Travel Medicine I

Front 1

What "different" exposure factors put travelers at risk?

Back 1

– culture
– activities
– food
– diseases
– environmental risks

Front 2

How distance from the known puts travelers at risk?

Back 2

– routines
– culture
– support system
• social
• medical
• legal
– “rules of conduct”

Front 3

What is included in the travel medicine consultation?

Back 3

 Assess fitness for travel
 Assess need for preventive measures
 Counsel about illness prevention
 Assessment and care of the returned traveler

Front 4

What are the geographic considerations in a travel medicine consult?

Back 4

endemic diseases
- climate
- altitude
- availability of medical care
- political and cultural scenario

Front 5

Regarding the potential traveling host - who are they and what will they be doing... What are the host considerations?

Back 5

- underlying medical condition
- chronic conditions (CAD, COPD, DM, HIV)
- intermittent conditions (IBD, seizures, psych)
- special categories (pregnant, pediatric, elderly)
- fitness for planned travel
- purpose of travel
- behavior
 risk taking

Front 6

What are the disease specific issues that could make a traveler sick?

Back 6

- morbidity and mortality of specific illnesses
- relative risk to this traveler according to geography and host factors

Front 7

In travelers, what are the specific preventive measures to prevent them from getting sick?

Back 7

- vaccines
- prophylactic medications
- self-treatment
- behavior modification

Front 8

Besides shots, what else needs to be considered?

Back 8

 Food and water safety
 Malaria
 Insect protection
 Personal safety
 Vaccine preventable illness

Front 9

What are the basics of food and water safety?

Back 9

 Many diseases enter by oral route
- agents of traveler‟s diarrhea, protozoan and helminth parasites, Hep A, cholera, typhoid, brucella, TB
 Choose food and drink wisely
 Wash hands
“Boil it, cook it, peel it, or forget it”

Front 10

What are the charcteristics of "typical" traveler's diarrhea?

Back 10

 travelers from industrialized to developing areas
 watery stools, cramps, urgency, self-limited, low-grade fever or nausea
 90% of cases present in the first 2 weeks of travel
30-70% of travelers on a 2 week trip to the developing world will develop diarrhea

Front 11

What is the etiology of travelers diarrhea?

Back 11

Bacterial 85%
Parasitic 5-15%
Viral <5%

Front 12

What are the three key elements of prevention of diarrhea?

Back 12

 Educate traveler to avoid risks
 Consider chemoprophylaxis in some situations
 Provide plan for self-therapy

Front 13

When considering chemoprophylaxis, what does one consider?

Back 13

- short trip with important itinerary
- traveler at special risk

Front 14

What is included in a self-therapy plan for diarrhea?

Back 14

- hydration (e.g. ORS)
- symptom relief (e.g. loperimide)
- antimicrobial (e.g. flouroquinolone, macrolide)

Front 15

What are the key elements in manangement of traveler's diarrhea?

Back 15

 Hydration
- Avoid caffeine
- A bit of sugar and salt
 Symptom relief
- Imodium
 Antibiotics if severe
- quinolones or azithromycin for adults, azithromycin, tmp/smx for kids

Front 16

What are the antibiotics for adult severe diarrhea?

Back 16

quinolones or azithromycine

Front 17

What are the antibiotics for children with severe diarrhea?

Back 17

azithromycine or tmp/smx

Front 18

Which pathogens have quinolone resistance in traveler's diarrhea?

Back 18

 Campylobacter jejuni
 Salmonella

Front 19

What are the key features of quinolone resistance for C.jejuni?

Back 19

 Campylobacter jejuni
- Quinolone resistance increasing in prevalence
- South-east Asia, Latin America
- Usually responds to azithromycin
- Risk exists for resistance to azithromycin

Front 20

List the four new agents to prevent TD?

Back 20

 Anti-secretory agents
 Rifaximin – nonabsorbable antibiotic
 Probiotics - few good data, but safe
 Dukoral vaccine - licensed in Canada

Front 21

List the new anti-secretory agents:

Back 21

- Racecadotril (Hidrasec) – enkephalinase inhibitor
- Zaldaride – inhibition of intestinal calmodulin
- Provir / SB-NSF / sp-303 – derivative of sap from Croton lechleri tree
 available as non-regulated food supplement

Front 22

What is special about rifaximin?

Back 22

– nonabsorbable antibiotic
- Licensed for treatment of ETEC
- May be better as prophylactic – now licenced for that indication

Front 23

What is special about probiotics?

Back 23

- few good data, but safe
- Lactobacillus GG
- Saccharomyces boulardii

Front 24

What is special about the Dukoral vaccine?

Back 24

- licensed in Canada
- killed vaccine against cholera
- 85% effective against diarrhea due to Enterotixigenic E. coli (ETEC) - 3 mos

Front 25

What diseases are carried by insects?

Back 25

Yellow Fever,
Dengue,
Japanese Encephalitis, Filariasis,
Sleeping sickness,
Typhus,
and more

Front 26

Provide epi info on malaria

Back 26

 40% of world‟s population at risk
 2 million deaths yearly
- 1 million are children
 Increasing resistance to anti-malarials

Front 27

What are the presentations of Dengue?

Back 27

- Dengue fever – “break-bone fever”
-- typically begin 4-7 days after exposure (range 3-14d)
-- common findings fever, frontal headache, myalagia
-- 50% have skin findings - diffuse erythma or maculopapular or petechial erruption
-- intense pruritis may be present at end of febrile period.
-- leukopenia, thrombocytopenia, and elevated transaminases are common


- Dengue hemorrhagic fever
- - occur in persons who have a second dengue infections with a different serotype (4 serotypes)

Front 28

Where is dengue found?

Back 28

Increasing incidence in many parts of world (Asia, Latin America)

Front 29

Provide geodistribution information on Chikungunya fever?

Back 29

 Historically Africa and Asia
 Major recent outbreak from Indian Ocean area
- Comoros, Mauritius, Reunion and Seychelles
- Affected many travelers
 Recent autochthonous transmission in Italy, Singapore

Front 30

Describe clinical Si/Sx of Chikungunya Fever

Back 30

- Nonspecific flu-like
- Frequently mistaken for dengue
- Severe joint pains
- May be persistent

Front 31

Describe how and where one gets Trypansomoiasis ex Tanzania?

Back 31

 In recent years, >18 travelers to Tanzania and surrounding areas have been diagnosed with East African Trypanosomiasis
- game parks, safaris
 Tourist cases are sentinel for epidemic activity in the area (Angola, Uganda, Sudan, DRC)

Front 32

List different rickettsial infections

Back 32

RMSF, typhus (all types), tick typhus, Q fever

Front 33

Where do travelers get tick typhus?

Back 33

 Mediterranean – R. conori
 Africa – R. africae
- vectors are rapid feeders
- short exposure can result in infx
- exposure – walking through brush, cattle areas

Front 34

How does a traveler protect themselves from insects?

Back 34

 DEET (di-ethyl toluamide)
 Picaridin as possible alternative – now available up to 20% - same correlation
 Permethrin for clothes
 Bed nets
 Appropriate clothing

Front 35

What are the specifics of DEET protection?

Back 35

 20-30% for skin for several hours protection
 Concentration correlates with length of protection, not immediate efficacy
 Concentrations >50% provide little added benefit

Front 36

What is the advise for travelers traveling to areas where they might be exposed to trypanosomiasis?

Back 36

 Tsetse flies are relatively resistant to DEET and permethrin
 Tsetse flies prefer dark colors
 Long sleeves, long pants

Front 37

Where are you at greatest risk of getting P.vivax?

Back 37

India, central america

Front 38

where are you at greatest risk of getting p.falciparium?

Back 38

africa, haiti, and new guinea

Front 39

where are you at greatest risk fo getting p.vivax and p.falciparium

Back 39

SEA, Oceania and S.america

Front 40

what is the number one infectious disease killer of travelers?

Back 40

malaria

Front 41

How long do you need to have a steady state of chloroquine for prophylaxis?

Back 41

2 months

Front 42

What stage does chloroquine work on?

Back 42

only acts on erythrocytic stage

Front 43

does chloroquine prevent recurrence?

Back 43

no

Front 44

Antimalarial prophylaxis - what is the dose and regimen of chloroquine for prophylaxis

Back 44

300mb base (500mg salt) q week
- start 2 weeks before travel, once a week during travel and one month after travel

Front 45

se of chloroquine

Back 45

HA, dizziness, confusion, nausea, lower seizure trehashold, tinnitus
-- african decent may increase rate of pruritis and may make psoriasis worse

Front 46

What blood stage does chloroquine effect?

Back 46

Only works on the erythrocytic cycle (merozoites).
It does not work on the hypnozoites at all. - four weeks to wait for all merozoites to come out of the liver
- does not prevent recurrence

Front 47

For antimalarial chemoprophylaxis what is the dose and regimen for chloroquine phosphate?

Back 47

300mg base (500mg salt) q weekly, start 2 weeks before, weekly in endemic area and 4 weeeks post endemic travel

Front 48

Antimalarial chemoprophylaxis - dose and regimen of hydroxychlorquine sulfate (plaquinel)?

Back 48

310 base (400mg salt) q week - start 2 weeks before travel, weekly during travel, and 4 weeks post travel

Front 49

dose of mefloquine (Larium)?

Back 49

250mg q wk, start 2 weeks prior to travel, weekly in endemic area and 4 weeks post

Front 50

SE of mefloquine

Back 50

increased disturbed sleep, anxiety, dreams
- helps you remember dreams already having
- lowers seizure threshold, prolongs QT interval
- avoid with sig psych h/o, seizures, arrythmia (block)

Front 51

What is the preg and kid recs with mefloquine?

Back 51

safe for last 2 semesters and kids >5kg

Front 52

what is dose of doxycycline for antimalarial chemoprophylaxis?

Back 52

100 mg qd, start 2 days b4 travel, daily in endemic area and 4 weeks post

Front 53

Issues with doxy?

Back 53

short 1/2 life - missed doses increase risk for lat presentation

Front 54

In antimalarial chemoprophylaxis, what life cycle stage does doxy work on?

Back 54

Only works on the erythrocytic cycle (merozoites).
It does not work on the hypnozoites at all.

Front 55

Can you treat malaria with doxy?

Back 55

yes, but very slow acting to treat - it is a better prophylaxis med.

Front 56

SEs of doxy

Back 56

photosensitivity, yeast infections, esophageal ulcerations, nausa
- photosensitivity has no relation to the amount of melanin in skin.
-stains teeth

Front 57

can preggos and kids <8 take doxy?

Back 57

NO! Contraindicated in preggos and kids less than 5kg!

Front 58

Antimalaria Chemoprophylaxis - Dose and regimen for atovaquone/roguanil (Malarone)?

Back 58

250mg/100mg q day,
- start 2 days before, daily in endemic area and one week post

Front 59

Which drugs are good for areas that are chloroquine and mefloquine resistant?

Back 59

-doxy
-atovaquone/progranil
-primaquine

Front 60

SE malarone

Back 60

GI, HA

Front 61

Regarding atovaquone/proguanil (Malarone), can preggos and breas-feeding or kids take it?

Back 61

No data for preggos or breastfeeding
- kids take wt based dose
(fyi, progquanil should not be taken while breasteeding per manufacterer)

Front 62

Is malarone a causal antimalarial chemoprophylaxis med?

Back 62

NO, not causal for all liver stages especially vivax and ovale

Front 63

Whats bad about malarone

Back 63

$$$$$$$$$$$$

Front 64

In antimalarial chemoprophylaxis, what medicine is a causal med and will get the hypnozoite stage?

Back 64

primaquine - that is why it is a terminal proph for vivax/ovale areas

Front 65

dosing/regimen for primaquine

Back 65

Terminal dosing: 15-30mg qd for two weeks
Primary proph - 30mg qd, 2 days before, daily in endemic area and 1 week post

Front 66

SEs of primaquine

Back 66

MUSt GET G6PD status BEFORE PRESCRIBING - hemolysis in g6pd deficient

Front 67

What is the dose and regimen of Chloroquine/progruanil for antimalarial chemoprophylaxis?

Back 67

dont use - poor efficacy

Front 68

malaria self-testing

Back 68

- reliable in trained hands
- questionable reliability in others
- if sick hard to do by self
- dipstick methods (ParaSight F, ICT Malaria PF)

Front 69

When is self-TREATMENT for malaria okay?

Back 69

only in situations where medical care is not immediately available (24hrs)
- NOT a substitute for medical care
- take dose and proceed to medical care

Front 70

Ways to self-treat for malaria?

Back 70

- Fansidar (pyrimethamine/sulfadoxone) 3 tablets x 1
- Malarone 4 tablets qd x3d
- Mefloquine maybe
- Coartem (ACT)

Front 71

What are the live vaccines?

Back 71

measles
mumps
rubella
polio
yellow fever
typhoid
varicella
tuberculosis (BCG)
smallpox
nasal flu

Front 72

What are the inactivated vaccines?

Back 72

tetanus
diphtheria
pertussis
polio
pneumococcal
influenza
typhoid
hepatitis A
hepatitis B
meningitis
Japanese encephalitis
rabies
cholera
H. influenza type B
plague
anthrax
tick-borne encephalitis

Front 73

what vaccines need updated?

Back 73

 First verify they received primary series!
 Can accelerate pediatric schedules
 DPT, Td or Tdap, MMR, varicella (need to make sure second measles given)
 Polio – OPV or IPV x 1 adult booster
- Western hemisphere is polio-free
- (except for that nasty little outbreak on Hispaniola)
 Pneumovax - now smokers
 Influenza – year-round in tropics

Front 74

what vaccine is mandated by WHO?

Back 74

YF - Only vaccine currently mandated by WHO regulations for certain destinations
- Goal is to prevent importation of disease into disease-free area which has potential for establishment of zoonotic cycle
 Must be given at approved center (Yellow card)
- each country makes their own rules to protect the country not individuals!

Front 75

How is YFvaccine produced?

Back 75

Live attenuated vaccine produced in chick embryos – single dose

Front 76

How often do you need to boost YF?

Back 76

Excellent efficacy – probably lifelong
- international regulations require 10 yr booster

Front 77

Any YF vaccine restrictions to preggos or kiddos?

Back 77

Pregnancy – relative contraindication
- live virus - pregnant women were targeted without problems
 Infancy – contraindicated < 6 mo - encepholitis <4months old, prefer to wait until >9months

Front 78

SEs with YF vaccine?

Back 78

 Possible increased risk of serious SE w age - EID Sept 2001
- >65 3.7 x risk
- >75 11 x risk
- can write waiver in areas with low risk of transmission but high risk - vaccinate
 Severe YF-vaccine related illness (MOSF) – Lancet Sept 2001
 Severe illness with thymus disorders

Front 79

What is the first most common vaccine for preventable disease in travelers?

Back 79

influenza

Front 80

What is the 2nd most common vaccine preventable disease of travelers?

Back 80

- Hepatitis A
- 5 in 1,000 per week off usual tourist routes

Front 81

What is the morbidity of hepatitis A

Back 81

 Significant morbidity
- 10 % of (1-14 yr.) hospitalized, 20 % of (15-19 yr) hospitalized
- Adult time off work - 4 weeks
- 2 % mortality in >40 y/o

Front 82

Hepatitis A - when is it good to give serum immune globulin?

Back 82

Serum Immune globulin – passive protection
- immediate travel (<4wk)
- short term protection (< 6 mos)
- can give with vaccine
 but do you need to?

Front 83

What are the 2 inactivated hepA vaccines?

Back 83

- 2 inactivated vaccines
 Vaqta®
 Havrix®
- 1st dose protects for 6 months
- 2nd dose – maybe lifelong
- Vaccines licensed for > 1 yrs of age
- Now integrated into routine schedule in US

Front 84

Who is recommended to get HepB vaccine?

Back 84

 Transmitted by sex, blood products, needles, health care
 Risk depends on area and behavior
 Third most common vaccine-preventable disease in travelers
- Short term travelers - 1/2,000 - 1/10,000 per month of stay
- Expatriates - 1/1,000 per month of stay

Front 85

What HBV vaccines are available and give dosing

Back 85

- 2 options –
 Recombivax HB
 Engerix B
- Both licensed for 3 dose series, 0, 1, 6 months
 accelerated schedules possible
- Recombivax approved for 2 dose schedule for 11-15 y/o

Front 86

What is the name of the combined HAV and HBV vaccine? Give dosing

Back 86

Twinrix®
 Seroconversion with combined HepA/B vaccine Dose: 0,1,6 months

Front 87

What is the accelorated Twinrix schedule?

Back 87

Twinrix Accelerated Schedule (day 0,7,21, 1 yr) (n=100/grp)
- Anti-HAV Anti-HBV
 Mo. Sc (%) GMT Sp(%) GMT
 1 100 832 82 123
 2 100 956 86 83
 3 100 662 97 247

Front 88

Do you need a titer verification for HAV or HBV vaccine in travelers?

Back 88

No - do not need to in HBV vaccine and
- DO NOT Want to for HAV - just below lab assays so it says there was no seroconversion even if there was

Front 89

What three typhoid vaccines are available?

Back 89

- Capsular polysaccharide (Typhum Vi®)
 > 2 yrs of age, single injection, 2-3 yrs protection
- Oral live attenuated (Vivotef Berna®)
 > 6 yrs of age, 5 yrs protection, less convenient
 4 capsules taken every other day
- Heat phenol inactivated vaccine (series of 2)
 lots of SE, but cheaper, > 6mo age, 3 yrs protection

Front 90

Who should get typhoid vacc?
Is it effective?

Back 90

 Recommended for “adventurous eaters”, longer term stay
 Efficacy about 75% for all
 Effective at 2-4 wks

Front 91

What is the restriction with oral typhoid vacc?

Back 91

cannot be on antibiotics
- rifaxiamine kills typhoid on way down

Front 92

if you had the typhoid vaccine, can you get paratyphoid?

Back 92

Yes

Front 93

Who needs to get the meningococcal vaccine?

Back 93

 “meningitis belt” of Africa, dry season (Dec-June)
 required by Saudi Arabia for Hajj and Umla

Front 94

What are the two US vaccines for meningococcal vaccine?

Back 94

- capsular polysaccharide (MPSV4 - Menimmune®)
 Variable duration (3-5 yrs)
 Poorly immunogenic < 2 y/o
- Conjugate (MCV4 - Menactra® )
 Much longer duration - ? Need for revaccination?
 Licensed in US for 2-55 y/o, likely to be expanded
 Conjugate C vaccine used in Europe/Canada in >2mos

Front 95

What strains do the US meningococcal vaccine protect from?

Back 95

 2 US vaccine options: both quadrivalent A/C/Y/W-135

Front 96

What is the draw back of capsular polysaccharide (MPSV4 - Menimmune®)?

Back 96

does not produce good immunity in kiddos <2 y/o

Front 97

Who should get the japanese encephalitis vaccine?

Back 97

 Risk is seasonal, depends on rural exposure, insect protection

Front 98

Why give JEV?

Back 98

high morbidity and mortality if get clincal disease

Front 99

What is the current JEV for adults? and dosing schedule?

Back 99

 Japanese Encephalitis Virus Vaccine IC51
- IXIARO
- So far only approved for adults
- 2 doses 1 month apart
- Better side effect profile
- $$$$$$$$$

Front 100

What is the current JEV for children? and dosing schedule?

Back 100

 Biken Vaccine: inactivated, from mouse brain
- Series of 3: day 0, 7, 14-30
- booster q 3 yrs? – duration unknown
- effective at 10 days
- High rate of side effects
- 20% with mild – fever, myalgia, malaise, HA
- 0.6% severe – urticaria, angioedema, anaphylaxis
- can occur up to 10d or more after vaccine
- $$$
- No longer in production! But still available for kids

Front 101

Who can carry rabies?

Back 101

Any mammal can carry rabies

Front 102

What are the three Rabies vaccine options for Pre-exposure prophylaxis?
- give dosing schedule

Back 102

 Pre-exposure prophylaxis:
- Human diploid cell rabies vaccine (HDCV)
- Rabies Vaccine Adsorbed (RVA)
- Purified Chick Embryo Cell (PCEC)
 series of 3: day 0, 7, 21 or 28

Front 103

if you had the pre-exposure prophylaxis for rabies, do you need a post-exposure if exposed?

Back 103

Yes - Does not eliminate need for post-exposure prophylaxis

Front 104

What is the first step in post-exposure rabies prophylaxis?

Back 104

 Wash wound with copious soap and water

Front 105

What is the Rabies Post-Exposure Prophylaxis if pt had NO prior vaccine?

Back 105

 NO prior vaccine:
- Rabies Immune Globulin 20 I.U./kg – as much as possible infiltrated around wound, remainder IM
- HDCV, RVA, or PCEC day 0, 3, 7, 14, 28 (will probably drop last dose for most persons)

Front 106

What is the rabie post-exposure prophylaxis if had pre-exposure series?

Back 106

 Prior pre-exposure series:
- NO RIG
- HDCV, RVA, or PCEC day 0, 3

Front 107

What are the issues of rabies treatment overseas?

Back 107

 Issues overseas:
- RIG is hard to find, expensive
- old nerve cell vaccines still in use in some areas – poor safety, efficacy

Front 108

Who are potentially contraindicated for live vaccines?

Back 108

 Live vaccines – potentially contraindicated in pregnancy, immunocompromised persons

Front 109

When should live vaccines be given?
Who does not meet these criteria?

Back 109

 Live injected vaccines should preferably be given same day or separated by 4 weeks
- (n.a. for OPV, rotavirus, and no longer for YF, MMR)

Front 110

What does immune globuline interfere with?

Back 110

 Immune globulin interferes with MMR and varicella
- delay live vaccine for months

Front 111

malaria self-testing

Back 111

- reliable in trained hands
- questionable reliability in others
- if sick hard to do by self
- dipstick methods (ParaSight F, ICT Malaria PF)

Front 112

When is self-TREATMENT for malaria okay?

Back 112

only in situations where medical care is not immediately available (24hrs)
- NOT a substitute for medical care
- take dose and proceed to medical care

Front 113

Ways to self-treat for malaria?

Back 113

- Fansidar (pyrimethamine/sulfadoxone) 3 tablets x 1
- Malarone 4 tablets qd x3d
- Mefloquine maybe
- Coartem (ACT)

Front 114

What are other sources of information for traveler's health?

Back 114

 1. CDC Web Page: http://www.cdc.gov
 2. World Health Organization: http://www.who.org, International Travel and Health Section: http://www.who.int/ith
 3. Shoreland Web Page: http://www.tripprep.com for information arranged alphabetically by country.
4. International Society of Travel Medicine: http://www.istm.org

Front 115

Who can get inactivated vaccines?

Back 115

 Inactive vaccines generally relatively safe for pregnancy, immunocompromised

Front 116

What are the top three causes of mortality in travelers?

Back 116

- cardiovascular 49%
- Injury - 22%
- medical 14%

Front 117

What are the top three injury deaths in travelers?

Back 117

- MVCs - 27%
- Drowning - 18%
- Homocide - 8%

Front 118

What personal safety measures do travelers need to be educated on?

Back 118

 Personal Safety
 Injury prevention
- vehicular (driving, seat belts, mopeds)
- swimming
- feet (shoes)
 know limits
 Sun and heat exposure
 Altitude
 Sex
 Traveler‟s insurance

Front 119

What special issues need to be discussed with immigrants?

Back 119

 Immigrants
 Carry disease with them
- Disease may not be recognized
- Disease may be transmitted to new area
 No immunity to endemic diseases of new home
 Legal and socio-political aspects of providing health care
- Screening – public health vs. personal privacy
- Interventions – cost-effectiveness, follow-up
 Cultural barriers
- Communication
- Traditional patterns of health care

Front 120

What special issues occur with refugees?

Back 120

 Same as immigrants plus:
- Involuntary displacement
- Loss of belongings, structure, family
- Often due to violence
- Psychiatric trauma
- Physical trauma

Front 121

What are the issues with refugee camps?

Back 121

- Crowding
- Sanitation
- Food supply
- Epidemics

Front 122

What special issues occur with the military?

Back 122

 Primary concern is readiness and ability of troops to fight
 Short term preventative care of young healthy adults
 Structure and support system exist
 Psychiatric stress of battle
 Crowded living conditions
 Epidemics
 Sanitation and food not usually a problem

Front 123

What is frostbite (freezing injury)?

Back 123

inadequate bloodflow allows freezing causes tissue death
o -4C for tissue to freeze

Front 124

What are the predisposing factors of frostbite?

Back 124

Predisposing factors:
o normal vasoconstriction
o poor blood supply – tight clothing, cramped position, trauma with swelling, dehydration, shock, Raynaud’s, other peripheral vascular dz

Front 125

In frostbite, what does freezing and thawing do?

Back 125

Feezing and thawing results in ischemia, hypoxia, and microvascular damage
o While frozen is painless (white, hard); very painful after rewarming
o initial cyanosis, blebs
o ischemic gangrene
o axonal degeneration
o eventual autoamputation
 - cannot tell degree of tissue loss initially; often not for weeks
o delay surgery

Front 126

How do you treat frostbite?

Back 126

Therapy:
o hydrate (plasma volume expanders)
o feed
o rewarm (do not allow refreezing!) carefully
o sympathetic block, vasodilating drugs (Ca++ channel, etc) or
antiprostaglandins may help
o eventual surgery once degree of damage is demarcated
 some advocating early surgery with coverage
 platelet derived growth factor

Front 127

When does a person have hypothermia?

Back 127

core T < 35C
Does not require very cold temperatures, especially in debilitated individuals

Front 128

What are the predisposing factors to hypothermia?

Back 128

High surface area to mass ratio
Impaired vasoconstriction (EtOH, other drugs)
Age extremes

Front 129

What is mild hypothermia and releated s/s?

Back 129

Mild (32-35c):
= Increased HR, BP, CO. Shivering, mild incoordination, tachypnea,
mydriasis.

Front 130

What is moderate hypothermia and s/s?

Back 130

Moderate (30-32c): Slowing VS. Leftward shift of oxyhemoglobin dissociation curve--less 02 release. Cold diuresis. Hyper to hyporeflexia

Front 131

What is severe hypothermia and clinical sequella?

Back 131

Severe (<30c): Decreasing HR, BP, CO. No longer able to shiver. Osborne J wave on EKG; high risk of arrythmias when hypothermic. Myocardium is very irritable: decreased fibrillation threshold, decreased resting potential, conduction delay, prolonged action potential. Bronchorrhea. Ataxia, dysarthria, confusion, lethargy, coma, death.

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How do you treat hypothermia?

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- external warming
- internal warming
- gentle handling to avoid precipitationg arrhythmias.

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How do you do external warming for hypothermia?

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- remove from cold -
insulate
- warm H20 immersion heating
- blankets
- heated objects
- Don’t massage

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What is the most important thing about treating hypothermia?

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BEWARE OF PARADOXICAL TEMPERATURE AFTERDROP

External heat can cause peripheral vasodilatation, which can bring cool blood back to the heart, which cools the core and can worsen the situation, including precipitating arrythmias.

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How do you do internal warming for hypothermia?

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Warm IVF, Air/02, NGT/foley lavage. ?peritoneal/pleural lavage -
?practicality.

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What is the most important thing to remember with frostbite progression?

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
cannot tell degree of tissue loss initially; often not for weeks
 delay surgery

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What medications help with hypothermia induced arrythmias?

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Most arrythmias non-responsive to Rxs (except bretylium) until patient is warmed.

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If a pt is hypothermic and without vital signs, when can you pronounce them dead?

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“Authorities agree that hypothermia victims without vital signs (prolonged asystole) should not be pronounced dead until they have been rewarmed to 36C and remain unresponsive to CPR at that temperature” (Harrison’s Principles of Internal Medicine).
i.e. No one is dead until they are warm and dead.