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Question 1

ACUTE MUSCULOSKELETAL BACK PAIN

Answer 1

Definition: Back pain resulting from injury due to mechanical stress or functional demands
S/S: Acute or gradual onset of back pain that can be severe and debilitating; with or without radiation; aggravated

by movement or certain positions, alleviated with rest; usually history of previous back pain

MGMT: 1. Acetaminophen (Tylenol) 500mg PO qid or Ibuprofen (Motrin) 800mg PO tid or Naproxen (Naprosyn) 500mg PO bid, 2. Cyclobenzaprine (Flexeril) 10mg PO tid or Methocarbamol (Robaxin) 1500mg PO qid, 3. Encourage fluid hydration, avoid bed rest, use ice pack if acute or heat pack if subacute, stretch as tolerated, 4. If acute and severe back pain and spasm, provide Ketorolac (Toradol) 15-30mg IV/IM and Diazepam (Valium) 5- 10mg IV, and repeat once in 6-8h if needed, 5. Refer to Spinal Trauma protocol if abnormal neurological exam

Disposition: Evacuation usually not required; Routine evacuation if no response to therapy or acute lumbar disk disorder suspected; Urgent if neurological involvement (weakness, numbness, bowel or bladder dysfunction)

Question 2

ACUTE (SURGICAL) ABDOMEN

Answer 2

Definition: Common causes in young healthy adults include appendicitis, cholecystitis, pancreatitis, perforated ulcer, diverticulitis, or bowel obstruction

S/S: Severe, persistent or worsening abdominal pain; rigid abdomen, rebound tenderness, fever, anorexia, nausea/vomiting, absent bowel sounds, mild diarrhea if present

MGMT: 1. Keep patient NPO, except for water and meds, 2. NS IV at 150cc/hr, 3. Ertapenem (Invanz) or Ceftriaxone (Rocephin) 1gm IV/IM q24h, 4. Acetaminophen (Tylenol) 1000mg PO q6h prn pain, 5. Ondansetron (Zofran) 4mg IV over 2-5 minutes or IM bid or Phenergan (Promethazine) 12.5-25mg IV q4-6h for nausea/vomiting, 6. For severe pain, use Fentanyl Oral Lozenge (Actiq) 800mcg or Morphine Sulfate (MSO4) 5-10mg IV initially, then 5mg q30-60min prn pain, medicate to keep patient comfortable without loss of sensorium

Disposition: Urgent evacuation to facility with surgical capability

Question 3

ACUTE DENTAL PAIN

Answer 3

Definition: Common causes are deep decay, fractures of tooth crown or root, or periapical abscess
S/S: Intermittent or continuous pain; heat or cold sensitivity; visibly broken tooth; severe pain on percussion;

swelling or abscess

MGMT: 1. Acetaminophen (Tylenol) 1000mg PO q6h or Ibuprofen (Motrin) 800mg PO q8h prn pain, 2. If signs and symptoms of infection, Clindamycin (Cleocin) 300-450mg PO q6h or Amoxicillin/Clavulanic Acid (Augmentin) 500/125mg PO tid or 875/125mg PO bid or Ceftriaxone (Rocephin) 1gm IV/IM daily x 7d

Disposition: Evacuation is usually not required; Routine evacuation if no response to therapy

Question 4

ALLERGIC RHINITIS

Answer 4

Definition: Inflammation of the nasal passages due to environmental allergy
S/S: Rhinorrhea with clear discharge, boggy or inflamed nasal mucosa, +/- nasal congestion, sneezing, nasal

pruritis; +/- concurrent watery, pruritic, or red eyes; history of environmental allergy

MGMT: 1. Fluticasone (Flonase) 2 sprays in each nostril daily, 2. Antihistamines and decongestants prn, 3. Increase PO fluid intake

Disposition: Evacuation usually not required

Question 5

ASTHMA (REACTIVE AIRWAY DISEASE)

Answer 5

Definition: Inflammatory disorder of the airway with bronchiolar hyper-responsiveness and narrowing of the distal airways; acute exacerbation seen with change in environment or level of allergen or irritant

S/S: Wheezing, dyspnea, chest tightness, decreased oxygen saturation, respiratory distress

MGMT: 1. Albuterol (Proventil) MDI 2-3 puffs q5min x 3 doses, 2. If no response, Epinephrine 0.5mg (0.5ml of 1:1000 solution) IM, repeat in 5-10 minutes if needed, 3. Saline lock, 4. Dexamethasone (Decadron) 10mg IV/IM, 5. Oxygen (if available), 6. Monitor with pulse ox, 7. If fever, chest pain, and cough, consider and treat as per Pneumonia protocol; if airway compromise refer to Airway protocol

Disposition: If adequate response, continue Albuterol q6h and Dexamethasone daily; if poor response, Urgent evacuation

Question 6

BRONCHITIS

Answer 6

Definition: Inflammation of trachea, bronchi, and bronchioles resulting from upper respiratory tract infection (URI) or chemical irritant; viruses are the most common cause

S/S: Preceding URI symptoms, cough (initially unproductive, then productive), fatigue, +/- fever > 100.4, +/- dyspnea, injected pharynx

MGMT: 1. Hydrate, 2. Acetaminophen (Tylenol) 1000mg PO q6h prn fever, 3. Treat symptoms with antitussive, decongestants, expectorant, as needed, 3. Albuterol (Proventil) MDI 2 puffs q4-6hrs, 4. Smoking cessation, 5. If symptoms worsen or persist, consider and treat as per Pneumonia protocol

Disposition: Evacuation usually not required

Question 7

CELLULITIS

Answer 7

Definition: Acute superficial spreading bacterial skin infection due to trauma or scratching of other lesions

S/S: Local warmth, pain, erythema, swelling with well-demarcated borders, +/- fever/chills, +/- lymphadenopathy; if rapidly spreading and very painful consider necrotizing fasciitis (life-threatening deep tissue infection) and treat per Bacterial Sepsis protocol

MGMT: 1. Acetaminophen (Tylenol) 1000mg PO q6h or Ibuprofen (Motrin) 800mg PO q8h prn pain, 2. Clindamycin (Cleocin) 300-450mg PO q6h or TMP-SMZ (Septra) DS PO bid or Moxifloxacin (Avelox) 400mg PO qd x 10 d, or Azithromycin (Zithromax) 250mg 2 tabs PO day 1 then 1 tab PO day 2-5, 3. Clean/dress wound, 4. Use marker to demarcate infection border, 5. Limit activity as feasible, 6. Reevaluate at least daily, 7. Identify and drain abscess if present, and 8. If severe or no response, use Ceftriaxone (Rocephin) or Ertapenem (Invanz) 1gm IV/IM qd and continue PO antibiotics

Disposition: Priority evacuation if infection fails to improve or worsens within 24-48hrs on antibiotics

Question 8

CHEST PAIN (CARDIAC ORIGIN SUSPECTED)

Answer 8

Definition: Possible heart attack or myocardial infarction (MI)

S/S: Usually in patients over 40; history of hypertension, diabetes, smoking, elevated cholesterol, obesity; family history of MI at a young age; substernal pressure/squeezing chest pain +/- radiation to left arm or jaw, dyspnea, diaphoresis (sweating)

MGMT: 1. “MONA”: Morphine Sulfate (MSO4) 4mg IV initially then 2mg IV q5-15min prn pain, Oxygen (if available), NTG (if available) 0.4mg SL initially, repeat q5min for total of 3 doses, Acetylsalicylic Acid (Aspirin) 325mg chew 2 tabs and swallow 2 tabs, 2. IV access, 3. Pulse oximetry and cardiac monitor (if available)

Disposition: Urgent evacuation on platform with ACLS personnel, medications, and equipment

Question 9

COMMON COLD

Answer 9

Definition: Inflammation of nasal passages due to a respiratory virus
S/S: Nasal congestion, sneezing, sore throat, cough, hoarseness, malaise, headache, low-grade fever

MGMT: 1. Increase PO hydration, 2. Acetaminophen (Tylenol) 1000mg PO q6h, 3. Treat symptoms with decongestants, antihistamines, cough suppressants, and other symptomatic relief medications prn

Disposition: Evacuation is usually not required

Question 10

CONJUNCTIVITIS

Answer 10

Definition: Eye conjunctiva inflammation due to allergic, viral, or bacterial cause

S/S: All causes (burning, irritation, tearing); allergic (bilateral, serous or mucoid discharge, itching, redness); viral (unilateral, redness, watery discharge, conjunctival swelling, tender preauricular node, photophobia, foreign body sensation, associated URI); bacterial (unilateral, eye injection, mucopurulent or purulent discharge with morning crusting)

MGMT: 1. Discontinue contact lenses if applicable, 2. Cleanse with warm, wet wash cloth qid, 3. If allergy or viral, other than herpetic, artificial tears prn and Naphazolin/Pheniramine (Naphcon-A) 2 drops in affected eye qid, 4. If bacterial, Gatifloxacin (Zymar) 0.3% 1 drop in affected eye qid

Disposition: Evacuation usually not required

Question 11

CONSTIPATION

Answer 11

Definition: Infrequent, hard, dry stools

S/S: Infrequent, hard, dry stools with possible pain/straining with defecation, abdominal fullness, and poorly localized cramping abdominal pain; if pain becomes severe with N/V and lack of flatus or stools consider bowel obstruction; if acute onset, severe pain, rigid board-like abdomen, rebound or point tenderness, and/or fever, consider other disorders (appendicitis, bowel obstruction, cholecystitis, diverticulitis, pancreatitis, and ulcer) and treat as per Acute (Surgical) Abdomen protocol

MGMT: 1. Increase PO fluids and fiber – fruits, bran, vegetables, 2. Docusate (Colace) 100mg PO bid, 3. Acetaminophen (Tylenol) 1000mg PO q6h prn pain (no narcotics – they cause constipation!), 4. If impacted or no response give 500cc NS enema per rectum (lubricate IV tubing), 5. If continued no response, perform digital rectal exam (DRE) and digital disimpaction, 6. Consider parasitic infection

Disposition: Routine evacuation if no response to treatment; Urgent evacuation if acute abdomen

Question 12

CONTACT DERMATITIS

Answer 12

Definition: Skin reaction to external substance (plants, metals, chemicals, topical medications)

S/S: Acute onset of skin erythema and pruritis; may see edema, papules, vesicles, bullae, and possible discharge and crusting; evaluate and monitor for secondary bacterial infection and treat per Cellulitis protocol if suspected; consider insect bite and fungal infection in differential diagnosis

MGMT: 1. Remove offending agent and evaluate pattern, 2. Wash area with soap and water, 3. Change and/or wash clothes, 4. Topical cold wet compress AAA, 5. Topical calamine lotion AAA, 6. Topical high-potency steroid cream AAA qid (low-potency on face), 7. Diphenhydramine (Benadryl) 25-50mg PO qid prn pruritis, 8. If severe, Solu-Medrol 125 mg IM x 1; or Dexamethasone (Decadron) 10mg IM daily x 5 d; or Prednisone 60mg PO daily x 5 d burst or taper dose down every 3 days for a 14-21 day course

Disposition: Priority evacuation if severe, eye or mouth involved, or > 50% BSA involved

Question 13

CORNEAL ABRASION & CORNEAL ULCER

Answer 13

Definition: A traumatic disruption of the epithelial covering of the cornea; three major concerns: intense eye pain, corneal ulcer (vision-threatening infection), and potential for ruptured globe

S/S: History of eye trauma or contact lens wear with eye pain; redness, tearing, blurred vision, light sensitivity, positive fluorescein stain/cobalt blue light (bright yellow area on cornea); increasing pain and white or gray spot on cornea with tangential penlight indicative of corneal ulcer; blood in anterior chamber, bulging subconjunctival hemorrhage (chemosis), and peaked pupil indicative of ruptured globe; if history of LASIK, consider flap dislocation

MGMT: 1. Examine eye, to include eyelid eversion, and remove any foreign body, 2. Gatifloxacin (Zymar) 0.3% 1 drop in affected eye qid until after 24h fluorescein negative (q2h if corneal ulcer), 3. If available, Tetracaine 0.5% 2 drops in affected eye for pain (do not give bottle to patient), 4. Acetaminophen (Tylenol) 1000mg PO q6h prn pain, 5. No patching, 6. Reduce light exposure/stay indoors/wear sunglasses as feasible, 7. Monitor daily with fluorescein

Disposition: Routine evacuation if not improving; Priority evacuation if corneal ulcer; Urgent evacuation and eye shield if ruptured globe suspected; Urgent evacuation if LASIK flap dislocation

Question 14

COUGH

Answer 14

Definition: Usually viral etiology, but may occur with HAPE, pneumonia, GERD, and smoking history
S/S: Cough with or without scant sputum production, often accompanied by other URI S/S (sore throat, rhinorrhea,

post-nasal drip)

MGMT: 1. Treat symptomatically if history and physical exam do not suggest pneumonia, 2. Increase PO hydration, 3. Avoid respiratory irritants (smoke, aerosols, etc), 4. Benzonatate (Tessalon perles) 100mg PO tid or Dextromethorphan (Robitussin DM) 30mg PO bid prn cough, 5. Albuterol (Proventil) MDI 3-4 puffs q4h can help if cough continues; Treat per Pneumonia protocol if fever, chest pain, dyspnea, colored sputum (green, dark yellow, red-tinged)

Disposition: Evacuation usually not required

Question 15

CUTANEOUS ABSCESS

Answer 15

Definition: Cutaneous abscess
S/S: Focal pain, erythema, warmth, tenderness, swelling, and fluctuance

MGMT: 1. Clindamycin (Cleocin) 300-450mg PO q6h or TMP-SMZ (Septra) DS PO bid or Moxifloxacin (Avelox) 400mg PO qd x 10 d, or Azithromycin (Zithromax) 250mg PO 2 tabs PO day 1 then 1 tab PO day 2-5, 2. I&D if not on eyelid, face, or neck (sterilize site with betadine, anesthetize with 1% Lidocaine, incise parallel to skin tension lines with scalpel and make opening large enough to allow purulence to drain, pack with iodoform gauze or nu- gauze, cover with loose bandage; check, redress, and wick q12-24hrs); Do not suture, drainage is the key to treatment!

Disposition: Evacuation usually not required; If condition worsens treat per Cellulitis protocol and evacuate as Priority

Question 16

DEEP VENOUS THROMBOSIS (DVT)

Answer 16

Definition: Potentially life-threatening condition in which a clot is present in the large veins of a leg and may dislodge and localize in the pulmonary system, a pulmonary embolism (PE)

S/S: History of recent trauma, air travel, altitude exposure, birth control pills, or family history of DVT; pain, swelling, and warmth seen in legs (usually calf), but may occur in any deep vein; palpable venous “cord”; pain with passive stretching or dorsiflexion of the foot

MGMT: 1. Acetylsalicylic acid (Aspirin) 325mg PO q4-6h, 2. Immobilize and do not allow to walk on affected extremity, 3. Monitor with pulse oximetry (sudden decrease suggests PE), if tachypnea, tachycardia, respiratory distress, and chest pain develop, treat per Pulmonary Embolism protocol

Disposition: Priority evacuation; Urgent if PE suspected

Question 17

DIARRHEA

Answer 17

Definition: Loose bowel movements (BM); abrupt onset in healthy individuals usually related to infectious cause (viral, bacterial, parasitic)

S/S: Loose or watery BMs, +/- blood or mucous, +/- fever, abdominal cramping, discomfort, and/or distension; possible S/S of dehydration (decreased and/or dark urine output, lightheadedness, headache, dry mucosa, poor skin turgor, degradation in performance)

MGMT: 1. Replace lost fluids and electrolytes, PO if tolerated, if not then IV LR or NS, 2. Loperamide (Imodium) 4mg PO initially, then 2mg after every loose BM, max of 16mg/day, 3. If diarrhea persists > 24 hrs, give Azithromycin (Zithromax) 500mg or Moxifloxacin (Avelox) 400mg PO qd or Ciprofloxacin (Cipro) 500mg PO bid x 3d, 4. If diarrhea > 3 days, treat as Giardia or Amebiasis with Tinidazole (Tindamax) 2gm PO qd or Metronidazole (Flagyl) 500mg PO tid x 3d

Disposition: Evacuation usually not required, if dehydration despite therapy or antibiotic-related diarrhea, evacuate as Priority. Grossly bloody stools or circulatory compromise require Urgent evacuation

Question 18

EPIGLOTTITIS

Answer 18

Definition: Inflammation of the epiglottis
S/S: Sore throat, difficulty speaking and swallowing, drooling, respiratory distress, erythematous pharynx; first

symptom of severe sore throat progresses to epiglottal swelling and potential for airway obstruction

MGMT: 1. Place patient in sitting or comfortable position, 2. IV access, 3. Ceftriaxone (Rocephin) 2gm IV/IM q12h, 4. Dexamethasone (Decadron) 8mg IV/IM x 1, 5. Pulse oximetry, 6. Oxygen if available, 7. Do not manipulate airway unless required, let the patient protect his own airway, 8. If definitive airway is needed, make one attempt at intubation, and if failed, perform a cricothyroidotomy

Disposition: Urgent evacuation

Question 19

EPISTAXIS

Answer 19

Definition: Nosebleed

S/S: Nosebleed, often with previous history of nosebleeds; common at altitude and in desert environments due to mucosal drying; may be anterior or posterior; posterior epistaxis may be difficult to stop and may cause respiratory distress due to blood flowing into airway; posterior epistaxis is more commonly seen in older hypertensive patients

MGMT: 1. Clear airway by having patient sit up and lean forward, 2. Oxymetazoline (Afrin) 2-3 sprays intranasally and pinch anterior area of nose firmly for full 10 minutes without releasing pressure, 3. If bleeding continues, insert Afrin-soaked nasal sponge along floor of nasal cavity, remove 30 minutes after bleeding is controlled, and apply Mupirocin (Bactroban) bid-tid, 5. If severe nosebleed and bleeding continues, initiate saline lock or NS TKO and consider inserting 14 French Foley catheter intranasally for 72h, 6. If packing and/or catheter required for > 12h, treat with Moxifloxacin (Avelox) 400mg PO qd

Disposition: Evacuation not required for mild, anterior, and resolving epistaxis; Priority evacuation for severe epistaxis not responding to therapy or if Foley used

Question 20

FUNGAL SKIN INFECTION

Answer 20

Definition: Fungal skin infection

S/S: Scaling plaques, erythema, pruritic, slow spreading, irregular or circumferential borders; often initially diagnosed as contact dermatitis but gets worse with steroid cream; most common sites of infection are feet (“athlete’s foot” or tinea pedis), groin (“jock itch” or tinea cruris), scalp (tinea capitus), and torso or extremities (“ring worm” or tinea corporis); differential diagnosis includes eczema, insect bites, cellulitis, and contact dermatitis

MGMT: 1. Antifungal cream AAA tid until one week after lesion resolves, 2. In moderate to severe cases, use Fluconazole (Diflucan) 150 mg PO qwk x 2 wks or Ketoconazole (Nizoral) 200-400 mg PO qd or Terbinafine (Lamisil) 250 mg PO qd

Disposition: Evacuation not required

Question 21

GASTROENTERITIS`

Answer 21

Definition: Usually due to an acute viral infection of the GI tract, but bacteria or parasite infections are common in deployed environments

S/S: Sudden onset of N/V/D, abdominal cramping, +/- fever

MGMT: 1. Loperamide (Imodium) 4mg PO initially, then 2mg after every loose BM, max of 16mg/day (do not use if bloody stools or fevers), 2. If nausea/vomiting, Promethazine (Phenergan) 12.5-25mg PO/IM/IV or Ondansetron (Zofran) 4mg IV over 2-5 minutes or IM bid, 3. If diarrhea persists > 24 hrs, give Azithromycin (Zithromax) 500mg PO daily or Moxifloxacin (Avelox) 400mg PO daily or Ciprofloxacin (Cipro) 500mg PO bid; Azithromycin new primary agent due to emerging quinolone resistance among enteropathogenic E. coli, 4. PO hydrate with ORS, Cyralyte, Gatorade, Powerade, and water, 5. 1-2 liters NS or LR IV if PO not tolerated and titrate fluid intake to regain normal urine frequency and color, good skin turgor, and moist mucous membranes, 6. If diarrhea > 3 days treat as Giardia or Amebiasis treat with Tinidazole (Tindamax) 2gm PO qd or Metronidazole (Flagyl) 500mg PO tid x 3d

Disposition: Evacuation usually not required; Priority evacuation if dehydration despite therapy or antibiotic-related diarrhea; Urgent evacuation if grossly bloody stools or circulatory compromise

Question 22

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Answer 22

Definition: Reflux of gastroduodenal contents into esophagus due to improper lower esophageal sphincter relaxation

S/S: Heartburn, regurgitation, dysphagia

MGMT: 1. Avoid high-fat food, onion, tomato chocolate, peppermint, citrus, tobacco, coffee, alcohol, 2. Elevate head on bed when sleeping and do not eat just before bedtime, 3. Ranitidine (Zantac) 150mg or Cimetidine (Tagamet) 400mg PO bid, or Rabeprazole (Aciphex) or Omeprazole (Prilosec) 20mg PO qd or bid, 4. If on Doxycycline for malaria chemoprophylaxis, take the doxy early in the day with a meal

Disposition: Evacuation usually not required

Question 23

HEADACHE

Answer 23

Definition: Headache

S/S: Episodic or chronic, secondary to stressor; unilateral or bilateral, localized or general, dull or band-like, with or without nausea/vomiting; sometimes associated with caffeine withdrawal, neck muscle tightness, teeth grinding; if atypical, check for elevated blood pressure, fever, neck rigidity, visual symptoms, photophobia, mental status changes, neurological weakness, rash, and hydration and treat per appropriate protocol

MGMT: 1. If caffeine withdrawal, consider caffeine 100-200mg (1-2 cups coffee), 2. Acetaminophen (Tylenol) 1000mg PO q6hrs or Ibuprofen (Motrin) 800mg PO tid or Naproxen (Naprosyn) 500mg PO bid, 3. If nausea/vomiting, Promethazine (Phenergan) 12.5-25mg PO/IM/IV or Ondansetron (Zofran) 4mg IV over 2-5 minutes or IM bid, 4. If dehydration suspected, PO or IV hydration, 5. If new-onset migraine suspected, refer to a medical officer; usually benign, but consider AMS, intracranial bleed, or meningitis

Disposition: Evacuation usually not required; Urgent evacuation if acute headache with fever, severe nausea/vomiting, mental status changes, focal neuro signs, or preceding seizures, LOC, or history of “it’s the worst headache of my life”

Question 24

INGROWN TOENAIL

Answer 24

Definition: Usually big toe; due to trimming nails in curved fashion, nail deformity, tight fitting shoes, and rotational toe deformity

S/S: Pain, edema, erythema, hyperkeratosis at lateral nail fold; pressure on nail margin increases pain

MGMT: 1. Partial toenail removal: clean site with soap, water, and betadine; local anesthesia through digital block using 1% lidocaine without epinephrine; apply tourniquet at base; remove lateral 1⁄4 of nail toward cuticle, using sharp scissors; separate nail from the underlying matrix and remove; curette posterior and lateral nail grooves to remove debris; rub matrix with silver nitrate stick; apply Mupirocin (Bactroban) and cover with nonadherent and dry sterile dressings; wash, clean, recheck wound and change dressing daily, 2. Acetaminophen (Tylenol) 1000mg PO q6h prn pain, 3. Systemic antibiotics usually not needed, however use Moxifloxacin (Avelox) 400mg PO qd x 10d or Azithromycin (Zithromax) 250mg 2 tabs PO day 1 then 1 tab PO day 2-5 if in tactical setting or infection (increasing pain, redness, and swelling)

Disposition: Evacuation usually not required

Question 25

JOINT INFECTION

Answer 25

Definition: Bacterial joint infection, septic arthritis, septic joint; may result from penetrating trauma
S/S: Fever and red swollen painful joint; pain with axial load; inability to straighten joint; history of animal or human

bite, needle aspiration of joint effusion, gonorrhea

MGMT: 1. Immobilize joint, 2. Ertapenem (Invanz) 1gm IV/IM daily or Ceftriaxone (Rocephin) 2gm IV/IM bid, 3. Acetaminophen (Tylenol) 1000mg PO q6h or Ibuprofen (Motrin) 800mg PO tid prn pain

Disposition: Priority evacuation

Question 26

LACERATION

Answer 26

Definition: Skin laceration
S/S: Simple uncomplicated laceration of skin without involvement of deeper structures

MGMT: 1: Irrigate and clean wound thoroughly, 2. Prepare area in sterile fashion, 3. Provide local anesthesia with 1% Lidocaine, 4. Close with absorbable suture, non-absorbable suture, dermabond, or steri-strips as dependent on depth of wound, 5. If dirty wound or environment, Clindamycin (Cleocin) 300-450mg PO q6h or TMP-SMZ (Septra) DS PO bid or Moxifloxacin (Avelox) 400mg PO qd x 10 d, 6. Check tetanus status and treat as needed; do not suture if wound is > 12 h old (> 24 h on face), or if puncture/bite wound

Disposition: Evacuation usually not required

Question 27

MALARIA

Answer 27

Definition: Protozoan infection transmitted by Anopheles mosquito; prevention through personal protective measures is the key (anti-malarial meds, DEET, permethrin, minimize exposed skin)

S/S: History of travel to malaria-endemic area, non-compliance with anti-malarial meds and/or personal protective measures; malaise, fatigue, and myalgia followed by recurrent episodes of fevers, chills, rigors, profuse sweats, headache, backache, nausea, vomiting, diarrhea; tachycardia, orthostatic hypotension, tender hepatomegaly, moderate splenomegaly, and delirium

MGMT: 1. If available, attempt to diagnosis with lab (serial blood smears and rapid test); if unavailable and malaria suspected, empirically treat with Mefloquine (Larium) 750mg PO initially followed by 500mg PO 12h later or Malarone 4 tabs PO daily with food x 3 days or Chloroquine 10mg/kg base PO x 2 days then 5mg/kg PO x 1 day (concomitant Primaquine may also be required) 2. Acetaminophen (Tylenol) 1000mg PO q6h prn fever

Disposition: Routine evacuation for uncomplicated cases; Urgent evacuation if cerebral, pulmonary, or vital sign instability

Question 28

OTITIS EXTERNA

Answer 28

Definition: Bacterial or fungal infection of external ear canal, “swimmer’s ear”
S/S: Ear pain and pain with passive ear movement; swelling, erythema, pruritis in area; possible exudate and

erythema in ear canal, decreased auditory acuity, sensation of fullness and moisture in ear

MGMT: 1. Gatifloxacin (Zymar) 0.3% 4 drops in affected ear q2h while awake and laying on side for at least 5 minutes; ophthalmic used to minimize meds carried, but if available, Cortisporin otic 5 drops tid-qid until 48h after symptoms resolve, 2. Sterile dry dressing wick into ear canal, 3. (Acetaminophen) Tylenol 1000mg PO q6h prn pain, 4. If no response or worsens, use Moxifloxacin (Avelox) 400mg PO daily x 10d or Azithromycin (Zithromax) 250mg 2 tabs PO day 1 then 1 tab PO day 2-5 , 5. No internal hearing protection until resolution

Disposition: Evacuation usually not required; Priority evacuation if “malignant” otitis externa (Severe headache, otorrhea (purulent ear drainage), cranial nerve palsy)

Question 29

OTITIS MEDIA

Answer 29

Definition: Eustachian tube dysfunction, viral infection, or bacterial infection of middle ear

S/S: Ear pain, +/- fever, decreased hearing, sensation of ear fullness; erythema and bulging of TM are hallmark signs, increased pressure may cause TM rupture and discharge; often noted with accompanying URI symptoms, recent air travel, or recent ascent to altitude

MGMT: 1. Acetaminophen (Tylenol) 1000mg PO q6h or Ibuprofen (Motrin) 800mg PO tid prn pain, 2. Oxymetazoline (Afrin) nasal spray 2 squirts per nostril bid (max 3 days), 3. If grossly apparent, or no resolution in 1- 2 d, add antibiotics: Moxifloxacin (Avelox) 400mg PO daily or TMP-SMZ (Septra) DS PO bid x 10d or Azithromycin (Zithromax) 250mg 2 tabs PO day 1 then 1 tab PO day 2-5

Disposition: Evacuation usually not required; Routine evacuation for TM rupture or complicated cases not responding to therapy

Question 30

PERITONSILLAR ABSCESS

Answer 30

Definition: Infection with abscess formation and pus collection between anterior and posterior tonsillar pillars, usually following acute episode of tonsillopharyngitis

S/S: Extreme sore throat or neck pain, dysphagia, dysphonia, fever, erythema, edema, asymmetry of oropharynx with deviation of uvula

MGMT: 1. Clindamycin (Cleocin) 300-450mg PO q6h or Amoxicillin/Clavulanic Acid (Augmentin) 500/125mg PO tid or 875/125mg PO bid or Ceftriaxone (Rocephin) 1gm IV/IM daily x 7d, 2. Acetaminophen (Tylenol) 1000mg PO q6h or Ibuprofen (Motrin) 800mg PO tid prn pain/fever, 3. If unresolving or worsening symptoms to include airway obstruction, the patient must be evacuated for needle aspiration or I&D (caution must be used to avoid carotid artery perforation)

Disposition: Routine evacuation; Priority evacuation if airway obstruction

Question 31

PNEUMONIA

Answer 31

Definition: Acute lung infection due to virus, mycoplasma, or other bacteria
S/S: Fever, chills, productive cough (dark yellow, green, red tinged), chest pain, malaise, wheezes, rhonchi and/or

rales, decreased breath sounds, dyspnea, tachypnea, SOB

MGMT: 1. If mild to moderate, Azithromycin (Zithromax) 250mg 2 tabs PO day 1 then 1 tab PO day 2-5 or Moxifloxacin (Avelox) 400mg PO daily x 5d or Doxycycline 100mg PO bid x 10 d; If severe, start with Ceftriaxone (Rocephin) 2gm q12h or Ertapenem (Invanz) daily IM/IV, then oral antibiotic regimen, 2. Acetaminophen (Tylenol) 1000mg PO q6h prn pain/fever, 3. Albuterol (Proventil) MDI 2 puffs qid prn wheezing, 4. PO hydration, 5. Pulse oximetry, 6. Oxygen if hypoxic, 7. If at altitude > 8000 ft, descend 1,500 – 3,000 feet; differential diagnosis should include HAPE, PE, and pneumothorax

Disposition: Priority evacuation; Urgent evacuation for severe dyspnea

Question 32

PULMONARY EMBOLUS (PE)

Answer 32

Definition: Usually occurs when leg DVT dislodges and enters pulmonary arterial circulation

S/S: Acute onset of dyspnea, tachypnea, tachycardia, localized chest pain, anxiety, diaphoresis (sweating), decreased oxygen saturation, full breath sounds with no wheezing, no prominent cough, and low-grade fever; usually proceeded by DVT with lower extremity pain, swelling, and tenderness with history of trauma, air travel, or long periods in sitting positions

MGMT: 1. Monitor with pulse oximetry and provide oxygen (if available), 2. Acetylsalicylic Acid (Aspirin) 325mg chew 2 tabs, 3. Morphine Sulfate (MSO4) 4mg IV initially then 2mg IV q5-15min prn pain, 4. Consider Myocardial Infarction and treat as per Chest Pain protocol, 5. If at altitude > 8,000ft, descend 1500–3000 ft as per HAPE protocol

Disposition: Urgent evacuation

Question 33

RENAL COLIC / KIDNEY STONES

Answer 33

Definition: Spasmodic kidney pain typically caused by kidney stone; may be associated with preceding lower urinary tract infection (UTI) or obstruction

S/S: Back pain, flank pain, nausea/vomiting, CVAT, fever, chills, frequency, urgency, dysuria

MGMT: 1. Moxifloxacin (Avelox) 400mg PO daily x 7d or Azithromycin (Zithromax) 250mg 2 tabs PO day 1 then 1 tab PO day 2-5 ; If PO not tolerated, Ceftriaxone (Rocephin) 2gm q12h or Ertapenem (Invanz) daily IM/IV, 2. Acetaminophen (Tylenol) 1000mg PO q6h or Ibuprofen (Motrin) 800mg PO tid prn pain, 3. Promethazine (Phenergan) 12.5-25mg IV or Ondansetron (Zofran) 4mg IV over 2 to 5 minutes or IM bid prn nausea/vomiting, 5. PO hydration, NS or LR IV at 250cc/hr if unable to tolerate PO, 6. monitor urine output

Disposition: Priority evacuation; may progress to life-threatening systemic infection and septic shock

Question 34

SEPSIS/SEPTIC SHOCK

Answer 34

Definition: Severe life-threatening bacterial blood infection, rapid onset, death may occur within 4-6 hrs without antibiotic therapy

S/S: Hypotension, fever, chills, tachycardia, altered mental status, dyspnea, possible purpuric skin rash

MGMT: 1. IV or IO access, 2. Ertapenem (Invanz) 1gm IV/IM daily or Ceftriaxone (Rocephin) 2gm IV/IM daily, q12hrs if considering meningitis, 3. If hypotensive, give 2L NS or LR bolus (if unavailable, give 1L Hextend), 4. If hypotension continues, give Epinephrine (1:1000) 0.5mg IM, repeat 2L NS bolus, and titrate fluids to maintain SBP > 90 mmHg (NOTE: May require 10L crystalloid fluids within first 24 hrs), 5. Monitor urine output with goal of 30cc/hr (insert foley catheter if available), 6. Monitor mental status and be prepared to manage airway

Disposition: Urgent evacuation

Question 35

SMOKE INHALATION

Answer 35

Definition: Common after closed space exposure to fire; consider airway burns, carbon monoxide poisoning, other toxin inhalation, and need for hyperbaric oxygen

S/S: History of smoke exposure, burns, singed nares, facial burns, coughing, respiratory distress

MGMT: 1. Refer to Airway Management protocol and consider early cricothyroidotomy or intubation, 2. Albuterol (Proventil) MDI 2-4 puffs q4-6h, 3. Dexamethasone (Decadron) 10mg IV/IM daily x 2 days, 4. Oxygen if available, 5. Limit exertion and activity

Disposition: Priority evacuation if significant inhalation; Urgent evacuation if respiratory distress

Question 36

SPRAINS & STRAINS

Answer 36

Definition: Sprain or strain of musculoskeletal structures
S/S: Swelling, pain, erythema, ecchymosis, tenderness, decreased range of motion

MGMT: 1. “RICE” (Rest, Ice, Compression, Elevation), 2. Orthosis/splint/crutches for pain relief and stability, 3. Ibuprofen (Motrin) 800mg PO tid or Naproxen (Naprosyn) 500mg PO bid prn pain, 4. If no fracture, initiate rehab immediately; active range of motion exercises as tolerated; encourage weight bearing as tolerated; suspect occult fracture if no improvement within one week

Disposition: Evacuation usually not required

Question 37

SUBUNGAL HEMATOMA

Answer 37

Definition: Collection of blood under the nail; typically occurs after trauma to fingernail or toenail S/S: Pain and purplish-black discoloration under nail

MGMT: 1. Decompress nail with large gauge needle introduced through nail over discolored area with a gentle but sustained rotating motion until underlying blood and pressure is relieved; gentle pressure to the nail immediately after the procedure may evacuate additional blood, 2. Acetaminophen (Tylenol) 1000mg PO q6h prn pain, 3. Tape/splint if fracture suspected

Disposition: Evacuation usually not required

Question 38

SYNCOPE

Answer 38

Definition: Orthostatic hypotension; fainting as a result of vasovagal response
S/S: Sudden and brief loss of consciousness, without seizures, and with return to normal mentation

MGMT: 1. Supportive care; place in supine position and ensure airway is open, should regain consciousness within a few seconds, if not: 2. Check blood glucose, and use oral glucose gel or sugar sublingually, 3. If no response, consider heat injury, anaphylaxis, cardiac, and pulmonary etiologies and treat as per protocol, 4. Check vitals and pulse oximetry, 5. Oxygen if available, 6. Cardiac monitoring

Disposition: Evacuation usually not required; unless other diagnosis or symptoms continue/recur

Question 39

TESTICULAR PAIN

Answer 39

Definition: Testicular pain due to torsion, epididymitis, orchitis, STDs, hernias, masses, and trauma

S/S: Torsion: sudden onset of pain, pain-induced nausea/vomiting, swelling, abnormal lie of testicle, symptoms increase with elevation, associated with activity; Epididymitis: gradual onset of worsening pain, +/- fever, +/- dysuria, +/- trauma

MGMT: 1. If torsion suspected, manually detorse by rotating outward “open the book”, if pain increases attempt once to rotate in opposite direction, 2. If other cause suspected, consider and treat as per Urinary Tract Infection protocol and treat pain as per Pain Management protocol

Disposition: Urgent evacuation for unrelieved torsion; Priority evacuation for relieved torsion; for other causes consider evacuation as symptoms warrant or treatment fails

Question 40

TONSILLOPHARYNGITIS

Answer 40

Definition: Acute bacterial or viral infection/inflammation of the pharynx, 1⁄4 caused by Group A Beta Hemolytic Streptococcus (GABHS)

S/S: Sore throat, enlarged and edematous tonsils, erythema and exudates, palatal petechiae, anterior cervical lymphadenopathy; fever > 102.5 suggestive of bacterial cause; throat culture is most accurate test for GABHS

MGMT: 1. Salt water gargles, 2. Acetaminophen (Tylenol) 1000mg PO q6h, 3. If bacterial suspected, Azithromycin (Zithromax) 500mg PO daily x 3 days, 4) Observe and treat as per Peritonsillar Abscess protocol as required, 5) Consider concurrent infection with Ebstein-Barr virus (Infectious Mononucleosis)

Disposition: Evacuation usually not required

Question 41

URINARY TRACT INFECTION (UTI)

Answer 41

Definition: Infection of urinary tract; more common in females, tactical setting, dehydration, kidney stones
S/S: Frequency, urgency, dysuria; no CVAT/back/flank pain, no fever; possible cloudy malodorous or dark urine,

suprapubic discomfort

MGMT: 1. Moxifloxacin (Avelox) 400mg PO daily x 3d and Azithromycin (Zithromax) 1000mg x 1 dose (to treat for STDs), 2. Acetaminophen (Tylenol) 1000mg q6h prn pain, 3. PO hydration, 4. If fever, CVAT, back pain, or flank pain, suspect and treat per Renal Colic protocol

Disposition: Evacuation usually not required; Routine evacuation if symptoms worsen or no resolution

Question 42

Length Conversions

Answer 42

1 inch = 2.54 cm
1 foot = 30.5 cm = 0.305 m 1 yard = 0.91 m
1 mile = 1.6 km

1 mm = 0.1 cm = 0.039 in 1 cm = 10 mm = 0.39 in 1 m = 100 cm = 39 in
1 km = 100 m = 1093 yd

Question 43

Weight Conversions

Answer 43

1 oz = 30 g
1 lb = 16 oz = 0.45 kg
1 ton = 2000 lbs = 907 kg

1 grain = 65 mg

1 g = 001 kg = 0.36 oz
1 kg = 1000 g = 2.2 lbs
1 ton (metric) = 1000 kg = 2200 lbs

Question 44

Volume Conversions

Answer 44

1 fl oz = 30 ml = 30 cc
1 US Gal = 128 fl oz = 3785 ml

1 cc = 0.001 liter
1 ml = 1 cc = 0.34 fl oz
1 liter = 1000 ml = 340 fl oz

Question 45

Temperature Conversions

Answer 45

F = (1.8) X C + 32

C = (F – 32) / (1.8)

Question 46

The Ranger Medic Code

Answer 46

1. I will always remember that these are the finest Infantry on this earth, and that as such they deserve the finest health care.
2. No Ranger or Ranger dependent who comes to me for health care will ever be turned away without their needs being addressed, even if their paperwork/administrative requirements are not in order.
3. I will never let slip my mind the fact that in chaos of battle, I am all that stands between that bleeding, wounded Ranger and the finality of death. I will perform my job with such skill that the grim reaper will walk away empty-handed.
4. I will always remember that I must not only treat wounded Rangers, I must also carry them sometimes. I will maintain the physical conditioning necessary to accomplish this.
5. I will always remember that uniforms, weapons and supplies can all be DX’d but that each Ranger only comes with one body. I will never jeopardize the safety and/or recovery of that body by performing medical tasks beyond my skill and training.
6. I will always be cognizant of the fact that people do not suddenly get well after 1700 hours and on weekends, and that as such, I will willingly provide or coordinate for health care 24 hours a day, 7 days a week.
7. I will never do anything stupid because “they” or “regulations” require it to be so. I will find a way to accomplish my mission and serve the Rangers of this Regiment.
8. I will always remember that everything I use is paid for by US citizens. I will remember those tax dollars are collected from the American people and given to the Rangers because those people believe that in exchange for that money they will be kept safe from the tyrants of the world.
9. I will never forget that this is an Infantry unit supported by a medical team; not a medical team supported by a plethora of Infantry.
10. I will never forget that when the tyrants of the earth look towards the USA and plot mischief, they see a wall of cold steel backed up by determined men wearing Tan Berets; and then they plot their mischief somewhere else. The extent to which I support that wall is the extent to which I have a right to consume oxygen.

Question 47

Quotes

Answer 47

“It is not the strongest of the species that survive, but the one most responsive to change”-Charles Darwin

“Greater love has no one than this, that he lay down his life for his friends.”-John 15:13 (NIV)

“The quality of a person’s life is in direct proportion to their commitment to excellence, regardless of their chosen endeavor”
-Vince Lombardi

“To know what you know and to know what you don’t know, that is knowledge”-Confucius

Question 48

The Ranger Creed

Answer 48

• Recognizing that I volunteered as Ranger, fully knowing the hazards of my chosen profession, I will always endeavor to uphold the prestige, honor, and high esprit de corps of my Ranger Regiment.
• Acknowledging the fact that a Ranger is a more elite soldier who arrives at the cutting edge of battle by land, sea, or air, I accept the fact that as a Ranger, my country expects me to move further, faster and fight harder than any other soldier.
• Never shall I fail my comrades. I will always keep myself mentally alert, physically strong, and morally straight and I will shoulder more than my share of the task whatever it may be, one hundred percent and then some.
• Gallantly will I show the world that I am a specially selected and well trained soldier. My courtesy to superior officers, neatness of dress, and care of equipment shall set the example for others to follow.
• Energetically will I meet the enemies of my country. I shall defeat them on the field of battle for I am better trained and will fight with all my might. Surrender is not a Ranger word. I will never leave a fallen comrade to fall into the hands of the enemy, and under no circumstances will I ever embarrass my country.
• Readily will I display the intestinal fortitude required to fight on to the Ranger objective and complete the mission, though I be the lone survivor.

Rangers Lead the Way

Question 49

THE 8 “CRITICAL” RFR TASKS:

Answer 49

1) Contain Scene and Assess Casualties o Return Fire and Secure Scene

o Direct Casualties to Cover
o Evaluate for Life Threatening Injuries
o Triage – Immediate, Delayed, Minimal, Expectant o Call Medical Personnel for Assistance as Required

2) Rapidly Identify and Control Massive Hemorrhage o Direct & Indirect Pressure

o Tourniquet
o Emergency Trauma Dressing

3) Inspect and Ensure Patent Airway o Open and Clear Airway

o Nasopharyngeal Airway

4) Treat Life Threatening Torso Injuries o Occlusive Seal Dressing

o Needle Decompression
o Abdominal wound management

5) Inspect for Bleeding, Gain IV Access, Manage Shock o Head to Toe Blood Sweeps

o 18 Gauge Saline Lock
o IV Fluids when dictated by Shock o Prevent Hypothermia

6) Control Pain and Prevent Infection o Combat Wound Pill Pack

7) Aid and Litter Team
o Package and Prepare for Transfer o SKEDCO, Litters, Manual Carries

8) Leader Coordinated Evacuation
o Casualty Precedence – Critical (Urgent), Priority, Routine o CASEVAC or MEDEVAC Coordination