Q. Sinikar. Berea College.

Primitive treatment: Doxycycline or ciprofloxacin Simple barrier precautions should be sufficient as Tularaemia is usually not contagious imitrex 25 mg lowest price muscle spasms youtube. Pneumonic Plague (Yersinia pestis) Symptoms: Fatigue buy imitrex 25 mg with mastercard muscle relaxant 24, fever buy imitrex 25mg without a prescription spasms icd 9 code, cough, shortness of breath, and malaise. Fleas on rodents also transmit plague zoonotically – keep the rat population under control and there will be fewer rats to spread the fleas. Botulism Symptoms: Blurry vision, difficulty speaking and swallowing, sore/dry throat, dizziness, and paralysis. Smallpox Symptoms: Fever, rigors (uncontrolled shaking), malaise, headache, and vomiting. As a rule in primitive conditions assume all suspected cases are highly contagious. Brucellosis (Brucella melitensis) Symptoms: Fever, headache, sweating, chills, back pain Primitive treatment: Doxycycline + rifampicin Usually nonfatal. Second line biological agent due to low kill potential but has the potential to overwhelm medical services due to epidemic outbreaks. Encephalomyelitis Symptoms: Fever, headache, severe photophobia (aversion to light). Meliodosis and Glanders (Burkholderia pseudomalleri) Symptoms: Pneumonia with associated septicaemia. Primitive treatment: Ceftazidime for acute infection, doxycycline to prevent recurrence. Psittacosis (Chlamydia psittaci) Symptoms: Atypical pneumonia with fever and cough. Primitive treatment: Doxycycline or Chloramphenicol Human transmission usually from inhaled dust infected with placental tissue or secretions from infected sheep, cows, or goats. Typhus fever (Rickettsia prowazekii) Symptoms: Fever, headaches, chills, generalised pain and rash. Second line bio agent Ricin (technically a chemical agent) Symptoms: Block protein synthesis within the body. This is the support of the body’s organ systems (heart, brain, liver, kidneys) to help them continue to function following damage but is not specifically aimed at treating the underlying injury or disease. It is usually delivered in an intensive care unit and consists of treatments such as oxygen, ventilation, dialysis, fluid therapy, nutrition, and using medications to maintain blood pressure. In an austere situation your ability to deliver supportive care will be minimal and potentially a massive drain on limited resources. Since it is likely any exposure would be the result of a terrorist attack it may be difficult to avoid. If dealing with a patient of suspected chemical agent poisoning ensure you are protected and that the patient is decontaminated. Where - 123 - Survival and Austere Medicine: An Introduction formal decontamination is not possible – remove and dispose of their clothes and wash them down with soap and water. If you suspect a chemical attack try and stay up wind from the location and on the high ground. Chemical agents will be carried by the wind and as most are heavier than air the chemicals will settle in low lying areas. Inside try and find a room with minimal windows (ideally an interior room with no windows), tape cracks around doors and windows and place a wet towel around the base of the door Equipment The single most important piece of equipment is a protective facemask and appropriate filters for all the members of your family. Ensure your filters meet the standard for both biologicals, and organic chemicals, and that you have spares. The following is the Australian commercial standard for mask filters which is the most appropriate for this application: A2B2E2K2 Hg P3. A protective over-suit protects you from liquid and dense vapour contamination on your skin. Usually liquid does not spread over a wide area while vapour can disperse over wide distances. Vapour is poorly absorbed from the skin but it can be if the vapour is dense enough but this is only likely close to the release point. For most people the priority is the purchase of appropriate gasmasks before considering over-suits. If you are unable to afford commercial chemical protective suits consider purchasing those recommended for spraying agricultural chemicals; they do offer the same level of protection but are cheaper, and many nerve agents are based around organophosphate agricultural sprays. Medical preparations In an austere situation Tincture of green soap (or another mild soap) is still the recommended low-tech decontamination agent for suits and bodies. They cause their effects by blocking the breakdown of acetylcholine – a communication chemical between nerves and muscles. When the enzyme, which breaks it down, is blocked, it accumulates, and causes the symptoms of nerve agent poisoning. Treatment: Pre-treatment: This consists of the administration of medication prior to exposure to a nerve agent to minimise the effect of the agent. This binds reversibly to the same receptors to which the nerve agents bind irreversibly helping to reduce their effects. This was tolerated for prolonged periods by troops during Gulf War 1 with minimal minor side effects. If exposure occurs then pre-treatment combined with post-exposure treatment significantly reduces the death rate. Post-exposure treatment: This should be administered immediately upon suspicion of exposure to nerve agents (i. Large amounts of atropine may be required, but the indications and administration are beyond the scope of this book. The dose is titrated against signs of atropinization: dry mouth, dry skin, and tachycardia > 90 min. In the complete absence of medical care and confirmed nerve agent exposure atropine can be continued to maintain atropinization for 24 hours (usually 1-2 mg Atropine 1-4 hourly). Atropine effects are essentially peripheral and it has only a limited effect in the central nervous system 2. Oxime treatment: While atropine minimises the symptoms it does not reverse the enzyme inhibition caused by the nerve agent. By administering oximes this encourages the reactivation of the enzymes required to breakdown the acetylcholine. Different oximes work better with different nerve agents usually a mix of Pralidoxime and Obidoxime is given. Anticonvulsants: In severe exposures there is the risk of seizures leading to serious brain injury. Patients with severe exposures may also require assisted ventilation and suctioning of their airways. If you are able to get access to military autoinjectors then this is ideal first aid/initial therapy. If the patient survives the initial contact then it is likely that the patient will survive.

Scale: The type of scale isn’t as important as the fact that whatever device is used measures the same way each time generic imitrex 25 mg fast delivery muscle relaxant alcohol addiction. The actual scale can be electronic discount 50mg imitrex free shipping muscle relaxant end of life, mechanical buy 50mg imitrex otc spasms gallbladder, or improvised such as a balance beam and counterweights of known measurement. Even - 149 - Survival and Austere Medicine: An Introduction water displacement can be used so long as you have a means of measuring the volume accurately since water has a known weight per volume. A measuring device that will wrap around an extremity is more practical than a rigid ruler. Fever charting can confirm a diagnosis or help you differentiate between diseases. Determining morning basal temperatures (by taking the temperature first thing in the morning before getting out of bed or moving around much) is important in identifying and managing certain chronic conditions. Basal temperatures are also used for other purposes, such as determining the expected time of ovulation for women desired to become pregnant. All of this means that you should include at least one, and preferably several, thermometers in your kit. Clinical thermometers used to be all one of one basic kind - the mercury thermometer - but today you have a variety of options, including electronic thermometers, electronic tympanic membrane thermometers, and single use (disposable) thermometers. However, you should also count on breaking them, and may want to consider doubling or even tripling the number of thermometers you purchase above the recommended number to help guard against this. Electronic thermometers may also be usable over wider ranges than conventional thermometers. Electronic tympanic membrane thermometers (which let you read temperature from the ear) make it easy to avoid cross-infection, but again, they need a power supply. Basal thermometers are thermometers designed to be read to at least 1/20th of a degree (1/10th of a Fahrenheit degree), rather than the 1/10th degree (2/10th of a Fahrenheit degree) of most standard mercury thermometers. Hypothermia thermometers are thermometers that allow the reading of temperatures lower than standard thermometers, usually having ranges that extend down to 30 degrees (86 degrees F) or lower. Hyperthermia thermometers are thermometers that allow the reading of higher than normal temperatures to more accuracy than standard thermometers. Purchase recommendations: For each ten people have at least two standard thermometers, one basal thermometer, and one hypothermia thermometer. Hyperthermia thermometers should be purchased at the rate of one to every twenty people if you expect to see heat injuries commonly, otherwise, a normal clinical thermometer will usually suffice. Rectal versus oral versus universal tips - get universal tips (midway between oral and rectal, and they can be used for either in a pinch) for the clinical and basal thermometers, rectal for the hypothermia and hyperthermia thermometers. Then there are the simple but easily overlooked tools that make ongoing care not only practical but less strenuous and safer for both patient and caregiver. Bandage Scissors: Designed to cut away bandages next to the body without poking holes in your patient. Permanent Marker: To write on dates or times on dressings to know when they were last changed if there is more than one caregiver. Also used to mark skin (it wears off with repeated washing and normal skin replacement). Transfer Belt: Known by various names such as walking belt, safety belt, gait belt, etc. The commercial version is a 3” wide sturdy fabric strap that is easily buckled around the patient so the caregiver can assist them with standing up, transferring, or walking. It can also be fashioned from a pair of sturdy pants suspenders or an ordinary (wide) clothing belt. It provides a handle for the caregiver to grab on to by placing it around the middle (lower stomach area) of the patient and holding onto the rear of the belt. It isn’t always practical to reach into your pocket for everything and setting tools, dressings, etc. Clothing Protectors: Another simple yet important item that can be fashioned readily from any soft or fluid resistant material. Intended to catch spills while eating/feeding and protect the patient while washing hair or performing treatments. They may tie behind the neck or have a wrap-around collar that fastens with Velcro. By protecting from spills they also save a lot of time by guarding against the necessity of clothing and bed linen changes. Flashlight: This serves a dual role as both as assessment tool for the eyes, ears, nose and mouth, and the means to check a patient at night without awakening them with overhead lighting. Gowns: Caring for people may routinely require exposing differing areas of their body for washing, administering medications, changing dressings and bandages or measuring vital signs. Having to undress a person each time is time-consuming and impractical as well as potentially painful. Modesty dictates that we be able to cover the patient when exposure is not otherwise needed. Open back gowns while the bane of hospitalized patients world-wide represent the most practical means of combining protection with accessibility when shirt and pant style clothing is not practical or possible, as when casts or external appliances interfere. Vanity issues aside it may be necessary to trim nails to address issues of hygiene (germs love to hide under nails) and prevent inadvertent self-injury by a patient who may flail about with pain or fever delirium. Having properly designed and sized clippers for the fingers and toes makes this task much easier for all concerned. Providing On-Going Care Having identified our goals we can move on the issue of how we are to address them. There are several areas that need to be addressed as part of the entire care “package” or plan. Databases: Vital Signs Having a database of vital signs is the key to recognizing abnormal vital signs later on. In an ideal situation you would have a record that details normal laying, sitting and standing blood pressures for your patient, as well as a resting pulse, and respirations, along with a temperature. Make sure to note whether the normal pulse is - 152 - Survival and Austere Medicine: An Introduction regular and strong in quality and rhythm, or irregular, weak, or bounding (very strong). Having a database of temperatures over time will allow you to gauge the effectiveness of antibiotics, for instance, or the onset of an infection. Similarly a person who is acutely dehydrated will see an increase in their temperature. Pulse Pulses may indicate a general state of health in the absence of illness or injury. A very rapid, thin pulse may indicate the presence of shock, whereas a slow pulse might signal that the patient is relaxed and relatively pain free. Since pulse rates vary widely amongst people the change in pulse rate and quality is more important than the rate itself. For example, for a person whose normal pulse rate at rest is 68 an increase of 20 per minute may indicate the presence of unaddressed pain. Blood Pressure Blood pressures are always obtained using a blood pressure cuff, either manually operated or electronic. Cuffs come in different sizes with a standard blood pressure cuff suitable for adolescents and adults.

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A study of 71 patients 6 of whom were lost to follow-up Original study “Highest” case “Lowest” case Relapse rate 39/65 = 60% 45/71 = 63% 39/71 = 55% Mortality rate 1/65 = 1 purchase genuine imitrex muscle relaxant properties of xanax. As a general rule cheap imitrex 25 mg fast delivery spasms below middle rib cage, the lower the rate of an outcome buy imitrex now muscle relaxant modiek, the more likely it is to be affected by patients lost to follow-up. The intervention There should be a clear and easily reproducible description of the intervention being tested. The reader should be able to duplicate the process of the study at another institution. It is of paramount importance that the intervention proposed in the study be one that can be performed in settings other than at the most advanced tertiary care setting only. Similarly, testing a drug against placebo may not be as important or useful as testing it against the drug that is currently the most favorite for that indication. Most of these issues have been discussed in the chap- ter on randomized clinical trials in Chapter 15. The out- come assessment should also be done in a blinded manner to avoid diagnostic suspicion and expectation bias in the assessment of patient outcomes. There can be significant bias introduced into the study if the outcomes are not measured in a consistent manner. Death or life are clear and easily measured outcome variables although the cause of death as measured on a death certificate is not always a reliable, clear, or objective outcome measure of the actual cause of death. Admission to the hospital appears to be clear and objective, but the reasons or threshold for admission to the hospital may be very subjective and subject to significant inter- rater variability. Outcomes such as “full recovery at home” or “feeling better” have a higher degree of subjectivity associated with them. The researcher should determine whether the prognostic factor is merely a marker or actually a factor that is responsible for the causation. This determines whether or not there are alternative explanations for the outcomes due to some confounding variable. Count on the article being reviewed by a statistician who can determine if the authors used the correct statistical analysis, but be aware that the correct adjustment for extraneous factors may not have been done correctly if at all. If the authors suggest that a group of signs, symptoms, or diagnostic tests accu- rately predict an outcome, look for a validation sample in a second study which attempts to verify that indeed these results occurred because of a causal rela- tionship and not just by chance. Look for at least 10 and preferably 20 patients who actually had the outcome of interest for each prognostic factor that is eval- uated to give clinically and statistically significant results. One is interested in the association of an inde- pendent variable such as drug use, therapy, risk factor, diagnostic test result, tumor stage, age of patient, or blood pressure with the dependent or outcome variable. Diagnostic-suspicion bias occurs when the physician caring for the patient knows the nature and purpose of the outcomes being measured and as a result, changes the interpretation of a diagnostic test, the actual care or observation of the patient. Expectation bias occurs when the person measuring the outcome knows the clinical features of the case or the results of a diagnostic test and alters their interpretation of the outcome event. This is less likely when the interven- tion and outcome measures are clearly objective. Ideally blind diagnosis, treat- ment, and assessment of all the patients going through the study will prevent these biases. Another problem in the outcomes selected occurs when multiple outcomes are lumped together. Many more studies of therapy are comparing two groups for several outcomes at once and these so-called composite outcomes have been discussed in Chapter 11 in greater detail. Commonly used measures of heart therapies might include death, an important outcome, non-fatal myocar- dial infarction, important but less than death and need for revascularization pro- cedure much less important than death. The use of these measures can lead to over-optimistic conclusions regarding the therapy being tested. When combined, multiple or composite outcomes may then show statistical significance. The primary outcome measures were overall number of Survival analysis and studies of prognosis 363 deaths, and of deaths due to stroke, myocardial infarction, or vascular causes. The end result was that there were no decreases in death from stroke or myocardial infarction, but a 20% reduction in deaths in the patients with peripheral arterial disease. If these patient outcomes were considered as separate groups, the differences would not have been statistically significant. Another danger is that some patients may be counted several times because they have several of the outcomes. There are basically three types of data that are used to indicate risk of an out- come. Interval data such as blood pressure is usually considered to be normally distributed and measured on a continuous scale. Nominal data like tumor type or treatment options is categorical and often dichotomous like alive and dead or positive and negative test results. Ordinal data such as tumor stage is also cate- gorical but with some relation between the categories. There are three types of analyses applied to this type of problem: frequency tables, logistic analysis, and survival analysis. Decision theory uses probability distributions to estimate the probability of an outcome. Frequency tables Frequency tables use a chi-square analysis to compare the association of the out- come with risk factors that are nominal or ordinal. For the chi-square analysis, data are usually presented in a table where columns are outcomes, rows are risk factors, and the frequencies appear as table entries. The observed data are com- pared with the data that would be expected if there were no association. The analysis results in a P value which indicates the probability that the observed outcome could have been obtained by chance when it was really no different from the expected value. Logistic analysis This is a more general approach to measuring outcomes than using frequency tables. Logistic regression estimates the probability of an outcome based on one or more risk factors. Results of logistic regression analysis are often reported as the odds ratio, relative risk, or hazard ratio. For one independent variable of interval-type data and relative risk, this method calculates how much of an increase in the risk of the outcome occurs for each incremental increase in the exposure to the risk fac- tor. An example of this would answer the question “how much additional risk of 364 Essential Evidence-Based Medicine stroke will occur for each increase of 10 mm Hg in systolic blood pressure? For multiple variables, is there some combination of risk factors that will bet- ter predict an outcome than one risk factor alone? The identification of significant risk factors can be done using multiple regressions or stepwise regression analyses as we discussed in Chapter 29 on clinical prediction rules. Survival analysis In the real world the ultimate outcome is often not known and could be dead as opposed to “so far, so good” or not dead yet. It would be difficult to justify waiting until all patients in a study die so that survival in two treatment or risk groups can be compared.

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