Lecture 10: Insomnia, Fatigue, Bites, Stings and Pediculosis Flashcards
Sleep characteristics
- Most adults require at least 8 hours of sleep: true avg 6.7 hours
- 64% of adults experience sleep issues a few nights a week
Common management techniques: - Alcohol (7%)
- NonRX sleep aid (7%)
- Prescription hypnotic (8%)
Insomnia
Issues with any of the following:
- falling asleep
- Staying asleep
- Waking up too early
- Not feeling refreshed after sleep
Insomnia Clinical Presentation
- Difficulty falling asleep (more than 30 min)
- Awakening w/o falling back asleep
- disturbed quality of sleep
poor sleep
Insomnia Daytime symptoms
- Fatigue
- naps
- decreased attention and concentration
- mood alterations
- impacted ADLs (activities of daily living)
Insomnia contributing factors
- Life events like stress/ anxiety, sickness/illness, sleep hygiene and shift work
- Comorbidities (simultaneous presence of two or more disease in a patient)
- meds
- caffeine
- nicotine
- meals
- exercise
- increased age
Disorders contributing to insomnia
- Allergies
- Arthritis
- BPH (Benign prostatic hyperplasia
- Chronic pain
- DM
- HF
- Asthma/ COPD
- Pregnancy
- Menopause
- Depression/ Anxiety
- Restless leg syndrome
- Obstructive Sleep apnea
Insomnia exacerbating drugs
- Alcohol
- Certain antidepressants. (bupropion, fluoxetine, venlafaxine)
- Certain anticonvulsants
- Amphetamines
- Anorexiants
- Albuterol
- Decongestants
- Diuretics
- Nicotine
- Caffeine
Transient Insomnia
less than a week
Short-term insomnia
1-3 weeks
Chronic insomnia
more than 3 weeks
Primary insomnia
not a symptom of another condition
Secondary Insomnia
symptoms of another condition
Initiation insomnia- Type
more than 30 min to fall asleep
Maintenance insomnia Type
frequent awakenings
Exclusions to self care - insomnia
- younger than 12 yo or greater than 65 yo
- pregnant/breastfeeding- check w provider first
- frequent awakenings or early morning awakenings (maintenance insomnia)
- chronic insomnia
- secondary insomnia such as narcolepsy, obstructive sleep apnea and/or restless leg syndrome
- diphenhydramine contraindication
Non-pharmacologic options
Improve sleep hygiene and change daily activities
- Review sleep log
Institute 1-2 changes at a time
Sleep Hygiene
First line option before trying pharmacologic option: consists of sleep environment and pre-sleep activities
Sleep environment (sleep hygiene)
- bed should be for sleeping and intimacy
- follow regular sleep schedule 7 days a week
- comfortable cool environment
- avoid visible clocks
Pre-sleep activities (sleep hygiene)
- avoid electronics
- do relaxing activities
- light snacks only
- no caffeine, alcohol or nicotine 4-6 hrs before
Daily activities (non-pharmacologic)
- Regular exercise in morning or early afternoon
- avoid naps or limit to 20-30 min and before 5 pm
Natural light
Pharmacologic treatment for insomnia
- Diphenhydramine (first generation antihistamine)
- Doxylamine
- recommended for short term use b/c tolerance develops quickly
- improves sleep efficiency vs placebo
- self- perceived insomnia severity
Diphenhydramine for insomnia
- standard dosing 25-50mg
- start with a low dose at bedtime
- use for 3 days with an off night
- use no more than 7-10 night in a row
Diphenhydramine side effects
For older patients: Increased fall risk and medication interactions
- Can interfere with cooking/ driving
- avoid alcohol
- can cause morning grogginess/ sedation
Diphenhydramine contraindications
Narrow angle glaucoma
- Use of MAOI medications
- Lactation ( regular use)
Diphenhydramine interactions
Sedatives
Alcohol
Opioids
Other anticholinergic agents
Diphenhydramine Special populations
- Pregnancy- Caution, refer
- Breastfeeding/ Lactation
• Increased CNS effects in infants, decreased milk production
Children/ Adolescents: - Ask about sleep hygiene and Refer if less than 12
Older adults:
Beers criteria recommend avoiding use of anticholingeric agents and refer is older than 65
Complementary and Alternative therapy
for insomnia
Agents that can be used?
Melatonin (2-10 mg/day)
- May decrease time to fall asleep (7mins) and increase total length of sleep (8 minutes); improved sleep quality
- Relatively safe
- Valerian root (only for chronic)
- withdrawal is possible
Kava- (avoid b/c hepatotoxicity)
Drowsiness and Fatigue Goals and Approach
- Identify and eliminate underlying cause
- Prioritize sleep hygiene
- avoid chronic caffeine
- You can use some caffeine
Drowsiness and fatigue exclusions to self care
- younger than 12
- pregnancy/ lactation
- heart disease
- anxiety, medication
- Medication induced drowsiness
- chronic fatigue
Caffeine characteristics
- nonselective adenosine antagonist at A1 and A2A receptors
- The only FDA approved non-prescription stimulant
- low/moderate doses increase arousal, decrease fatigue, elevate mood, increase in BP and HR
- high doses may cause anxiety, nausea, jitteriness and nervousness
- Completely absorbed: Peak in 30-75 mins
T1/2≈ 5 hours (3-7)
Caffeine dosing
- 100-200mg every 3-4 hours as needed
- consuming less than 400mg/day is not associated with adverse effects in healthy adults
- Withdrawal (1-5 days)
- Not a substitute for sleep
- Occasional restoration of mental alertness or wakefulness
Caffeine contraindications
- coronary artery disease
- uncontrolled hypertension
- cardiac arrhythmias
- ## concurrent MAOI use
Caffeine Drug Interactions
- Adenosine
- Cannabinoid
- Ciprofloxacin
- Lithium
- Tobacco smoking
Products with caffeine
- Migraine relief
- Menstrual analgesics
- Energy drinks
- Dietary supplements
Caffeine Special pops
- Pregnancy- Less than 200mg/ day MDD )crosses placenta
- Breastfeeding/Lactation- Usual dietary doses are ok
- Children are more susceptible to cardiovascular and CNS effects
- Older adults have increases pharmacologic effect
Insect Bites and stings characteristics
Often local reactions: erythema, pruritus, swelling
- Systemic toxicity possible
- allergy/ sensitivity
Insects, mites, parasites-> non-venomous
Spiders: venomous-> may cause anaphylaxis
secondary infection, vector transmission
Death (rare): multiple simultaneous stings
Prevention > treatment
Mosquito bites
Exposure: Humid and warm climates
- Bites often develop into wheal with redness and itching
Mosquitoes as Vectors: Malaria
Malaria: Travel risk-> preventative medications
Symptoms: Chills, fatigue, fever
West Nile Virus
Found throughout the US
Commonly: asymptomatic or flu-like symptoms
Severe: encephalitis, meningitis, weakness
Zika Virus
Symptoms: asymptomatic, fever/headache/joint pain
Testing: Blood, urine
Transmission: mosquitos, intercourse
Clinical Effects: microcephaly, Guillain-Barre syndrome
Treatment: symptomatic/ supportive care
Fleas
Exposure: infested pets, vacant infested homes
Bites: tend to be in multiple/ groups
- more common in lower extremity
- erythematous and pruritic
Fleas as vectors
Plague, typhoid
Mites/Scabies
Exposure: mite burrowing in skin and/or physical contact with infected host
Infestation/Burrowing is characterized by inflammation and intense itch
Common location: buttock, between fingers, wrist
Treatment: Rx only meds - no self care
Bed bugs
Exposure: eggs -> bedding, floor, furniture
Bites: occur at night in exposed areas like arms, head and neck
- cluster pattern is usually in a straight line
- characterized by erythema and pruritus (itching)
Ticks
Exposure: warm and humid climate
- happens in spring/summer and fall
- tall grass and woods
- found on variety of animals
Bite: itching papule, target lesion
Ticks as Vectors
- Lyme Disease: Flu like symptoms, rash or tender lesions
Severe: arthritis, cardiac, CNS
-Rocky Mountain Spotted Fever
Fever, headache, rash
Remove tick within 36 hours to decrease transmission risk
Chiggers
Exposure: outdoor areas, warm/humid climate
Bite: Tend to be grouped
-Larvae secrete enzyme which leads to cellular disintegration and itching
Insect Bites: Spiders
Black widow:
- Diaphoresis
- Fever/chills
- Immediate pain
Brown recluse:
- Hemolysis (destruction of red blood cells)
- Necrotic lesion
Exclusions to self care - Insect Bites
- Hypersensitivity resulting in systemic symptoms
- Less than 2
- history of tick bite with systemic effects indicating possible infection
- Suspected spider bite
- Signs of secondary infection like Fever, spreading redness, warmth, pus
Insect Bites: Goals of Self-Treatment
- Improve symptoms
2. Prevent secondary bacterial infections
Preventing Bites
- Avoid insects (cover skin, mosquito netting)
- Use insect repellent (DEET) is most effective
- <30% for children
-10-40% short exposure to 50-100% long exposure for adults
Adverse effects: skin irritation
Insect Repellent Application
Reapply every 4-8 hours
Spray on hands to apply to face avoiding eyes and mouth
Wash clothes/ skin after use
Do not spray indoors
Non-pharmacologic therapy for bites and stings
Ice packs:
- Decrease pain and swelling
- Wrap in washcloth to applu
- 10 mins on 10 mins off
Avoid itching/ scratching -> increases risk for secondary infection
stinger removal
Local Anesthetics OTC products
- Benzocaine
- benzyl alcohol
- dibucaine
- lidocaine
- phenol
- pramoxine
Local Anesthetics MOA
Inhibit sodium channels which decreases nerve conduction which decreases sensation which ultimately results in reduced itching/irritation
Local Anesthetic Adverse Effects
- Contact dermatitis - red, itchy rash caused by direct contact or an allergic rxn to the anesthetic
- Avoid phenol in pediatrics
Local Anesthetic Administration
- Apply to site of bite only - Apply 3-4 times daily as needed for up to 7 days
Topical Antihistamines MOA
Depress cutaneous histamine receptors
Topical Antihistamines OTC Products
Diphenhydramine cream or ointment 0.5-2%
Topical Antihistamines Administration
- Apply to bite site only
- Apply 3-4 times daily as needed for up to 7 days
Topical Antihistamines Adverse effects
Systemic absorption unlikely
-Ingestion-> anticholinergic toxicity
Counterirritants MOA
-Produces mild, local inflammatory reaction which decrease sensation/ analgesia( inability to feel pain)
Counterirritants OTC Products
Camphor, Methol
Counterirritants Adverse effects
Well tolerated
-Strong smell?
Counterirritants Administration
- Apply to bite site only
- Apply 3-4 times daily as needed for up to 7 days
Protectants (bites and stings) OTC Products
Calamine, Titanium dioxide, Zinc oxide
Protectant Mechanism
- Decrease inflammation and irritation
- Absorb fluids from weeping lesions
- Zinc oxide has antiseptic properties
Protectant Administration
- Apply to bite site only
- Apply 3-4 times daily as needed for up to 7 days
Hydrocortisone mechanism- Corticosteroid
Low Potency corticosteroid capable of vasoconstriction which decreases inflammation and pruritus
- OTC: 1%
Hydrocortisone Administration
- Apply to bite site only
- Apply 3-4 times daily as needed for up to 7 days
Oral antihistamines may be
more effective than topical antihistamines
-First or second generation can be used
Insect Stings
Common stinging insects: honey bees, hornets, yellow jackets, wasps
Recognizing toxicity
Local: irritation, itching, pain
Systemic: hives, itching, swelling
Anaphylaxis: chest tightness, shortness of breath, decreased blood pressure, dizziness
Exclusions to self care - Insect Stings
- Systemic or anaphylactic response:
- Hives, excessive swelling, dizziness, weakness, nausea, vomiting, difficulty breathing
- Any significant allergic response away from sting site
- Previous sting of honeybee, wasp or hornet bc we need to evaluate possible development of hypersensitivity
- Less than 2 yo
- Personal or family history of significant allergic rxns
Pharmacologic therapy - insect stings and bites
- Anesthetics
- antihistamines
- counterirritants
- hydrocortisone
- protectants
Non-Pharmacologic Therpay- Treatment
- Ice packs
- Stinger removal:
- Fingernail or credit card to scrap away
- Avoid tweezers/squezzing
- Clean with alcohol or hydrogen peroxide
Head Lice Clinical Presentation
- Located on the crown of head, ears, base of neck
- Bites may present as a wheal
- Typically accompanied by pruritus : Risk of secondary infection from scratching
Head Lice Risk Factors
Daycare, school in fall months, incarceration
- Spread by close contact: hats, combs, brushes
- Size of a sesame seed
Head Lice Life Cycle
- Lice lay eggs (nits) near scalp-> hatch and then feed within 24 hrs
- 8-9 days to mature; cycle every 3 weeks
-As eggs mature they become 1st nymph, 2nd nymph, 3rd nymph and then finally an adult
Body Lice Clinical Presentation
Bites, Pruritus, infection transmission
- Epidemiology: Lice live and lay eggs in clothes
- Poor hygiene and dirty clothes increase risk
Pubic Lice (crabs)
May be spread through sexual contact, toilet seats, shared bedding
- Can be located in pubic hair, eye brows, arm pits beard, armpits
Often causes itching and redness
Pediculosis: Exclusions to self care
- Hypersensitivity to chrysanthemums and ragweed
- Secondary infection
- Less than 2 (pyrethrins
-Less than 2 months (permethrins)
Eyebrow/ lid infestation - Pregnancy lactation
Non-pharmacologic Therapy - pediculosis
important to prevent reoccurrence
- avoidance
- nit comb (utilize after treatment to remove nits bc it does not kill 100% eggs)
- Wash bedding and clothing in hot wash/dry (seal for 2 weeks)
Pharmacologic therapy - Pediculosis
Pyrethrin in ages above 2 years
Permethrin in ages above 2 months
Pyrethrin MOA
- Blocks louse nerves which leads to paralysis and death
- can be synergized with piperonyl butoxide to increase duration of activity
- Only approved for head and pubic lice
Pyrethrin Application
- Apply for 10 minutes, then wash out
- Comb out nits
- Repeat after 7-10 days if needed
Pyrethrin Adverse Effects
Irritation, itching, erythema
-Hypersensitivity reaction (allergies)
Pyrethrin and Permethrin Monitoring
Infestation after 2 applications= referral
Resistance can develop
Permethrin
Synthetic pyrethrin compound
Available in 1% concentration
-For head lice only
Permethrin Application
Apply cream rinse for 10 minutes then rinse
- Comb out nits
- Is active for 10 days
- Only reapply if lice remains
Permethrin Adverse Effects
Irritation, itching, burning, stinging
Emergency Therapies
- Cetaphil Skin Cleanser (Nuvo Method)
- Dimethicone 100% gel
- Lice enzyme shampoos
- Tea tree
- Lavender Oil
Battery operated Louse Combs
Little evidence to support use and should be avoided in patients with pacemakers or history of seizure
Other oil based products
- Petro, Jelly, Mayo is not recommended
AirAlle (formally LouseBuster
- Machine uses heat to dehydrate lice/nits
