91W10

Advanced Individual
Training Course

Clinical Handbook
Supportive Care

Department of the Army

Academy of Health Sciences
Fort Sam Houston, Texas 78234
 Academy of Health Sciences
91W10
Field Training Workbook - Index

Treat Metabolic Endocrine Symptoms………………………………………………….1-7

ƒ Review of principles of glucose metabolism
ƒ Assess the casualty for hypoglycemia and hyperglycemia
ƒ Disorders of the Thyroid Gland
ƒ Hypothyroidism

Treat Neurological Symptoms………………..…………….……………………………8-20

ƒ Determine the cause and/or mechanism of injury
ƒ Assess a casualty in a field setting using the Glasgow Coma Scale
ƒ Assess a patient with neurological symptoms in a clinical setting
ƒ Assessment of Patient with Specific Neurological Symptoms
ƒ Refer to further medical care

Treat Cardiopulmonary Symptoms………………………………………………….….21-31

ƒ Assess Cardiac Compromise
ƒ Provide Care for Cardiac Compromise
ƒ Assess Respiratory Symptoms
ƒ Provide Care for Respiratory Illness

Treat Gastrointestinal Symptoms…………..………………………………………..…32-43

ƒ General assessment
ƒ Identify and manage specific gastrointestinal illness

Treat Genitourinary Symptoms ………………...……………………………………....44-59

ƒ Recognize specific illnesses
ƒ Recognize Sexually Transmitted Diseases
ƒ Review Male and Female Catheterization

Treat Skin Disorders…………………………..………………………..…………………60-73

ƒ Assess for Skin Disorders
ƒ Identify and Manage Viral Disorders of the Skin
ƒ Identify and Manage Bacterial Disorders
ƒ Identify and Manage Inflammatory Disorders
ƒ Identify and Manage Fungal Infections of the Skin
ƒ Identify and Manage Other Skin Disorders

Treat infectious Disease & Immunologic Symptoms………………………………..74-92

ƒ Review Concepts Associated with Infectious Diseases
ƒ General Assessment of Suspected Infectious or Communicable Disease
ƒ Assess and Treat Eye, Ear, Nose, Throat, and Respiratory Complaints
ƒ Assess and Treat Gastrointestinal (GI) Complaints
ƒ Assess and Treat a Fever, Headache, and Sinus Symptoms
ƒ Assess and Treat Hepatitis
ƒ Assess for Human Immunodeficiency Virus (HIV)
ƒ Assess and Treat for Lyme Disease
ƒ Identify Viral Diseases of Childhood
ƒ Reporting an Exposure to an Infectious/ Communicable Disease

Appendix A – Insert and Remove NG Tube Catheter, Competency Skill Sheets

Appendix B - Insert and Remove Foley Catheter, Competency Skill Sheets

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TERMINAL LEARNING OBJECTIVE

Given a standard fully stocked M5 Bag or Combat Medic Vest System, IV administration
equipment and fluids, oxygen, suction and ventilation equipment (if available) and
glucometer. You encounter a casualty who has a metabolic and endocrine systems
problem.

Principles of glucose metabolism

All body cells use glucose as an energy source
The brain requires a constant supply of glucose
The blood stream delivers glucose to the cells for use as energy
Insulin must be present for glucose to enter the cells
Glucose and insulin balance are necessary for effective metabolism and use of
glucose as an energy source
Without insulin
(1) Glucose cannot enter the cell from the bloodstream
(2) Acids are formed when fat is used for energy needs and can lead to
diabetic ketoacidosis
The three Ps of weight loss occur when glucose is not adequately
metabolized. Frequently seen in undiagnosed diabetics.
(1) Polyuria – The excess amount of glucose in the blood forces water
into the bloodstream. The extra water is secreted as excess urine.
(2) Polydipsia – increased thirst that results in increased water drinking.
Secondary to increased volume of urine.
(3) Polyphagia – The cells and tissues cannot utilize the sugar in the
blood; therefore, the cells begin to starve. This starvation causes
hunger and excessive eating.
(4) Weight loss – The cells cannot use the sugar, so they break down fat
and protein for energy causing weight loss

Assess the casualty for hypoglycemia and hyperglycemia

Hypoglycemia is a true medical emergency!

Hypoglycemia
(1) Generally defined as a serum glucose level of less than 50 mg/dl
(2) Signs and symptoms (tachycardia, cool, moist or clammy skin,
dizziness, complaints of hunger) are consistent with the diagnosis
(3) Signs and symptoms are resolved following glucose administration.

Causes of hypoglycemia
(1) In an insulin-dependent diabetic is often the result of too much
insulin, too little food, or both
(2) A diabetic who has not eaten does not have enough dietary intake of
glucose to use for a circulating level of insulin
(3) Excessive exercise or exertion uses up the glucose energy stores
(4) Vomiting or diarrhea depletes the body of fluids, electrolytes, and
potential sources of glucose

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Signs and symptoms of hypoglycemia

(1) Rapid onset - over a period of minutes
(2) Intense hunger
(3) Cold, pale, moist, or clammy skin
(4) Full, rapid pulse
(5) May appear intoxicated
(6) Dizziness and headache
(7) Copious saliva (drooling)
(8) Normal blood pressure
(9) Altered mental status and seizures are symptoms of severe
hypoglycemia (blood glucose < 30 mg/dl)

Treatment and transport considerations for hypoglycemia

(1) Conscious patient
(a) Perform the initial assessment. Check for a medical alert
identification
(b) Perform a focused history and physical exam and
SAMPLE history
(c) Perform a D (dextrose) stick or Accucheck as per local
protocol
(d) Administer oral glucose IAW local protocol if all three of
the following are present:
(i) The patient has a history of diabetes
(ii) The patient's mental status is altered
(iii) The patient is awake enough to swallow
(iv) Dose - one glucose tube
(e) Adult - Place glucose on the tongue depressor between
the cheek and the gum or self administer it between the
cheek and the gum
(f) If oral glucose is not available, give granular sugar, honey,
hard candy, or orange juice
(g) If a patient becomes unconscious, remove the tongue
depressor and assure and open the airway
(h) Monitor and maintain airway
(2) Unconscious patient and/or inability to swallow

WARNING: DO NOT GIVE UNCONSCIOUS PATIENTS ANYTHING BY

MOUTH!

(a) Initiate and maintain IV of normal saline (promotes

excretion of keynote bodies)
(b) Administer pharmacological interventions
(i) 50% Dextrose
(ii) Therapeutic effects: Rapidly restores blood
sugar levels to normal in states of hypoglycemia
(iii) Indications: To treat suspected hypoglycemia or
a coma of unknown cause
(iv) Contraindications: Intracranial hemorrhage,
known stroke (CVA)

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(v) Side effects: Will cause tissue necrosis if it

infiltrates
(vi) How supplied: Prefilled syringes containing 50
cc of 50% dextrose (25 Grams)
(vii) Administration and dosage: Give through patent
IV line. If possible obtain serum glucose prior to
administration dosage is 50ml of 50% solution
(c) Treat patient like any other with an altered mental status
(d) Continue to monitor and maintain airway
(e) Administer oxygen, if available
(f) Start artificial ventilations if necessary
(g) Transport - Continue ongoing assessment en route.
(3) Position patient - If the patient does not require artificial ventilations,
place him in a lateral recumbent position in case s/he vomits
When cause is known, treat as though hypoglycemia; give sugar
(1) A patient in diabetic ketoacidosis will not be harmed by having sugar
(2) A patient in severe hypoglycemia will respond rapidly

CAUTION: When a patient appears intoxicated, treat the patient as a

diabetic emergency. Always check for underlying conditions.
Never assume the patient is "only drunk."

Hyperglycemia
(1) Generally defined as a random blood glucose > 200 mg/dl or a
fasting blood glucose > 140 mg/dl

Causes of hyperglycemia
(1) Undiagnosed/untreated diabetic condition
(2) Insulin not taken
(3) Overeating
(4) Infection that disrupts glucose/insulin balance
(5) Myocardial infarction (heart attack)

Signs and symptoms (Blood glucose 200-400 mg/dl)

(1) Patients are often asymptomatic. Increased blood glucose is found
on incidental laboratory examination or a random self glucose test.
(2) Slow onset - occurs over a period of days or weeks
(3) Dry mouth
(4) Intense thirst
(5) Frequent urination
(6) Blurred vision
(7) Frequent infections

Signs and symptoms (Blood glucose > 400 mg/dl)

(1) Usually more dramatic presentation
(2) Intense thirst
(3) Abdominal pain
(4) Vomiting
(5) Progressive restlessness/confusion
(6) Respiration may be very deep and rapid (Kussmaul respirations)

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(7) Weak, rapid pulse

(8) Warm, red, dry skin
(9) Sunken eyes
(10) Acetone breath (fruity odor)
(11) May appear intoxicated
(12) Normal to slightly low blood pressure

Treatment and transport considerations

(1) Maintain an open airway
(2) Administer a high concentration of O2, if available
(3) Perform D (dextrose) stick or Accucheck per local protocol
(4) Initiate and maintain an IV of Normal Saline
(5) Transport immediately
(6) Continuously monitor vital signs

WARNING: If untreated, hyperglycemia will eventually lead to diabetic

ketoacidosis. The metabolism of substances other than sugar
creates high levels of acid in the blood. THIS PROCESS CAN
LEAD TO DEATH.

Disorders of the Thyroid Gland

Common acute thyroid disorders include
(1) Hyperthyroidism – presence of excess thyroid hormones in the blood
(2) Thyrotoxicosis – a condition that reflects prolonged exposure of body
organs to excess thyroid hormones, with resultant changes in
structure and function. Thyrotoxicosis is generally caused by Grave’s
Disease
(3) Thyrotoxic Crisis – "Thyrotoxic Storm" life threatening emergency
characterized by hyperthermia, nervous symptoms, and rapid
metabolism
(4) Hyperthyroidism – presence of inadequate thyroid hormones in the
blood
(5) Myxedema – condition that reflects long-term inadequate levels of
thyroid hormones with resultant change in function and structure
(6) Myxedema Coma – uncommon complication of myxedema that can
be fatal if respiratory depression occurs. Usually triggered by acute
infection, trauma, cold infection, exposure to CNS depressants such
as alcohol and drugs.

Thyrotoxicosis
(1) Less serious than Thyroid Storm
(2) Important causes of palpitations
(3) Commonly caused by undiagnosed or untreated Graves’ disease,
infectious process or surgery

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Thyroid storm (more serious form of Thyrotoxicosis)

(1) Medical emergency
(a) Elevated temperature (T>38.7o C, but may be as high as
41 o C)
(b) CNS dysfunction (anxiety, emotional lability, delirium)
(c) Cardiovascular dysfunction
(d) Gastrointestinal dysfunction (nausea, vomiting,
hyperdefecation or diarrhea, crampy abdominal pain)
(e) May mimic or complicate sepsis, sympathomimetic
intoxication, or a drug withdrawal
Signs and symptoms
(1) Sinus tachycardia (heart rate > 100 bpm) is almost always present
(2) Heart rate may be fast and irregular
(3) Enlarged thyroid may be palpable
(4) Proptosis and other eye findings indicative of Graves’ disease
(5) Brisk reflexes
(6) Anxiety
(7) Tremor
(8) Weakness
(9) Heat intolerance
(10) Weight loss
(11) Hyperdefecation
(12) Sweating
(13) Angina and congestive heart failure (CHF) may be present

Treatment considerations

NOTE: In most cases mild thyrotoxicosis is referred for outpatient evaluation

and treatment. If patient is symptomatic but not acutely ill, beta–
adrenergic blockade with propranolol (slow 1 mg IV bolus may be
administered in accordance with physicians’ orders).

(1) Emergency care for Thyroid storm

(a) Provide supportive care including cooling measures (ice
packs, cooling blankets)
(b) Contact MD/PA immediately for specific guidance
(c) Initiate and maintain IV access and fluids
(d) Administer oxygen
(2) Provide on-going management for Thyroid storm
(a) Monitor patient’s response to treatment
(b) Monitor airway if unconscious
(c) Place patient in quiet, reassuring environment, if possible
(d) Maintain IV fluids as directed
(e) Evacuate for further treatment as required
(3) It is imperative to consider other processes as precipitants of thyroid
storm or as a primary cause of symptoms
(a) Infection
(b) Surgery
(c) Trauma
(d) Emotional stress

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Hypothyroidism
Hypothyroidism-
A condition of decreased activity of the thyroid gland
(1) Body’s normal rate of functioning slows causing mental and physical
sluggishness
(2) Most severe form is called myxedema, which is a medical
emergency

Risk factors
(1) Over 50 years old
(2) Female
(3) Obesity
(4) Thyroid surgery
(h) X-ray or radiation treatments to the neck

Signs and symptoms

(1) Physical Examination and X-Ray
(a) Enlarged thyroid on physical exam
(b) Delayed reflexes
(c) Slow heart rate
(d) Low blood pressure
(e) Low temperature
(f) Chest x-ray indicates an enlarged heart
(2) Early symptoms:
(a) Weakness
(b) Fatigue
(c) Cold Intolerance
(d) Constipation
(e) Weight gain
(f) Depression
(g) Joint or muscle
(h) Thin, brittle fingernails
(i) Coarse thick hair
(j) Pale color
(3) Late symptoms:
(a) Slow speech
(b) Dry flaky skin
(c) Thickening of the skin
(d) Puffy face, hands and feet
(e) Decreased taste and smell
(f) Thinning of eyebrows
(g) Hoarseness
(h) Menstrual disorders

Myxedema –
Untreated severe hypothyroidism
(1) Thickness of connective tissue in the skin and other tissues including
the heart
(2) Most commonly seen in middle aged or elderly

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(3) Myxedema Coma is a medical emergency and is manifested by

profound hypothermia, bradycardia, and respiratory depression
(4) Treatment is supportive – maintain and monitor airway
(5) Transport/evacuate to definitive care facility immediately
(6) May be fatal if left untreated

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TERMINAL LEARNING OBJECTIVE

Given a CMVS or M5 aid bag standard packing list, IV administration equipment and
fluids, oxygen, suction and ventilation equipment (if available), selected medications,
documentation forms. You encounter a suspected casualty complaining of neurological
symptoms. No other injury (ies) is/are present.

Determine the cause and/or mechanism of injury

Levels of Consciousness –
Abnormal levels of consciousness may be associated with decreased or
increased neurological activity, such as stupor, coma, delirium, or violent
behavior. There may be partial to complete mental clouding or loss of
consciousness.
(1) Frequent causes of altered levels of consciousness are
cerebrovascular accident (CVA), drugs, poisons, metabolic illness,
fever, head injury, subarachnoid hematoma (SAH), Subdural
hematoma (SDH), and epidural hematoma
(2) The two major categories of altered levels of consciousness are
stupor and coma
(a) Stupor ranges from partial to almost complete loss of
consciousness
(b) Coma is complete unconsciousness from which the patient
cannot be roused
(3) Emergency Management of Life-Threatening Neurological Problems
(a) Confirm an unconscious state
(i) Attempt to arouse the patient by pinching or
shouting to rule out sleep or a simple faint
(b) Secure the airway
(c) Give supplemental oxygen, if needed
(d) Establish adequacy of ventilation
(i) If respirations are slow or diminished, begin
assisted ventilation
(e) Establish circulation - Begin CPR, if needed. Obtain vital
signs, and treat shock, if present.
(f) Obtain description of the onset of illness or injury and a
history of chronic illnesses e.g. diabetes, hypertension,
drug abuse, chronic headaches
(g) Perform a rapid physical examination, utilizing the
Glasgow Coma Scale
(4) The Glasgow Coma Scale
(a) Widely used method of evaluating the level of
consciousness
(b) Glasgow Coma Scale assigns a numerical score to the
patient’s responses in three categories
(i) Eye opening
(ii) Best motor response
(iii) Best verbal response
(c) Repeat assessment frequently to assess for changes
(d) Assess the patient’s score in each category, and total the
scores of the tree categories.

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(5) Treatment - the immediate objective of emergency treatment and

stabilization is to maintain life until a specific diagnosis can be made.
DONT Protocol:
(a) Dextrose
(b) Oxygen
(c) Narcan
(d) Thiamin
Assess a casualty in a field setting using the Glasgow Coma Scale
Seek an appropriate location to conduct the neurological status exam
(1) In a hostile zone
(a) Move the casualty to an area that provides adequate cover
and concealment
(b) As with all injuries a primary survey must be conducted
focusing on the ABC's and stabilizing life-threatening
injuries before any type of assessment is started
(c) Time and Circumstances may not permit a full neurological
assessment and in fact may dictate that the soldier medic
move on to the next casualty after treating for life
threatening injuries
(d) Assess the casualty using the Glasgow Coma Scale
Assess a patient with neurological symptoms in a clinical setting
A clinical environment lends itself to the conduct of a full neurological
assessment.
Seek an appropriate setting to conduct the neurological status exam.
(1) Use a well-lit room
(2) Free of distractions
(3) If available, question family and friends

Assess mental status and speech

(1) Determine level of consciousness
(a) Normal
(b) Drowsiness
(c) Stupor
(d) Coma
(2) Observe posture and motor behavior
(a) Gait
(b) Gestures
(c) Mannerisms
(d) Speed of movement - fast, normal, and slow
(e) Over or under active
(f) Purposeful or disorganized
(3) Observe dress, grooming, and personal hygiene
(a) Appropriately dressed for age, social status
(b) Cleanliness
(c) Hair, teeth, and nail care
(4) Observe facial expressions
(a) Appropriate to topics being discussed
(b) Describe
(i) Alert
(ii) Tense

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(iii) Worried
(iv) Sad
(v) Happy
(vi) Angry
(vii) Laughing
(5) Observe and record the patient’s manner, affect, and relationship to
persons and things
(a) Describe (afraid, seeking help, evasive, etc.)
(b) Affect- is the patient’s voice, facial expression, and
movement appropriate to topic being discussed?

Observe speech and language for

(1) Quantity
(2) Rate
(3) Volume - rapid and loud, mania, soft and low

Observe Mood - as reported by patient

(1) Intensity
(2) Duration
(3) Appropriate to circumstances

Observe thought and perceptions – are the patient’s perceptions appropriate

to the situation?

Memory and orientation

(1) Orientation
(a) person - does pt know who he/she is
(b) place - location, where he/she lives
(c) time - day of week, date, time of day
(2) Attention- does the patient answer appropriately?
(3) Remote memory - place of birth, where he/she is from
(4) Recent memory - questions related to the presenting problem. (the
days weather, appointment time, etc.)

Suicidal and homicidal patients

(1) MUST be evaluated by a Medical Officer (MO)
(2) Most are not mentally ill, but overwhelmed by life stressors

Summary/Assessment of Mental Status

(1) Summary of findings/conclusions
(2) The mental exam is the psychiatric counterpart of the physical exam

General approach to the neurologic exam

(1) Organize exam into 5 basic areas
(a) mental status/speech -as previously discussed
(b) cranial nerves
(c) cerebellar
(d) motor
(e) sensory
(f) reflexes

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Techniques of examination
(1) Mental status and speech- as described above
(2) Cranial nerves
(a) Mnemonics for remembering nerves (1st letter stands for
first letter of nerve)
(i) On Old Olympus Towering Tops, A Finn And
German Viewed Some Hops (Tests the
olfactory, optic, oculomotor, trochlear, trigeminal,
abducens, facial, acoustic, glossopharyngeal,
vagus, spinal accessory, & hypoglossal)
(b) Cranial Nerve I (CN-I): Olfactory
(i) Sense of smell
(ii) Test by holding familiar items under the patient’s
nose with their eyes closed. Clamp each nostril
testing each one separately.
(c) Cranial nerve II (CN-II): Optic
(i) Vision sense
(ii) Tests visual acuity, visual fields, peripheral
vision, and fundoscopic exam
(d) Cranial nerves III, IV, & VI: Oculomotor = CN-III, Trochlear
= CN-IV, Abducens = CN-VI
(i) Function
* CN-III - extraocular muscle
movement, pupillary light
accommodation and consensual
reflexes, and elevation of eyelid
* CN-IV – extraocular muscle
movement
* CN-VI – extraocular muscle
movement
(ii) Test for extraocular muscle movement by:
* Holding a small object in front of
patient
* Have patient follow object as it is
moved through the 6 cardinal
positions of gaze
(iii) Test for size and shape of pupils and pupillary
reaction to light
(e) Fifth cranial nerve (CN-V): Trigeminal nerve
(i) Function
* Motor - temporal, and masseter
muscles along with lateral movement
of the jaw
* Sensory - three separate distributions,
V-1 = to the forehead, V-2= to the
cheeks, V-3 = to the chin
(ii) Test function
* Test motor function by having patient
clench teeth and move jaw side to

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side. Palpate strength of muscle

contraction. Feel contraction of
temporal muscles.
* Test sharp/dull sensation with a safety
pin and light touch to forehead,
cheeks, and chin on both sides
(f) 7th cranial nerve (CN-VII): Facial nerve
(i) Function
* Motor - muscle of facial expression
(ii) Test function
* Inspect face for symmetry or abnormal
movements
* Have patient raise eyebrows, frown,
close eyes tightly (and test strength by
trying to open them with your fingers).
Show upper and lower teeth, smile
and puff out cheeks
(g) 8th cranial nerve (CN-VIII): Vestibulocochlear
(i) Function
* Hearing
(ii) Test hearing
* Snap fingers in front of each ear to
assess gross hearing function
(h) 9th & 10th cranial nerves: CN-IX Glossopharyngeal, CN-X
Vagus
(i) Function
* CN-IX: sensory - posterior ear
drum/canal, pharynx. Motor -
pharynx.
* CN-X: sensory - pharynx & larynx.
Motor - soft palate, pharynx, and
larynx/vocal cords.
(ii) Test for
* Vocal quality
* Observe upward movement of
posterior oropharynx and symmetry
* Stimulate gag reflex on each side with
cotton swab
* Ability to elevate palate
(i) 11th cranial nerve (CN-XI): Spinal accessory nerve
(i) Function
* Motor - upper portion of
sternocleidomastoid and trapezius
muscles
(ii) Test for
* Ability to turn head side to side
* Ability to shrug shoulders upwards
against resistance
(j) 12th cranial nerve (CN-XII): Hypoglossal nerve
(i) Function

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* Motor to tongue
(ii) Test for function
* Symmetry, atrophy, or fasciculations
* Have patient move tongue side to side
* Have patient stick tongue out, should
not deviate from midline
(3) Cerebellar
(a) Inspection
(i) Ask pt to walk across room, down hall, turn and
come back
(ii) Observe posture
(iii) Note presence of involuntary movements or
swaying
(iv) Special maneuvers
* Heel to toe walking in a straight line
* Walk on toes
* Walk on heels
* Romberg test - have pt stand with
heels and feet together, arms at sides
and eyes closed. Observe for loss of
position sense and tendency to fall.
* Hop in place on each foot. This
indicates intact lower extremity motor
systems, cerebellar function and
position sense.
(4) Motor
(a) Assessment of muscle tone
(i) Passive range of motion (with pt relaxed,
perform range of motion to limbs for each joint.)
(b) Testing muscle strength
(i) Test specific motor groups
(ii) Have patient actively resist your attempts to flex
or extend across specific joints
(iii) Grade muscle strength on scale of 0-5
* 0 = no muscular contraction noted
* 1 = barely detectable flicker of
contraction
* 2 = active movement of body part with
gravity
* 3 = active movement against gravity
* 4 = active movement against gravity
with some resistance
* 5 = active movement against full
resistance & without any evidence of
fatigue (normal muscle strength)
(5) Sensory
(a) General principles
(i) Note ability to perceive stimulus
(ii) Compare sensation

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(iii) Scatter stimuli to cover most major peripheral

nerves
(iv) Vary the placement of your exam
(v) Map areas of altered sensation by proceeding in
a stepwise fashion outwards until patient detects
change
(b) Pain
(i) Use sharp/dull areas of a safety pin
(ii) Use light pressure
(c) Light touch
(i) Touch skin lightly with wisp of cotton and ask
patient to respond
(ii) Compare sides
(6) Reflexes
(a) Graded on a 0-4 scale
(i) Four plus (4+) = very brisk, hyperactive
(ii) Three plus (3+) = brisker than normal
(iii) Two plus (2+) = normal
(iv) One plus (1+) = diminished
(v) Zero (0) = absent, no response

Assessment of Patient with Specific Neurological Symptoms

Dizziness and Vertigo
(1) Dizziness is a perception of self-motion or a distortion of gravitational
orientation. Dizziness is not a defined disease, but a sensory
syndrome that may be produced by numerous diseases.
(2) Vertigo is an illusionary sensation of motion or having objects move
around the patient
(3) Dizziness and vertigo should be distinguished from imbalance and
syncope (loss of consciousness)
(4) Symptoms - the patient is usually in an upright position when an
acute attack occurs. They may experience:
(a) Motor weakness
(b) Epigastric distress
(c) Perspiration
(d) Restlessness
(d) Nausea and vomiting
(e) Tinnitus (ringing in the ears)
(h) Patients commonly have recurrent episodes
(5) Treatment
(a) Management of the patient depends on the disease
causing the dizziness or vertigo. All patients MUST have a
full cardiac and neurological examination during initial
assessment. Dizziness and vertigo are common
symptoms in the elderly with cardiac disease.
(b) Initial stabilization utilizing a Glasgow Coma Scale should
be performed if the patient is rapidly deteriorating. Serial
neurological examinations should be performed while
transporting patient to a MD/PA to assess.

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(c) All patients with an acute onset of dizziness or vertigo

need to be evaluated by an MD/PA

Headaches –
Headaches are the most common pain complaint in patients. The number of
different types of headache, their causes, signs, symptoms and treatments
often make headache difficult to diagnose and treat. They may be caused by,
tension, tumors, trauma, or any number of other causes. The following are the
more common types of headaches:
(1) Tension - These headaches are caused by spasm or contraction of
muscles or adjacent structures, or they may be associated with
fatigue or emotional stress. The muscles attached to the occiput and
temple are the most frequently involved. These muscles will be
tender to palpation
(a) Symptoms
(i) Feeling of pressure or a bandlike constriction
around head. Pain is almost always bilateral
(ii) Not associated with vomiting. Nausea may be
present
(iii) Patient with a tension headache will have a
normal neurological examination
(b) Treatment - general measures consist of:
(i) Analgesics
(ii) Rest
(iii) Relaxation
(iv) Massage, and heat applied to the involved
musculature
(v) Oral fluid hydration usually benefits headache
patients- particularly in a field environment
(2) Migraine - this type of headache is characterized by a paroxysmal
attack often preceded by psychological or visual disturbance that is
followed by drowsiness. Migraine headaches are believed to be the
result of inflammatory vascular changes.
(a) Symptoms
(i) Specific symptoms vary with the type of
migraine
(ii) Before the onset of a migraine headache, some
patients experience a prodrome or aura. Visual
auras are the most common (flashing lights or
diminished vision)
(iii) Pain is usually unilateral- sometimes severe
(iv) Nausea, vomiting, photophobia (intolerance to
light), phonophobia (intolerance to loud noise)
may occur
(v) Patients may have an ill appearance
(vi) Other than an ill appearance, the physical
examination are normal
(b) Often there is a family history of migraines, and the
frequency of attacks may vary from daily to once every few
years

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(c) Treatment Overview

(i) Treatment of migraine is a three-faceted
approach: abortive (at the immediate onset of
headache); interval (during the headache) and
prophylactic (to prevent future headaches
(ii) Abortive therapy is useful during the aura or at
the start of a migraine. Various oral, nasal and
subcutaneous medications (i.e. Cafergot,
Imitrex) can be used as abortive therapy.
(iii) Interval therapy is directed at treating the
migraine headache. Medications include
analgesics (Toradol), antiemetics (Phenergan,
Compazine) and abortive agents as above
(iv) Prophylactic therapy is aimed at prevention or
reduction of the frequency and severity of
headaches. Numerous categories of
medications are used for this.
(d) Treatment of an Acute Migraine
(i) Place the patient on bed rest in a darkened
room, withhold any food or drink and initiate IV
hydration. Fluids are helpful in migraine
headaches
(ii) Utilize the medications described above for
abortive or interval therapy as ordered by a
MD/PA
(iii) Serial neurological evaluations should be
performed. Reassess the patient after each
medication is given
(iv) Evacuate the patient to be evaluated by an
MD/PA for assessment and management

Seizures –
A seizure is defined as the behavioral manifestation of abnormal neurologic
activity. Seizures are usually accompanied by altered levels of consciousness.
Epilepsy is a pattern of two or more recurrent seizures. In 75% of nontraumatic
seizures the cause is unknown. There are two types of seizure classifications
(1) The two major classifications are:
(a) Generalized- bilateral foci that begin simultaneously
(b) Partial- single focus in cerebrum
(2) Generalized Seizures
(a) Most commonly encountered and include the petit mal and
grand mal types
(b) Typical generalized seizure
(i) Signs and symptoms
* The patient may fall down and cry out,
lose bladder and bowel control, and
froth at the mouth
* There is convulsive movement of the
body, dyspnea, and cyanosis

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* Often the patient bites the tongue and,

if not completely unconscious, will be
confused and disoriented. The
seizure usually lasts 2 to 5 minutes.
* A period of deep sleep is common
after the seizure, and the patient will
complain of muscle soreness and
stiffness upon awakening

(ii) Treatment - immediate treatment is aimed at

airway, breathing, and circulation (ABC's) while
preventing the patient from injuring him or
herself. The second goal is identification of the
seizure cause
* Do not use rigid restraints (may cause
fractures) or insert objects into the
patient’s mouth during a seizure
* Never leave the patient alone. Protect
the patient from further injury until
seizure ends
* Loosen the clothing around the neck,
and turn the head to the side to
prevent aspiration of saliva and mucus
* Administer an anticonvulsant, such as
Ativan 1-2 mg, or diazepam (Valium)
5-10 mg IV over 1-2 minutes. Give
Valium only in the presence of active
seizures. The objective of drug
therapy is complete suppression of
symptoms
* Refer the patient immediately to an
MD/PA for evaluation. Perform serial
neurological examinations during
transport

Cerebrovascular Accident (Stroke)

(1) Strokes are caused by destruction of brain matter by intracerebral
hemorrhage, thrombosis, embolism, or vascular insufficiency
(2) Stroke presentation is varied, depending on the area of brain that is
involved. Symptoms include:
(a) Headache
(b) Nausea
(c) Vomiting
(d) Convulsions
(e) Coma
(f) Consciousness may not always be altered
(g) The patient may experience speech disturbances
(h) Confusion
(i) Loss of memory

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(j) Reduction of sensation, and paralysis of extremities or of a

complete side of the body
(k) The onset may be sudden and violent, with the patient
falling into an immediate coma and exhibiting stertorous
breathing
(l) Death from a serious stroke may result in a few minutes to
a few days
(3) Treatment
(a) ABC's
(b) Administer IV fluids (TKO)
(c) Place the patient on immediate and strict bed rest
(d) Keep head elevated 30 degrees
(e) Evacuate the patient for hospitalization immediately
(f) Cardiac monitoring, if available
(g) Serial neurological examinations during transport

Subarachnoid Hemorrhage (SAH) –

Characterized by sudden bleeding into the subarachnoid space that may be
the result of trauma or a ruptured aneurysm
(1) Symptoms - before the aneurysm ruptures
(a) The aneurysm applies pressure to nerves that will manifest
as headaches, ocular palsies, diplopia, facial pain, and a
diminished visual field
(b) After rupture, severe headache
(c) Nausea
(d) Vomiting
(e) Stiffness of the neck
(f) Positive Kernig's sign
(i) A diagnostic meningeal sign marked by loss of
the ability of a supine patient to completely
straighten the leg when it is fully flexed at the
knee and hip
(ii) Pain in the lower back and resistance to
straightening the leg constitutes a positive
Kernig’s sign
(g) Bilateral Babinski's reflex is usually present
(i) Dorsiflexion of the big toe with extension and
fanning of the other toes elicited by firmly
stroking the lateral aspect of the sole of the foot
(h) The consciousness of the patient may or may not be
affected, and the blood pressure is often elevated
(2) Treatment
(a) ABC's
(b) Keep the patient at rest
(c) IV hydration (TKO)
(d) Avoid any medications
(e) Evacuate the patient immediately
(f) Cardiac monitoring
(g) Serial neurological examinations during transport

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Subdural hematoma-
Caused by the rupture of a cerebral vein. They may be caused by trauma,
tumors or a medication side effect (i.e. anticoagulants). There may be a loss of
consciousness at the time of the injury followed by an asymptomatic period that
may last for several hours to days
(1) Signs and symptoms the patient may have later
(a) Increased intracranial pressure as described above
(b) About one half of all persons with subdural hematoma will
experience facial muscle weakness
(2) Treatment
(a) Ensure that the patient has a patent airway
(b) Oxygen, if available
(c) Cardiac monitoring, if available
(d) Serial neurological examinations during transport
(f) Evacuate the patient immediately

Epidural Hematoma –
Result of blood collecting in the potential space between the skull and the dura
mater. Most (80 to 90 percent) result from blunt trauma to the temporal of
temporoparietal area with an associated skull fracture and middle meningeal
arterial disruption.
(1) The classic history of an epidural hematoma is for the patient to
experience immediate loss of consciousness after significant blunt
head trauma. The patient then awakens and has a lucent period prior
to again falling unconscious as the hematoma expands.
(2) This "classic“ syndrome occurs in only about 20 percent of cases.
The majority of patients either never looses consciousness or never
regains consciousness after the injury.
(3) Signs and Symptoms
(a) Increase intracranial pressure as previously described
(b) Neurological status/mental status may change rapidly due
to the high pressure arterial bleeding of an epidural
hematoma and can lead to herniation. The sequence of
bleeding and herniation usually occurs within hours.
(4) Treatment
(a) Ensure open, patent airway
(b) Assist with ventilations, as needed
(c) Administer oxygen, if available
(d) Cardiac monitoring, if available
(e) Elevate head of body 30 degrees
(f) Serial neurological examinations during transport
(g) Evacuate the patient immediately

Herniated Disk –
In most cases, herniation or rupture of an intervertebral disk is the result of
trauma. It may occur with sudden straining of the back in an odd position or
while lifting in the trunk flex position. Herniation may occur immediately (acute
trauma) or may take years to occur (repetitive trauma). Most herniation occurs
in the lumbosacral area but may also occur in the cervical or thoracic regions.
(1) Signs and symptoms

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(a) Over 90 percent of all herniated disks occur at the fourth or

fifth lumbar interspace
(b) There is pain upon palpation of the affected area
(c) The patient will have a limited range of motion
(d) The posture of the spine will be abnormal due to the loss
of curvature of the spine
(e) The patient may exhibit mild weakness of the foot or
extensor areas of the great toe
(f) There may be impaired sensations of pain or touch, and
coughing or sneezing may cause radiation of the pain to
the calf
(2) Treatment
(a) Place the patient on bed rest with a backboard and
administer analgesics for pain
(b) Prevent the patient from using any physical effort
(c) Applications of heat to the area of tenderness is beneficial
(d) Definitive treatment of herniated disks will occasionally
require surgery. Most herniated discs can be managed
medically, with rest and medications.
(e) Evacuate the patient as soon as possible

Refer to further medical care

Treatment for neurological symptoms
May take many forms, which are beyond the scope of the soldier medic
Several emergency medical procedures-,
Soldier medic can perform to minimize and or prevent further injury in trauma
cases, and instances where the cause of injury is not obvious
(1) Ensure that the casualty is removed from the source of injury and is
stabilized, focusing on the ABC's and that life threatening injuries are
treated promptly
(3) Treat an unconscious casualty as having a potential neck or spinal
injury. Immobilize and do not move the casualty unless absolutely
necessary
(2) If fractures of the spine are suspected in-line stabilization of the
spine is maintained and the casualty is immobilized as necessary
(4) If fractures of the skull are suspected that the casualty is placed in a
position where the head is elevated at least 30 degrees unless other
injuries prohibit that position
(5) Avoid the use of pain medications that are CNS depressants
(6) Evacuate the casualty a timely manner to the next level of care
(7) Provide on going care to maintain the casualty's condition or prevent
the condition from getting worse
(8) As the situation permits document as much information as is
available to send along with the casualty, so that more definitive
medical care can be administered

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TERMINAL LEARNING OBJECTIVE

Given a standard fully stocked Combat Medic Vest System (CMVS) or fully stocked M5
Bag, IV administration equipment and fluids, oxygen, suction and ventilation
equipment (if available), selected medications, and documentation forms. You
encounter a casualty complaining of cardio-pulmonary symptoms. No other injury(ies)
is/are present. NBC agents have been ruled out

Assess Cardiac Compromise

Primary assessment
(1) Ensure open airway
(2) Assess breathing
(3) Assess circulation
(a) If pulse is present, continue assessment
(b) If no pulse, begin CPR

Secondary assessment (specific to cardiopulmonary symptoms)

(1) Recognize signs of cardiac compromise
(a) Squeezing, dull pressure, chest pain commonly radiating
down arms or to the jaw
(b) Sudden onset of sweating
(c) Difficulty breathing (dyspnea)
(d) Anxiety, irritability
(e) Feeling of impending doom
(f) Nausea/vomiting
(g) Unresponsive to stimuli
(2) Assess vital signs
(a) Respirations
(b) Pulse
(c) Blood pressure
(d) Temperature
(e) Pulse oximetry
(3) Focused history
(a) Onset of symptoms
(i) Sudden
(ii) Gradual over time
(iii) Known cause or "trigger"
(b) Duration of symptoms
(i) Constant
(ii) Recurrent
(c) Pain on inspiration
(d) Length of time
(e) Fever
(f) Smoking history
(g) Past medical history of associated diseases
(4) Assess location and level of pain
(a) Use acronym: OPQRST
(i) Onset
(ii) Provocation
(iii) Quality

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(iv) Radiation
(v) Severity
(vi) Time
(b) Apply pain scale
(i) 0 = no pain
(ii) 10 = worst pain

Assess specific cardiovascular disease/disorder

(1) Angina pectoris
(a) Sudden chest pain caused by lack of oxygen supply to a
portion of heart muscle
(b) Reduced blood flow to heart muscle usually due to
coronary artery disease
(c) Concurrent with or following:
(i) Physical activity
(ii) Stress
(iii) Heavy meals
(iv) Exposure to cold
(v) Windy weather
(d) Signs and symptoms
(i) Pain, pressure, tightness, or squeezing feeling
in chest area lasting 3-5 minutes
(ii) Radiation of pain to neck, jaw, teeth, shoulder,
arms, upper back, or abdomen
(iii) Shortness of breath
(iv) Weakness
(v) Nausea/indigestion
(vi) Sweating
(2) Acute myocardial infarction (AMI)
(a) Death of a portion of the myocardium caused by
inadequate blood/oxygen supply through the coronary
arteries
(b) Causes include:
(i) Inadequate blood supply through the coronary
arteries long enough in duration that
myocardium is damaged from oxygen
starvation
(ii) Damage of myocardium causes disruption of
normal electrical conduction, resulting in
irregular and/or ineffective heart activity
(iii) Blood supply may be reduced or stopped by:
coronary artery spasm, embolus,
arteriosclerosis, and atherosclerosis
(c) Signs and symptoms
(i) Some or all signs and symptoms of angina pectoris
(ii) Pain may be intermittent (come and go)
(iii) Duration of pain may be 30 minutes to several
hours
(iv) Pain may occur while at rest
(v) Rest and/or nitroglycerin do not relieve pain

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(vi) Signs of shock

(vii) Dyspnea
(viii) Anxiety, irritability, or denial
(3) Congestive Heart Failure (CHF)
(a) Failure of heart to pump blood adequately to maintain
tissue perfusion
(b) Causes include:
(i) Diseased heart valves
(ii) Hypertension
(iii) Obstructive pulmonary disease
(iv) Ineffective pumping of left ventricle. Causes
blood to back up into pulmonary circulation,
resulting in congestion in the lungs. Can
progress to pulmonary edema (an
accumulation of fluid in lung tissues and
alveoli)
(v) Ineffective pumping of the right ventricle.
Causes blood to back up into the systemic
circulation, causing edema in hands, lower
extremities, and sacral area, and distention of
jugular veins.
(c) Signs and symptoms
(i) Agitation
(ii) Tachycardia
(iii) Dyspnea with shallow and labored respirations
(iv) Orthopnea - an abnormal condition in which a
person must sit or stand to breathe deeply or
comfortably
(v) Noisy respirations
(vi) Edema in extremities
(vii) Diaphoresis
(viii) Possible chest pain
(ix) Distended neck veins
(x) Upright posture

Provide Care for Cardiac Compromise

Primary assessment
(1) Assess airway - ensure open airway
(2) Assess breathing - ensure adequate ventilation
(v) Assess circulation

Manage patient with known cardiac history

(1) Place patient in position of comfort and in a quiet environment
(2) Apply oxygen, as indicated
(3) Apply cardiac monitor, if available
(4) Minimize patient exertion
(a) Use appropriate transfer procedures
(b) Do NOT allow patient to walk to stretcher or down steps
(5) Loosen restrictive clothing
(6) IV access before administering nitroglycerin

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(7) Administer NTG as directed by MD/PA (See LP C191W063,

Medication administration)
(a) Reassess patient history
(b) If nitro is not prescribed to that patient, gain permission
from MD/PA or follow local SOP
(c) Ensure systolic blood pressure is 100 or above
(d) Administration
(i) Dose is one tablet or spray under tongue
(ii) Have patient keep mouth closed until
dissolved and absorbed
(iii) Verify effectiveness - Patient should report
burning sensation under tongue
(8) Initiate cardiac monitoring (See LP C191W059, Cardiac
monitoring)
(a) Placement of electrodes (12-lead EKG)
(i) Arms - anterior forearm or biceps
(ii) Legs - medial aspect of lower leg
(iii) Chest position
* V1 - fourth intercostal space, right sternal
* V2 - fourth intercostal space, left sternal
* V3 - midway between V2 and V4
* V4 - fifth intercostal space, midclavicular line
* V5 - same level as V4, anterior axillary line
* V6 - same level as V4 and V5 - midaxillary line
(iv) Ensure patient information has been entered
(v) Check leads for contact
(vi) Record as needed
Use AED, if needed
(1) Reassess patient's unresponsiveness
(2) Begin or continue CPR efforts
(3) Deliver shock
(a) Turn on power
(b) Attach device
(i) One pad to right of sternum just below the
clavicle
(ii) Other to left of precordium
(c) Initiate analysis of rhythm
(d) Deliver shock in a series of three as indicated by AED
(e) Check for pulse after three shocks
(4) Reassess vital signs
Perform ongoing management
(1) Monitor vitals signs every 3-5 minutes
(2) Initiate CPR as needed
(3) Prepare to provide artificial respiration as needed
(4) Run EKG as indicated by MD/PA

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Assess Respiratory Symptoms

Primary assessment
(1) Assess airway - ensure open airway
(2) Assess breathing - ensure adequate ventilation
(3) Assess circulation
(a) If pulse is present, continue assessment
If no pulse, begin CPR

Secondary assessment (specific to pulmonary symptoms)

(1) Assuming ABCs are intact, begin AMPLE history
(a) Allergies
(b) Medications
(c) Past medical history
(i) Asthma
(ii) Heart disease
(iii) Emphysema
(iv) Smoking history
(d) Last oral intake
(e) Events leading to onset, consider asking:
(i) Onset of symptoms
* Sudden?
* Gradual over time?
* Known cause or "trigger"?
(ii) Duration of symptoms
* Constant?
* Recurrent?
(iii) Fever? Chills?
(iv) Chest pain? Shortness of breath? Difficulty
breathing?
(iii) Have you had a cough?
* Productive or non-productive?
* Color of sputum?
(iv) Other symptoms, such as nausea and
vomiting?
(2) Assess vital signs
(a) Respirations
(b) Pulse
(c) Blood pressure
(d) Temperature
(e) Pulse oximetry
(3) Assess patient complaints
(a) When did the medical problems start?
(b) What are the medical problems?
(c) Duration of symptoms
(i) Constant
(ii) Recurrent
(4) Inspect chest
(a) Use of accessory muscles and sternal or muscle
retraction
(b) Skin color

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(c) Flaring of nares

(d) Difficulty breathing or periods of apnea
(e) Splinting the chest
(f) Stridor
(g) Productive cough
(h) Altered mechanical effort
(i) Limited rise and fall of chest
(ii) Gasping
(iii) Pursed lips
(iv) Chest wall paradoxical motion
(i) Medical - physiological barriers
(i) Pneumonia
(ii) Pulmonary edema
(iii) Chronic Obstructive Pulmonary Disease
(COPD)
(5) Palpate the chest
(a) Tenderness
(b) Pain
(c) Crepitus
(d) Skin temperature
(6) Auscultate the lungs
(a) Evaluate both inspiration and expiration
(b) Wheezing
(c) Rhonchi, rales
(d) Absence of breath sounds

Provide Care for Respiratory Illness

Assessment findings
(1) Signs of severe respiratory impairment
(2) Rapid, shallow and short breaths
(3) Decrease lung sounds and/or wheezing
Care for respiratory symptoms
(1) Place patient in position of comfort and in a quiet environment
(2) Apply oxygen, as indicated
(3) Minimize patient exertion
(a) Use appropriate transfer procedures
(b) Do NOT allow patient to walk to stretcher or down steps
(4) Loosen restrictive clothing
(5) IV access, if indicated
(6) Cardiac monitoring, if patient has shortness of breath or chest pain

Upper respiratory infection

(1) Contagious viral infections of the upper respiratory tract
(2) Common symptoms include:
(a) Inflammation of the mucous membranes
(i) Nasal congestion
(ii) Runny nose
(b) Sneezing
(c) Sore throat
(d) Coughing

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(3) Provide care - supportive measures

(a) Consider pain relievers
(b) Drink plenty of fluid
(c) Rest
Pharyngitis
(1) Most often caused by viral infections. May be cause by bacteria,
such as group A streptococcus, which is commonly termed strep
throat.
(2) Symptoms include:
(a) Sore throat
(b) Difficulty swallowing
(c) Fever
(d) Swollen lymph nodes
(e) Exudate on tonsils
(f) Beefy red throat
(3) Provide care
(a) For viral infections, treatment is to relieve symptoms only
(i) Consider pain relievers for pain
(ii) Consider gargle with warm salt water
(b) Bacterial pharyngitis is treated with antibiotics

Bronchitis
(1) Acute bronchitis
(a) Generally follows a viral respiratory infection
(b) May be caused by any number of respiratory viruses
(c) Symptoms include:
(i) Cough, usually productive
(ii) Shortness of breath
(iii) Wheezing
(iv) Rales, rhonchi
(v) Sore throat
(d) Provide care
(i) Consider inhaled bronchiodilators to open
constricted air passages
(ii) Consider antibiotics only if sputum color
changes to yellow, gray, or green
(iii) Consider mucolytic agents to moisten
secretions
(iv) Provide supportive measures
* Rest
* Increase humidity to soothe air passages
* Increase fluid intake
* Refer to MD/PA for treatment

Chronic Obstructive Pulmonary Disease (COPD)

(1) The term COPD identifies patients with emphysema and chronic
bronchitis. Although emphysema and chronic bronchitis are
diagnosed as treated as separate diseases, most patients with
COPD have features of both conditions. Chronic bronchitis is
characterized by an excess of bronchial secretions. Emphysema

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is characterized by a destruction of air spaces with permanent

airspace enlargement
(2) Causes include:
(a) Smoking- the most common
(b) Pollution
(ci) Infection
(d) Allergies
(3) Symptoms include:
(a) Excessive, chronic cough
(b) Sputum production
(c) Chronic, increasing shortness of breath
(d) Dyspnea on exertion (DOE)
(e) In early stages of the disease, patient may be
asymptomatic
(4) Provide care
(a) COPD is largely preventable. Stress smoking cessation
(b) Consider respiratory treatments to facilitate the removal
of thick mucous from airways
(c) Suggest breathing exercises
(d) Vaccination against influenza and pneumococcal
disease
(e) Refer patient to MD/PA for treatment

Pneumonia
(1) Viral
(a) Inflammation of lungs caused by a viral infection
(b) Two most common viral infections that cause pneumonia
(i) Respiratory syncytial virus - Pediatrics
(ii) Influenza
(c) Symptoms include:
(i) Cough
(ii) Headache
(iii) Muscle stiffness
(iv) Shortness of breath
(v) Fever
(vi) Sweating
(vii) Fatigue
(d) Provide care - supportive care
(i) Humidified air
(ii) Increase fluids
(iii) Supplemental oxygen may be indicated
(iv) Antiviral medications may be considered.
Consult MD/PA for treatment
(2) Bacterial
(a) Inflammation of lungs caused by bacterial infection
(b) Caused by different organisms and can range in
seriousness. Two common types of organisms are:
(i) Pneumococcal
(ii) Mycoplasma
(c) Symptoms include:

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(i) Rigors
(ii) Bloody sputum
(iii) Fever
(iv) Chest pain
(d) Provide care
(i) Treat with antibiotics as directed by MD/PA
(ii) Provide supportive treatment
(3) Asthma
(a) Chronic inflammatory disorder characterized by
increasing responsiveness of the airways to multiple
stimuli
(i) Most acute attacks are reversible and improve
spontaneously or within minutes to hours with
treatment
(ii) The recognition that asthma is a chronic
inflammatory disorder of the airways has
significant implications for diagnosis,
management, and potential prevention
(iii) Asthma is common in adults and more common in
children. Death rates from asthma have been increasing
since 1990, despite improved therapies
(b) Occur spontaneously or can be triggered by:
(i) Respiratory infections
(ii) Exercise
(iii) Cold air
(iv) Smoke and other pollutants
(v) Stress or anxiety
(vi) Allergies
(c) Symptoms include:
(i) Tightness in chest
(ii) Audible expiratory wheeze
(iii) Tachypnea
(iv) Course breath sounds
(v) Prolonged expiration
(vi) Restlessness/anxiety
(vii) Paroxysmal cough progressing from dry and
hacking to productive
(viii) Diaphoresis
(d) Identify key historical points
(i) Pattern of symptoms
* Perennial
* Seasonal
* Perennial and seasonal
* Continual
* Episodic
* Onset
* Duration
* Frequency
(ii) Aggravating factors
(iii) History of disease

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* Age of onset and method of diagnosis

* Course of disease
* Present management and medications
* History or oral corticosteroid use
* Intensive care unit admissions
* History of intubation for asthma exacerbation
* Other medical diseases
(iv) Family history
(v) Social history
* Condition of home
* Exposure to allergens
* Smoking
* Identification of participating causes
(vi) Medications used
(e) Identify risk factors
(i) Past history of sudden severe exacerbations
(ii) Prior intubation for asthma
(iii) Prior admissions for asthma to an intensive
care unit
(iv) Two or more hospitalizations for asthma in
past year
(v) Three or more emergency care visits for
asthma in past year
(vi) Use of more than two canisters per month
(vii) Current use of systemic Corticosteroids or
recent withdrawal from systemic
corticosteroids
(f) Provide care
(i) Inhaled bronchodilators
(ii) Inhaled corticosteroids
(iii) Oral corticosteroids
(iii) Supportive care
* Nebulization with inhaled sympathomimetics
* Monitor pulse oximetry
* Monitor BP and pulse after each nebulization
(iv) Yearly influenza vaccine
(v) Pneumococcal vaccine
(vi) Refer patient to MD/PA for treatment - medical
emergency
(g) Status asthmaticus- Severe prolonged asthma refractory
to conventional modes of therapy. Management
consists of:
(i) Oxygen therapy
(ii) Nebulization with inhaled bronchodilators
(iii) Intravenous corticosteroids
(iv) Intravenous fluids
(v) May progress to require endotracheal
intubation and mechanical ventilation

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Administer prescribed inhaler

(1) Reassess patient history
(2) If medication is not prescribed to that patient, gain permission from
MD/PA or follow local SOP
(3) Administration
(a) Patient should first inhale deeply
(b) Have patient place lips around opening of inhaler
(c) Press inhaler to activate the spray as the patient inhales
deeply
(d) Patient should hold their breath as long as possible to
ensure medication is absorbed
(4) Verify effectiveness. Repeat second dose as needed and
according to SOP or MD/PA

Administer prescribed inhaler

(1) Reassess patient history
(2) If medication is not prescribed to that patient, gain permission from
MD/PA or follow local SOP
(3) Administration
(a) Patient should first inhale deeply
(b) Have patient place lips around opening of inhaler
(c) Press inhaler to activate the spray as the patient inhales
deeply
(d) Patient should hold their breath as long as possible to
ensure medication is absorbed
(4) Verify effectiveness. Repeat second dose as needed and
according to SOP or MD/PA

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Treat Gastrointestinal Symptoms

TERMINAL LEARNING OBJECTIVE

Given a standard fully stocked M5 Bag or Combat Medic Vest System, IV administration
equipment and fluids, oxygen, suction and ventilation equipment (if available), selected
medications, and documentation forms, You encounter a casualty complaining of
gastrointestinal symptoms. No other injury(ies) are present. Treat gastrointestinal
symptoms IAW cited references.

General assessment

Take focused history for gastrointestinal symptoms

(1) OPQRST
(a) O-Onset
(b) P-Provoking/palliative factors
(c) Q-Quality
(d) R-Region/Radiation
(e) S-Severity
(f) T-Time
(2) Allergies
(3) Medications
(4) Past medical history/past surgical history
(5) Previous history of similar events
(6) Nausea/ vomiting
(7) Change in bowel habits/ stool
(a) Constipation
(b) Diarrhea
(8) Weight loss/ Appetite changes
(9) Last meal
(10) Chest pain
(11) Urinary symptoms- burning on urination, frequency
(12) Fever, shakes, chills

Abdominal examination

Note: The abdomen is divided into four quadrants by imaginary lines crossing
at the umbilicus — the Right Upper Quadrant (RUQ), Left Upper Quadrant
(LUQ), Right Lower Quadrant (RLQ), and Left Lower Quadrant (LLQ)

(1) Inspection: check for scars, bruising, rashes, dilated veins, umbilical
hernia or abdominal distention (swelling)
(2) Auscultation: listen for bowel sounds. An arterial bruit (a vascular
murmur like sound) may be heard and is always abnormal. Bowel
sounds may be present, hyperactive, or absent. If sounds are not
heard in five minutes of continuous auscultation, consider them
absent.
(3) Percussion: begin to percuss the liver down from the right upper
chest. Liver dullness begins around the 5th or 6th rib extending

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down to the costal (rib) margin. Liver length is usually less than 15
cm.
(4) Palpation: palpate superficially (lightly) and deeper in all quadrants
with the patients knees bent to relax the abdominal wall muscles.
Assess for tenderness in all 4 quadrants. (will add picture for
students)
(a) RUQ: palpate for the liver during inspiration, usually not
palpated. If enlarged, you will feel the edge of the liver as
it passes beneath the fingers.
(b) LUQ: palpate for the spleen on inspiration, usually not
palpable.
(c) RLQ and LLQ: palpate for tenderness (pain increased by
pressure). Check for involuntary guarding (tightness of the
abdomen), and for rebound tenderness by quickly
releasing pressure from the abdomen. Check for
peritoneal irritation using the heeltap test.
(5) Rectal Exam: with the patient standing while bending at the waist or
curled on his/her side and using a glove and lubricant, slowly insert
your index finger. Check the prostate anteriorly (in males) and
obtain a stool specimen for blood and test using the hemocult test.
This may be outside the scope of 91W.
(6) The Routine Abdominal Examination:
(a) Inspect abdomen
(b) Auscultate all four quadrants
(c) Percuss liver size
(d) Palpate for enlarged liver
(e) Rectal examination for blood in stool
(f) ALWAYS include cardiac and respiratory examination
when performing an abdominal examination
(g) ALWAYS consider whether a male or female genital
examination by a M.D./P.A. may be required for complete
assessment for the patient. All patients with abdominal
pain require genital exam.

Assess for abdominal pain

(1) Types of abdominal pain
(a) Somatic pain – Sharp, localized pain that originates in the
peritoneal walls. Often described as a stabbing or burning
pain
(b) Visceral pain – Poorly localized pain that originates in the
walls of hollow organs. Often described as a vague, dull
or cramping pain
(c) Referred pain – is pain that is felt at a location removed
from the diseased organ that is causing pain

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Identify and manage specific gastrointestinal illness

Upper Gastrointestinal (GI) Disease
(1) Gastroenteritis: an acute syndrome characterized by inflammation of
the stomach and intestinal tract. Viral or bacterial infections are the
most common cause of acute gastroenteritis
(a) Signs and symptoms
(i) Nausea, vomiting and diarrhea-may be mild or
severe
(ii) Fever- may or may not be present
(iii) Abdominal cramping. Normal to increased
bowel sounds
(iv) Rectal examination may show blood in the stool
(v) May become dehydrated if fluid loss is severe
(b) Treatment:
(i) Rest
(ii) Correct fluid loss- either orally or with IV
hydration
(iii) If vomiting is severe, control with an antiemetic,
either orally or by intravenous injection at
direction of physician. Contraindicated with
invasive organisms.
(iv) Refer to a MD/PA for further care, especially
when fever, severe abdominal pain or rectal
blood is present
(2) Upper GI Bleeding
(a) The vomiting of blood (hematemesis), passage of black
tarry stool (melena), or occult chronic bleeding from the GI
tract
(b) Caused by a number of factors such as: cancerous
tumors, peptic ulceration, erosive gastritis, and esophageal
varices
(c) Signs and symptoms: the manifestations of GI bleeding
depend on the source, rate of bleeding, and underlying or
coexistent disease. Patients with chronic blood loss may
present with symptoms and signs of anemia (e.g.,
weakness, easy fatigability, pallor, chest pain, and
dizziness) or chronic rectal bleeding.
(d) Treatment
(i) Hematemesis or melena is a medical
emergency
(ii) Fluid resuscitation and treatment for shock are
indicated
(iii) Refer to a PA/MD for more definitive care
(iv) Evacuate as soon as possible
(3) Peptic Ulcer Disease: erosion of the lining of the stomach or
duodenum as a result of gastric acid hyperacidity
(a) Risk factors- stress, diet, alcohol, caffeine, drugs (ASA,
NSAIDs), tobacco, H. Pylori infection and heredity
(b) Signs and symptoms

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(i) Epigastric pain 45-60 minutes after a meal

(ii) May be nocturnal — becoming most severe
between midnight and 0200 hrs.
(iii) Pain, described as burning, may be relieved by
food or antacid intake
(iv) Epigastric tenderness, occult blood on rectal
exam if the ulcer is bleeding
(v) UGI or endoscopy confirms the diagnosis
(c) Treatment
(i) Restriction of coffee, tea, cola, alcohol, aspirin,
NSAIDs and tobacco
(ii) Antacids: 30 ml P.O. 1 and 3 hours after meals
and at bedtime, Cimetidine (Tagamet) 400 mg
P.O. BID or 800 mg P.O. at bedtime.
(iii) Refer to MD/PA for full evaluation
(4) Esophageal varices: An esophageal varix is a dialated vein of the
esophagus. Primary causes of esophageal varices are alcohol
consumption, portal hypertension, and the ingestion of caustic
substances.
(a) Signs and symptoms: the physical findings in esophageal
varices are:
(i) Hematemesis with bright red blood
(ii) Dysphagia (difficulty swallowing)
(iii) Burning or tearing sensation as the varices
continue to bleed, irritating the lining of the
esophagus
(iv) May exhibit classic signs of shock, including
tachycardia, tachypnea and cool diaphoretic skin
(b) Treatment:
(i) Two large bore IV’s
(ii) Treatment for shock and immediate evacuation
to a definitive care facility
(5) Esophageal reflux: "Gastroesophageal Reflux Disease" (GERD) is a
term applied to the symptoms of tissue damage caused by the reflux
of gastric contents (usually acidic) into the esophagus
(a) Signs and symptoms
(i) Heartburn, burping, regurgitation — worse when
lying down, frequently severe substernal pain,
occurring 30 — 60 minutes after eating
(ii) May manifest as laryngitis, chronic cough due to
aspiration of gastric contents
(iii) The physical exam is usually normal
(iv) Cardiac disease MUST be ruled out prior to a
diagnosis of reflux esophagitis is given
(b) Treatment:
(i) Weight reduction if obese
(ii) Avoid eating near bedtime
(iii) Antacids after meals and at bedtime
(iv) Avoid tobacco, alcohol and caffeine

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(v) Elevation of the head of the bed with 6 inch

blocks helps
(vi) Avoid large meals
(vii) Tagament, Zantac, and Prilosec are oral
medications to be used to reduce acid reflux

Lower Gastrointestinal (GI) Disease

(1) Constipation: considered if defecation is delayed for days beyond the
patients normal, or if the stools are unusually hard, dry, and difficult
to move
(a) Signs and symptoms: difficulty or straining on defecation,
occasionally with abdominal cramping. Usually no severe
pain, nausea, vomiting or blood in stools. Normal bowel
sounds on physical examination. Usually has no bleeding
on hemoccult rectal exam.
(b) Treatment: increase intake of water and fiber (fruits, bulky
vegetables, and bran cereals. Daily exercise. Metamucil
2 tsp. in water or juice 2 —3 x qd Milk of Magnesia 2 tsp.
at Hs Bisacodyl (Dulcolax) 10 — 15 mg orally or
suppository one rectally at hs, Fleets enemas.
(2) Diarrhea: frequent passage of unformed watery bowel movements.
May be due to viral, bacterial or parasitic infections
(a) Four basic mechanisms of diarrhea
(i) Increased intestinal secretion
(ii) Decreased intestinal absorption
(iii) Increased osmotic load
(iv) Abnormal intestinal motility
(b) Signs and symptoms
(i) Frequent, loose or watery stools
(ii) Change in consistency
(iii) Bloody (refer to Colitis) or nonbloody
(iv) Mucus
(v) Pus
(vi) Fatty materials, oil, grease (stools will float if
high in fat)
(vii) Character and volume
* Describe the stools appearance:
watery, bloody, or black and tar-like?
* How long does it last? Number of
bowel movements per day?
* Do you have cramping associated
with the bowel movement
(c) Etiology
(i) Can be caused by nerves, viral, or bacterial
infection
(ii) Nocturnal diarrhea may suggest organic disease
of the bowel
(iii) Toxic substances
(iv) May be found in family history of GI disorders

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(v) Different food or water as in history of travel

(vi) Poor water or food sanitation or poor hygiene
(Food Poisoning)
(vii) Sexual transmission
(viii) May have fever associated with dehydration
(ix) Determine circumstances surrounding the onset
* Acute diarrhea - usually caused by
infection; chronic may be caused by
systemic illness; intermittent by
psychological factors: Did it begin
rapidly or gradually?; Were you under
any stress at the time of onset?;
What foods did you eat
before it began?; Have you recently
changed your diet?; Any travel
history? Camping? Deployment?
* Chronic: when do you last recall not
having the symptom?
* Intermittent: How long do intervals
between episodes last?; Does
diarrhea alternate with constipation?
(d) Treatment
(i) Dictated by cause when known
(ii) Clear liquids for 24 hours, then diet as tolerated
* Replacing lost fluid and electrolytes is
the most important therapeutic
measure in acute diarrhea
* If patient is significantly dehydrated,
start IV fluid
* If patient is not vomiting and mild
dehydration: oral rehydration
(iii) Avoidance of agents that worsen diarrhea:
* Caffeine
* Dairy products
* Raw fruits and vegetables
(iv) Kaopectate indicated only if illness and diarrhea
continues
(v) May give Lomotil or Imodium if no blood in stool
or no fever
(vi) If febrile or blood in stool, refer to MD/PA for
antibiotic therapy and lab studies
(vii) Withhold food for 24 hrs — clear liquid diet only,
force clear liquids. Kaopectate liquid: 2 tbs. after
each loose bowel movement (or 2 tbs.). Refer
to MD/PA if not improved.
(3) Lower GI Bleeding
(a) Signs and symptoms: Hematochezia (passage of bright
red rectal blood), melena (dark or black tarry stool). 10%
of hematochezia is due to an UGI bleed (Fast transit of
blood)

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(b) Caused by a number of factors: colitis, malignancy,

anorectal disease, inflammatory bowel disease,
hemorroids
(c) Treatment
(i) Hematochezia and melena are medical
emergencies
(ii) Initiate two Large Bore IV’s
(iii) Fluid resuscitation and treatment for shock are
indicated
(iv) Referral to an MD/PA for definitive management
(v) Evacuate as soon as possible
(4) Colitis: the term colitis applies to inflammatory diseases of the colon
(e.g. ulcerative, granulomatous, ischemic, radiation, infectious colitis
or irritable bowel syndrome)
(a) Signs and symptoms: bloody diarrhea of varied intensity
and duration is interspersed with asymptomatic intervals.
Usually an attack begins insidiously, with increased
urgency to defecate, mild lower abdominal cramps, and
blood and mucus in the stools. However, an attack may
be acute and fulminant, with sudden violent diarrhea, high
fever, signs of peritonitis, and profound toxemia. Some
cases develop following a documented infection (e.g.,
amebiasis, bacillary dysentery).
(b) Treatment: dependent on diagnosis. Initial onset to be
considered a medical emergency. Refer to MD/PA for
management
(5) Appendicitis: obstruction of the appendix by a fecalith, inflammation,
foreign body or tumor
(a) Signs
(i) Classic presentation: Anorexia and pain in the
epigastric or periumbilical area of the abdomen
that evolves into pain in RLQ over 8 hours,
often, signs and symptoms do not follow classic
presentation
(ii) Nausea, diarrhea, and vomiting may accompany
pain. Occasionally, constipation is present. The
pain is moderately severe and after several
hours localizes to the RLQ
(iii) Acute abdomen
(iv) Patient often will point precisely to the RLQ area
of pain (positive McBurney’s sign)
(b) Symptoms
(i) Abdominal tenderness
(ii) Fever may be present
(iii) Decreased bowel sounds if perforated
(iv) Rebound tenderness
(v) Rovsing sign (peritoneal irritation producing right
lower quadrant pain with palpation of the left
lower quadrant)

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(vi) Psoas sign (pain with active flexion against

resistance or passive extension of the right hip)
(vii) Obturator sign (pain with passive internal
rotation of the flexed right hip)
(viii) Voluntary or involuntary guarding
(ix) Rectal tenderness is common
(c) Treatment: Appendicitis is a surgical emergency. Refer to
PA/MD and evacuate immediately
(6) Diverticular Disease: typically presents with left lower quadrant pain
and tenderness, similar to the right-sided pain and tenderness of
appendicitis
(a) Signs and symptoms:
(i) Abdominal pain, usually in the left lower
quadrant
(ii) Nausea and vomiting
(iii) Constipation
(iv) Diarrhea
(v) Left lower quadrant tenderness, guarding,
rebound
(vi) Fever
(vii) General peritonitis with tachycardia, high fever,
and sepsis if colonic perforation occurs
(b) Treatment
(i) Diverticular disease is primarily a clinical
diagnosis
(ii) Outpatient treatment: bowel rest and broad-
spectrum oral antibiotic therapy. Patients are
instructed to limit activity and maintain a liquid
diet for 48 hours. If symptoms improve, low-
residue foods are added to the diet.
(iii) If patient demonstrates signs of toxicity: fever,
tachycardia, leukocytosis and severe abdominal
pain, intravenous antibiotics are administered
(authorized by MD/PA)
(7) Bowel Obstruction: complete arrest or serious impairment of the
passage of intestinal contents caused by a mechanical blockage.
Mechanical obstruction is divided into obstruction of the small bowel,
including the duodenum, and the large bowel. Major causes are
hernia and adhesions
(a) Signs and symptoms:
(i) Obstruction of the small bowel is based on a
triad of symptoms:
* Abdominal cramps are centered
around the umbilicus or in the
epigastrium; if cramps become severe
and steady, consider strangulation
(lack of blood flow to the bowel)
* Vomiting starts early with small-bowel
and late with large-bowel obstruction

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* Constipation occurs with complete

obstruction, but diarrhea may be
present with partial obstruction
(ii) Obstruction of the large bowel: symptoms
usually develop more gradually than with small-
bowel obstruction. Increasing constipation leads
to obstipation and abdominal distention. If the
ileocecal valve is competent, there may be no
vomiting; if it allows reflux of colonic contents
into the ileum, vomiting may occur (usually
several hours after onset of symptoms). Lower
abdominal cramps unproductive of feces are
present.
(b) Treatment
(i) A nasogastric tube is inserted and placed on
suction
(ii) An inlying bladder catheter helps monitor urinary
output
(iii) IV hydration
(iv) Complete obstruction is treated surgically after
supportive therapy has been initiated
(v) Bowel obstruction should be considered a
surgical emergency. Refer patient to an MD/PA
and evacuate immediately
(7) Hemorrhoids: a varicose vein in the lower rectum or anus. Caused
by straining at stool, constipation, prolonged sitting and a diet poor in
fiber.
(a) Signs and symptoms: itching, irritation and bleeding with
bowel movements. Obvious external hemorrhoid or
internal hemorrhoids found on rectal examination. Mucoid
discharge from rectum
(b) Treatment: high roughage/fiber diet. Sitz bath (sitting in
warm water reduces pain and swelling). Metamucil 2 tsp.
in water or juice 1-3 times daily. Anusol or Anusol HC
suppositories for internal hemorrhoids can be given two-
three times a day.
(c) Complications: A thrombosed hemorrhoid is caused by
the rupture of a vein, forming a clot in the subcutaneous
tissue. A tender bluish mass is visualized. Thrombosed
hemorrhoids require evaluation by an MD/PA.

Liver, Biliary Tract and Pancreatic Diseases

(1) Hepatitis
(a) Hepatitis is a liver inflammation that stems from a virus or
hepatotoxic agent
(b) Viral hepatitis is the most common of the serious,
contagious
diseases caused by a virus that attacks the liver

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(c) Hepatitis B & C are classified as sexually transmitted

diseases
(d) Types
(i) Hepatitis A - formerly called infectious hepatitis
* Ranks as most common type of
hepatitis
* Highly contagious
* Transmitted primarily in food handled
by individuals in the infectious stages
of the disease is very contagious and
often spread within families
* Public health problems occur from
contaminated shellfish after raw
sewage releases and accidents as
well as, from commercial food
handlers
* Acute onset
* No treatment has been shown to alter
the disease course
* Immunization: An inactivated hepatitis
A vaccine is available, Prophylactic IG
may be administered within two weeks
after exposure to hepatitis A, Persons
traveling to Africa, the Middle East,
Central and South America, and Asia
should be immunized FEMA team
personnel should be offered vaccine if
they travel out of the United States
(ii) Hepatitis B - formerly called serum hepatitis;
most serious form
* A prominent source of acute/chronic
hepatitis and cirrhosis of the liver
* Hepatitis B virus is very hardy, the
virus’ ability to survive outside its
normal environment for an extended
period of time demonstrates the need
for appropriate application of universal
precautions
* Signs and symptoms are vague and
can be mistaken for influenza or the
common cold (fatigue, gastrointestinal
disorders, headaches)
* In prehospital care workers, needle
stick injuries, mucous membrane
contact and open lesions of the skin
are the primary mode
* Needle stick injuries are the most
common cause of contraction

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* Workers are at risk of HBV infection to

the extent they are exposed to blood
and body fluids
* Modes of transmission are
preventable by the application of
engineering controls, proper work
practices (universal precautions), and
HBV vaccination
* Prophylaxis: Hepatitis B vaccine
before exposure and Hepatitis B
immune globulin after exposure
(iii) Hepatitis C - formerly called non A, non B
hepatitis
* Transmission: transfused blood (most
common), body fluids
* Individuals at high risk for developing
hepatitis C include: Intravenous drug
users, renal dialysis patients, multi-
transfused patients, hemophiliacs
* Prevention: clean water supply, safe
disposal of human waste, hygienic
handling of food, good personal
hygiene, and medical prophylaxis
includes active immunization with
Immunoglobulin (1g)
* Treatment: no specific treatment or
drug can kill the hepatitis viruses
(3) Acute pancreatitis: inflammation of the pancreas- alcoholism
accounts for 80% of all causes
(a) Signs and symptoms
(i) Abrupt onset of epigastric pain, radiating to back
(ii) Nausea, vomiting, sweating, weakness
(iii) Abdominal tenderness and distention
(iv) Fever
(v) May have a history of previous episodes, often
related to alcohol abuse
(vi) Jaundice may occur – may be caused by stones
(b) Treatment:
(i) NPO until patient is pain free
(ii) Nasogastric suction
(iii) IV hydration
(iv) Bed rest
(v) Pain control with narcotics IV (by MD/PA order)
(vi) Refer patient to MD/PA
(vii) Evacuate as soon as possible
(4) Acute Cholecystitis: acute inflammation of the gallbladder wall,
usually as a response to cystic duct obstruction by a gallstone
(a) Signs and symptoms

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(i) Steady, severe pain and tenderness in the right

upper quadrant or umbilical area. Acute attack
is often precipitated by a large, fatty meal.
(ii) Nausea and vomiting
(iii) Painful splinting of respiration during deep
inspiration and right upper quadrant palpation
(Murphy's sign) is frequent
(iv) Fever
(b) Treatment
(i) NPO
(ii) IV hydration
(iii) Pain control with narcotics IV (by MD/PA order)
(iv) IV antibiotics – as directed by MD/PA
(v) Cholecystectomy usually performed 2-3 days
after acute episode subsides
(vi) Refer patient to MD/PA
(vii) Evacuate as soon as possible
(5) Cholelithiasis: formation or presence of calculi (gallstones) in the
gallbladder.
(a) Signs and symptoms
(i) The clinical consequences of stone formation in
the gallbladder are exceedingly variable. Most
patients remain asymptomatic for long periods,
frequently for life.
(ii) Persistent obstruction usually produces
inflammation and acute cholecystitis. Stones in
the duct cause colicky pain associated with
peristaltic motion.
(b) Treatment: symptomatic gallstones - biliary colic recurs
with irregular, pain-free intervals of days or months.
Symptomatic patients are at increased risk of developing
complications, and cholecystectomy is indicated. Refer to
PA/MD and evacuate.

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TERMINAL LEARNING OBJECTIVE

Given a standard fully stocked M5 Bag or Combat Medic Vest System, IV administration
equipment and fluids, oxygen, suction, and ventilation equipment (if available), selected
medications, and documentation forms. You encounter a casualty complaining of
genitourinary problems. No other injury(ies) are present. Performed initial management
interventions for genitourinary symptoms identified during focus history and exam.

Recognize specific illnesses

Cystitis

(1) Definition - inflammation of the urinary bladder

Urine is normally sterile. Bacteria reach the bladder by way of

infected kidneys, lymphatics, and the urethra. Because the urethra is
short in women, ascending infections are more common in women.
(2) Causes
(a) Fecal contamination
(b) Catheters
(c) Sexual intercourse - occurs after long periods without
sexual intercourse. Also called "Honeymoon cystitis“
(3) Symptoms
(a) Urgency (a feeling of the need to void although the bladder
is not full)
(b) Frequency
(c) Dysuria (painful urination)
(d) Perineal and suprapubic pain
(e) Hematuria
(f) Chills and fever are rare, but may indicate a more serious
illness
(4) Diagnosis
(a) Patient's history and physical examination
(a) Urinalysis, urine culture and sensitivity (C&S)—may show
an increase in the number of red and white cells, as well
as the causative microorganism
(5) Treatment
(a) Increase fluid intake
(b) Identify and correct contributing factors
(c) Antimicrobial therapy as prescribed by the MD/PA
(d) Urinary (Pyridium) for dysuria

Urethritis
(1) Definition - inflammation of the urethra, more common in men than in
women
(2) Causes
(a) If caused by organisms other than gonorrhea--it is known
as nonspecific urethritis (NSU)

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(b) Gonorrhea causes a specific form of infection that can

attack the mucous membrane of the urethra
(c) Urethritis may accompany cystitis in women
(d) Nonspecific urethritis in men caused by:
(i) Irritation during vigorous intercourse
(ii) Intercourse with an infected partner
(iii) Most common cause of urethritis is caused by
chlamydia trachomatis
(3) Symptoms
(a) Dysuria - ranging from slight tickling to burning or severe
discomfort
(b) Urinary frequency
(c) Fever is NOT common and implies a more serious
infection to prostate, testes, and epididymis in males
(d) Urethral discharge
(4) Diagnosis
(a) Patient's history and symptoms
(b) In men, urethral smear (gram stain)/ C & S to identify
causative organism
(c) In women, clean catch urinalysis
(5) Treatment
(a) Antibiotic therapy as prescribed by the MD/PA. Depending
on organism must involve MD/PA as treatment needs to
be tailored and treatment of syphilis is also required in
many cases.
(b) Increase fluid intake
(c) Analgesics for pain/discomfort

Pyelonephritis
(1) Definition - infection of the renal parenchyma (the functional tissue of
an organ as distinguished from supporting or connective tissue) and
the lining of the collecting system
(2) Causes
(a) Acute pyelonephritis
(i) Associated with diabetes, pregnancy and
extremes of age
(ii) Bacterial infection such as E-coli, streptococcus,
pseudomonas, and staph aureus
(iii) More common causes are bladder
instrumentation, neurogenic bladder, and
inability to completely empty the bladder
(b) Risk factors
(i) Diabetes
(ii) Pregnancy
(iii) Recent instrumentation
(iv) Extremes of age
(3) Symptoms
(a) Acute pyelonephritis
(i) Flank pain

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(ii) Chills, fever, and malaise

(iii) Frequency and burning on urination may be
present if bladder is also infected.
(iv) Nausea and vomiting, dehydration with
secondary
(v) Headache
(4) Diagnosis
(a) Urinalysis positive for leukocyte (WBC’s) casts
(b) Positive urine culture
(c) Physical examination reveals CVA (costovertebral angle)
or flank tenderness
(5) Treatment
(a) Symptomatic treatment for fever and pain
(b) Antibiotic therapy prescribed by MD/PA. May consider
ampicillin. gentamycin or fluoroquinolone (Cipro/Levaquin)
(c) Liberal oral fluid intake, if unable to tolerate fluids IV
hydration and antibiotics
(d) Relief of any urinary obstruction
(e) All patients need to be evaluated by a physician

NOTE: Damage to the kidney can be life threatening if not treated promptly.

(6) Discharge Teaching

(a) Follow diet and fluid regime as prescribed
(b) Take medications exactly as directed
(i) Do not omit or discontinue medication unless
told by the physician
(ii) Do not take nonprescription drugs unless
cleared by the physician

Infections of the female reproductive system

(1) Vaginitis
(a) Definition - inflammation of the vagina (The normal acidity
of the vaginal secretion is a natural defense against
infection but, if infected by certain pathogenic organisms,
an infection results)
(b) Causes
(i) Bacteria- most common
(ii) Trichomonas vaginalis - a protozoan
(iii) Candida albicans – yeast (fungal)
(c) Facts
(i) Commonly occurs during pregnancy and after
antibiotic therapy
(ii) Frequently seen in women with diabetes
(iii) Vaginitis may persist for years
(iv) Factors that influence the development of a
vaginal infection include
* A change in the vaginal ph.

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* Hormonal changes during the

menstrual cycle, pregnancy or for any
other reason (such as taking steroids).
* Long-term use of birth control pills
* Use of systemic antibiotics
* Compromised immunity
(d) Types of Vaginitis:
(i) Bacterial Vaginosis (BV)
* Known as nonspecific vaginitis.
* Caused by a combination of
organisms.
* Increased discharge (white, yellow or
gray) with a "fishy" odor.
* Redness or edema not significant.
* May be sexually transmitted
(ii) Trichomonas Vaginalis (Trichomoniasis) - a
sexually transmitted disease
(iii) Candidiasis albicans— "typical yeast infection“
may be a sexually transmitted disease
(e) Signs and symptoms
(i) Leukorrhea - whitish or yellow white vaginal
discharge
(ii) Discharge may be frothy or thick
(iii) Odorous and profuse discharge (more so in
trichomoniasis)
(iv) Perineal, vaginal and urethral burning and
itching
(v) Possible discomfort in lower abdominal region
(vi) Redness or rash around vagina
(vii) Painful intercourse
(viii) Occasionally asymptomatic

NOTE: Diagnosis is made upon microscopic examination of the vaginal

discharge (usually a wet prep/KOH) and normal saline.

(f) Treatment
(i) Metronidazole (Flagyl) if BV or trichomoniasis
infection - dose 250mg po tid x7 days or 2gm po
in single dose. Instruct patient not to drink
alcohol while taking Flagyl and for three days
after completion of therapy. Using together will
cause nausea, vomiting, headache, cramps and
flushing)
(ii) Nystatin cream (Mycostatin, Nilstat); Miconazole
(Monistat, Micatin) Clotrimazole (Mycelex) if
candida infection
(iii) If has glycosuria (glucose in urine), patient will
need work-up to rule out the diagnosis of
diabetes mellitus

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(iv) Women with any of the following clinical

situations should notify the physician at the first
sign of a vaginal infection
* First vaginal infection
* Unsure if it is a yeast infection
* High risk for HIV or AIDS
* Diabetic
* Temperature over 100 degrees
* Under 12 years of age
* Pregnant
* New onset pain especially lower
abdomen, back, or shoulder
* Malodorous vaginal discharge
(2) Pelvic Inflammatory Disease (PID)
(a) Definition - an infection or inflammation of the ovaries,
fallopian tubes, uterus, or pelvic cavity
(b) Causes and transmission
(i) Infection usually enters the pelvic organs (uterus
fallopian tubes, ovaries) through the cervix and
vagina
(ii) Organisms commonly associated with causing
PID are N. gonorrhea and Chlamydia
(c) Signs and symptoms
(i) Foul-smelling vaginal discharge
(ii) Back ache
(iii) Pelvic pain
(iv) Abdominal pain
(v) Fever, chills, malaise
(vi) Nausea, vomiting
(vii) Menorrhagia
(viii) Dysmenorrhea
(ix) Dyspareunia
(d) Risk factors
(i) Multiple sexual partners
(ii) History of STDs in the past
(iii) Frequent vaginal douching
(iv) IUD (intrauterine device for contraception)-
highest risk first four months after insertion
(v) Younger age
(e) Diagnosis
(i) Based on symptoms and physical exam
findings-lower abdominal pain is the most
frequent presenting complaint
(ii) Wet prep (saline/KOH (potassium hydroxide) of
vaginal secretions)
(iii) Culture and sensitivity of vaginal discharge to
determine causative organism
(iv) Ultrasound if available
(v) This is a cause of serious illness and death if not
treated quickly and properly – Patient may

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develop toxic shock syndrome that can be

rapidly fatal.
(f) Treatment
(i) Serious illness that requires hospitalization for
administration of IV antibiotics and supportive
care Patient must be treated quickly and
properly.
(ii) IV antibiotics as prescribed by the MD/PA
(iii) During the active disease process, douches and
sexual intercourse should be avoided
(iv) Remove IUD if in place
(g) Discharge Teaching:
(i) Both sex partners must be instructed to take
their prescribed medications even though one
partner may be asymptomatic

Kidney Stones
(1) Stones form throughout the urinary system. Patients usually present
when the stone has migrated into a ureter
(2) Cause
(a) Dehydration
(b) Increase in minerals in water supply
(c) Occurs three times more often in males than females
(3) Symptoms
(a) Acute onset of severe flank pain
(b) Flank pain radiates to the groin, scrotum or labia
(c) Nausea, vomiting, secondary dehydration, anxious
(d) Cool clammy skin, diaphoresis, tachycardia and increased
blood pressure due to severe pain
(e) Hematuria with dysuria, urinary frequency
(4) Diagnosis
(a) Urine analysis – hematuria
(b) Physical assessment - acute CVA /flank tenderness on
affected side
(c) Fever and/or hypotension are unusual and would suggest
possibility of infection or diagnosis other than renal colic
(5) Differential Diagnosis
(a) Aortic dissection
(b) Abdominal aortic aneurysm
(c) Renal obstruction
(d) Acute myocardial infarction
(e) Acute abdomen
(6) Treatment
(a) Pain control-IV narcotics almost always required
(b) IV hydration
(c) Strain all urine to recover stone, if passed
(d) Refer immediately to nearest MTF for management

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Acute scrotal pain

(1) Differential Diagnosis
(a) Testicular torsion
(i) Cause
* History of athletic event or trauma
(ii) Symptoms
* Pain is sudden and severe with
radiation into abdomen
(iii) Diagnosis
* Malpositioned testes-lateral
orientation and elevated
* Ultrasound
(vi) Treatment
* Immediate referral to the nearest
treatment facility
* Manual detorsion of the affected testis
may be attempted. This is
accomplished standing at the foot of
or on the right side of the patient’s
bed. The torsed testis is detorsed in a
fashion similar to "opening a book“.
That is, the patient’s right testis is
rotated in a counterclockwise fashion
and the patient’s left testis in a
clockwise fashion.
* Surgical Emergency – patient will lose
testicle if torsion is not corrected
(b) Epididymitis
(i) Cause
* Bacterial infection, often STD
* Urinary tract infection
* Prostatitis
* Prolonged use of indwelling catheters
(ii) Signs and symptoms
* Pain more gradual than onset of
torsion
* Causes lower abdominal, inguinal and
scrotal or testicular pain alone or in
combination
(iii) Diagnosis
* Painful urination
* Transient relief of scrotal/testicular
pain in the recumbent position with
scrotal elevation
* Pyuria (WBC’s and bacteria) on
urinalysis
* Epididymis tender on palpation. May
feel like a 'bag of worms“
(iv) Management

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* Antibiotic therapy as prescribed by

MD/PA
* Increase fluid intake – oral or IV
* Rest with scrotal elevation
* Oral analgesics

Sexual Assault Assessment

(1) 5% of violent crimes in U.S.
(a) Much higher incidence in 3rd world countries
(b) Grossly under reported
(2) Assessment
(a) Assess for and treat any life-threatening injuries
(compromised airway, hypovolemic shock)
(b) Provide "safe“ environment –shield from other patients,
visitors
(c) Avoid touching patient without permission
(d) Tell patient not to shower, bathe, change clothes or throw
clothes away until examined by the physician. Evidence
preservation is paramount.
(e) Notify MD/PA immediately

Recognize Sexually Transmitted Diseases

Factors that contribute to Sexually Transmitted Diseases (STD)

(1) Unknown carrier of disease

(2) Casual sex
(3) Absence of laws that require reporting of ALL STDs
(4) Length of time between exposure and appearance of symptoms (or
positive antibody tests)
(5) Failure to:
(a) Recognize signs and symptoms
(b) Seek early treatment
(c) Refrain from sexual activity until treatment complete
(6) Lack of knowledge regarding STDs and their prevention
(7) Failure of sexually active person to heed STD warnings
Factors related to prevention and control of STDs
(1) Public education:
(a) School Systems
(b) Television and newspapers
(2) Refrain from sexual activity until disease eradicated
(3) Locate and treat contacts
(4) Continued research
(5) STD clinics

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Chlamydia (Appears 7-10 Days after exposure)

(1) Caused by the organism, Chlamydia trachomatis (parasite)
(2) Signs and Symptoms
(a) Urethritis & epididymitis in men
(b) Cervicitis & macopurulent discharge in women
(c) Some patients may be asymptomatic, especially women
(d) Can be transmitted from mother to infant at birth
(e) Additional problems
(i) Pelvic inflammatory disease
(ii) Ectopic pregnancy
(iii) Sterility
(iv) Systemic infections
(3) Diagnosis
(a) Direct microscopic examination-will observe flagellated
parasite
(b) Culture of secretions or tissue scrapings
(4) Management
(a) Antimicrobials, such as tetracycline, erythromycin,
sulfonamide as prescribed by MD/PA
(b) Explain the prescribed treatment
(i) Length of treatment is 7-21 days
(ii) Patient should refrain from sexual activity during
treatment
(c) Referral to Preventative Medicine for reporting

NOTE: Treatment failure can be due to either reinfection or patient

noncompliance with antimicrobial therapy.
Gonorrhea
(1) Caused by the organism Neisseria gonorrhea. Often co-exists with
chlamydial infections.
(2) Signs and Symptoms
(a) Appear 2 to 6 days after exposure
(b) Men
(i) Urethritis with a purulent discharge.
(ii) Pain on urination
(iii) May spread to prostate, seminal vesicles,
epididymis
(iv) Sometimes there are no symptoms in men
(v) Gonococcal infection occur in the pharynx and
rectum
(c) Women
(i) Vaginal discharge
(ii) Abnormal menstrual bleeding
(iii) Painful urination
(iv) 80% experience no symptoms
(3) Diagnosis
(a) Gram stain and culture

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(b) In men, specimen of urethral discharge is obtained; anal

and pharyngeal smears if person has practiced anal or oral
sex.
(c) In women, specimen obtained from cervix

NOTE: Lubricants are not used on speculum because these products may
destroy the gonococci.

(4) Management
(a) Antibiotics as prescribed by MD/PA. Rocephin 250 mg IM
is usually effective treatment
(b) Explain the treatment regimen
(c) Explain the importance of contacting all sexual partners for
examination and treatment
(d) Refrain from sexual activity until follow-up smears are
negative
(e) Referral to Preventative Medicine for reporting

Syphilis
(1) Caused by spirochete, Treponema pallidum. If untreated,
progresses through secondary & tertiary stages.
(2) Signs and Symptoms
(a) Primary (early) stage (Appears 2-6 weeks after exposure)
(i) Chancre appears on genitals, anus, cervix, and
other parts of body.
(ii) Chancre first resembles papule, later appears
ulcerated, painless
(iii) Heals by itself in several weeks
(b) Secondary Stage: (Appears 2-6 weeks after primary stage)
(i) Fever
(ii) Malaise
(iii) Rash – most common manifestation
(iv) Headache
(v) Sore throat
(vi) Enlarged lymph nodes
(c) Tertiary Stage: Non-infectious – involvement of the
nervous and cardiovascular systems
(i) May occur years after initial infection.
Sometimes as much as twenty years later.
(3) Diagnosis
(a) Lab tests (serum)
(i) VDRL - Venereal Disease Research Laboratory
(ii) RPR - Rapid Plasma Reagent
(iii) Fluorescent treponemal antibody absorption test
(4) Management
(a) Explain the treatment regimen
(b) Instruct the patient to avoid intercourse until permitted
(c) Primary and secondary stages
(i) Penicillin G - drug of choice

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(ii) Tetracycline or erythromycin - if allergic to

penicillin
(iii) Follow-up examination at 3,6, & 12 months
(d) Tertiary stage:
(i) Larger doses of penicillin G
(ii) Response is poor in patients with cardio-
vascular syphilis

Herpes Genitalis
(1) Caused by Herpes Simplex Virus
(2) Signs and Symptoms
(a) Painful vesicular lesions on buttocks, penis, perineum,
vulva, cervix, vagina (if transmitted by anal intercourse,
lesions may appear in rectum and perianal area).
(b) Lesions may persist for several weeks
(c) Malaise
(d) Fever
(e) Chills
(f) Headache
(g) Reoccurrence in 60 – 90 % of patients
(3) Diagnosis
(a) Examination of lesions-linear vesicles. Microscopic exam
will show giant cells.
(b) Viral culture
(4) Management
(a) Acyclovir (Zovirax) - oral, topical, intravenous

NOTE: Acyclovir may decrease the frequency and magnitude of

reoccurrences.

(b) Analgesics for pain and discomfort

(c) If eye infection, use Vira-A, Herpes Liquafilm or Viroptic
(d) Instruct the patient to use a condom at all times if there is
a periodic reoccurrence of the lesions
(e) Refrain from sexual intercourse or use a condom
(f) Pregnant women must inform the physician if they have a
history of herpes. Delivery during an active outbreak can
be fatal to the infant.

Genital Warts
(1) Caused by human papilloma virus (HPV)
(2) Signs and Symptoms
(a) Incubation period is normally 1-2 months, but may be
longer
(b) Painless, soft, fleshy wart-like growths on the genitalia or
cervix or in vagina
(3) Diagnosis: visual examination
(4) Management

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(a) No cure
(b) RPR for syphilis
(c) Treat with podophyllin, a topical solution that is left in place
for 4-6 hours, and then washed off
(d) Teach the patient to use a condom

NOTE: There appears to be an increased risk of cancer of the vulva, cervix,

and vagina in women with genital warts.
Review Male and Female Catheterization
Urinary Catheterization
(1) Definition - Insertion of a catheter (tube for injecting or removing
fluids) through the urethra into the bladder for the purpose of
removing urine.
(2) Purposes of Urinary Catheterization
(a) Relieve urinary retention
(b) Obtain sterile urine specimen from female
(c) Measure amount of residual urine in bladder (an amount
greater than 50 ml is considered abnormal)
(d) Empty bladder before, during, and after surgery
(e) To obtain a urine specimen when a specimen cannot be
obtained by any other means
(3) Urinary Catheter Sizes
(a) The smaller the number, the smaller the catheter
(b) No. 8 Fr and 10 Fr - used for children
(c) No. 14 Fr and 16 Fr - used for female adult
(d) No. 18 Fr, 20 Fr - usually used for male adult

NOTE: Larger size catheter used for male because it is stiffer, thus easier to
push the distance of the male urethra.
Types of Urinary Catheters
(1) Intermittent catheter
(a) Used to drain bladder for short periods (5-10 min)
(b) Commonly used for self-catheterization by patients in the
home environment (after proper amount of training)
(c) Commonly used with spinal cord injury patients
(2) Indwelling/retention catheter
(a) Continuous bladder drainage
(b) Gradual decompression of over-distended bladder

NOTE: Do not remove more than 750cc to 1000cc of urine from the bladder
at any one time. Gradual decompression will prevent bladder
damage and shock.

(c) Intermittent bladder drainage and irrigation

(d) Drainage tube and collection device connected to this type
of catheter

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(e) Most commonly used indwelling catheter is a Foley

catheter
(i) Designed with balloon at distal tip which can be
inflated with sterile water or saline
(ii) Inflated balloon keeps catheter from slipping out
of bladder
(3) Supra pubic catheter
(a) Inserted into bladder through small incision above pubic
area
(b) Occasionally used for continuous drainage

Procedure for the insertion of Foley Catheter in the male and female patient

It is important to remember that the bladder normally is a sterile cavity and the
external opening to the urethra can never be sterilized. Pathogens introduced
into the bladder can ascend the ureters and lead to bladder and kidney
infections.
(1) Gather all equipment - wash hands
(a) Sterile catheterization kit
(b) Flashlight or lamp
(c) Urine collection bag
(d) Velcro leg strap or anchoring tape
(e) Disposal bag
(f) Waterproof pad or chux
(2) Explain procedure to patient. He/she may experience a
burning/pressure sensation as the catheter is inserted, and a feeling
of needing to void, once catheter is in place
(3) Provide for adequate lighting
(4) Provide for privacy
(5) Position patient
(a) Males - assist patient into supine position with thighs
slightly apart. First place waterproof pad under patient’s
buttocks. Drape patient so only penis is exposed.
(b) Females - assist patient to dorsal recumbent position with
knees flexed and about 2 feet apart. Females may also be
positioned in the Sim's or lateral position with upper leg
flexed. Place waterproof pad under patient.
(6) Cleanse genital and perineal areas with soap and water. Rinse and
dry. Wash hands.
(7) Open sterile catheterization tray and supplies, using sterile
technique.
(8) Put on sterile gloves. Open sterile drape and place on patient's
thighs. Place drape with opening over penis (males) or labia
(females).
(9) Place catheter set on or next to patient's legs on sterile drape.
(10) For indwelling catheters, test catheter balloon:
(a) Attach pre-filled irrigation syringe to injection port
(b) Inject appropriate amount of fluid

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(c) If balloon inflates properly, withdraw fluid and leave

syringe attached to port
(11) Pour antiseptic solution over cotton balls
(12) Lubricate catheter for about 6 to 7 inches (males) or 1-2 inches
(females)
(13) Insertion of Catheter
(a) Males
(i) Lift penis with non-dominant hand, which is then
considered contaminated.
(ii) Retract foreskin in uncircumcised male
(iii) Cleanse area at meatus with a cotton ball that is
held with forceps
(iv) Use circular motion, moving from meatus toward
base of penis. Repeat this three times
(v) Hold penis with slight upward tension and
perpendicular to patient's body
(vi) Instruct patient to bear down as if voiding
(vii) With dominant hand, place drainage end of
catheter into receptacle (if pre-attached to
drainage bag, place bag close to sterile field)
(viii) Insert catheter tip into meatus
(ix) Advance tip 6 to 8 inches until urine flows
(x) Do not use force to introduce catheter
(xi) For slight resistance, ask patient to take a deep
breath and rotate catheter slightly
(xii) Once urine drains, advance catheter another 1/2
to 1 inch
(xiii) Inflate the balloon with the pre-filled syringe
(b) Females
(i) With thumb and one finger of non-dominant
hand, spread labia and identify meatus.
Maintain separation of labia with one hand
(ii) Using antiseptic soaked cotton balls held with
forceps, cleanse area from clitoris toward anus,
using a different sterile cotton ball each time-first
to the right of the urinary meatus, then to the left
of the urinary meatus then down the center over
the urinary meatus. Discard each cotton ball
after one downward stroke.
(iii) With sterile gloved hand, place drainage end of
catheter into receptacle. (If pre-attached to
drainage bag, place bag close to sterile field)
(iv) Insert catheter tip into meatus 2 to 3 inches
or until urine flows.
(v) Do not use force to push catheter through
urethra into bladder
(vi) For slight resistance, ask patient to take a deep
breath and rotate catheter gently as it reaches
external sphincter.

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(vii) Once urine drains, advance catheter 1/2 to 1

inch
(viii) Inflate the balloon with the prefilled syringe
(14) Check to insure balloon is properly filled:
(a) Tug gently on catheter to feel for resistance
(b) Attach catheter to drainage system if required
(15) Secure catheter to upper thigh (males and females) or lower
abdomen with penis directed toward patient's chest (males). Leave
some slack in catheter to prevent tension.
(16) Secure drainage bag below level of bladder. Check that tubing is not
kinked and movement of side rails does not impede drainage.
(17) Cleanse and dry perineal area
(18) Remove equipment and make patient comfortable
(19) Wash your hands
(20) Document procedure in record
(a) Type and size of catheter
(b) Time of catheterization
(c) Amount of urine removed
(d) Description of urine
(e) Client's reaction to procedure
(f) Client's teaching and level of understanding

Removing a Retention Bladder Catheter

(1) Assemble all equipment
(a) 10 cc syringe
(b) Waterproof drape
(c) Soap and water
(d) Exam gloves
(e) Privacy drape
(2) Explain procedure to patient, and advise that he/she may feel a slight
burning sensation during removal of the catheter and the first time
or two that they void.
(3) Provide for privacy and assist female patient to a dorsal recumbent
position, or the male patient to a supine position.
(4) Place waterproof drape under patient's buttocks and provide a drape
for patient privacy.
(5) Wash hands and don disposable gloves
(6) Remove securing tape on catheter
(7) Attach syringe to balloon valve and aspirate entire amount of water
from balloon. Check size of balloon so you know how much to
remove.
(8) Encourage patient to take deep breath and relax while gently
removing catheter per ward SOP. Wrap catheter in towel or
disposable waterproof drape.
(9) Clean the perineal area after the catheter is removed.
(10) Remove gloves and wash hands
(11) Reposition patient comfortably

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(12) Instruct patient to drink plenty of fluids, if appropriate. Record intake

and output, and instruct patient regarding need to void into bedpan
or urinal.
(13) Inform patient that it may take a while for bladder to reestablish
voluntary control, and that an accident is not unusual.
(14) Discard equipment and return it to appropriate area
(15) Record procedure, including the following
(a) Time of procedure
(b) Description and amount of urine in drainage bag
(c) Record all patient teaching accomplished and patient's
level of understanding
(16) Record and report any unusual signs to the charge nurse. These
include, but are not limited to:
(a) Discomfort
(b) Bleeding
(c) Change in vital signs (Increased pulse/decreased BP)
(d) Increase in temperature
(e) Strong odor

Care of the patient with an indwelling urinary catheter

(1) Catheter care
(a) Wash hands before and after catheter care
(b) Clean perineal area and proximal third of catheter twice a
day and after bowel movements. Use soap and water, or
designated solution per hospital SOP. Do not use
powders or lotions, rinse well.
(c) Note color, character and odor of urine
(i) Empty catheter bag every 8 hours or as directed
by SOP/physician’s order
(ii) Ensure drainage spout does not contact
contaminated surface.
(iii) Measure and record I&O as ordered
(iv) Observe patient for fever, chills or a sudden
onset of pain
(v) Apply topical antibiotic ointment to meatus, as
ordered
(vi) Check catheter frequently for patency and
drainage of urine
(vii) Secure catheter to patient to avoid pulling or
pressure
(viii) Clamp catheter temporarily if urine bag must be
elevated higher then bladder. This prevents
urine from draining back into bladder.
(ix) Drainage system tubing should extend straight
down from bed to drainage bag

NOTE: Any loops hanging down from bed level may promote stasis of urine,
leading to infection.

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TERMINAL LEARNING OBJECTIVE

Given a standard fully stocked M5 Bag or Combat Medic Vest System, oxygen, suction
and ventilation equipment (if available). You encounter a casualty with symptoms of a
skin disorder. No other injury (ies) or anaphylaxis symptoms are present, treat skin
disorders IAW Basic Trauma Life Support, Emergency Care in the Streets, Adult Health
Nursing, Basic Nursing: A Critical Thinking Approach, Habif's Clinical Dermatology

Assess for Skin Disorders

Temperature
Skin color
(1) Lips
(2) Oral membranes
(3) Sclera
(4) Conjunctiva
(5) Palms and soles of feet
Skin integrity - palpate with gloved hands
(1) Is the skin intact or not?
(2) Texture (e.g., smoothness, and roughness)
Moist/dry
Skin lesion identification:
(1) Primary lesions are early skin changes that have not yet undergone
natural evolution or change caused by manipulation. These are the
best clues to diagnosis.
(a) A macula is flat; color varies from white to brown to red to
purple, and small (< 1 cm). A patch is a large macule (> 1
cm). Examples include freckles, flat moles, and tattoos.
(b) A papule is a solid, elevated lesion usually < 1 cm. A
plaque is a plateau-like lesion > 1 cm or a group of
confluent papules. Examples include warts, some moles
and some types of skin cancer
(c) A nodule is a palpable, solid lesion >1-2 cm, elevated.
Larger nodules (>2 cm) are called tumors. Examples
include cysts or lipomas
(d) A vesicle is a circumscribed, elevated lesion containing
serous fluid that is < 1 cm; if > 1 cm, it is called a bulla
(blister). Vesicles or bullae are commonly caused by
primary irritants, allergic contact dermatitis, physical
trauma, sunburn, insect bites
(e) Pustules are superficial and elevated lesions containing
pus < 1 cm. They may result from infection or seropurulent
evolution of vesicles or bullae. Some causes are impetigo,
acne and folliculitis
(f) Wheals (hives) are transient, elevated lesions caused by
localized edema. Wheals are a common allergic reaction,

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e.g., from drug eruptions, insect stings or bites, or

sensitivity to cold, heat, pressure, or sunlight.
(g) Purpura is a general term referring to areas of
extravasated blood. Petechiae are small-circumscribed
punctate foci of extravasation, whereas ecchymoses
(bruising) are larger confluent areas of extravasation. The
term hematoma refers to an area of massive bleeding into
the skin and underlying tissues
(8) Telangiectasias are dilated superficial blood vessels. They
appear as red, threadlike lines. They may occur in certain
systemic diseases or in long-term therapy with topical
corticosteroids
(2) Secondary lesions result when primary lesions undergo a natural
evolution
(a) Scales are particles of epithelium. Common scaling
diseases are psoriasis and superficial fungal infections
(b) Crusts (scabs) consist of dried serum, blood, or pus.
Crusting occurs in many inflammatory and infectious
diseases
(c) Erosion is focal loss of part or all of the epidermis. It often
occurs with herpes viral diseases
(d) Ulcers are focal loss of the epidermis and at least part of
the dermis. When ulcers result from physical trauma or
acute bacterial infection, the cause usually is apparent.
Less obvious causes include chronic bacterial and fungal
infections
(e) Excoriation is a linear or hollowed-out crusted area caused
by scratching, rubbing, or picking
(f) Lichenification is a thickened skin area with accentuated
skin markings
(g) Atrophy manifests as paper-thin, wrinkled skin. It occurs in
the aged, after long-term use of topical potent
corticosteroids, and sometimes after burns
(h) Scars are areas of fibrous tissue that replace normal skin
after destruction of some of the dermis. Scars may be
caused by burns or cuts or less commonly by systemic
diseases
Presence of skin lesions
(1) Identify type of lesion
(2) Excretions
(a) Color, odor, amount
(b) Thick, oily etc.
(3) Size, does it change over time?
(4) Location

Turgor and mobility

(1) Turgor checks the hydration status of the patient

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(2) Pinch skin to form dent on back of patient's hand, abdomen, or

sternum. Release skin and note how long it takes to return to normal
position
Edema
(1) Common sites are - face, eyelids, ankles, feet, sacral and scapular
area
(2) Indications of edema are - skin puffiness, tautness, or hardness
(3) Types of edema - press in on area with thumb for 5 seconds and
release
(a) Trace or shallow - slight indention that disappears (1+
second)
(b) Pitting - deep indentation that remains visible for several
seconds (3-4 + seconds)
(c) Dependent - gravity causes fluid to pool in areas lowest to
the earth.

Identify and Manage Viral Disorders of the Skin

Herpes simplex:
An infection from the herpes simplex virus (HSV) is characterized by one or
many clusters of small vesicles filled with clear fluid on slightly raised
inflammatory bases

(1) Signs and symptoms

(a) The lesions may appear anywhere on the skin or mucosa
but are most frequent around the mouth, on the lips, on the
conjunctiva and in the genital area
(b) Incubation period is 2-20 days. Asymptomatic „carriers“
shed the virus and spread the disease
(c) After a prodromal period; tingling, discomfort or itching and
small tense vesicles appear on an erythematous base
(d) Single clusters vary in size from 0.5 to 1.5 cm, but groups
may coalesce
(e) The vesicles persist for a few days, and then begin to dry,
forming a thin yellowish crust or ulcer
(f) Primary (initial) infection is generally the most severe, with
fever, lymphadenopathy and urinary symptoms (if the
outbreak is genital)
(g) A herpetic whitlow is a HSV infection of the fingers,
resulting from an inoculation of HSV through a cutaneous
break. Common in health care workers. Symptoms
include swelling and pain over lesions around the finger
nail.
(2) Treatment
(a) Healing generally occurs in 8 to 12 days after onset
(b) Individual herpetic lesions usually heal completely, but
recurrent lesions at the same site may cause atrophy and
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(c) Antiviral medications (acyclovir) are used for initial

outbreaks, recurrent infections and suppressive therapy
(d) Secondary bacterial infections are treated with systemic
antibiotics
(e) Avoid sexual intercourse while genital lesions are present.
Viral shedding may occur even if patient is symptom free.
Discuss condom usage with all genital herpes patients
(f) Refer the patient to a MD/PA for treatment
Herpes zoster
(Shingles) An infection with varicella-zoster virus primarily involving the dorsal
root ganglia and characterized by vesicular eruption and neuralgic pain in the
dermatome of the affected root ganglia

(1) Signs and symptoms

(a) Pain along the site of the future eruption usually precedes
the rash by 2 to 3 days
(b) Characteristic crops of vesicles on an erythematous base
then appear, following the cutaneous distribution of one
dermatome
(c) The involved zone is usually hyperesthetic, and pain may
be severe
(d) Eruptions occur most often in the thoracic or lumbar region
and are unilateral
(e) Lesions usually continue to form for about 3 to 5 days
(f) Crusting occurs by 7-10 days and resolves by 14-21 days
(2) Treatment
(a) Locally applied wet compresses are soothing, but systemic
analgesics are often necessary
(b) Oral antiviral medications are used for treatment of herpes
zoster
(c) Refer the patient to a MD/PA for treatment

Identify and Manage Bacterial Disorders

Cellulitis-
An acute infection of the skin and subcutaneous tissues. It may arise from an
entry of bacteria through the skin (i.e. laceration, puncture wound) or extension
from an abscess. Cellulitis is a serious disease because of the possibility of
the infection spreading to the lymphatic and blood systems resulting in
bacteremia and sepsis.

(1) Signs and Symptoms

(a) Infection is most common in the lower extremities
(b) The major findings are local erythema and tenderness,
frequently with lymphangitis and regional
lymphadenopathy
(c) The skin is hot, red, and edematous

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(d) Vesicles and bullae may develop and rupture, occasionally

with necrosis of the involved skin
(e) Systemic manifestations (fever, chills, tachycardia) may
precede the cutaneous findings by several hours, but
many patients do not appear ill
(f) Local abscesses form occasionally, requiring incision and
drainage
(2) Treatment
(a) Oral antibiotic therapy to cover streptococci and
staphylococci is required as first line outpatient therapy.
Keflex 500 mg four times a day or Dynapen 500 mg four
times a day. For penicillin allergic patients; Erythromycin
500mg four times a day is generally used. Duration of
therapy is 10-14 days.
(b) For severe infections, which require hospitalization, Ancef
2 grams intravenously four times a day is used. For
penicillin allergic patients, clindamycin 150-300 mg
intravenously is given
(c) Immobilization and elevation of the affected area help
reduce edema, and cool, wet dressings relieve local
discomfort
(d) Refer patient to MD/PA for treatment

Impetigo: Impetigo is a superficial skin infection

(1) Signs and Symptoms: Impetigo may occur on normal skin, especially
on the legs in children. Impetigo usually occurs near the lips or
nasolabial folds
(a) Lesions initially are pea-sized papules, becoming vesicular
and rupturing, leaving the classic „honey-colored crusts“
(b) Regional lymphadenopathy is seen in the majority of cases
(c) Constitutional symptoms are absent
(2) Treatment
(a) Application of mupirocin ointment 3 times daily has been
effective in treating impetigo
(b) Patients showing no response to mupirocin in 3 to 5 days
should be treated systemically. Because most cases are
caused by either streptococci or staph- erythromycin is the
drug of choice. Adults are given 250 mg four times a day
(c) Impetigo is extremely contagious. Avoidance of patients’
towels or linens is crucial to avoid the spread of infection
(d) Refer patient to MD/PA for treatment

Cutaneous Abscesses:
(1) Signs and symptoms include localized collections of pus causing
fluctuant soft tissue swelling surrounded by erythema.
(2) Treatment

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(a) Incision of the fluctuant area, thorough draining of pus with

meticulous probing
(b) Pack the cavity loosely with a gauze wick that is removed
24 to 48 h later
(c) Local heat and elevation may resolve tissue inflammation
(d) Refer patient to MD/PA for incision and drainage
Folliculitis:
Superficial or deep bacterial infection and inflammation of the hair follicles
(1) Signs and symptoms
(a) A superficial pustule or inflammatory nodule surrounding a
hair follicle
(b) The condition may follow or accompany other skin
infections
(c) Chronic low-grade irritation or inflammation without
significant infection may occur when stiff hairs in the
bearded area emerge from the follicle, curve, and reenter
the skin (pseudofolliculitis barbae)
(2) Treatment
(a) Topical antibiotics and antiseptics (e.g., chlorhexidine)
may be useful adjuncts to systemic therapy but should not
be used without concomitant systemic treatment
(b) Treatment with systemic antibiotics may be indicated
(c) Refer patient to MD/PA for treatment

Furuncle (Boil)
Acute, tender, perifollicular inflammatory nodules resulting from infection by
staphylococci. The condition often occurs in healthy young persons.
(1) Signs and symptoms
(a) Furuncles occur most frequently on the neck, breasts,
face, and buttocks but are most painful when on skin
closely attached to underlying structures (e.g., on the
nose, ear, or fingers)
(b) The initial nodule becomes a .5-2 cm pustule that
discharges a core of necrotic tissue and pus
(2) Treatment
(a) Incision and drainage or application of liquid soap
containing either chlorhexidine gluconate with isopropyl
alcohol or 2 to 3% chloroxylenol, which may be
prophylactic but is not therapeutic
(b) A single furuncle is treated with intermittent hot
compresses to allow the lesion to point and either drain
spontaneously or incised and drained
(c) Facial furuncles should be managed closely, due to the
possibility of retrograde spread of infection through cranial
channels
(d) Patients with furuncles are usually treated with systemic
antibiotics. Usually a penicillinase-resistant penicillin is

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required, such as cloxacillin 250 to 500 mg P.O. qid, or a

cephalosporin, such as cephalexin in the same dosage
(e) Refer patient to MD/PA for treatment

Carbuncle
A cluster of furuncles with subcutaneous spread of staphylococcal infection,
resulting in deep suppuration, often extensive local sloughing, slow healing,
and a large scar
(1) Signs and symptoms
(a) Carbuncles occur most frequently in males and most
commonly on the nape of the neck
(b) Carbuncles develop more slowly than single furuncles and
may be accompanied by fever and prostration
(2) Treatment is the same as for clusters of furuncles (see above)
(3) Refer patient to MD/PA for treatment

Bites
1-3 million animal bites to humans occur annually in the U.S. Dog bites
represent 70-90% of all bites. Cat bites represent 7-20% and have a higher
incidence of infection. Human and rodent bites make up the remainder of
bites.
(1) Signs and symptoms
(a) The extremities are involved in 75% of cases when victims
handle or attempt to avoid the animal. Head and neck
injuries are the next most common
(b) Wounds should be described as to size, location and type.
Include diagrams. If infected, describe adenopathy and
diagram extent of cellulitis
(c) These organisms are resistant to many antibiotics but are
generally sensitive to ampicillin and penicillin
(d) All bite injuries are potentially dangerous and can cause
significant infection
(2) Treatment
(a) Wash with warm soapy water
(b) Provide aggressive and meticulous wound care
(c) Provide tetanus prophylaxis, as indicated
(d) Systemic antibiotics for anaerobic and aerobic organisms
are given. The type of antibiotic given is dependent on
type of animal involved
(e) Review rabies postexposure prophylaxis guidelines.
Exposure is defined as an open bite or wound in contact
with body fluids
(f) Review for possibility of hepatitis B or C transmission in
human bites and provide immunoprophylaxis if necessary
(g) Refer all bite wounds to a MD/PA for assessment and
treatment

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Felon
Infection of the distal fat pad of a digit. The most common site is the distal
pulp, which may be involved centrally, laterally, and apically. Staph aureus is
the usual bacteria involved

(1) Signs and symptoms

(a) The area between pulp spaces ordinarily limit the spread
of infection, resulting in an abscess, which creates
pressure of adjacent tissues
(b) The underlying bone, joint, or flexor tendons may become
infected, and intense throbbing pain and a swollen pulp
are present
(2) Treatment
(a) Treatment involves prompt incision and drainage
(b) Systemic antibiotics are generally given
(c) Wound should be checked in 1-3 days
(d) Refer patient to MD/PA for treatment

Identify and Manage Inflammatory Disorders

Contact Dermatitis
Contact dermatitis can be subdivided into allergic contact dermatitis and irritant
contact dermatitis
(1) Primary irritants may damage normal skin or irritate existing
dermatitis
(2) Allergic contact dermatitis patients may become allergic to
substances that they have sometimes used for years or to drugs
used to treat skin diseases
(3) Examples of agents that may cause contact dermatitis
(a) Medications- topical
(b) Plants-poison oak, poison ivy
(c) Chemicals used in the manufacture of shoes and clothing,
metal compounds, dyes, and cosmetics
(d) Industrial agents
(e) Sensitivity to rubber and latex in gloves is a particular
problem for many health professionals
(f) Sensitivity to latex condoms may preclude their use in
some men
(g) Photodermatitis occurs after sunlight exposure of a patient
wearing photosensitizers that exaggerates the suns effect.
Aftershave lotions, sunscreens, and topical sulfonamides
are commonly responsible for photoallergic contact
dermatitis
(h) Perfumes
(4) Signs and Symptoms
(a) Transient redness to severe swelling with bullae
(b) Pruritus and vesiculation are common

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(c) Any skin surface exposed to an irritant or sensitizing

substance
(d) Typically, the dermatitis is limited to the site of contact but
may later spread
(e) Vesicles and bullae may rupture, ooze, and crust
(f) As inflammation subsides, scaling and some temporary
thickening of the skin occur
(g) Continued exposure to the causative agent (e.g., irritation
from or allergy to a topical drug, excoriation, and infection)
may perpetuate the dermatitis
(5) Diagnosis
(a) Typical skin changes and a history of exposure facilitate
diagnosis
(b) The patient's occupation, hobbies, household duties,
vacations, clothing, topical drug use, cosmetics, and
spouse's activities must be considered
(c) Knowing the characteristics of irritants or topical allergens
and the typical distribution of lesions is helpful
(d) The site of the initial lesion is often an important clue
(6) Treatment: Unless the causative agent is identified and removed,
treatment will be ineffective. Patients with photodermatitis should
also avoid the photosensitizing chemical or exposure to light
(a) In acute dermatitis, gauze or thin cloths dipped in water
and applied to the lesions (30 min 4 to 6 times/day) are
soothing and cooling
(b) An oral corticosteroid (e.g., predispose 60 mg/day) may be
given (if not contraindicated) for 7 to 14 days in extensive
cases, or even in limited cases when facial inflammation is
present. The prednisone dose can be decreased by 10 to
20 mg q 3 to 4 days
(c) Topical corticosteroids are not helpful in the blistering
phase, but once the dermatitis is less acute, a topical
corticosteroid cream or ointment can be rubbed in gently
three times daily
(d) Antihistamines are ineffective in suppressing allergic
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Pruritus (Itching)
A sensation that the patient instinctively attempts to relieve by scratching or
rubbing

(1) Etiology: Pruritus is a symptom and not a disease. It may accompany

a primary skin disease or a systemic disease. Skin diseases causing
severe pruritus and lesions include scabies, pediculosis, insect bites,
urticaria, atopic dermatitis, and contact dermatitis
(2) Systemic conditions that cause generalized pruritus, usually without
skin lesions, include
(a) Liver disease
(b) Kidney disease
(c) Uremia-excessive amounts of urea and other waste
products in the blood
(d) Pregnancy
(e) Medications
(3) Signs and symptoms:
(a) Persistent scratching may produce redness, linear
urticarial papules, and excoriation of preexisting papules,
fissures, and elongated crusts along scratch lines, which
may obscure the underlying disease
(b) Lichenification and pigmentation may also result from
prolonged scratching and rubbing. Occasionally, patients
who complain of severe generalized pruritus have few
signs of scratching or rubbing the skin
(4) Treatment: The cause of generalized pruritus should be sought and
corrected. If no skin disease is apparent, a systemic disorder or
drug-related cause should be sought
(a) If feasible, all drugs should be stopped
(b) Clothing that is irritating (e.g., woolens) or tight should be
avoided
(c) Bathing should be brief, as it may aggravate generalized
pruritus, especially if the patient has dry skin; lukewarm
(not hot) water should be used
(d) Emollients (e.g., white petrolatum or other oil-based
products) are good moisturizers to apply after bathing
while the skin is still wet (excess water should be blotted)
(e) Topical corticosteroids seldom alleviate generalized
pruritus (without dermatitis) but may be useful if used with
lubricants in elderly patients with dry skin
(f) If a drug has been ruled out as the cause of pruritus,
hydroxyzine (10 to 50 mg P.O. q 4 h prn) may be
prescribed. If antihistamines are helpful, their sedative
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Bulla (blister)
(1) Definition - a large blister or skin vesicle filled with fluid below the
epidermis
(2) Causes
(a) Thermal or chemical burns (2nd degree)
(b) Friction or pressure (e.g., poorly fitted shoes, rug burn)
(c) Ruptured blood vessels due to trauma
(d) Herpes simplex (fever blister)
(3) Signs and symptoms
(a) Large elevated fluid filled lesion greater than 1 cm in
diameter
(b) Discoloration at borders of blister, may be red or pale pink
(c) Pain and tenderness with palpation or pressure. Mostly
occurs on feet
(4) Treatment
(a) Avoid aggravating area by removing cause as soon as
possible (e.g., tight shoes/boots, wet socks)
(b) "DO NOT" lance blister unless unable to remove cause
(e.g., blister located on foot during a road march)
(c) If cause can not be removed, lance bottom of blister with a
sterile needle or scalpel, and allow to drain
(d) Keep area covered and clean. Build up dressing around
blister to prevent friction

Identify and Manage Fungal Infections of the Skin

Fungal infections are common on the feet and the body
(1) Fungal infections may be pruritic or asymptomatic. Occasionally
there is tenderness and inflammation
(2) Symptoms- depend on the location
(a) Scalp (tinea capitus)- alopecia, scaling, swelling and
occasional purulent discharge
(b) Feet (tinea pedis)- scaling, thickened soles, occasional
blisters
(c) Skin (tinea corporis)- inflammation and scaling
(3) Skin (Tinea Corporis)
(a) Erythematous plaque with central clearing and sharp
margins
(b) The organism may persist indefinitely, causing intermittent
remissions and exacerbations of a gradually extending
lesion with a scaling, slightly raised border
(c) Intense inflammation with or without pustules may be
present
(d) Treatment- Most skin infections respond very well to
topical antifungal preparations, such micatin, tinactin or
lamisil. Resistant cases or those with widespread
involvement require systemic antifungal therapy.
(4) Tinea pedis (Athlete's Foot)

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(a) Infections typically begin in the 3rd and 4th interdigital

spaces and later involve the plantar surface of the arch
(b) Toe web lesions often are macerated and have scaling
borders; they may be vesicular
(c) Acute flare-ups, with many vesicles and bullae, are
common during warm weather
(d) Tinea pedis may be complicated by secondary bacterial
infection, cellulitis, or lymphangitis, which may recur
(e) Treatment- Interdigital infections can be successfully
treated with topical agents. Good foot hygiene is
essential. Interdigital spaces must be dried after bathing,
macerated skin gently debrided, and a bland, drying
antifungal powder (eg, miconazole) applied
(f) Cure with topical treatment is difficult, but control may be
obtained with long-term therapy. Recurrence is common
after therapy is discontinued
(5) Tinea capitis (Scalp): Tinea capitis mainly affects children. It is
contagious and may become epidemic
(a) Inflammation that is low-grade and persistent. Alopecia
may occur with characteristic black dots on the scalp result
from broken hairs
(b) Treatment- topical treatment is not advised. Oral
antifungal therapy is indicated
(6) Tinea cruris (Jock Itch)
(a) Typically, a ringed lesion extends from the crural fold over
the adjacent upper inner thigh. Both sides may be affected
(b) Scratch dermatitis and lichenification often occur. Lesions
may be complicated by maceration, miliaria, secondary
bacterial or candidal infection, and reactions to treatment
(c) Recurrence is common because fungi may repeatedly
infect susceptible persons. Flare-ups occur more often
during summer, due to heat and humidity of the skin area
(d) Tight clothing or obesity tends to favor growth of the
organisms
(e) Treatment- Topical therapy with a cream or lotion, as in
tinea corporis, is often effective. Instruct the patient to
keep the area as clean and dry as possible,

Identify and Manage Other Skin Disorders

Scabies
The arthropod itch mite causes the dermatitis scabies in humans.
Transmission occurs between people via skin-to-skin contact or through bed
linens and clothing
(1) Signs and Symptoms
(a) Intense itching, especially at night, with vesicles, papules
and linear burrows which contain the mites and eggs
(b) Lesions prominent around finger webs, elbows, buttocks
and genital area

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(c) Complications are generally due to infection of lesions that

are broken from scratching
(2) Treatment
(a) Treatment should include the patient, sexual partners,
household members and caregivers
(b) Overnight applications of topical medications have proven
to be the most effective
(c) Bag patient’s linen separately. Instruct the patient to wash
bedding in HOT water
Lice
(1) Three types:
(a) Pediculosis Pubis
(i) Infestation in the pubic region
(ii) Spread by intimate contact, often sexual
(iii) The lice survive for about one day off the host.
(b) Pediculosis capitis
(i) Infestation on the scalp
(ii) Spread by casual contact and by fomites such
as shared combs or hats
(iii) Survive only a few days off the host.
(c) Pediculosis corporis
(i) Usually found on clothing, particularly in the
seams around warm areas
(ii) Come onto the skin only to feed
(2) Signs and Symptoms
(a) Pediculosis Pubis
(i) Complains of perineal pruritus
(ii) Examination shows adult lice attached to the
skin and nits attached to hair shafts
(iii) Blue macules around the thighs and pubic area
may occur at sites where the organism is
feeding
(b) Pediculosis capitis
(i) Complains of itching of the scalp or eyelashes
(ii) Examination shows adult lice in hair
(iii) Nits at the base of the hair shaft, macules,
wheals, and excoriations are present
(c) Pediculosis corporis
(i) Complains of diffuse pruritus (especially if there
is evidence of generally poor hygiene)
(ii) Examination reveals erythematous macules,
wheals, and excoriations, often with
superinfection
(iii) Lice are found in clothing rather than on body
(3) Treatment of Pediculosis pubis, capitis, corporis
(a) Overnight applications of topical medications have proven
to be the most effective
(b) Bag patient’s linen separately. Instruct the patient to wash
bedding in HOT water

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(c) Hats, combs, and brushes should be thoroughly cleaned

before being reused
(d) Sexual contacts of patients should be also be treated and
close contact of patient with pediculosis capitis and
corporis should be examined for lice.
(e) Since both scabies and pediculosis may be sexually
transmitted, examination for other sexually transmitted
diseases should be performed and a serologic test for
syphilis (VDRL or other ) obtain

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TERMINAL LEARNING OBJECTIVE

Given a standard fully stocked M5 Bag or Combat Medic Vest System, oxygen, suction
and ventilation equipment (if available), selected medications, and documentation forms.
You encounter a casualty complaining of infectious disease and/or immunological
symptoms. No other injury(ies) are present.

Review Concepts Associated with Infectious Diseases

Public health principles relative to infectious diseases
(1) All humans are susceptible to infectious disease
(2) Individuals display varying susceptibilities to infection
(3) When dealing with infectious diseases, the soldier medic must
consider the needs of the casualty, potential consequence on public
health and his own health protection
(4) The soldier medic should think of the consequences of the patients’
contact with family members, roommates and friends
Infectious agents
(1) Bacteria- unicellular microorganisms
(2) Viruses- submicroscopic organism. Able to replicate only in a living
cell
(3) Fungi- spore bearing plants
(4) Rickettsia- microorganisms, which combine qualities of bacteria and
viruses
(5) Helminths (worms)- various invertebrates, having round or flattened
bodies
Terminology of the immune system
(1) Antibodies- a protein produced by lymphocytes in response to
infectious agents
(2) Antigen- A substance which causes the formation of an antibody
(3) Epitope- a specific site where an antibody binds. May be numerous
epitopes on one antigen
(4) Leukocytes- White blood cells
(a) Five types:
(i) Lymphocytes
* T cells - Divide rapidly when exposed
to antigen. May assist in destroying
foreign protein
* B cells - circulate in immature form,
activated when exposed to antigen
(ii) Monocytes
* Ingest dead or damaged cells via
phagocytosis (absorption of foreign
bodies in the bloodstream)
* Provide immunological defenses
against infectious organisms
(iii) Neutrophils

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* Essential for phagocytosis

(iv) Basophils
* Increased number during healing
phase and inflammation
* Immediate immune response to
external antigens
(v) Eosinophils
* Increase numbers in certain diseases,
especially infections by helminths and
allergies
Host defense mechanisms
(1) Nonspecific immune system defenses
(a) Skin
(i) Effectively bars invading microorganisms
(ii) Some exceptions occur, as with human
papillomavirus (causative agent of warts) which
can invade normal skin
(iii) Normal dermal flora - alteration of this
flora can lead to overgrowth of inherently
pathogenic microorganisms
(b) Respiratory system
(i) Inhaled microorganisms must penetrate the filter
system of the upper airways and tracheobroncial
tree
(ii) Coughing also helps remove organisms
(iii) Smoking greatly impairs effectiveness
(iv) These defense mechanisms can be overcome
by large numbers of organisms or by
compromised effectiveness resulting from air
pollutants
(c) Inflammatory response
(i) Directs immune system components to injury or
infection sites and is manifested by increased
blood supply and vascular permeability
(ii) Microorganisms are engulfed by phagocytic cells
in an attempt to contain the infection
(2) Specific immune system defenses
(a) Humoral immunity
(i) Component of the immune system involving
antibodies
(ii) Recognizes antigens associated with
microorganisms or foreign substances
(iii) Recognition is coupled with ability to initiate
appropriate actions against these
microorganisms or foreign substances
(b) Cell-mediated immunity
(i) Phagocytic and/or cytotoxic cells play major role
(ii) Antibody plays minor role

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(iii) Macrophages and neutrophils important in

combating bacteria
(iv) T cells essential to elimination of virus-infected
cells
General Assessment of Suspected Infectious or Communicable Disease
Primary assessment
(1) Ensure open airway
(2) Assess breathing
(3) Assess circulation
Secondary assessment (specific to infectious disease)
(1) History of present illness
(2) Past medical history
(a) Chronic infections, inflammation
(b) Medications
(c) Medical and surgical history
(3) Detailed history and physical
(a) Vital signs
(b) Assess skin
(i) Temperature
(ii) Turgor (hydration)
(iii) Color (jaundice)
(iv) Abnormal lesions
(c) Assess Head, Ears, Eyes, Neck, and Throat (HEENT)
(d) Assess neck
(i) Lymphadenopathy - localized or generalized
enlargement of lymph nodes or lymph vessels
(ii) Rigidity
(e) Assess for abnormal breath sounds
(f) Assess abdomen
(i) Tenderness
(ii) Rebound
(iii) Guarding or organomegaly
(g) Assess extremities for edema, pain and joint range of
motion (ROM)

Assess and Treat Eye, Ear, Nose, Throat, and Respiratory Complaints
Conjunctivitis (pink eye)
(1) Infection of the membrane lining the eyelids (conjunctiva)
(2) Signs and Symptoms- may be unilateral or bilateral
(a) Pruritus
(b) Burning
(c) Itching
(d) Swelling
(e) Excessive purulent discharge or tearing
(f) Redness

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(3) Provide medical care

(a) Perform visual acuity before any treatment is initiated
(b) Ensure eye is not injured and no foreign body is present
(c) Administer ophthalmic ointments or solutions for
conjunctivitis as ordered by MD/PA
(d) Use universal precautions gloves), conjunctivitis is very
contagious
Pharyngitis (sore throat)
(1) The majority of sore throat complaints are viral in origin, not bacterial
(2) Most common bacteria causing pharyngitis is group A Beta hemolytic
streptococcus
(3) Signs and symptoms
(a) Often difficult to clinically differentiate between viral and
bacterial infections
(b) Patients with a bacterial (strep) infection may present with:
(i) Sudden on set of sore throat
(ii) Painful swallowing
(iii) Chills and fever
(iv) Headache, nausea, vomiting and abdominal
pain are common associated symptoms
(c) Physical examination of patients with strep throat reveals
(i) Foul smelling breath
(ii) Beefy red throat
(iii) Tonsillar exudate
(iv) Enlarged, tender anterior cervical lymph nodes.
There is no posterior cervical adenopathy.
(v) Patient may have petechiae on the palate and
strawberry tongue
(d) Patient with a viral pharyngitis usually present with a more
vesicular and petechial pattern on the soft palate and
tonsils and no exudate
(e) Throat culture remains the most effective method for
diagnosis
(4) Provide medical care
(a) Symptomatic treatment
(i) Gargling with warm salt water
(ii) Drinking warm liquids
(iii) Rest
(iv) Consider IV hydration in patients who are unable
to tolerate oral fluids or who become dehydrated
(b) Antibiotics
(i) Drug of choice for strep throat is penicillin.
Ampicillin or amoxicillin may also be used.
(ii) May also consider cephalosporin
(iii) Erythromycin is drug of choice for patients
allergic to penicillin
(iv) Oral medications usually administered for 10
days even though pain from sore throat may
resolve in 24-48 hours

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(v) Refer to MD/PA for appropriate therapy

(c) Untreated strep throat (group A B – hemolytic
streptococcus) is associated with significant sequela in the
form of acute rheumatic fever or acute glomerulonephritis.
Because of this, early diagnosis and treatment of strep
throat is essential.
(d) Prevent spread
(i) Handwash
(ii) Avoid using same utensils or drinking from same
container
(iii) Avoid close contact
(e) Infectious mononucleosis
(i) Acute viral infection is primarily caused by an
Epstein-Barr virus (EBV). Infrequent causes are
Cytomegalovirus (CMV) and Human
Immunodeficiency Virus (HIV)
(ii) Humans are the sole source, with transmission
by close contact. Incubation period is 3-7
weeks.
(iii) Assessment findings
* High fever
* Swollen lymph glands
* Sore throat
* Fatigue
* Persistent headache
* Acute phase lasts 1-3 weeks, with
complete recovery expected in 6-8
weeks
* Most serious complication is splenic
rupture due to an enlarged spleen,
combined with physical activity.
Limited activity during the acute phase
is required. All soldiers must be
assessed by an MD/PA for suspected
mono cases.
(iv) Provide care
* Uncomplicated acute infectious
mononucleosis usually only requires
supportive therapy
* Consider Tylenol for fever and pain
* Warm salt water gargles for sore
throat
* Patient should get ample bed rest.
Isolation is unnecessary because EBV
shedding continues after the acute
illness
* Recovery occurs in a few weeks;
however, some people take months to
regain former level of energy

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Influenza
(1) Viral infection of the respiratory tract
(2) Flu vaccine is available annually. Influenza is self-limited in healthy
individuals, but its potentially severe consequences must be stressed
to elderly or chronically ill patients to ensure their annual vaccination.
(3) Assessment findings
(a) Fever- may be high (up to 103 degrees)- rapid onset and
may last 3-5 days
(b) Cough- usually nonproductive. If a secondary bacterial
infection occurs, cough turns productive with purulent
sputum
(c) Headache
(d) Muscle aches- may to tender to palpation
(e) Shortness of breath
(f) Chills
(g) Sweating
(h) Fatigue
(i) Nausea and vomiting
(j) Joint stiffness and aches
(k) Nausea, vomiting
(4) Provide medical care
(a) Because influenza is a viral infection, antibiotics are not
helpful
(b) Bed rest
(c) Provide analgesics for muscles aches
(d) Provide oral or intravenous fluids
(e) Symptoms may last 7 - 10 days
(f) Notify MD/PA if:
(i) Symptoms increase
(ii) Fever is present
(iii) Unable to keep food or fluids down
Cough
(1) Sudden, forceful release of air from the lungs
(a) Helps clear material
(b) May produce and expel mucus and/or pus - productive
cough
(c) Minor irritations in throat can start cough reflex though
normal mucus is only material expelled - dry cough
(2) Common causes include:
(a) Smoking
(b) Common cold or flu
(c) Allergies
(d) Bacterial infection
(e) Viral infection
(f) Asthma
(g) Emphysema
(3) Assessment Findings
(a) Shortness of breath requires immediate evaluation.

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(b) Productive or nonproductive cough - Productive may be

rusty/blood-streaked, yellow-green or yellow sputum
(c) Elevated temperature
(d) Chest may be clear to auscultation or have abnormal
breath sounds (wheezing, rhonchi or crackles)
(4) Provide medical care
(a) Increase air humidity, if available
(b) Inform patient to drink extra fluids
(c) Consider an expectorant to help liquefy secretions
(d) Consider a decongestant if cough is accompanied by
runny nose
(e) Consider antihistamines if caused by allergy or sinus
infection
(f) Dry tickling coughs can be relieved by lozenges
(5) Notify MD/PA if:
(a) Violent cough begins suddenly or high-pitched sound
(stridor)
(b) Produce blood
(c) Shortness of breath and/or difficulty breathing
(d) Abnormal breath sounds are heard on auscultation
(e) Fever or abdominal swelling
(f) Unintentional weight loss
(g) Thick, foul-smelling, rusty, or greenish mucous
(h) Lasts more than 10 days
Pneumonia
(1) Inflammation of lungs caused by an infection
(2) Prevention
(a) Vaccination (flu, pneumovax) may be helpful in preventing
some types of pneumonia
(b) Coughing and deep breathing
Bronchitis
(1) Inflammation of the bronchi
(2) Prevention
(a) Early recognition
(b) Treat small airway disease
(c) Smoking cessation
Viral Upper Respiratory Infection (Common Cold)
(1) Contagious viral infection of the upper respiratory tract.
Transmission may occur through air droplets (sneezing) or lack of
handwashing
(2) Assessment Findings (usually minimal)
(a) Runny nose
(b) Nasal congestion
(c) Sneezing
(d) Sore throat
(e) Cough
(f) Muscle aches
(g) Headache

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(h) Low grade fever (100 F or lower)

(3) Provide medical care
(a) Consider antihistamine and/or decongestant for nasal
congestion
(b) Consider Tylenol for minor aches and pains
(c) Patient should get able bed rest
(d) Instruct patient to drink plenty of fluids
(e) Patient should return to MTF if:
(i) Develop temperature greater than 101F
(ii) Develop a productive cough
(iii) Symptoms do not begin to improve within the
next 2-3 days
Assess and Treat Gastrointestinal (GI) Complaints
Nausea/Vomiting
(1) Nausea is the sensation leading to the urge to vomit
(2) Vomit is to force the contents of the stomach up through the
esophagus and out of the mouth
(3) A common cause is a viral infection. Assessment findings include:
(a) Presence of absence of abdominal pain
(b) Description of emesis
(c) Fever
(4) Provide care
(a) Instruct patient to drink clear fluids for 24 hours. Solids
should be increased as tolerated.
(b) Patient should get bed rest
(c) Instruct patient to return to MTF if:
(i) Blood is in vomitus
(ii) Increasing abdominal pain
(iii) Nausea/vomiting persists for greater than 24
hours
Diarrhea
(1) Frequent passage of unformed, watery stool
(2) Infectious diarrheal disease can be grouped:
(a) Viruses
(b) Bacteria
(c) Parasites
(d) Funguses
(3) Assessment findings include:
(a) Abdominal cramps
(b) Fever
(4) Provide care
(a) Observe good hygiene. Wash hands frequently.
(b) Consider Imodium (only if non bloody) or Pepto-Bismol
(i) May be given to the patient for the symptomatic
control of diarrhea
(ii) Best treatment is NOT to interfere with the
mechanical cleansing of the GI tract

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(c) If diarrhea is not controlled in 24-48 hours with normal

medications, refer patient to MD/PA for assessment
Gastroenteritis
(1) Inflammation of stomach and intestines due to bacterial or viral
infection
(2) Modes of transmission
(a) Fecal-oral
(b) Ingestion of infected food or non-potable water
(3) Susceptibility and resistance
(a) Travelers into endemic areas are more susceptible
(b) Populations in disaster areas, where water supplies are
contaminated, are susceptible
(c) Native populations in endemic areas are generally
resistant
(4) Assessment findings include:
(a) Nausea/Vomiting
(b) Diarrhea
(c) Fever
(d) Abdominal pain and cramping
(e) Diarrhea
(f) Heartburn
(5) Provide care
(a) Antibiotic therapy is usually not indicated
(b) Consider antidiarrheal medications, though not generally
given because they may prolong infectious process
(c) Clear liquid diet
Assess and Treat a Fever, Headache, and Sinus Symptoms
Fever-
Fever is a common presenting symptom, accounting from 2-6 percent of adults
presenting to hospital emergency rooms and clinics.
(1) Fever can be due to:
(a) Infection: all causes, whether bacterial, viral or parasitic
(b) Trauma
(c) Immunologic: serum sickness or acute inflammatory
arthritis
(d) Drug induced
(e) Vascular disorders: acute myocardial infarction, pulmonary
emboli
(2) Acute bacterial infection requires a timely diagnosis and treatment.
The initial approach to evaluating a patient with an acute fever is
detecting a treatable infection or excluding a bacterial infection with
reasonable certainty.
(3) Fever above 100 F must be evaluated by an MD/PA
(4) Provide care
(a) Administer Tylenol or Motrin. The use of aspirin should
not be used due to bleeding problems

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(b) If fever is uncontrolled, seek methods of cooling patient.

Such as cooling mats, tepid baths or showers.
Headache
(1) Meningitis- an infection of the meninges (the membranes
surrounding the brain)
(a) Causes:
(i) Bacterial
(ii) Viral
(iii) Fungal
(c) Signs and Symptoms
(i) Headache, sudden onset, severe, usually
occipital
(ii) Fever
(iii) Chills
(iv) Photophobia
(v) Neck stiffness or nuchal rigidity (more
pronounced on flexion)
(vi) Petechial rash - Bacterial
(vii) Altered mental status
(viii) Nausea and vomiting
(d) Provide medical care
(i) Protective measures should include BSI with
surgical masks applied to casualties displaying
suggestive signs/ symptoms
(ii) Meningitis is a medical emergency. Delay in
treatment will result in death. Notify MD/PA
immediately and evacuate
(iii) Initiate IV
(iv) Perform serial neurological examinations
Sinusitis
(1) Disorder involving infection and/or inflammation of one or more of the
paranasal sinuses. The maxillary sinuses are the most frequently
affected. Factors predisposing to sinusitis are upper respiratory
infection, smoking, allergies and nasal polyps.
(2) Assessment findings include:
(a) Headache
(b) Purulent nasal discharge
(c) Cough
(d) Pain in the sinus area with palpation or percussion
(e) Facial pain
(f) Pain may also be referred to the teeth. Patients may
complain of a "toothache“.
(3) Provide medical care
(a) Administer analgesics to relieve pain
(b) Administer saline or decongestant nasal sprays to
increase drainage
(c) Consider an expectorant/mucolytic to thin secretions and
promote drainage

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(d) Antibiotic therapy is indicated for 10-21 days. Antibiotic

choice is based on duration of symptoms and the
individual patient
(e) Refer patient to MD/PA for suspected sinus infections

Assess and Treat Hepatitis

Viral Hepatitis-
Management of viral hepatitis has been through major changes, therefore
knowledge of the various types is important. At least 7 major viruses have
been identified and cause the majority of disease
(1) Hepatitis A- inflammation of liver caused by hepatitis A virus
(a) Seen worldwide and is a food and water-borne disease
(b) Spread by fecal-oral contact
(2) Signs and symptoms
(a) Symptoms are similar to flu
(i) Fever
(ii) Weakness
(b) Jaundice of skin and eyes - liver is not able to filter bilirubin
from blood
(c) Darkening of urine
(d) Clay colored stools
(e) Nausea and vomiting
(3) Provide care
(a) Treatment is primarily supportive
(b) Rest should be recommended during acute phases
(c) Patient should avoid alcohol and substances toxic to liver
(d) Full recovery usually within 1 month
(e) Patient education should be given advising avoidance of
unbottled drinking water, ice, shellfish or unpeeled fruits
and vegetables in endemic areas
(f) Hepatitis A vaccine is available prior to deployment to
endemic areas
(4) Hepatitis B and Hepatitis C- inflammation of the liver caused by a
Hepatitis B virus or Hepatitis C virus
(a) Transmission is parenteral, with the virus found in body
fluids such as blood, semen and saliva
(b) Sexual transmission is common
(c) IV drug usage is also and important mode for transmission
(5) Assessment findings
(a) Jaundice
(b) Fatigue
(c) Nausea and vomiting
(d) Low grade fever
(e) Pale or clay color
(f) Abnormal urine color/dark urine
(g) Abdominal pain and enlarged liver
(h) In Hepatitis C, many patients are asymptomatic
(6) Provide care

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(a) Treatment is primarily supportive. Interferon is used with

some success in Hepatitis B and C patients.
(b) Bedrest and occasionally hospitalization during the acute
phase is necessary
(c) Patient should avoid alcohol and substances toxic to liver
(d) Patient should be informed of preventative measures
(i) Hepatitis B vaccination series
(ii) Condoms if sexually active
(iii) Test for HIV
(7) Hepatitis D
(a) Hepatitis D occurs only in association with Hepatitis B
infection. Mode of transmission is similar to Hepatitis B
(b) May increase severity of disease associated with Hepatitis
B
(c) Treatment is same as for hepatitis B
(8) Hepatitis E
(a) Hepatitis E is a food and water-borne disease
(b) Associated with epidemics where there is fecally
contaminated water
(c) Treatment and travel precautions are identical to Hepatitis
A
(9) Hepatitis G- has recently been identified is patients with Hepatitis
that was not Hepatitis C
(a) Liver disease has not been proven
(b) Signs and symptoms have not yet been characterized

Assess for Human Immunodeficiency Virus (HIV)

A viral infection-
Caused by the human immunodeficiency virus (HIV) that gradually destroys the
immune system. Although the virus has been found in all body fluids, only
blood, semen and vaginal secretions have been implicated in transmission.
There are three known routes of transmission:
(1) Sexual transmission (anal, oral or vaginal)
(2) Blood or blood products (transfusions, infected needles)
(3) Perinatal transmission (in utero, at delivery or through breastfeeding)
History of HIV
(1) Initial case definition was established by CDC in 1982
(2) In 1987 and 1993, case definitions were expanded to include
additional illnesses
Body systems affected and potential secondary complications - generally
related to opportunistic infections that arise as immune system compromise
develops
(1) Nervous system - toxoplasmosis of CNS
(2) Immune system - major site of compromise
(3) Respiratory system - pneumocystis carinii pneumonia
(4) Integumentary system - Kaposi's sarcoma

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Health care workers -

(1) At risk increased when:
(a) The exposure involves a large quantity of blood
(b) Needle or instrument stick needle size, type (hollow bore
versus suture), and depth of penetration
(c) The exposure to a patient with a terminal HIV related
illness, possibly reflecting a higher viral load in the late
course of AIDS
(d) Universal precautions not adhered to
(2) Risk needs to be understood in terms of how the exposure occurred,
and what factors were involved
(3) Potential may appear to be high, but the probability may actually be
quite low
Assessment findings- Asymptomatic HIV Infection
(1) Asymptomatic HIV patients must have had no previous signs or
symptoms attributable to HIV infection
(2) History may be suggestive of an acute mononucleosis or flulike
syndrome in the past
(3) Physical examination of asymptomatic HIV patient is completely
normal
(4) Diagnosis is made with laboratory evidence only
Assessment Findings-
Early Symptomatic HIV Infection
(1) With disease progression, CD4 lymphocyte counts decrease. There
is an increased risk of opportunistic infections
(2) Signs and symptoms associated with early HIV disease are
frequently nonspecific
(a) Fever (h) Chronic cough
(b) Sore throat (i) Shortness of breath
(c) Fatigue (j) Oral lesions, ulcers
(d) Myalgia (k) Chronic diarrhea
(e) Weight loss (l) Skin rashes
(f) Night sweats
(g) Lymphadenopathy
(3) Diagnosis is made with laboratory evidence and presence of one or
more opportunistic infections:
(a) Oral candidiasis
(b) Generalized wasting
(c) Generalized lymphadenopathy
(d) Hepatosplenomegaly
(e) Severe herpes zoster in a previously healthy person
(f) Pneumocystis carinii pneumonia
Assessment Findings-
Late Symptomatic HIV Infection

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(1) Progressive destruction of CD4 cells by the HIV virus places the
patient at risk for opportunistic infections, routine infections and
malignancies
(2) Symptoms depend on reactivation of previous illness or exposure to
new infections. Commonly seen are:
(a) Chronic headaches
(b) Seizures
(c) Chronic diarrhea
(d) Weight loss leading to wasting
(e) Chronic fever
(f) Visual changes leading to blindness
Provide care
(1) Treatment of HIV is complex and beyond the scope of the handout
(2) Isolation is unnecessary, ineffective and unjustified
(3) Observe BSI when treating an HIV patient
(4) Psychosocial evaluation of the patient is indicated because of the
high incidence of family dysfunction, depression and suicide
associated with HIV infection
(5) Sexual partner notification by Preventive Medicine is essential to
prevent transmission
(6) Consistent use of latex condoms, preferably with nonoxynol-9, a
spermicide is recommended to prevent sexual transmission of HIV.
Petroleum based lubricants should be avoided because they
increase the risk of condom rupture
Assess and Treat for Lyme Disease
An acute inflammatory disease-
Caused by the spirochete Borrelia burgdorferi Transmitted by the bite of a deer
tick.
Assessment findings-
(1) An early localized stage with a painless skin lesion at the site of the
bite, called erythema migrans (EM), and a flu-like syndrome with
malaise, myalgia
(2) EM starts off as a red, flat, round rash which spreads out; the outer
border remains bright red, with the center becoming clear, blue, or
even necrose and turn black
(3) Incubation period until EM - 3 to 32 days post tick exposure
(4) Fever and headache
(5) Inflammation in the knees and other large joints in systemic infection
Patient management and control measures
(1) The 91W Medic who works, or treats/ transports casualties in a
wilderness environment, should be vigilant to the presence of ticks
on themselves and their casualties
(2) There is no evidence of natural transmission from person-to-person
(3) Tetracycline is the drug of choice given 500mg four times a day for
10-30 days

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(4) Consider anti-inflammatory medications to relieve joint stiffness

Identify Viral Diseases of Childhood
Chickenpox
(1) A highly contagious, usually mild childhood disease caused by the
Herpes varicella-zoster virus.
(2) Assessment findings
(a) Begins with:
(i) Mild respiratory symptoms
(ii) Malaise
(iii) Low-grade fever
(b) Rash begins as small red spots that become raised
blisters on a red base. These fluid-filled vesicles
eventually collapse and dry into scabs
(c) Intense itching
(3) Provide care
(a) Do NOT give aspirin due to association with Varicella and
Reye's syndrome.
(b) Isolation of patient from medical offices, emergency
departments, and public places until all lesions are crusted
and dry
(c) Consider antiviral drugs exist that shortens the duration of
symptoms and pain in the older patient
(d) Soldier medics who have not had chickenpox should
inquire with their chain of command about receiving the
chickenpox vaccine
(e) VZIG (Varicella Zoster immune globulin) is recommended
for pregnant women with a substantial exposure
(household contact, close indoor contact > 1 hour, or
prolonged direct face-to-face contact with infected person)
to chickenpox with no history of previous exposure to
chickenpox
Mumps
(1) An acute, contagious viral disease that causes painful enlargement
of the salivary or parotid glands
(2) Assessment findings
(a) Fever
(b) Swelling
(c) Tenderness of salivary glands, especially parotid
(d) Sore throat
(3) Provide care
(a) There is no specific treatment for mumps. Measles,
Mumps, Rubella (MMR) immunization should be
considered.
(b) Symptoms may be relieved by:
(i) Ice or heat to affected neck area
(ii) Acetaminophen for pain relief
(iii) Warm salt water gargles

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(iv) Soft foods

(v) Extra fluids
Rubella (German Measles)
(1) A contagious viral infection with mild symptoms associated with a
rash
(2) Assessment findings
(a) A rash that spreads from forehead to face to torso to
extremities, and lasts 3 days,
(b) Serious complications, such as encephalitis, which may
occur in measles, do not occur in Rubella
(c) Younger females sometimes develop a self-limiting
arthritis
(d) Cloudy cornea
(e) Low grade fever
(f) Inflammation of the eyes
(3) Provide medical care
(a) Consider MMR immunization
(b) There is no treatment- supportive care primarily
(c) Acetaminophen can be given to reduce fever
Measles (rubeola, red measles)
(1) Highly contagious viral illness
(2) Assessment findings
(a) Conjunctivitis
(b) Swelling of the eyelids
(c) Photophobia
(d) High fevers to 105 degrees
(e) Hacking cough
(f) Malaise
(g) Rash
(3) Provide care
(a) Immunization
(i) Effective immunization should be instituted for
every person, and is available for combination
with other vaccines and/ or toxoids (MMR)
(ii) Immunization in children is believed to confer
99% immunogenicity
(b) There is no specific treatment. Symptomatic care:
(i) Bed rest
(ii) Acetaminophen
(iii) Humidified air

Pertussis (Whooping cough)

(1) A highly contagious bacterial disease that affects the respiratory
system and produces spasms of coughing that usually end in a high-
pitched crowing inspiration (whooping sound)
(2) Assessment findings

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(a) Cough
(b) Crowing or high-pitched inspiratory whoop
(c) Expulsion of clear mucous
(d) Vomiting
(3) Provide care
(a) Erythromycin is given 500mg four times a day for 10 days
(b) Consider oxygen with high humidity
(c) Intravenous fluids may be indicated if coughing is severe
enough to prevent adequate oral fluid intake
Reporting an Exposure to an Infectious/ Communicable Disease
What constitutes an exposure?
The following should be considered an exposure incident:
(1) Eye
(2) Mouth
(3) Other mucous membranes
(4) Non-intact skin
(5) Parenteral contact with blood
(6) Blood products
(7) Other potentially infectious materials
Why it is important to report?
(1) Permits immediate medical follow up, permitting identification of
infection and immediate intervention
(2) Enables the Designated Officer (DO) to evaluate the circumstances
surrounding the incident and implement engineering or procedural
changes to avoid a future exposure
(3) Facilitates follow up testing of the source individual if permission for
testing can be obtained
(a) Under provisions of the Ryan White Act, the exposed
employee has the right to request the infection status of
the source casualty from the casualty's health care
provider, but neither the agency nor the employee can
force testing of the source individual
(b) Employers must, and should as part of an effective
Exposure Control Plan, tell the employee what to do if an
exposure incident occurs
Preventing disease transmission
(1) Notify supervisor for proper disposition
(a) If you have diarrhea
(b) If you have a draining wound or any type of wet lesions;
wait until lesions are crusted and dry
(c) If you are jaundiced
(d) If you have been told you have mononucleosis/hepatitis
(e) If you have not been treated with a medication and/ or
shampoo for lice and scabies
(f) Until you have been taking antibiotics for at least 24 hours
for a step throat

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(g) Observe BSI

(i) Always wear gloves
(ii) If chance of splash, wear protective eyewear or face
shield
(iii) If large volumes of blood are possibility, wear a gown
(iv) When contacting a possible TB casualty, wear
appropriate particulate mask
(h) Patients with coughs, headaches, general weakness,
recent weight loss, stiff necks, high fevers, and taking
medications suggestive of an infectious process are tip-
offs in history taking, with experience, the list will get
longer for you
(i) If after a call with lice, scabies, ticks or other insect vectors
(i) Spray the stretcher and casualty compartment
with an insecticide, then wipe off/ mop up
insecticide residue
(ii) Bag the linen separately, and ensure that it not
be taken home; bottom line is that it needs to be
washed separately
(iii) Report any infectious exposure to the
designated officer/ manager of your agency
identified as such
(2) Effective hand washing, to include the webs of the hands
(3) The major infectious diseases that 91W Medic personnel should
have in-depth knowledge of for purposes of regulatory compliance
(a) HIV
(b) Hepatitis
(c) Tuberculosis
(d) Sexually transmitted diseases
(4) Understand the concept of occupational risk
(1) Appreciate that infectious agent mode of entry,
virulence, dose, and host resistance factors
combine to define risk, or potential for infection
(2) Just because there is risk, doesn't mean that
you will become infected
(3) Not all infectious diseases are communicable
and do not always pose risks to family members
(4) Risk and potential does not necessarily equate
to probability; HIV is a good example - risks for
infection may appear to be high, but the
probability of occupational exposure is very low
(0.2-0.44%)

Medical and legal aspects of reporting and recording an exposure

(1) Out-of-hospital personnel deal with very few infectious disease
emergencies, but must be vigilant about consequences to
themselves, as well as their casualties and coworkers, based on
daily, often unknown exposures to infectious agents

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(2) Universal/ standard precautions for soldier medics are superseded

by body substance isolation guidelines, based upon the premise that
all body fluids, in any situation, may be infectious
(3) Contact Preventive Medicine for any questions concerning infectious
diseases and reporting protocols

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 Appendix A
Insert and Remove NG Tube
Competency Skill Sheets
NG Tube Insertion

Soldiers Name: _________ SSN: _______________ CO: ______ TM: _____

Start: _____ Stop: _____Initial Evaluator: _____________________________
Start: _____ Stop: _____ Retest Evaluator: ____________________________
Start: _____ Stop: _____ Final Evaluator: _____________________________

1st 2nd 3rd

a. Checked doctors orders. P/F P/F P/F
b. Washed hands. Removed rings and watch. P/F P/F P/F
c. Gathered and assembled equipment. P/F P/F P/F
d. Identified patient and explained procedure. P/F P/F P/F
e. Prepared and positioned patient. P/F P/F P/F
(1) Removed dentures, if used.
(2) Washed hands.
(3) Hyperextended neck.
(4) Protected patient with protective pad or
towel.
(5) Donned gloves.
f. Measured the tube for insertion distance (Tip of P/F P/F P/F
nose-proximal earlobe-tip of sternum). Marked with
tape.
g. Inspected nasal. P/F P/F P/F
h. Lubricated the tip of NG tube with water soluble P/F P/F P/F
lubricant.
i. Inserted NG tube. P/F P/F P/F
(1) Inserted tube into nostril while pointing tip
backward and downward.
(2) Stopped when first mark on tube is at tip
of the nose.
(3) Used flashlight to inspect back of throat.
(4) Instructed patient to lower chin to chest
and swallow sips of water through straw.
(5) Advanced tube 3 to 5 inches each time
patient swallows.
(6) Continued advancing until reach second
tape mark.
j. Checked tube placement. P/F P/F P/F
k. Anchored tube. P/F P/F P/F
l. Clamped or connected tube to suction. P/F P/F P/F
m. Positioned patient with a minimum head elevation P/F P/F P/F
of 30 degrees, to prevent gastric reflux.
n. Removed gloves and washed hands. P/F P/F P/F
o. Recorded procedure. P/F P/F P/F

Instructor Comments:
NG Removal

Soldiers Name: _________ SSN: _______________ CO: ______ TM: _____

Start: _____ Stop: _____ Initial Evaluator: _____________________________
Start: _____ Stop: _____ Retest Evaluator: ____________________________
Start: _____ Stop: _____ Final Evaluator: _____________________________

1st 2nd 3rd

a. Identified patient and explained procedure. P/F P/F P/F
b. Washed hands and donned gloves. P/F P/F P/F
c. Untapped tube. P/F P/F P/F
d. Enclosed tube within the towel or glove. P/F P/F P/F
Discarded appropriately.
e. Removed gloves and washed hands. P/F P/F P/F
f. Instructed patient on mouth care (or provide if P/F P/F P/F
necessary).
g. Encouraged patient to clear nose of mucus P/F P/F P/F
and debris.
h. Documented. P/F P/F P/F

Instructor Comments:
 Appendix B
Insert and Remove Foley Catheter
Competency Skill Sheets
Insert Foley Catheter

Soldiers Name: ____________ SSN: _______________ CO: ______ TM: _____

Start: _____ Stop: _____ Initial Evaluator: _____________________________
Start: _____ Stop: _____ Retest Evaluator: ____________________________
Start: _____ Stop: _____ Final Evaluator: _____________________________

1st 2nd 3rd

a. Checked doctor's orders. P/F P/F P/F
b. Washed hands. P/F P/F P/F
c. Gathered and assembled equipment. P/F P/F P/F
d. Identified patient and explained procedure. P/F P/F P/F
e. Positioned and draped patient. P/F P/F P/F
f. Opened catheter tray. P/F P/F P/F
g. Donned sterile gloves. P/F P/F P/F
h. Positioned moisture-proof pad under patient P/F P/F P/F
buttocks (female)
(1) Placed moisture-proof pad across upper
thighs with fenestrate pad over genitalia
(males)
(2) Placed fenestrated pad with opening
exposing genitalia for females.
i. Set up sterile field. Prepared equipment and P/F P/F P/F
tested balloon.
j. Cleaned genitalia. P/F P/F P/F
k. Lubricated catheter. P/F P/F P/F
l. Inserted catheter until urine flow is observed. P/F P/F P/F
Inserted an additional one inch.
m. Inflated balloon and repositioned catheter. P/F P/F P/F
n. Hung drainage bag from bed frame. P/F P/F P/F
o. Removed tray and secured catheter. P/F P/F P/F
(1) Taped to thigh of female patient.
(2) Taped to abdomen of male patient.
p. Removed and disposed of gloves. Washed P/F P/F P/F
hands.
q. Recorded procedure. P/F P/F P/F

Instructor Comments:
Remove Foley Catheter

Soldiers Name: _______________________ SSN: _______________ CO: ______ TM:

_____
Start: _____ Stop: _____ Initial Evaluator: _____________________________
Start: _____ Stop: _____ Retest Evaluator: ____________________________
Start: _____ Stop: _____ Final Evaluator: _____________________________

1st 2nd 3rd

a. Checked doctor's orders. P/F P/F P/F
b. Washed hands. P/F P/F P/F
c. Identified patient and explained procedure. P/F P/F P/F
d. Positioned and draped patient. P/F P/F P/F
e. Untaped catheter. P/F P/F P/F
f. Deflated balloon. P/F P/F P/F
h. Removed catheter. P/F P/F P/F
i. Removed equipment and drainage system. P/F P/F P/F
j. Recorded procedure. P/F P/F P/F

Instructor Comments: