excess can cause GI irritation, nausea, vomiting, diarrhea, and constipation . RDA: Men = 8 mg; Women = 18 mg Sources: Consider beef (2.32 mg per 3 cooked ounces), oysters (5.04 mg per 6 medium oysters), raisins (0.81 mg per small box), prune juice (2.28 mg per 6 fluid ounces), potatoes (1.87 mg per medium potato), cooked lentils (3.30 mg per half cup), tofu (2.15 mg per Вј block), and cashews (1.89 per ounce). Threshold45 mg Magnesium: вЂў Ionically drawn to calcium, magnesium is a macromineral that partners with calcium to assist with proper muscle contraction, blood clotting, cell signaling, energy metabolism, blood pressure regulation, and building healthy bones and teeth. вЂў Magnesium deficiency is rare and so are toxicities 182 вЂў вЂў Excess leads diarrhea, lethargy, heart rate disturbances, and muscle weakness. May play a role in fibromyalgia, if deficient RDA: Men = 400 mg; Women = 310 mg Sources: oat bran (96 mg per half cup), almonds (78 mg per ounce), brown rice (86 mg per cup), cooked spinach (78 mg per half cup), bananas (32 mg per banana), and molasses (48 mg per tablespoon). Threshold: There is no upper limit for dietary magnesium, but supplemental magnesium should not exceed 350 mg/day. Manganese: вЂў вЂў Though an essential trace mineral and antioxidant, it is also potentially toxic in excess . Important for energy, bone development, and wound healing, overindulgence of this magic mineral вЂ” usually a result of water contamination вЂ” may cause a dip in intellectual function . RDA: Men = 2.3 mg; Women = 1.8 mg Sources: pineapples (0.77 mg per half cup), pecans (1.28 mg per ounce), oatmeal (0.99 mg per instant oatmeal packet), brown rice (1.07 mg per half cup), and green tea (0.41-1.58 mg per cup). Threshold: 11 mg Molybdenum: вЂў A necessary factor of many enzymes, which speed up the bodyвЂ™s biochemical reactions that break down dietary and stored nutrients into energy. вЂў Molybdenum deficiency has never been documented in healthy people, and toxicity is similarly rare. RDA: 45 mcg Sources: rich in molybdenum includes legumes like black beans (130 mcg per cup) and split peas (148 mcg per cup), and nuts like almonds, chestnuts, and peanuts (all about 42 mcg per cup). Threshold: 2,000 mcg Niacin ( a.k.a. Vitamin B3 or Nicotinic Acid): вЂў Like other water-soluble B vitamins, niacin is essential for converting food into energy. вЂў ItвЂ™s also central for the health of skin, hair, eyes, liver, and the nervous system, and is believed to lower risks of high cholesterol and heart disease . вЂў Extreme deficiencies in niacin may lead to pellagra, which is associated with the вЂњthe four DвЂ™sвЂќ: dermatitis (skin irritation), diarrhea, dementia, and death . RDA Men = 16 mg; Women = 14 mg Sources: peanuts (3.8 mg per ounce), chicken (7.3 mg per 3 ounces), salmon (8.5 mg per 3 ounces), fortified cereals (20-27 mg per cup), and coffee (0.5 mg per cup). Threshold: 35 mg вЂњniacin flushвЂќ вЂ” if doses exceed 50 mg per day . Pantothenic Acid (a.k.a. Vitamin B5): вЂў Important in food metabolism and helps synthesize neurotransmitters, steroid hormones, red blood cells, and more. вЂў Toxicity is virtually nonexistent, and while B5 deficiency is fairly rare (it tends to accompany severe malnutrition) neurologic symptoms such as burning feet may crop up. RDA: 5 mg (AI) Sources: chicken (0.98 mg per 3 ounces), eggs (0.61 mg per large egg), whole grains (0.19 mg per slice of whole wheat bread), mushrooms (0.52 mg per half cup), sweet potato (0.88 mg per medium potato), avocados (1.99 mg per whole avocado), and yogurt (1.35 mg per cup). Threshold: Not determined 183 Phosphorus: вЂў A macromineral that primarily builds and protects teeth and your skeleton. вЂў Phosphorus is also a component of DNA and RNA, helps convert food into energy, and aids in shuttling nutrients to the organs that need them . вЂў Rare cases of phosphorus deficiency can lead to anemia, muscle weakness, loss of appetite, rickets (in children), and numbness and tingling in the legs . RDA: 700 mg Sources: milk (257 mg per cup), yogurt (385 mg per cup) and cheese (131 mg per ounce). Salmon (252 mg per 3 ounces), eggs (104 mg per large egg), beer (173 mg per 3 ounces), chicken (155 mg per 3 ounces), and carbonated cola drinks (40 mg per 12 ounces). Threshol 4,000 mg Potassium: вЂў A macromineral and electrolyte thatвЂ™s essential for a steady heartbeat, the transmission of nervous system signals, and muscle function. вЂў Alongside sodium, potassium is also utilized in balancing fluids by helping the kidney save fluids when we are dehydrated or excrete fluids that are in excess. вЂў Potassium is thought to lower blood pressure and benefit bones вЂў Short-term potassium deficiencies (often from prolonged vomiting or diarrhea) may cause fatigue, muscle weakness and cramps, bloating, abdominal pain, and constipation. вЂў Consuming high doses (typically from supplements) can lead to muscle weakness, tingling in hands and feet, GI symptoms, and abnormal heart rhythms. RDA: 2,000 mg Sources: baked potatoes (926 mg per medium potato), artichokes (343 mg per medium artichoke), plums (637 mg per ВЅ cup), raisins (598 mg per ВЅ cup), and bananas (422 per medium banana). Threshold: Not determined Riboflavin (Vitamin B2): вЂў This water-soluble B vitamin helps convert food to fuel, encourages iron absorption in the intestines, and also enhances the health of hair, skin, muscles, eyes, and the brain. вЂў Riboflavin deficiency is uncommon, but is associated with a sore throat, cracks and sores around the lips, an inflamed вЂњmagenta tongueвЂќ , and scaly skin. вЂў Administration of niacin will reverse the neurologic symptoms and signs. 10-20 mg per day in the presence of adequate amounts of dietary protein is sufficient. вЂў While enormous intake of riboflavin may turn your urine bright yellow (a phenomenon called flavinuria), this side effect is harmless. RDA: Men = 1.3mg; Women = 1.1mg Sources: milk (0.34 mg per cup), almonds (0.23 mg per ounce), cheddar cheese (0.11 mg per ounce), eggs (0.27 mg per large egg), and enriched grains and cereals (0.59-2.27 mg per cup). Threshold: Not determined Selenium: вЂў Thyroid hormone regulation, and also acts as an antioxidant . вЂў Antioxidants вЂў Chronic excess of this trace mineral is known to cause nausea, GI discomfort, and hair and nail brittleness, and can be fatal RDA: 55 mcg 184 Threshold: Brazil nuts (544 mcg per six kernels) are sky-high in selenium, and shrimp (34 mcg per 1012 shrimp), crabmeat (41 mcg per 3 ounces), salmon (40 mcg per 3 ounces), enriched noodles (38 mcg per cup), beef (16 mcg per 3 ounces), and pork (35 mcg per 3 ounces) Threshold: 400 mcg Sodium Chloride (a.k.a. salt): вЂў NaCl orsalt. вЂў While it is essential for fluid balance, nerve signal transmission, muscle contractions, digestion, and blood pressure, excess sodium intake can raise blood pressure above normal limits, increasing the risk for hypertension and cardiovascular disease down the road . вЂў Since the average daily diet already includes salt waaaay in excess, consider low-salt alternatives like olive oil (instead of butter), unsalted nuts in favor of salted ones, and fresh fruit. вЂў Salt toxicity has been noted where salt water has been used. RDA: 500 mg of sodium; 750 mg of chloride Sources: white bread (850 mg per two slices), pickles (800 mg per 1 spear), hot dogs (1,300 mg per hot dog), and canned goods such as chicken noodle soup ( 3,400 mg of NaCl per cup). Threshold: 2,300 mg of sodium (the equivalent of 5.8 g of salt per day) Thiamin (a.k.a. Vitamin B1): вЂў Another member of the water-soluble B pack, thiamin helps with food metabolism and boosts the health of hair, skin, muscles, and the brain . вЂў Toxicity has never been observed, and though thiamin deficiency (also known as beriberi) is rare in the U.S., itвЂ™s not nonexistent. вЂў Whole and enriched grains, dried beans, peas, sunflower seeds, pork вЂў Dry beriberi-peripheral neuropathy in legs Cerebral beriberi-dementia, Wernicke- Korsakoff syndrome Wet beriberi-heart failure вЂў The usual treatment daily dose for adults is 50 to 100 mg IV or IM x 7 -14 days. Subsequently, a dose of 10 mg per day po until the patient is fully recovered. Adjust dosage for children. Improvement should be apparent within 6- 24 hours by reduced restlessness; the disappearance of cyanosis, reduction in heart rate, respiratory rate, and cardiac size, and clearing of pulmonary congestion. вЂў Symptoms affect the cardiovascular, nervous, muscular, and gastrointestinal systems in a variety of ways . RDA: Men = 1.2 mg; Women = 1.1 mg Sources: milk (0.10 mg per cup), lentils (0.17 mg per ВЅ cup), cantaloupe (0.11 mg per ВЅ fruit), enriched long grain white rice (0.26 mg per cup), and pecans (0.19 mg per ounce). Threshold: Not determined Vitamin A (a.k.a. retinol, retinal, retinoic acid): вЂў Though known as being good for vision, vitamin A has many other vital tasks: вЂў It encourages red and white blood cell production and activity, keeps the immune system fit and blood vessels healthy, helps rebuild bone, regulates cell growth and division, and may reduce the risk for some cancers . вЂў Retinoids, variations of Vitamin A, are also used in medications to treat various skin diseases and acne . вЂў Vitamin A deficiency can cause night blindness and, in extreme instances, complete blindness. Vitamin A deficiency also plays a role in diarrhea and increased susceptibility to infectious diseases in developing countries . вЂў The only case of toxicity was when explorers were ingesting raw polar bear liver. вЂў You can NOT overdose on carotene, but will turn a orangish yellow 185 RDA: Men = 900 mcg; Women = 700 mcg Sources: Consider kale (443 mcg per ВЅ cup), eggs (91 mcg per large egg), carrots (538 mcg per ВЅ cup) baked sweet potatoes (961 mcg per ВЅ cup), canned pumpkin (953 mcg per ВЅ cup), cantaloupe (467 mcg per ВЅ a melon), mango (79 mcg per fruit), and butternut squash (572 mcg per ВЅ cup). Threshold: 3,000 mcg Vitamin B6 (a.k.a. pyridoxal, pyridoxine, pyridoxamine): вЂў This essential, water-soluble vitamin flies high above the others. вЂў Vitamin B6 helps out with the production of serotonin, a hormone that plays a hand in sleep, appetite, and mood. вЂў It also assists with manufacturing red blood cells and steroid hormones, influences cognitive and immune function, and is linked to reducing the risk of heart disease . вЂў Diets lacking B6 show evidence of seizures and other neurologic systems are observed in extreme deficiency. вЂў Adverse effects from high doses are primarily seen in people taking supplements, and include pain and numbness in the limbs . RDA: 1.3 mg Sources: salmon (0.48 mg per 3 ounces), chicken (0.51 mg per 3 ounces), bananas (0.43 mg per medium banana), baked russet potatoes with the skin (0.70 mg per medium potato), hazelnuts (0.18 mg per ounce), and cooked spinach (0.44 mg per cup). Threshold: 100 mg Vitamin B12: вЂў Another water-soluble B vitamin, vitamin B12 offers a helping hand in the metabolism of fatty acids and amino acids, cell creation, and the protection of nerve cells , and also may reduce the risk of AlzheimerвЂ™s . вЂў Deficiencies are common in the elderly and may cause memory loss, dementia, and anemia . вЂў Toxicities are not observed, and vegetarians and vegans may even need supplements. вЂў Requires an acidic stomach for ingestion. Elder should take this sublinquinally RDA: 2.4 mcg Sources: clams (84 mcg per 3 ounces) and mussels (20.4 mcg per 3 ounces). Beef (2.1 mcg per 3 ounces), salmon (2.4 mcg per 3 ounces), poached eggs (0.6 mcg per large egg), skim milk (0.9 mcg per cup), and brie chees (0.5 mcg per ounce). Treshold: Not determined Vitamin C (a.k.a. asorbic acid): вЂў Vitamin C is thought to lower the risk for some cancers, including cancers of the mouth, esophagus, stomach, and breast . вЂў It also helps make collagen,t its antioxidant properties and immune-boosting effects вЂў A review of 30 research trials that included over 11,000 people showed that the incidence of the common cold is not decreased with high Vitamin C intake . вЂў Scurvy вЂ” the severe vitamin C deficiency linked to bleeding, bruising, join pain, and hair and tooth loss . RDA: Men = 90 mg; Women = 75mg (Smokers should add 35 mg) Sources: Choose citrus, like OJ (100+ mg per cup) and grapefruits (76 mg per medium fruit), strawberries (85 mg per cup), tomatoes (16 mgg per medium tomato), red peppers (95 mg per ВЅ cup), and broccoli (51 mg per ВЅ cup). Threshold: 2,000 mg 186 Vitamin D: вЂў This essential fat-soluble vitamin is vital for normal calcium metabolism, immunity, nervous system function, and bone density . вЂў Before vitamin D can live up to its expectations, it must be activated by a burst of UV rays. вЂў consider supplements or cereals, milk, and juices that are fortified with the active form, which is equally effective. вЂў Chronic deficiency puts you at risk for osteoporosis later in life. RDA: 15 mcg Sources: fortified cereals (1.0-1.3 mcg per cup), fortified milk (2.4 mcg per cup), canned salmon (13.3 mcg per 3 ounces), and egg yolks (0.53 mcg per large egg. Threshold: 50 mcg Vitamin E: вЂў There are eight antioxidants, vitamin E protects essential lipids from damage, battles free radicals, and maintains the integrity of cell membranes . вЂў Deficiencys: impaired balance and coordination, muscle weakness, and pain and numbness in the limbs, all signs of extreme deficiency . вЂў More than 90 percent of Americans do not meet the recommendations for this vitaminвЂ™s daily intake, due to the lack of being in the sun. RDA: 15 mg Sources: vegetable oils like olive oil (1.9 mg per tablespoon), canola oil (2.4 mg per tablespoon), almonds (7.4 mg per ounce), avocados (2.7 mg per avocado), and hazelnuts (4.3 mg per ounce). Threshold: 1,000 mg Vitamin K: вЂў This essential fat-soluble vitamin is a must for normal wound healing and bone development . вЂў K is for вЂњkoagulation,вЂќ the German word for coagulation, or clotting. вЂў While blood clots sound menacing, consider the importance of scabs, which are simply patches of clotted blood to protect cuts and scrapes. вЂў Ladies taking birth control pills should be careful with overconsumption of vitamin K, as a combination of the birth control pill and excess Vitamin K could put you at risk for unwanted clots deficiencies in vitamin K include easy bruisability, bleeding, nosebleeds, and heavy menstrual periods. RDA: Men = 120 mcg; Women = 90 mcg (AI) Sources: cooked broccoli (220 mcg per cup), kale (547 mcg per cup), parsley (246 mcg per Вј cup), and Swiss chard (299 mcg per cup). Threshold: Not determined Zinc: вЂў A trace element that is a building block for enzymes, proteins, and cells. вЂў It is also responsible for freeing Vitamin A from the liver, through its enzymatic activity . вЂў Zinc also plays a role in boosting the immune system, mediating senses such as taste and smell, ( a lack of taste in the elderly is an indication of a deficiency) and wound healing . вЂў Zinc toxicity is rare, вЂў zinc deficiency (most commonly occurring in the developing world) may lead to delays in growth and development, rough skin, cognitive impairment, a weakened immune system (leading in increased susceptibility of infectious diseases, particularly in kids вЂў Topically used as an antimicrobial. RDA: Men = 11 mg; Women = 8 m 187 Sources:oysters (76.3 mg per 6 oysters), beef (6 mg per 3 ounces), turkey (3.8 mg per 3 ounces), milk (1.8 mg per cup), and cashews (1.6 mg per ounce). Vegetarians and vegans take note: zinc is less easily absorbed from vegetables so consider supplements or munching on more zinc rich foods. Threshold: 40 mg 188 STANDARD MEDICATIONS PHARMACOLOGY GUIDELINES AND CONSIDERATIONS: The key to drug use is using caution. Familiarity with adverse drug effects and preparedness to deal with those effects are also paramount to safe use. The following factors can influence the therapeutic effects of medications: вЂў Age вЂў Body Weight вЂў Sex вЂў Route of administration вЂўTime of administration вЂў Rate of inactivation and excretion вЂў Pathological state вЂў Genetic factors вЂў Drug interaction вЂў Tolerance Pharmaceuticals are expiration dated and should be rotated to avoid waste. Allergy and Hypersensitivity: Hypersensitivity reactions can vary in their presentation. Antibiotics are the most common cause, however, any medication may be at fault. Allergic reaction to any antigen, e.g. snake envenomation, insect stings, pollens, etc., can cause similar symptoms. Reactions may include, but are not limited to: вЂў Allergic rhinitis, urticaria (hives), reactive airway/asthma or profound hypotension. вЂў Local reactions may include GI distress and/or dermal presentation, e.g. nausea, vomiting, cramps, diarrhea, pruritic skin, hives, local rash. вЂў Life threatening reactions (such as anaphylaxis) can occur in seconds to minutes and may include: вЂўвЂў Tightness in the chest and wheezing вЂўвЂў Skin changes: diffuse redness, hives and flushing вЂўвЂў Angioedema or swelling of the periorbital and perioral area вЂўвЂў Rapidly progressive respiratory distress due to laryngeal edema, bronchospasm and fluid accumulation in the lungs. вЂўвЂў Hypotension/overt signs of shock OBSERVE THE FOLLOWING: 1. Medications are not always indicated. You must weigh the benefits against the potential adverse patient and mission effects. 2. All medications have potential adverse effects and many patients have a history of adverse reactions to various medications. In a conscious patient obtain a drug history. In an unconscious patient search for identification/warning tags denoting medication sensitivities. 3. Recommended doses will be followed. 4. When using IV medication, have a reliable IV fluid line running and inject the medication into the rubber fitting in the IV line. 5. When injecting through a saline lock, flush the lock with 10 cc of normal saline after administering the medication. 6. In addition to medication, your patient will require maintenance fluids, electrolytes, and nutritional balance. 7. CAUTION: Be prepared for anaphylactic reactions at all times. 189 CHAPTER 36 MEDICINES OF CHOICE AEROBIC BACTERIA Infecting Organism Medication of Choice Alternatives A. Gram-positive Cocci 1. Staphylococi a. S. aureus (methicillin-sensitive) PRP, Cephalosporin b. S. aureus (methicillin-resistant) Vancomycin c. S. epidermidis Quinupristin-dalfopristin Vancomycin Linezolid, Quinupristindalfopristin 2. Streptococci a. Streptoccocus, Group A, B, C, G, S. viridans and penicillin-sensitive pneumoniae pneumoniae with high level penicillin-resistance c. Enterococci Penicillin G or V Vancomycin Vanocomycin, Clindamycin, (1st generation) Sulfatrimethaprim Clindamycin, Sulfatrimethoprim, Linezolid, Cephalosporin (1st generation), Vancomycin, Clindamycin, S. Erythromycin, Azithromycin b. S. Levofloxacin Ampicillin and Gentamicin Vancomycin and Gentamicin B. Gram-positive Bacilli 1. Bacillus anthracis 2. Corynebacterium diphtheriae 3. Listeria monocytogenes Penicillin or Ciprofloxacin Erythromycin and Antitoxin Ampicillin or Penicillin Doxycycline Clindamycin, Penicillin G Sulfa-trimethoprim C. Gram-negative Cocci 1. Neisseria gonorrhoeae Ceftriaxone or 2. Neisseria meningitidis 3. Moraxella catarrhalis Penicillin G or V Sulfa-trimethoprim, D. Gram-negative Bacilli 1. Escherichia coli Sulfa-trimethoprim (if sensitive) Cefixime Fluoroquinolone Ceftriaxone Azithromycin, doxycycline Amoxicillin-clavulanate Cephalosporin (3rd generation), fluoroquinolone 190 2. Enterobacter species Imipenem 3. Klebsiella species Imipenem 4. Pseudomonas aeruginosa 5. Proteus species APP APP 6. Serratia marcescens Cephalosporin (3rd generation) 7. Salmonella typhi Fluoroquinolone, Cephalosporin (3rd generation) Fluoroquinolone, Cephalosporin (3rd generation) Ceftazidime Cephalosporin (3rd generation), fluoroquinolone Imipenem, Fluoroquinolone 10. Brucella species Sulfa-trimethoprim fluoroquinolone Ceftriaxone or Azithromycin, doxycycline, fluoroquinolone Amoxacillin-clavulanic acid Ceftriaxone or Amoxicillin-clavulanic acid, Azithromycin, fluoroquinolone Erythromycin Doxycycline and rifampin Doxycycline and Gentamicin 11. Francisella tularensis Streptomycin or gentamicin 12. Yersinia pestis Streptomycin 8. Haemophilus influenzae 9. Haemophilus ducreyi Ceftriaxone or Doxycycline Gentamicin ANAEROBIC BACTERIA 1. Clostridium tetani 2. Bacteroides species ACID FAST BACILLI 1. Mycobacterium tuberculosis 2. M. kansasii 3. M. avium intracellulare complex 4. M. leprae Penicillin and tetanus toxoid Metronidazole Isoniazid + Rifampin+Pyrazinamide + Ethambutol Isoniazid + Rifampin+ Ethambutol Clarithromycin + Ethambutol Azithromycin + Ethambutol + + Rifabutin Rifabutin Rifampin + Dapsone (paucibacillary disease) ACTINOMYCETES Imipenem, Clindamycin, Metronidazole and tetanus immune globulin Imipenem, Clindamycin, Betalactam- betalactamase inhibitor Rifampin + Dapsone + Clofazamine (multibacillary disease) 1. Nocardia species 2. Actinomyces species Sulfa-trimethoprim Penicillin Minocycline + sulfonamide Clindamycin 191 MISCELLANEOUS 1. Chlamydia species 2. Rickettsia species 3. Treponema pallidum (syphilis) 4. Mycoplasma pneumoniae 5. Pneumocystis carinii Doxycycline Doxycycline Penicillin Azithromycin Sulfa-trimethoprim Erythromycin Chloramphenicol Ceftriaxone Doxycycline Pentamidine 1. Aspergillus species 2. Blastomyces dermatitidis 3. Coccidioides immitis 4. Cryptococcus neoformans Amphotericin Amphotericin Fluconazole Amphotericin Itraconazole Itraconazole Amphotericin Fluconazole 5. Histoplasma capsulatum 6. Candida species 7. Sporothrix schenckii iodide 8. Tinea versicolor Amphotericin Amphotericin Itraconazole Itraconazole Fluconazole Saturated solution of potassium Topical selenium sulfide Ketoconazole FUNGAL VIRUSES 1. Herpes simplex 2. Herpes zoster 3. Influenza Acyclovir Valacyclovir, Famciclovir Acyclovir Valacyclovir, Famciclovir Amantadine or rimantadine or zanamivir or oseltamivir ANALGESICвЂ™S & ANESTHETICS Lidocaine HCL 2% (Xylocaine): Local anesthetic вЂў See ACLS drugs for cardiac therapy. вЂў CAUTION: Some lidocaine solutions contain 1:10,000 epinephrine. This causes intense vasoconstriction, and prolongs the duration of the anesthesia. These solutions are identified by a red label or red lettering on the label. DO NOT use solutions containing epinephrine on or near the fingers, toes, nose, ears or penis. Rx: (As a local anesthetic): Suturing, debridement, nerve blocks, thoracostomy or other similar procedures. Duration of anesthesia is 30-60 minutes. Dose: To desired effect. вЂў Maximum single adult dose is 4.5 mg/Kg or 300 mg (15 ccвЂ™s of the 2% solution contains 300 mg lidocaine). вЂў NOTE 1: This is different max dose than with IV lidocaine for ACLS use. вЂў NOTE 2: 2% lidocaine contains 20 mg of lidocaine per cc. Diluting 2% lidocaine 1:1 with normal saline gives a 1% solution (10 mg per cc) that is just as effective as the 2% solution. Contra: 2nd degree, 3rd degree, hypotension, Stokes-Adams Syndrome SE: slurred speech, altered mental status, tinnitus, edema AR: Skin: dermatologic reactions, status asthmaticus, anaphylaxis, and seizures 192 Morphine Sulfate: Narcotic analgesic (opiod). Alters perception of pain and emotional response to pain. Have Narcan available when using Morphine. Rx: Severe Pain, pain from cardiac ischemia, CHF вЂў Alters perception & emotional response to pain Contra: Respiratory depression, hypotension, head injury Dose: 4-15 mg IV slow push (Dilute in 5 cc saline & inject slowly over 4-5 min) Peds: 0.1-0.2 mg/Kg SC. Do not exceed 15 mg.SE: в†“ RR, hypotension, bradycardia, N & V, dizziness, pruritus and skin flushing AR: Seizures with large doses, constipation, ileus, urinary retention Narcan (Naloxone HCL): Narcotic antagonist. Rx: Known or suspected narcotic-induced respiratory depression. вЂў NOTE: Have available when using morphine. вЂў WARNING: The duration of action of Narcan is 20-40 minutes, much less than the duration of action of morphine. After use of Narcan, observe patient closely, repeat doses of Narcan may be necessary after 20-30 minutes. Dose: 0.4-2 mg IV. Repeat q. 2-3 min/prn. вЂў Duration is 20-40 minutes (< duration of action of morphine). Repeat doses of may be necessary after 20-30 minutes. вЂў Peds: 0.01 mg/Kg dose IM, IV or SC q. 2-3 min. 116 вЂўвЂў If initial dose does not result in clinical response, increase dose up to 0.1 mg/Kg вЂўвЂў If no response after 10mg has been administered, diagnosis of narcotic-induced toxicity should be questioned. SE: In narcotic dependent patient, withdrawal symptoms may be precipitated. ANTIBIOTICS Cefotetan (cefotan): Broad-spectrum bactericidal antibiotic for IV/IM use (cephalosporin) Rx: For serious infections of: Lower respiratory tract (i.e. pneumonia); urinary tract; skin infections; intra-abdominal infections (especially penetrating abdominal trauma); & penetrating trauma to the extremities. вЂў NOTE: NOT effective in CNS infections (see Rocephin) Contra: Use caution in pts w/ hx of penicillin allergy, hepatic and/or liver dysfunction вЂў Not recommended for children Dose: 1-2 Gm IV/IM q. 12 hours SE: headaches, dizziness, nausea, vomiting, diarrhea, abdominal cramps, urticaria, elevated temperature AR: eosinophilia, thrombocytosis, leukopenia; pain at injection site; induration, sterile abscess, tissue sloughing, phlebitis; thrombophlebitis with IV use. Cipro (Ciprofloxacin): Broad-spectrum oral antibiotic (quinolone). Rx: Infectious diarrhea, Typhoid, acute sinusitis, wounds contaminated by seawater or freshwater, some biological warfare bacteria Contra: Not be used by pregnant women. Not recommended for children < 18 y.o. Dose: 500 mg q. 12hrs (take w/ meals). Continue for two days after symptoms resolve. SE: syncope, irritability, lethargy, drowsiness, urticaria, edema, dyspnea, AR: GI bleed, insomnia, nightmares, manic reaction, ataxia, seizures, depression, parethesias, blurred vision, diplopia, tinnitus, joint or back pain, gout, acidosis, HTN, angina, AMI, bronchospasm 193 Garamycin (Gentamycin) Ophthalmic Ointment: Ophthalmic antibiotic ointment. вЂў Erythromycin Opthalmic Ointment can be substituted. Use/dose are the same. вЂў No corneal toxicity noted w/ erythromycin. Rx: conjunctivitis, prophylaxis for ocular infection. Dose: Instill 1/2 to 1 inch of ointment into conjunctival sac q.i.d. and at bedtime. Contra: Known allergy SE: Hypersensentivity, photophobia, slowed corneal wound healing AR: corneal toxicity w/ prolonged use (> 5 days), overgrowth of nonsusceptible organisms. Keflex (Cephlexin): Broad-spectrum bactericidal oral antibiotic (cephalosporin) Rx: Respiratory, genito-urinary tract infections, skin and soft tissue infection, bone and joint infection. Contra: Use caution in pts w/ hx of penicillin allergy, hepatic and/or liver dysfunction Dose: 250 mg to 1 gm PO q. 6hrs. Peds: 6 - 12 mg/Kg PO q6h. SE: dizziness, headache, malaise, N & V, diarrhea, urticaria AR: neutropenia, eosinophilia, anemia, parethesias, abdominal cramps, skin disorders Mefoxin (Cefoxitin sodium): Broad-spectrum antibiotic for IV/IM use. (cephalosporin) вЂў Similar to Rocephin, but covers GI organisms better. Does not cover CNS infections or penetrating trauma to CNS. Similar in coverage to Cefotan. Rx: As an alternative to Rocephin. Infections of GI, lower respiratory, and urinary tracts. Contra: Use caution in pts w/ hx of penicillin allergy, hepatic and/or liver dysfunction Dose: 1-2 grams IV/IM q. 6вЂ“ 8/hrs. Peds: 80-160 mg/Kg per 24 hours, divided into 3-4 doses 6-8 hours apart. SE: headaches, dizziness, nausea, vomiting, diarrhea, abdominal cramps, urticaria, в†‘ temperature AR: eosinophilia, thrombocytosis, leukopenia; pain at injection site; induration, sterile abscess, tissue sloughing, phlebitis; thrombophlebitis with IV use. Rocephin (ceftriaxone sodium): Broad-spectrum bactericidal antibiotic for IV/IM use. (cephalosporin) Rx (Serious infections of): Lower respiratory tract (i.e. pneumonia); urinary tract; skin infections; intra-abdominal infections (especially penetrating abdominal trauma); penetrating trauma to the extremities; & CNS infections Contra: Use caution in pts w/ hx of penicillin allergy, hepatic and/or liver dysfunction Dosage: 1-2 gm IM/IV daily or in divided doses bid; Max dose 4 gm/day Peds: 50-75 mg/Kg given in divided doses q12 hours, max dose 2 gm/day. Preparation procedure: 1. W/draw 10cc NaCl from a 100cc bag. Inject 10cc NaCl into 1 gm Rocephin vial. Mix. 2. W/draw entire contents of vial and inject into original 100cc NaCl IV bag. Mix. 3. Piggyback with running IV. NOTE: If giving IM, reconstitute with 1% lidocaine WITHOUT epinephrine. SE: headaches, dizziness, N & V, diarrhea, abdominal cramps, urticaria, в†‘ temperature AR: eosinophilia, thrombocytosis, leukopenia; pain at injection site; induration, sterile abscess, tissue sloughing, phlebitis; thrombophlebitis with IV use. Silvadene Cream (Silver sulfadiazine) Topical microbial Rx: Treatment and prevention of sepsis in 2nd and 3rd degree burns. Dosage: Using sterile technique, apply thick layer to burn area, cover w/ saran wrap (if available), then bulky dressing. Change dressing q. 12-24 hours. вЂў It is normal for silvadine will turn gray/black color on exposure to light. Contra: G6PD deficiency. Do not use on face. Use extreme caution in sulfa sensitivity. SE: burning sensation, rash AR: transient leukopenia, systemic sulfa reaction 194 ANTIHISTAMINES Benadryl (Diphenhydramine HCL): Antihistamine. вЂў Prevents (but does not reverse) histamine-mediated responses. Rx: Mild to moderate allergic symptoms and/or allergic reactions, dystonic reaction Dose: 25-50mg IM/IV or 25-50mg/PO/t.i.d. вЂў Max dose 400mg/day вЂў May be given PO, IM or IV Peds: (Children < 12 years): 5 mg/Kg/day in divided doses q.i.d. вЂў May be given PO, IM or IV Contra: asthma, pregnant or lactating females SE: sedation, blurred vision, N & V, vomiting, diarrhea, headache AR: insomnia, vertigo, palpitations, dry mouth, constipation, dysuria, urine retention Phenergan (Promethazine Hydrochloride): Antihistamine вЂў Prevents but does not reverse histamine mediated response. вЂў Phenergan can induce an acute dystonic reaction (symptoms may resemble a stroke). Rx w/ 25-50 mg of Benadryl IV or IM. Symptoms normally resolve within 15-20 minutes. Rx: Motion sickness, nausea and vomiting, sedation. Dose: 25-50 mg IM q. 4-6h prn. (IM Injection is painful). Peds: 0.5-1mg/Kg IM q6-8h prn not to exceed 25 mg. IV administration: вЂў Administer over a prolonged time > 5 min and through a free flowing IV line, rather than a saline lock. вЂў The 50-mg/ml formulation must be diluted to 25 mg/ml (50/50 dilution) or less before being administered IV. вЂў Dosage is 12.5-25 mg every 6-8 hours. вЂў Peds: 0.5-1mg/Kg IM q6-8h prn not to exceed 25 mg. Contra: Additive effect w/ ALL other sedation medication. May cause excessive drowsiness or apnea. Monitor patient closely. SE: hypotension, dry mouth, constipation, restlessness, N & V AR: confusion, acute dystonic reaction, anorexia, photosensitivity, urine retention ANTI-INFLAMMATORYвЂ™S Decadron (Dexamethasone): Parenteral steroid. (glucocorticoid) Rx: Emergency treatment of AMS, HACE, HAPE, when tactical conditions preclude descent or acclimatization вЂў Use of Decadron в†“symptoms of AMS, but does not speed acclimatization. вЂў Use of Decadron does not preclude the need for an emergency descent. (Administer Decadron every 6 hours until descent is accomplished) Dosage: 4mg IV/IM or PO every 6 hours Contra: Use caution in pts w/ hx of diabetes, hypertension, and ulcers SE: delayed wound healing, acne, various skin eruptions, edema AR: Usually dose related. Psychotic behavior, CHF, HTN, cataracts, glaucoma, hypokalemia, hyperglycemia, and carbohydrate intolerance Motrin (Ibuprofen): Analgesic, antipyretic (NSAID) Rx: mild to moderate pain, arthritis Dose: 200-800 mg PO t.i.d. or q.i.d. Not to exceed 2400 mg/day (800 mg TID) Contra: Penetrating trauma, suspected internal bleeding, or suspected intracranial bleeding, pregnancy, nursing mothers. вЂў NOTE: Should not be given to pts w/ hx of aspirin sensitivity or severe asthma. SE: N & V, headache, dizziness, drowsiness AR: Prolonged bleeding time, tinnitus, edema, peptic ulcer 196 Solumedrol (Methylprednisolone): Parenteral steroid. Decreases inflammation, reduces immune response in allergic conditions. (glucocorticoid) Rx: Severe inflammation, severe asthma, severe allergic reaction, anaphylaxis. вЂў For blunt, Non-Penetrating, spinal chord trauma w/ SxS of spinal chord injury. вЂў Most effective when started as soon as possible after the injury occurs. Dose: 125 mg IM or IV q. 6hrs. Peds: 1-2 mg/Kg IV or IM q. 6hrs Anaphylaxis: 125 mg IV or IM (see protocol) Spinal trauma: Initial bolus = 30mg/kg IV slow push followed by IV drip of 5.4 mg/kg/hr for subsequent 23 hours (see protocol) вЂў If started > 6 hrs after the original injury, continue the IV drip for 48 hours. вЂў All persons started on the Solu-Medrol protocol should also receive ulcer prophylaxis of Zantac 50 Mg IV or IM every 6-8 hours, or 150 Mg orally every 12 hours. Contra: Use caution in pts w/ hx of diabetes, hypertension, ulcers SE: delayed wound healing, acne, various skin eruptions, edema AR: Usually dose related. Psychotic behavior, CHF, HTN, cataracts, glaucoma, hypokalemia, hyperglycemia, and carbohydrate intolerance Toradol (Ketorlac Tromethamine): Analgesic (NSAID) Rx: Short term pain relief (especially musculoskeletal pain). вЂў May be used as single or multiple dose, for the management of moderately severe, acute pain requiring analgesia at the opiate level вЂў Analgesic effect starts w/in 30 minutes of administration, peaks at 2 hours. вЂў Increasing dosage does not increase analgesic effect. If additional analgesia is needed, consider using small doses of morphine. Dose: 30 mg IM or IV. May be repeated every 6 hours prn; not to exceed 120 mg per day; total duration of therapy not to exceed 5 days вЂў Rapid IM injection is painful. Administer slowly into deep muscle вЂў IV bolus must be given over no less than 15 seconds Contra: Penetrating trauma; Suspected internal bleeding; Suspected intracranial bleeding; Pts currently receiving aspirin, NSAIDs, or anticoagulant therapy; active peptic ulcers or recent GI bleed вЂў Use w/ extreme caution in pts w/ hx of: renal & liver disease, COPD, asthma, ulcers, bleeding disorders, elderly, diabetes SE: Nausea, GI bleed, edema. вЂў Does not usually cause drowsiness or altered mental status. Check for other causes of altered mental status. AR: GI bleeding and/or perforation; renal impairment and/or failure; inhibits platelet function MISCELLANEOUS Activated Charcoal Class: Adsorbent Actions: Adsorbs toxins by chemical binding and prevents gastrointestinal adsorption. Indications: Poisoning following emesis or when emesis is contraindicated. Contraindications: None in severe poisoning. Precautions: Should only be administered following emesis, in cases in which it is so indicated. Use with caution in patients with altered mental status. May adsorb Ipecac before emesis; If Ipecac is administered, wait at least 10 minutes to administer activated charcoal. Side Effects: Nausea, vomiting, and constipation. Dosage: 1 g/kg (typically 50-75 grams) mixed with a glass of water to form a slurry. Routes: Oral Pediatric Dosage: 1 g/kg mixed with a glass of water to form a slurry 197 Alcohol, Ethyl (Ethanol) (EtOH) Class: Solvent, depressant Description:A colorless, volatile, flammable liquid of the formula C2H5OH. Acts as a depressant on the CNS when taken in excessive amounts. Used IV to stop premature labor. The other to "common" Alcohols are Isopropyl (C3H7OH, Isopropanol, IPA), and Methyl (CH3OH, Methanol, MeOH). Afrin Nasal Spray (Oxymetazoline HCL): Vasoconstrictor (decongestant) Rx: Use as an adjunct to clear ears and sinuses during compression and decompression. Dose: Spray into each nostril 2 times, twice daily. Not to exceed three consecutive days. вЂў NOTE: Do not tilt head backwards while spraying. Contra: Severe damage to tympanic membrane/sinuses from barotrauma (see Barotrauma) SE: Burning, sneezing and stinging of nasal mucosa AR: Rhinitus Atropine sulfate: Vagolytic Rx: Organophosphate or chemical poisoning, asthma, symptomatic bradycardia (see ACLS medications) вЂў NOTE: Successful treatment of organophosphate or chemical exposure may require mass quantities and repeated administration of atropine. Dosage: 0.5-1.0 mg q. 5 minutes up to max dosage is 3 mg (0.04 Mg/Kg). вЂў Organophosphate poisoning: 2-5 mg IV q. 15-30 minutes вЂў Pediatric: 0.015 mg/Kg up to a maximum dose of 0.04 mg/Kg. Contra: Atrial fibrillation, atrial flutter, glaucoma вЂў Use extreme caution in patients w/ hx of Type ll AV block and in 3rd degree block. SE: Dilated pupils, в†‘HR, VT, VF, dry mouth AR: Delirium Diamox (acetazolamide): Non-diuretic antihypertensive(carbonic anhydrase inhibitor) Rx: Prevention and/or amelioration of symptoms associated with acute mountain sickness in climbers attempting rapid ascent and/or in those who are very susceptible to acute mountain sickness despite gradual ascent. вЂў For maximum benefit begin regimen 7 days prior to ascent вЂў Of minimal benefit in Rx of AMS, HACE, or HAPE Dose: 125-250 mg b.i.d., 24 hours prior to ascent, continuing for 48 hours after ascent. вЂў Prevention and/or amelioration benefits is nominal once ascent has commenced вЂў If the 500 mg sustained release tablet is used, dose is 500 mg every 24 hours. Contra: Sulfa allergy. SE: Paresthesia in extremities, hearing dysfunction/tinnitus, loss of appetite, taste alterations, N & V, diarrhea, polyuria, drowsiness and confusion. NOTE: Use of Diamox results in a significant alteration in taste. Carbonated beverages will have seriously altered taste, and may be undrinkable. вЂў Increased fluid intake is required with use of Diamox: It is a diuretic, and can result in serious dehydration unless great care is taken to maintain proper hydration. AR: Transient myopia (usually resolves w/ DC of drug). Uticaria, melena, hematuria, flaccid paralysis, photosensitivity, convulsions. 198 Epinephrine (Adrenaline): Alpha and beta adrenergic sympathomimetic. First-line drug for anaphylaxis (See ACLS drugs for cardiac therapy) вЂў Causes bronchodilitation, vasoconstriction, increases blood pressure. вЂў Decreases edema/swelling due to allergic reactions. вЂў NOTE: 1:1,000 dilution epinephrine (1mg in 1 cc) is standard pararescue issue. 1:10,000 dilution (1 mg in 10cc) is the standard вЂ�CardiacвЂ™ dosage form, the only dilution that can be used IV. 1:1,000 epinephrine can be diluted to the 1:10,000 form by putting 1 cc of 1:1,000 epinephrine (1 mg epinephrine) in 9 ccвЂ™s of normal saline. Rx: Anaphylaxis, Allergic reactions (mild/moderate/severe), & Asthma Dose: Anaphylaxis: 0.3-0.5 mg (3-5 cc of 1:10,000 dilution) IV or 0.3-0.5 mg (0.3-0.5 cc of 1:1,000 dilution) IM Allergic reaction: 0.2-0.5 mg (0.3-0.5 cc of 1:1,000 dilution) SubQ or IM Asthma: 0.3-0.5 mg (0.3-0.5 cc of 1:1,000 dilution) SubQ Pediatric: 0.01 mg/Kg SubQ or IM. Not to exceed 0.5 mg Contra: 1:1,000 Epi is NOT given IV. вЂў Use caution in pts with a hx of heart disease, or over the age of 40. вЂў Do not inject Epi (or solutions containing Epi) into/near the fingers, toes, nose, ears or penis. Intense vasoconstriction may cause necrosis. SE: Cardiac arrhythmias, VT, VF, angina, HTN, в†‘BP, nausea and vomiting, vasoconstriction AR: Uncontrolled effects on myocardium & arterial system Imodium (loperamide HCL) Anti-Diarrheal (opiod) Rx: Treatment of acute diarrhea. вЂў For use in acute, non-invasive diarrhea only. вЂў Refer to medical emergencies if blood and/or mucus are present in stool, or diarrhea is associated with fever (infectious diarrhea). вЂў NOTE: The best course of action for acute diarrhea is to allow it to вЂњrun its courseвЂќ. Ensure copious hydration. Dose: 2 capsules (4 mg) first dose, then 1 capsule (2 mg) after every unformed stool, not to exceed 10 mg (5 capsules) in 24 hours. вЂў Use only if control of diarrhea is critical for continued operations. Contra: Acute dysentery. Not for use in children < 12 y.o. SE: Abdominal pain/distention, N & V, severe constipation, drowsiness, dizziness. AR: Hypersensitivity Lasix (Furosemide): Diuretic Rx: CHF w/ pulmonary edema, acute pulmonary edema, hypertensive crisis вЂў Use in HAPE is controversial, not currently recommended without direct physician control. вЂў Should have a urinary catheter in place to monitor urine output. Dosage: 20-40 mg slow IV push. Peds: 1mg/kg IV or IO slow push. Contra: Dehydration, hypotension, hypokalemia, hepatic coma SE: Hypokalemia, hypotension, dehydration AR: Agranulocytosis, leukopenia, thrombocytopenia; transient deafness w/ rapid IV Mannitol: Osmotic diuretic Rx: ICP; Myoglobinuria secondary to crush syndrome and rhabdomyolysis Dose: 0.25-1.0 grams/Kg IV (Takes effect w/in minutes of administration and can last 6-8 hours) вЂў Increases urine flow, making this an unreliable indicator of resuscitation. вЂў Use mannitol ONLY if there is evidence of ICP. 199 Contra: suspected/actual renal failure, suspected/actual intracranial hemorrhage SE: headache, nausea/vomiting, blurred vision, dizziness, rash, dehydration AR: seizures, pulmonary edema, cardiovascular collapse. Valium (Diazepam): General CNS depressant (Anticonvulsant/sedative). Rx: Acute anxiety, seizures, status epilepticus, relaxation of skeletal muscle вЂў Drug of choice for treatment of convulsions associated with chemical agents or organophosphates. NOTE: Successful treatment of convulsions from organophosphate or chemical exposure may require mass quantities and repeated administration Valium. вЂўOverdose may be reversed w/ Flumazenil Dose: вЂў Status Epilepticus: 5-10 mg IV slow push вЂў Acute anxiety: 5-15 mg IV slow push вЂў Relaxation of skeletal muscle: 5-15 mg IV slow push вЂў Chemical Warfareв€—: 10-15 mg IV slow push в€—Auto injection Diazepam should be used for seizures induced by chemicals Contra: head injury, в†“BP, acute narrow angle glaucoma вЂў Has additive effect with other respiratory depressants (morphine, phenergan and alcohol). Be prepared to perform BLS. SE: в†“BP, в†“Respirations, drowsiness, venous irritation, pain at injection site, N & V AR: bradycardia, CV collapse, amnesia, abdominal discomfort Zantac (ranitidine): H-2 blocker; в†“ secretion of stomach acid вЂў NOTE: Drug Interactions: в†“absorption of oral diazepam. Rx: Gastric and/or peptic ulcers, upper GI bleeds, prevention of stress ulcers in burn victims or patients on steroid treatment. вЂў Drug of choice for treatment of gastric or peptic ulcers. вЂў Adjunct in treatment of urticaria and anaphylaxis. Dosage: 50 mg IV or IM q. 6-8 hours for ulcers, burns, steroid use, upper GI bleeds, urticaria or anaphylaxis. вЂў Oral dose: 150 mg b.i.d. for ulcer, urticaria. вЂў Peds: 1.5 mg/Kg IV x 1, then 0.75 mg/Kg IV every 12 hours Contra: Known/suspected liver disease SE: Headache, diarrhea/constipation, muscle aches, vertigo, malaise, dry mouth, N & V AR: Thrombocytopenia, liver toxicity. ALAPHABETICAL RX Adenosine (Adenocard) Class: Antiarrhythmic Indications: symptomatic PSVT Contraindications: second- or third-degree heart block, sick-sinus syndrome Precautions: Arrhythmias, including blocks, are common at the time of cardioversion. Use with caution in patients with asthma. Side Effects: Facial flushing, headache, shortness of breath, dizziness, and nausea. Dosage: 6 mg given as a rapid IV bolus over a 1-2 second period; if, after 1-2 minutes, cardioversion does not occur, administer a 12-mg dose over 1-2 seconds. Routes: IV; should be administered directly into a vein or into the medication administration port closest to the patient and followed by flushing of the line with IV fluid. 200 Albuterol (Proventil) (Ventolin) Class: Sympathomimetic (Гџ2 selective) Actions: Bronchodilation Indications: Asthma reversible bronchospasm associated with COPD Contraindications: symptomatic tachycardia Precautions: Blood pressure, pulse, and EKG should be monitored use caution in patients with known heart disease Side Effects: Palpitations, anxiety, headache, dizziness, and sweating Dosage: Metered Dose Inhaler: 1-2 sprays (90 micrograms per spray) Small-Volume Nebulizer: 0.5 ml (2.5 mg) in 2.5 ml normal saline over 5-15 minutes Rotohaler: one 200-microgram rotocap should be placed in the inhaler and breathed by the patient Routes: Inhalation Aminophylline Class: Xanthine bronchodilator Actions: Smooth muscle relaxant, causes bronchodilation, has mild diuretic properties, increases heart rate. Indications: Bronchial asthma, reversible bronchospasm associated with chronic, bronchitis and emphysema, congestive heart failure, pulmonary edema. Contraindications: hypotension, patients with peptic ulcer disease. Precautions: Monitor for arrhythmias. Monitor blood pressure. Do not administer to patients on chronic theophylline. Preparations until the theophylline blood level has been determined. Side Effects: Convulsions, tremor, anxiety, and dizziness vomiting palpitations, PVCs, and tachycardia. Dosages: Method 1: 250 - 500 mg in 90 or 80 ml of d5w, respectively, infused over 20-30 minutes (approximately 5-10 mg/kg/hr) Method 2: 250 - 500 mg (5-7 mg/kg) in 20 ml of D5W infused over 20-30 minutes Routes: Slow IV infusion. Pediatric Dosage: 6 mg/kg loading dose to be infused over 20-30 minutes; maximum dose not to exceed 12 mg/kg per 24 hours. Amrinone (Inocor) Class: Cardiac inotrope. Actions: Increases cardiac contractility, vasodilator. Indications: Short-term management of severe CHF. Contraindications: Patients with history of hypersensitivity to the drug. Precautions: May increase myocardial ischemia. Blood pressure, pulse, and EKG should be constantly monitored. Amrinone should only be diluted with normal saline or 1/2 normal saline; no dextrose solutions should be used. Furosemide (Lasix) should not be administered into an IV line delivering Amrinone. Side Effects: Reduction in platelets, nausea and vomiting cardiac arrhythmias. Dosage: 0.75 mg/kg bolus given slowly over 2-3 minute interval followed by maintenance infusion of 2-15 Вµg/kg/minute. Routes: IV bolus and infusion as described earlier. Pediatric Dosage: Safety in children has not been established. Aspirin (Bufferin) Class: Platelet inhibitor/anti-inflammatory. Actions: Blocks platelet aggregation. Indications: New-onset chest pain suggestive of MI signs and symptoms suggestive or recent CVA. Contraindications: Patients with history of hypersensitivity to the drug. 201 Precautions: GI bleeding and upset. Side Effects: Heartburn, nausea and vomiting, wheezing. Dosage: 150-325 mg PO or chewed. Routes: PO. Pediatric Dosage: not recommended. Atropine Class: Parasympatholytic (anticholinergic). Actions: Blocks acetylcholine receptors, increases heart rate, decreases gastrointestinal secretions. Indications: Hemodynamically-significant bradycardia, hypotension secondary to bradycardia, asystole, organophosphate poisoning. Contraindications: None when used in emergency situations. Precautions: Dose of 0.04 mg/kg should not be exceeded except in cases of organophosphate poisonings, tachycardia, hypertension. Side Effects: Palpitations and tachycardia, headache, dizziness, and anxiety, dry mouth, pupillary dilation, and blurred vision, urinary retention (especially older males). Dosage: Bradycardia: 0.5 mg every 5 minutes to maximum of 0.04 mg/kg. Asystole: 1 mg. Organophosphate poisoning: 2-5 mg. Routes: IV, ET (ET dose is 2 - 2.5 times IV dose). Pediatric Dosage: Bradycardia: 0.02 mg/kg Maximum single dose (child 0.5 mg) (adolescent 1.0 mg) Maximum total dose (child 1.0 mg) (adolescent 2.0 mg) Bretylium (bretylol) Class: Antiarrhythmic. Actions: Increases ventricular fibrillation threshold, blocks the release of Norepinephrine from peripheral, sympathetic nerves. Indications: Ventricular fibrillation refractory to Lidocaine, ventricular tachycardia refractory to Lidocaine, PCVs refractory to first-line medications. Contraindications: None when used in the management of life-threatening arrhythmias. Precautions: Postural hypotension occurs in almost 50% of patients receiving Bretylium. Patient must be kept supine decrease dosage in patients being treated with catecholamine sympathomimetics. Side Effects: Hypotension, syncope, and bradycardia, Increased frequency of arrhythmias, dizziness and vertigo. Dosage: 5 mg/kg. may be repeated at dose of 10 mg/kg up to a total dose of 30 mg/kg. Routes: Rapid IV bolus. Pediatric Dosage: 5 mg/kg Calcium Chloride (CaCl) Class: Electrolyte. Actions: Increases cardiac contractility. Indications: Acute hyperkalemia (elevated potassium), acute hypocalcemia (decreased calcium), calcium channel blocker (Nifedipine, Verapamil, etc.), overdose, abdominal muscle spasm associated with spider bite and portuguese man-o-war stings, antidote for magnesium sulfate. Contraindications: Patients receiving digitalis. Precautions: IV line should be flushed between calcium chloride and sodium bicarbonate administration. Extravasation may cause tissue necrosis. Side Effects: Arrhythmias (bradycardia and asystole), hypotension. Dosage: 2-4 mg/kg of a 10% solution; may be repeated at 10-minute intervals. 202 Routes: IV. Pediatric Dosage: 5-7 mg/kg of a 10% solution. Dexamethasone (Decadron, Hexadrol) Class: Steroid. Actions: Possibly decreases cerebral edema, anti-inflammatory, suppresses immune response (especially in allergic reactions). Indications: Cerebral edema, anaphylaxis (after Epinephrine and diphenhydramine), asthma, COPD. Contraindications: None in the emergency setting. Precautions: Should be protected from heat, onset of action may be 2-6 hours and thus should not be considered to be of use in the critical first hour following an anaphylactic reaction. Side Effects: Gastrointestinal bleeding, prolonged wound healing. Dosage: 4-24 mg. Routes: IV. Pediatric Dosage: 0.2-0.5 mg/kg Dextrose 50% Class: Carbohydrate. Actions: Elevates blood glucose level rapidly. Indications: Hypoglycemia. Contraindications: None in the emergency setting. Precautions: A blood sample should be drawn before administering 50% dextrose. Side Effects: Local venous irritation. Dosage: 25 grams (50 ml). Routes: IV. Pediatric Dosage: 0.5 g/kg slow IV; should be diluted 1:1 with sterile water to form a 25% solution. Diazepam (Valium) Class: Tranquilizer (Benzodiazepine). Actions: Anticonvulsant, skeletal muscle relaxant, sedative. Indications: Generalized seizures, status epilepticus, premedication before cardioversion, skeletal muscle relaxant, acute anxiety states. Contraindications: Patients with a history of hypersensitivity to the drug. Precautions: Can cause local venous irritation. Has short duration of effect. Do not mix with other drugs because of possible precipitation problems. Side Effects: Drowsiness, hypotension, respiratory depression, apnea. Dosage: Status epilepticus: 5-10 mg IV. Acute anxiety: 2-5 mg IM or IV. Premedication before cardioversion: 5-15 mg IV. Routes: IV (care must be taken not to administer faster than 1 ml/min) IM rectal. Pediatric Dosage: Status epilepticus: 0.1 - 0.2 mg/kg. Digoxin (Lanoxin) Class: Cardiac glycoside. Actions: Increases cardiac contractile force, increases cardiac output, reduces edema associated with congestive heart failure, slows AV conduction. Indications: Congestive heart failure, rapid atrial arrhythmias, especially atrial flutter and atrial fibrillation. 203 Contraindications: Any patient with signs or symptoms of digitalis, toxicity, ventricular fibrillation. Precautions: Monitor for signs of digitalis toxicity. Patients who have recently suffered a myocardial infarction have greater sensitivity to the effects of digitalis. Calcium should not be administered to patients receiving digitalis. Side Effects: Nausea, vomiting, arrhythmias, yellow vision. Dosage: 0.25-0.50 mg. Routes: IV. Pediatric Dosage: 25-40 Вµg/kg. Diltiazem (Cardizem) Class: Calcium channel blocker. Actions: Slows conduction through the AV node, causes vasodilation, decreases rate of ventricular response, decreases myocardial oxygen demand. Indications: To control rapid ventricular response associated with atrial fibrillation and flutter. Contraindications: Hypotension, wide complex tachycardia, conduction system disturbances. Precautions: Should not be used in patients receiving intravenous Гџ blockers. Hypotension. Must be kept refrigerated or discarded one month after removal from refrigeration. Side Effects: Nausea, vomiting, hypotension, and dizziness. Dosage: 0.25 mg/kg bolus (typically 20 mg) IV over 2 minutes. This should be followed by a maintenance infusion of 5-15 mg/hour. Routes: IV, IV drip. Pediatric Dosage: Rarely used. Dimenhydrinate (Dramamine) Class: Antihistamine. Actions: Blocks histamine receptors, antiemetic. Indications: Nausea and vomiting, motion sickness, to potentiate the effects of analgesics. Contraindications: Comatose states, patients who have received large amounts of depressants (including alcohol). Precautions: Use with caution in patients with seizure disorders, asthma. Side Effects: May impair mental and physical ability, drowsiness, bronchial secretions. Dosage: 25-50 mg slow IVP (over 2 minutes) 50 - 100 mg IM. Routes: IV, IM. Pediatric Dosage: Not recommended. Diphenhydramine (Benadryl) Class: Antihistamine. Actions: Blocks histamine receptors, has some sedative effects. Indications: Anaphylaxis, allergic reactions, dystonic reactions due to phenothiazines. Contraindications: Asthma, nursing mothers. Precautions: Hypotension. Side Effects: Sedation, dries bronchial secretions, blurred vision, headache, palpitations. Dosage: 25-50 mg. Routes: Slow IV push deep IM. Pediatric Dosage: 2-5 mg/kg. Dobutamine (Dobutrex) Class: Sympathomimetic. Actions: Increases cardiac contractility, little chronotropic activity. Indications: Short-term management of congestive heart failure. 204 Contraindications: Should only be used in patients with an adequate heart rate. Precautions: Ventricular irritability. Use with caution following myocardial infarction. Can be deactivated by alkaline solutions. Side Effects: Increased heart rate, palpitations. Dosage: 2.5-20 Вµg/kg/minute. Method: 250 mg should be placed in 500 ml of d5w, which gives a concentration of 0.5 mg/ml. Routes: IV drip. Pediatric Dosage: 2 - 20 Вµg/kg/min. Dopamine (Intropin) Class: Sympathomimetic. Actions: Increases cardiac contractility, causes peripheral vasoconstriction. Indications: Hemodynamically significant hypotension (systolic BP of 70-100 mmhg) not resulting from hypovolemia, cardiogenic shock. Contraindications: Hypovolemic shock where complete fluid resuscitation has not occurred. Precautions: Should not be administered in the presence of severe tachyarrhythmias. Should not be administered in the presence of ventricular fibrillation, ventricular irritability. Beneficial effects lost when dose exceeds 20 Вµg/kg/min. Side Effects: Ventricular tachyarrhythmias, hypertension, palpitations. Dosage: 2-20 Вµg/kg/minute. Start low and increase as needed. Method: 800 mg should be placed in 500 ml of D5W giving a concentration of 1600 Вµg/ml. Routes: IV drip only. Pediatric Dosage: 2-20 Вµg/kg/minute. Epinephrine (Adrenalin): Description: A hormone produced by the adrenal gland (attached to the kidneys) and synthesized commercially. It is employed therapeutically as a vassoconstrictor, as a cardiac stimulant, and to relax bronchioles. It is also used to treat asthmatic attacks and treat anaphylactic shock. Epinephrine 1:1,000 Class: Sympathomimetic. Actions: Bronchodilation. Indications: Bronchial asthma, exacerbation of COPD, allergic reactions. Contraindications: Patients with underlying cardiovascular disease, hypertension, pregnancy, patients with tachyarrhythmias. Precautions: Should be protected from light. Blood pressure, pulse, and EKG must be constantly monitored. Side Effects: Palpitations and tachycardia, anxiousness, headache, tremor. Dosage: 0.3-0.5 mg. Routes: Subcutaneous (IV and ET for pediatric cardiac arrest). Pediatric Dosage: 0.01 mg/kg up to 0.3 mg. Epinephrine 1:10,000 Class: Sympathomimetic. Actions: Increases heart rate and automaticity. Increases cardiac contractile force. Increases myocardial electrical activity. Increases systemic vascular resistance. Increases blood pressure. Causes bronchodilation. Indications: Cardiac arrest, anaphylactic shock severe reactive airway disease. 205 Contraindications: Epinephrine 1:10,000 is for intravenous or endotracheal use; it should not be used in patients who do not require extensive resuscitative efforts. Precautions: Should be protected from light. Can be deactivated by alkaline solutions. Side Effects:Palpitations, anxiety, tremulousness, nausea and vomiting. Dosage: cardiac arrest: 0.5-1.0 mg repeated every 3-5 minutes. severe anaphylaxis: 0.3-0.5 mg (3-5 ml); occasionally and Epinephrine drip is required. Routes: IV, IV drip, ET. Pediatric Dosage: 0.01 mg/kg initially. with subsequent doses, Epinephrine 1:1,000 should be used at a dose of 0.1 mg/kg. Flumazenil (Romazicon) Class: Benzodiazepine antagonist. Actions: Reverses effects of benzodiazepines. Indications: To reverse CNS, respiratory depression associated with Benzodiazepines. Contraindications: Flumazenil should not be used as a diagnostic agent for Benzodiazepine overdose in the same manner Naloxone is used for narcotic overdose. Known hypersensitivity to the drug. Precautions: Administer with caution to patients dependent upon Benzodiazepines as it may induce life-threatening Benzodiazepine withdrawal. Side Effects: Fatigue, headache, nervousness, dizziness. Dosage: 0.2-0.3 mg IV over 30 seconds; repeated as needed to a maximum dose of 1.0 mg. Routes: IV. Pediatric Dosage: Pediatric data unavailable. Furosemide (Lasix) Class: Potent diuretic. Actions: Inhibits reabsorption of sodium chloride, promotes prompt diuresis, vasodilation. Indications: Congestive heart failure, pulmonary edema. Contraindications: Pregnancy, dehydration. Precautions: Should be protected from light, dehydration. Side Effects: Few in emergency usage. Dosage: 40-80 mg. Routes: IV. Pediatric Dosage: 1 mg/kg. Glucagon Class: Hormone (antihypoglycemic agent). Actions: Causes breakdown of glycogen to glucose. Inhibits glycogen synthesis. Elevates blood glucose level. Increases cardiac contractile force. Increases heart rate. Indications: Hypoglycemia. Contraindications: Hypersensitivity to the drug. Precautions: Only effective if there are sufficient stores of Glycogen within the liver. Use with caution in patients with cardiovascular or renal disease. Draw blood glucose before administration. Side Effects: Few in emergency situations. Dosage: 0.25-0,50 mg (unit) IV 1.0 mg, IM. Routes: IV, IM. Pediatric Dosage: 0.03 mg/kg. 206 Haloperidol (Haldol) Class: Major tranquilizer. Actions: Blocks dopamine receptors in brain responsible for mood and behavior has antiemetic properties. Indications: Acute psychotic episodes. Contraindications: Should not be administered in the presence of other sedatives. Should not be used in the management of dysphoria caused by Talwin. Precautions: Orthostatic hypotension. Side Effects: Physical and mental impairment, Parkinson-like reactions have been known to occur, especially in children. Dosage: 2-5 mg. Routes: IM. Pediatric Dosage: Rarely used. Heparin Class: Anticoagulant. Actions: Functions as an anticoagulant by accelerating neutralization of activated clotting factors. Indications: Situations where a hypocoaguable state is required (i.e. post MI, post-CVA, pulmonary embolism). Contraindications: Should not be used unless there is a medical reason to anticoagulate the patient. Precautions: Sever, urticaria, and anaphylaxis have been reported following heparin administration skin necrosis can develop at site of subQ injections. Side Effects: Fever, bruising, oozing of blood. Dosage: Loading dose: 5,000 iu IV is a typical loading dose although large patients and patients with heparin resistance may receive larger doses. Maintenance dose: Infusion therapy is typically started at 800 - 1,000 iu/hour. the dosage is modified based upon the patient's prothrombin (pt) time. Routes: IV subQ (for prophylaxis). Pediatric Dosage: Rarely used. Hydrocodone (Vicodin, Lortab) Class: Narcotic analgesic. Actions: CNS depressant, decreases sensitivity to pain. Indications: Relief of cough and moderate to severe pain. Contraindications: Patients with a history of hypersensitivity to the drug or acetaminophen (Tylenol). Precautions: May exaggerate the effects of other CNS depressants. May cause repiratory depression at high dosages. May elevate intracranial and cerebrospinal fluid pressure in the presence of a head injury or a pre-existing increase in intracranial pressure. Side Effects: Lightheadedness, dizziness, drowsiness, nausea, and vomiting. Dosage: 2.5/5.0/7.5 mg tablets; 1-2 every 4-6 hours. Routes: Oral. Pediatric Dosage: Not recommended. Hydroxyzine (Vistaril) Class: Antihistamine. Actions: Antiemetic, antihistamine, antianxiety, potentiates analgesic effects of narcotics and related agents. Indications: To potentiate the effects of narcotics and synthetic narcotics, nausea and vomiting, anxiety reactions. Contraindications: Patients with a history of hypersensitivity to the drug. Precautions: Orthostatic hypotension, analgesic dosages should be reduced when used with Hydroxyzine, urinary retention. Side Effects: Drowsiness. 207 Dosage: 50-100 mg. Routes: Deep IM. Pediatric Dosage: 1 mg/kg. Insulin (Humulin) Class: Hormone (hypoglycemic agent). Actions: Causes uptake of glucose by the cells, decreases blood glucose level, promotes glucose storage. Indications: Elevated blood glucose, diabetic ketoacidosis. Contraindications: Avoid overcompensation of blood glucose level; if possible, administration should wait until the patient is in the emergency department. Precautions: Administration of excessive dose may induce hypoglycemia. Glucose should be available. Side Effects: Few in emergency situations. Dosage: 10-25 units regular insulin IV followed by an infusion at 0.1 units/kg/hr. Routes: IV subQ. Pediatric Dosage: Dosage is based on blood glucose level. Ipatropium (Atrovent) Class: Anticholinergic. Actions: Causes bronchodilation, dries respiratory tract secretions. Indications: Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema. Contraindications: Patients with history of hypersensitivity to the drug, should not be used as primary agent in acute treatment of bronchospasm. Precautions: Blood pressure, pulse, and EKG must be constantly monitored. Side Effects: Palpitations, dizziness, anxiety, tremors, headache, nervousness, dry mouth. Dosage: Small-volume nebulizer: 500 Вµg should be placed in small volume nebulizer (typically administered with a Гџ agonist). Routes: Inhalation only. Pediatric Dosage: Safety in children has not been established. Isoetharine (Bronkosol) Class: Sympathomimetic (Гџ2 selective). Actions: Bronchodilation, increases heart rate. Indications: Asthma, reversible bronchospasm associated with chronic bronchitis and emphysema. Contraindications: Patients with history of hypersensitivity to the drug. Precautions: Blood pressure, pulse, and EKG must be constantly monitored. Side Effects: Palpitations, tachycardia, anxiety and tremors, headache. Dosage: Hand nebulizer: four inhalations. Small-volume nebulizer: 0.5 ml (1:3 with saline). Routes: Inhalation only. Pediatric Dosage: 0.25-0.5 ml diluted with 4 ml normal saline. Ketorolac (Toradol) Class: Non-steroidal anti-inflammatory agent. Actions: Anti-inflammatory, analgesic (peripherally-acting). Indications: Mild to moderate pain. Contraindications: Patients with a history of hypersensitivity to the drug, patients allergic to Aspirin. Precautions: GI irritation or hemorrhage can occur. Side Effects: Edema, rash, heartburn. Dosage: IV 15-30 mg, IM 30-60 mg. 209 Routes: IV, IM. Pediatric Dosage: Safety in children has not been established. Labetalol (Trandate) (Normodyne) Class: Sympathetic blocker. Actions: Selectively blocks Гї1 receptors and nonselectively blocks Гџ receptors. Indications: Sypertensive crisis. Contraindications: Sronchial asthma, congestive heart failure, heart block, bradycardia, cardiogenic shock. Precautions: Blood pressure, pulse, and EKG must be constantly monitored. Atropine and transcutaneous pacing should be available. Side Effects: Bradycardia, heart block, congestive heart failure, bronchospasm, postural hypotension. Dosage: Method 1: 20 mg by slow IV infusion over 2 minutes; doses of 40 mg can be repeated in 10 minutes until desired supine blood pressure is obtained or until 300 mg of the drug has been given. Method 2: 200 mg placed in 500 ml d5w to deliver 2 mg/minute. Routes: IV infusion or slow IV bolus as described earlier. Pediatric Dosage: Safety in children has not been established. Lidocaine (Xylocaine) Class: Antiarrhythmic. Actions: Suppresses ventricular ectopic activity, increases ventricular fibrillation threshold, reduces velocity of electrical impulse through conductive system. Indications: Malignant PVCs, ventricular tachycardia, ventricular fibrillation, prophylaxis of arrhythmias associated with acute myocardial infarction and thrombolytic therapy, premedication prior to rapid sequence induction. Contraindications: High-degree heart blocks, PVCs in conjunction with bradycardia. Precautions: Dosage should not exceed 300 mg/hr. Monitor for CNS toxicity. Dosage should be reduced by 50% in patients older than 70 years of age or who have liver disease in cardiac arrest, use only bolus therapy. Side Effects: Anxiety, drowsiness, dizziness, and confusion, nausea and vomiting, convulsions, widening of QRS. Dosage: Bolus: Initial bolus of 1.5 mg/kg; additional boluses of 0.5 - 0.75 mg/kg can be repeated at 810-minute intervals until the arrhythmia has been suppressed or until 3 mg/kg of the drug has been administered; reduce dosage by 50% in patients older than 70 years of age. Drip: after the arrhythmia has been suppressed a 2-4 mg/minute infusion may be started to maintain adequate blood levels. Routes: IV bolus, IV infusion. Pediatric Dosage: 1 mg/kg. Magnesium Sulfate Class: Anticonvulsant/Antiarrhythmic. Actions: CNS depressant, anticonvulsant, antiarrhyhmic. Indications: Obstetrical eclampsia (toxemia of pregnancy), pre-eclampsia/PIH, cardiovascular severe refractory ventricular fibrillation, pulseless ventricular tachycardia, post-MI as prophylaxis for arrhythmias, torsades de pointes (multi-axial ventricular tachycardia). Contraindications: Shock, heart block. Precautions: Caution should be used in patients receiving digitalis. Hypotension. Calcium Chloride should be readily available as an antidote if respiratory depression ensues. Use with caution in patients in renal failure. Side Effects: Respiratory depression, drowsiness. Dosage: 1-4 g. Routes: IV, IM. Pediatric Dosage: Not indicated. 210 Mannitol (Osmotrol) Class: Osmotic diuretic. Actions: Decreases cellular edema, increases urinary output. Indications: Acute cerebral edema, blood transfusion reactions. Contraindications: Pulmonary edema, patients who are dehydrated, hypersensitivity to the drug. Precautions: Rapid administration can cause circulatory overload crystallization of the drug can occur at lower temperatures. An in-line filter should be used. Side Effects: Pulmonary congestion, sodium depletion, transient volume overload. Dosage: 1.5-2.0 g/kg. Routes: IV. Pediatric Dosage: 0.25-0.5 g/kg IV over 60 minutes. Methylprednisolone (Solu-Medrol) Class: Steroid. Actions: Anti-inflammatory, suppresses immune response (especially in allergic reactions). Indications: Severe anaphylaxis, asthma/COPD, possibly effective as an adjunctive agent in the management of spinal cord injury. Contraindications: None in the emergency setting. Precautions: Must be reconstituted and used promptly. Onset of action may be 2-6 hours and thus should not be expected to be of use in the critical first hour following an anaphylactic reaction. Side Effects: GI bleeding, prolonged wound healing, suppression of natural steroids. Dosage: General usage: 125-250 mg. Spinal cord injury: Initial bolus of 30 mg/kg administered over 15 minutes, followed by a maintenance infusion of 5.4 mg/kg/hr. Routes: IV, IM. Pediatric Dosage: 30 Вµg/kg. Midazolam (Versed) Class: Benzodiazepine tranquilizer. Actions: Hypnotic, sedative. Indications: Premedication prior to cardioversion/RSI, acute anxiety states. Contraindications: Patients with known hypersensitivity to the drug, narrow-angle glaucoma, shock. Precautions: Emergency resuscitation equipment should be available. Flumazenil (Romazicon) should be available. Dilute with normal saline or D5W prior to intravenous administration. Respiratory depression more common with Midazolam than with other Benzodiazepines. Side Effects: Drowsiness, hypotension, amnesia, respiratory depression, apnea. Dosage: 1.0- 2.5 mg IV. Routes: IV, IM, intranasal. Pediatric Dosage: 0.03 mg/kg. Morphine Class: Narcotic. Actions: CNS depressant, causes peripheral vasodilation, decreases sensitivity to pain. Indications: Severe pain, pulmonary edema. Contraindications: Head injury, volume depletion undiagnosed abdominal pain, patients with history of hypersensitivity to the drug. Precautions: Respiratory depression (narcan should be available), hypotension, nausea. Side Effects: Dizziness, altered level of consciousness. 211 Dosage: IV: 2-5 mg followed by 2 mg every few minutes until the pain is relieved or until respiratory depression ensues. IM: 5-15 mg based on patient weight. Routes: IV, IM. Pediatric Dosage: 0.1-0.2 mg/kg IV. Nalbuphine (Nubain) Class: Synthetic analgesic. Actions: CNS depressant, decreases sensitivity to pain. Indications: Moderate to severe pain. Contraindications: Patients with a history of hypersensitivity to the drug. Precautions: Use with caution in patients with impaired respiratory function, respiratory depression (Naloxone should be available). Patients dependent on narcotics may experience, symptoms of withdrawal, nausea. Side Effects: Dizziness, altered level of consciousness. Dosage: 5-10 mg. Routes: IV, IM. Pediatric Dosage: Rarely used. Naloxone (Narcan) Class: Narcotic antagonist. Actions: Reverses effects of narcotics. Indications: вЂў Narcotic overdoses including the following: Codeine, Demerol, Dilaudid, Fentanyl, Heroin, Lortabs, Methadone, Morphine, Paregoric, Percodan, Tylox, Vicodin, synthetic analgesics, вЂў Overdoses including the following: Darvon, Nubain, Stadol, Talwin, alcoholic coma, вЂў To rule out narcotics in coma of unknown origin. Contraindications: Patients with a history of hypersensitivity to the drug. Precautions: Should be administered with caution to patients dependent on narcotics as it may cause withdrawal effects. Short-acting, should be augmented every 5 minutes. Side Effects: none. Dosage: 1-2 mg. Routes: IV, IM. ET (ET dose is 2.0-2.5 times IV dose). Pediatric Dosage: < 5 years old > 5 years old 0.1 mg/kg 2.0 mg. Nifedipine (Procardia) Class: Calcium channel blocker. Actions: Relaxes smooth muscle causing arteriolar vasodilation decreases peripheral vascular resistance. Indications: Severe hypertension, angina pectoris. Contraindications: Known hypersensitivity to the drug, hypotension. Precautions: Blood pressure should be constantly monitored. May worsen congestive heart failure. Nifedipine should not be administered to patients receiving intravenous beta blockers. Side Effects: Dizziness, flushing, nausea, headache, and weakness. Dosage: 10 mg sublingually; puncture the capsule several times with a needle and place it under the patient's tongue and have them withdraw the liquid medication. Routes: Oral, sublingual. Pediatric Dosage: 0.25-0.5 mg/kg. 212 Nitroglycerin Spray (Nitrolingual Spray) Class: Antianginal. Actions: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries. Indications: Angina pectoris, chest pain associated with myocardial infarction. Contraindications: Hypotension. Precautions: Constantly monitor vital signs. Syncope can occur. Side Effects: Dizziness, hypotension, headache. Dosage: One spray administered under the tongue; may be repeated in 10-15 minutes; no more than three sprays in a 15-minute period; spray should not be inhaled. Routes: Sprayed under tongue on mucous membrane. Pediatric Dosage: Not indicated. Nitropaste (Nitro-Bid) Class: Antianginal. Actions: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries. Indications: Angina pectoris, chest pain associated with myocardial infarction. Contraindications: Children younger than 12 years of age, hypotension. Precautions: Constantly monitor blood pressure, syncope, drug must be protected from light, expires quickly once bottle is opened. Side Effects: Dizziness, hypotension. Dosage: 1/2 to 3/4 inches. Routes: Topical. Pediatric Dosage: Not indicated. Norepinephrine (Levophed) Class: Sympathomimetic. Actions: Causes peripheral vasoconstriction. Indications: Hypotension refractory to other sympathomimetics, neurogenic shock. Contraindications: Hypotensive states due to hypovolemia. Precautions: Can be deactivated by alkaline solutions. Constant monitoring of blood pressure is essential. Extravasation can cause tissue necrosis. Side Effects: Anxiety, palpitations, hypertension. Dosages: 0.5-30 Вµg/minute. Method: 8 mg should be placed in 500 ml of D5W, giving a concentration of 16 Вµg/ml. Routes: IV drip only. Pediatric Dosage: 0.01-0.5 Вµg/kg/minute (rarely used). Oxygen (O2) Class: gas. Actions: Necessary for cellular metabolism. Indications: Hypoxia. Contraindications: None. Precautions: Use cautiously in patients with COPD, humidify when providing high-flow rates. NOTE: O2 FEEDS FIRE AND CAN BE EXPLOSIVE Side Effects: Drying of mucous membranes. Dosage: Cardiac arrest: 100%. Other critical patients: 100%. COPD: 35%. Routes: Inhalation. Pediatric Dosage: 24-100% as required. 213 Phenytoin (Dilantin) Class: Anticonvulsant/antiarrhythmic. Actions: Inhibits spread of seizure activity through motor cortex, antiarrhythmic. Indications: Status epilepticus, arrhythmias due to digitalis toxicity. Contraindications: Any arrhythmia except those due to digitalis toxicity, patients with history of hypersensitivity to the drug. Precautions: Should not be administered with glucose solutions. Hypotension. EKG monitoring during administration is essential. Side Effects: Local venous irritation, central nervous system depression. Dosages: Status epilepticus: 150-250 mg (10-15 mg/kg) not to exceed 50 mg/minute. Digitalis toxicity: 100 mg over 5 minutes until the arrhythmia is suppressed or until symptoms of central nervous system depression occur. Routes: IV (dilute with saline). Pediatric Dosage: Status epilepticus: 8-10 mg/kg IV. Digitalis toxicity: 3-5 mg/kg IV over 10 minutes. Procainamide (Pronestyl) Class: Antiarrhythmic. Actions: Slows conduction through myocardium, elevates ventricular fibrillation threshold, suppresses ventricular ectopic activity. Indications: Persistent cardiac arrest due to ventricular fibrillation and refractory to Lidocaine, PVCs refractory to Lidocaine, ventricular tachycardia refractory to Lidocaine. Contraindications: High-degree heart blocks, PVCs in conjunction with bradycardia. Precautions: Dosage should not exceed 17 mg/kg. Monitor for central nervous system toxicity. Side Effects: Anxiety, nausea, convulsions, widening of QRS. Dosage: Initial: 20 mg/minute until arrhythmia abolished, hypotension ensues, QRS widened by 50% of original width total of 17 mg/kg has been given. maintenance: 1-4 mg/minute. Routes: slow IV bolus, IV drip. Pediatric Dosage: Rarely used. Prochlorperazine (Compazine) Class: Phenothiazine antiemetic. Actions: Antiemetic. Indications: Nausea and vomiting, acute psychosis. Contraindications: Comatose states, patients who have received a large amount of depressants (including alcohol), patients with a history of hypersensitivity to the drug. Precaution: EPS (extra-pyramidal seizure) (dystonic) reactions have been reported. Side Effects: May impair mental and physical ability, drowsiness. Dosage: 5-10 mg slow IV or IM. Routes: IV, IM. Pediatric Dosage: Not recommended. Promethazine (Phenergan) Class: Antihistamine (h1 antagonist). Actions: Mild anticholinergic activity, antiemetic, potentiates actions of analgesics. Indications: Nausea and vomiting, motion sickness, to potentiate the effects of analgesics, sedation. Contraindications: Comatose states, patients who have received a large amount of depressants (including alcohol). Precautions: Avoid accidental intra-arterial injection. 214 Side Effects: May impair mental and physical ability, drowsiness. Dosage: 25 mg. Routes: IV. Pediatric Dosage: 0.5 mg/kg. Return to top of page Racemic Epinephrine (Micronefrin) (VapoNefrin) Class: Sympathomimetic. Actions: Bronchodilation, increases heart rate, increases cardiac contractile force. Indications: Croup (laryngotracheobronchitis). Contraindications: Epiglottitis, hypersensitivity to the drug. Precautions: Vital signs should be constantly monitored. Should be used only once in the prehospital setting. Side Effects: Palpitations, anxiety, headache. Dosage: 0.5-0.75 ml of a 2.25% solution in 2.0 ml normal saline. Routes: Inhalation only (small-volume nebulizer). Pediatric Dosage: 0.25-0.75 ml of a 2.25% solution in 2.0 ml normal saline. Rifabutin: Description: A drug used to help prevent mycobacterium avium complex disease in patients with HIV infections. Ringer's Solution (lactated): Description: A sterile solution of specified amounts of calcium, potassium chloride, sodium chloride, and sodium lactate in water for injection. It is used intravenously to treat dehydration and replace electrolytes. Sodium Bicarbonate Class: Alkalinizing agent. Actions: Combines with excessive acids to form a weak volatile acid, increases ph. Indications: Late in the management of cardiac arrest, if at all, tricyclic antidepressant overdose, severe acidosis refractory to hyperventilation. Contraindication: Alkalotic states. Precautions: Correct dosage is essential to avoid overcompensation of ph. Can deactivate catecholamines. Can precipitate with calcium preparations. Delivers large sodium load. Side Effects: Alkalosis. Dosage: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes as indicated by blood gas studies. Routes: IV. Pediatric Dosage: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes. Succinylcholine (Anectine) Class: Neuromuscular blocking agent (depolarizing). Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory muscles. Indications: To achieve paralysis to facilitate endotracheal intubation. Contraindications: Patients with known hypersensitivity to the drug. Precautions: Should not be administered unless persons skilled in endotracheal intubation are present. Endotracheal intubation equipment must be available. Oxygen equipment and emergency resuscitative drugs must be available. Paralysis occurs within 1 minute and lasts for approximately 8 minutes. Side Effects: Prolonged paralysis, hypotension, bradycardia. Dosage: 1-1.5 mg/kg (40-100 mg in an adult). Routes: IV. Pediatric Dosage: 1 mg/kg. 215 Terbutaline (Brethine) Class: Sympathomimetic. Actions: Bronchodilator, increases heart rate. Indications: Bronchial asthma, reversible bronchospasm associated with COPD, preterm labor. Contraindications: Batients with known hypersensitivity to the drug. Precautions: Blood pressure, pulse, and EKG must be constantly monitored. Side Effects: Palpitations, tachycardia, and PVCs, anxiety, tremor, and headache. Dosage: Metered-dose inhaler: two inhalations, 1 minute apart. Subcutaneous injection: 0.25 mg; may be repeated in 15-30 minutes. Preterm labor: 0.25 mg IM or IV. may be repeated in 15-30 minutes as needed. Routes: Inhalation, subcutaneous injection, IV (preterm labor only). Pediatric Dosage: 0.01 mg/kg subcutaneously. Torsemide (Demadex) Class: Potent diuretic. Actions: Inhibits reabsorption of sodium chloride, promotes prompt diuresis. Indications: Congestive heart failure, pulmonary edema. Contraindications: Patients with known hypersensitivity to the drug, anuria. Precautions: Should be used with caution in patients taking NSAIDs, dehydration. Side Effects: Dizziness, headache, nausea. Dosage: 10-20 mg. Routes: IV. Vecuronium (Norcuron) Class: Neuromuscular blocking agent (non-depolarizing). Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory muscles. Indications: To achieve paralysis to facilitate endotracheal intubation. Contraindications: Patients with known hypersensitivity to the drug. Precautions: Should not be administered unless persons skilled in endotracheal intubation are present. Endotracheal intubation equipment must be available. Oxygen equipment and emergency resuscitative drugs must be available. Paralysis occurs within 1 minute and lasts for approximately 30 minutes. Side Effects: Prolonged paralysis, hypotension, bradycardia. Dosage: 0.08-0.10 mg/kg. Routes: IV. Pediatric Dosage: 0.1 mg/kg. Verapamil (Isoptin) (Calan) Class: Calcium channel blocker. Actions: Slows conduction through the AV node, inhibits reentry during PSVT, decreases rate of ventricular response, decreases myocardial oxygen demand. Indications: PSVT. Contraindications: Heart block, conduction system disturbances. Precautions: should not be used in patients receiving intravenous Гџ blockers, hypotension. Side Effects: Nausea, vomiting, hypotension, and dizziness. Dosage: 2.5 - 5.0 mg. a repeat dose of 5 - 10 mg can be administered after 15-30 minutes if PSVT does not convert. maximum dose is 30 mg in 30 minutes. Routes: IV. Pediatric Dosage: 0-1 year: 0.1-0.2 mg/kg (maximum of 2.0 mg) administered slowly. 1-15 years: 0.1-0.3 mg/kg (maximum of 5.0 mg) administered slowly. 216 GLOSSARY MEDICAL TERMS @ -at b.i.d. -twice a day BM -Bowel Movement BPM -Beats/Breaths per Minute B/P -Blood Pressure BS -Bowel Sounds BVM -Bag-Valve-Mask CC -Chief Complaint cc -cubic centimeter CVA -Cerebrovascular Accident d/c -discontinue Dx -diagnosis ET -Endotracheal Tube ETOH -ethyl alcohol FB -Foreign Body FROM -Full Range of Motion Fx -Fracture gtts -drops GSW -Gun Shot Wound hr -hour HTN -Hypertension KVO -Keep Vein Open kg -kilogram LMP -Last Menstrual Period LR вЂ“ Lactated Ringers mmHg -millimeters of mercury NaCl -sodium chloride NG -Nasogastric NPO -Nothing by mouth NS -Normal Saline N&V -Nausea and Vomiting OCP -Oral Contraceptive Pills PE -Physical Exam PERLA -Pupils Equal and Reactive to Light and Accommodation PO -by mouth PRN -as needed q -every q.i.d. -four times daily ROM -Range of Motion SaO2 -oxygen saturation SC/SubQ - Subcutaneous SL Sublingual SOB -Short of Breath TKO -To Keep Open VA -Visual Acuity y/o -year old Pos -positive NEG -negative ANATOMIC LOCATIONS abd -abdomen AD -right ear AS -left ear AU -both ears CNS -Central Nervous System C1-C7 -Cervical Spine DIP -Distal Interphalangeal GI -Gastrointestinal GU -Genitourinary GYN -Gynecological LLL -Left Lower Lobe LUQ -Left Upper Quadrant LLQ -Left Lower Quadrant L1-L5 -Lumbar Spine OD -right eye OS -left eye OU -both eyes PIP -Proximal Interphalangeal RLL -Right Lower Lobe RUL -Right Upper Lobe RLQ -Right Lower Quadrant RUQ -Right Upper Quadrant TM -Tympanic Membrane TMJ -Tempomandibular Joint T1-T12 -Thoracic Spine 218 APGAR (ACCOMPLISHED 1 MIN AFTER BIRTH AND 5MIN AFTER BIRTH) APPEARANCE Blue or pale Body pink, extremities blue Completely pink PULSE RATE Below 100 Above 100 GRIMACE Grimaces Cries ACTIVITY Some flexion of extremities Active motion RESPIRATORY Slow, irregular Good, strong cry 0 1 2 Absent 0 1 2 No response 0 1 2 Limp 0 1 2 Absent 0 1 2 APGAR < 4 = SERIOUS CONDITION REQUIRING SOME DEGREE OF RESUSCITATION APGAR 4-6 = CONDITION IS GUARDED APGAR 7-10 = NORMAL STABLE INFANT MNEMONICS CAUSES OF COMA: A - Alcohol, acidosis (hyperglycemic coma) E - Epilepsy, Electrolyte abnormality, Endocrine problem I - Insulin (hypoglycemic shock) O - Overdose (or poisoning) U - Uremia and other renal problems T - Trauma; temperature (hypothermia, heat stroke) I - Infection (e.g., meningitis) P - Psychogenic ("hysterical coma") S - Stroke or space-occupying lesions in the cranium COMA ASSESSMENT: D - Depth of coma (verbal or painful stimuli) E - Eyes (PERLA) R - Respiration (rate and rhythm) M - Motor (loss of movement/sensation) LEVEL OF CONSCIOUSNESS: A - Alert V - Responds to Verbal stimuli P - Responds to Painful stimuli U - Unresponsive PATIENT HISTORY: A вЂ“ Allergies M вЂ“ Medications Weight 1 gr = 65 mg 15 gr = 1 gm 219 P - Past medical history (illness, injury) P вЂ“ Pain (PQRST) L - Last intake (food, fluid) E - Ever happen before? 1000 mg = 1 gm 1 oz. = 28 gm 454 gm = 1 lb 1000 gm = 1 kg 1 metric ton = 2,000 lbs P вЂ“ Pain (sharp or dull) Q вЂ“ Quality (diffuse or pinpoint) R - Radiating S -Severity (scale of 1-10) T вЂ“ Time of onset To convert В°F to В°C (В°F вЂ“ 32) divide by1.8 To convert В°C to В°F (В°C x 1.8) + 32 PUPIL REACTION P - Pupils E - Equal R вЂ“ Reactive L - Light A - Accommodation USEFUL CONVERSIONS TEMPERATURE В°F 106 105 104 103 102 101 100 99 98.6 98 97 96 95 94 93 92 В°C 41.1 40.6 40 39.4 38.9 38.3 37.8 37.2 37 36.7 36.1 35.6 35 34.4 33.9 33.3 WEIGHT POUNDS 396 374 352 330 308 286 264 242 220 209 198 187 176 165 154 143 KILOGRAM S 180 170 160 150 140 130 120 110 100 95 90 85 80 75 70 65 OTHER Volume 1 cc = 1ml 1 tsp = 5 cc 1 tbsp = 15 cc 1 fl. oz. = 30 cc 1 jigger = 45 cc 1 pt = 473 cc 2 pt = 1 qt 1 qt = 946 cc 4 qt = 1 gal 1 gal = 8 lbs Length 1 cm = .39 in 1 in = 2.54 cm 1 yard = 3 ft 1 ft = .31 m 91 90 85 80 75 70 32.8 32.2 29.4 26.7 23.8 21.1 132 121 110 99 88 77 60 55 50 45 40 35 1 m = 3.3 ft 1 km = .62 miles 1 mi = 1.61 km 1 mi = 5280 ft 220 References Katzberg, R., Anderson, Q., Manzione, J., Helms, C.A., Tallents, R., & Hayakawa, K.(1984). 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