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Military Preventive Medicine

STUDY
PLAY
Section 1
Intro to Preventative Medicine
What are the activities of Preventive Medicine found within military operations?
1) Cleanliness

2) Field Hygiene

3) Environmental Sanitation

4) Force Protection
What is the bridge that helps provide a strong relationship between the Command Staff & Military Medicine?
Preventative Medicine
Preservation of health cannot be accomplished via medical channels only.
1) Commander Responsibility

2) Legal & Regulatory basis
What is Preventative Medicine?
The anticipation, prediction, identification, surveillance, evaluation, prevention & control of disease and injuries
*What are the goals of Military Preventative Medicine?
1) Maintain health & operational performance of the force

2) Prevent disease, injury, & disability
* What are the foci of Military Preventative Medicine?
1) Safety orientation

2) Pro-active health programs

3) Trauma/sports injuries & communicable disease control (vs. chronic diseases)
What are some of the major contributions Preventative Medicine has provided to modern society?
1) Hospital isolation wards

2) Medical Surveillance (US Weather Bureau)

3) Identifying vectors in disease transmission

4) Water sanitation (Chlorination)

5) Vaccine Development (Yellow fever, Hep A & B)
Section 2
Medical Threat Assessment
*What is a medical threat?
*Composite of all ongoing or potential enemy actions and environmental conditions that will reduce combat effectiveness through wounding, injuring, causing disease or performance degredation

(During preparation for deployment, it is critical that commanders at strategic & operational levels acquire an estimate of the medical threat for the mission)
What is the driving force behind Force Health Protection (FHP)?
RISK (must accurately identify threats depending on who, what, where, & when)
What are the "Person Factors" that estimate risk (Who & What)?
1) Number

2) Demographics

3) Health Status

4) Psychosocial profile

5) Training

6) Equipment

7) Activity Level
What are the "Place Factors" that estimate risk (Where)?
1) Global position

2) Development & Stability

3) Terrain

4) Climate

5) Biomass

6) Enclosures
What are the "Time Factors" that estimate risk (When)?
1) Year/Season

2) Time of Day

3) Duration
This is raw data that MAY BE of interest to planners
Medical information
This is analyzed and interpreted data THAT IS of interest to planners
Medical intelligence
What is the significance of medical intelligence?
Operational level- develop health service support strategies
What are the "Strategic Sources" of MEDICAL intelligence?
National Committee for Military Intelligence (NCMI) is the single authoritative producer of medical and technical intelligence on foregin health threats and other medical intelligence issues to protect and advance US interests worldwide
What are the "Tactical Sources" of MEDICAL intelligence?
S2/G2/J2 and special Military Intelligence units in combat zone
* What does the NCMI provide?
1) Trends and Forecasts (Indications & Warnings)

2) Health risk/Hazard assessments

3) Health services assessment

4) Facility Database
* What does the NCMI NOT provide?
1) Recommend medical treatment protocol

2) Approved/Authorized prophylaxis

3) Medical Policy

4) Medical doctrine
What is the focus of the NCMI Risk Assessment?
What the commander needs to know

- What percentage of personnel are likely to be affected by a disease?

- How many days will likely be lost per case?
* What are the assumptions underlying the National Committee for Military Intelligence (NCMI) risk assessment?
1) A healthy US military force (routine vaccines, but no immunity to most tropical diseases)

2) Field conditions (e.e tents, crowding, field sanitation, and vector exposure)

3) Access to local economy

4) Minimal contact with household-type exposure in the local population
* What is the Risk Level Matrix?
A tool that can be used to determine level of risk during an activity using levels of disease severity & levels of disease expectance in troops
What is residual risk?
Risk remaining after known threats have been mitigated
Section 3
Medical Surveillance
Describe the historical significance of Disease & Non-Battle injuries (DNBI)
DNBI can have a rapid and widespread impact on the effectiveness of military organizations (Look at the Civil War)
*This is the ongoing collection and analysis of health data dissemination of information
Medical surveillance
*What are the three generic "purposes" of medical surveillance?
1) Identify public health problems

2) Stimulate public health interventions

3) Suggest hypotheses for epidemiological research
* What are the important public health "functions" of medical surveillance?
1) Detection of epidemics

2) Identification of significant events

3) Detection of changes in disease agents

4) Plans & Priorities for interventions

5) Projection of future health problems
*What do these important public health "functions" of medical surveillance serve as?
An early warning system
*What are the "objectives" of medical surveillance?
1) Determine extent of disease occurence (Baseline rates and trends)

2) Detect and monitor outbreaks

3) Indentify contacts & administer prophylaxis

4) Increase knowledge of disease processes

5) Generate hypotheses about disease etiology
What are the two types of surveillance?
1) Passive

2) Active
This type of surveillance is described as the following:

1) Provider Based

2) Mandated reporting

3) Most frequently used (local, state, public health systems, DoD)
Passive Surveillance
This type of surveillance is described as the following:

1) Health agency or PM based

2) Periodic field visits by project staff

3) Involves interviews, record reviews, pre-generate reports, etc
Active Surveillance
What are the advantages of "passive" surveillance?
1) Inexpensive

2) Easy to develop initially

3) Allows for internal comparisons
What are the drawbacks of "passive" surveillance?
1) Quality

2) Can miss local outbreaks
- Underreporting
- May miss a widespread problem if it is an internal system
What are the advantages of "active" surveillance?
1) Generally more accurate

2) Local outbreaks identified
What are the drawbacks of "active" surveillance?
1) More expensive

2) Difficult to develop initially
What is the TRISERVICE reportable events list?
1) Selected communicable and environmental diseases of military importance

2) Heat and cold injuries

3) Outbreak. generalized
There is a long list of diseases/events in the TRISERVICE reportable events. What diseases/events are NOT included in this list?
1) HIV/AIDS

2) Suicides

3) Occupational injuries/illnesses

~These are reported through other mechanisms
Describe the comprehensive military medical surveillance process
1) Threat/risk assessments

2) Hospital admission rates

3) Reportable medical events

4) DNBI rates
Section 4
Communicable Disease Control
What are the 3 levels of prevention?
1) Primary

2) Secondary

3) Tertiary
This level of prevention is prior to exposure to disease source; remove causes
Primary prevention
What is included in Primary prevention?
1) Health promotion/education

2) Nutrition/diet supplementation

3) Adequate housing, recreation, agreeable working conditions

4) Immunizations

5) Environmental sanitation

6) Protection against occupational hazards
This level of prevention occurs after exposure, but prior to the onset of symptoms or complications of the disease?
Secondary prevention
What is included in Secondary prevention?
1) Screening (cholesterol, BP, HIV, PKU, PAP, Mammogram, colonoscopy > 50 years old)

2) Case finding > 40 physicals***

3) Chemoprophylaxis (rabies, needle stick HIV, post exposure prophylaxis such as anthrax)
This level of prevention limits disability after irreversible changes have resulted from disease
Tertiary prevention
What is included in Tertiary prevention?
1) Environmental adaptations to home and/or work

2) Education, counseling support to assist individual and family to adapt

3) Employment to the maximum possible extent

4) Work therapy programs (OT/PT)

5) Sheltered workshops, group homes
What is the Epidemiological Triad?
1) Host (should consider Age, Sex, Race, Occupation, Genetics)

2) Agent (consider Biological, Chemical, Physical, Nutritional, Virulence)

3) Environment (Temperature, Altitude, Food, Crowding, Water)
This is defined as the period of time during which an infectious agent may be transferred from an infected person or animal to a susceptible host
Communicable period
This is defined as the time interval between exposure to the agent and the onset of clinical illness
Incubation period
What are the 3 types of disease transmission?
1) Direct Transmission

2) Indirect Transmission

3) Airborne Transmission
What are the types of Direct Transmission?
1) Person-to-Person spread
- Direct contact (touching, kissing, sexual activity)

2) Droplet spread
- Large droplets from the source (sneezing, coughing, singing)
- Travel short distance (less than 1 meter)
- NOT suspended in air
What are some examples of diseases that result from person to person spread?
1) Chlamydia, Herpes, HIV

2) Scabies, Syphilis

3) Impetigo
What are some examples of disease that are spread from droplet spread?
1) Meningococcus

2) Mumps
What are the types of Indirect transmission?
1) Vehicle Borne
- Food and Water (Single exposure, multiple exposure, continuous exposure)
- Fomite (contaminated object such as a tie or stethoscope)

2) Vector Borne
- Arthropods
o Mechanical (Roaches and Flies land on feces and then crawl on your food)
o Biological (Biting insects)
What are some examples of diseases that result from vehicle borne transmission?
1) Salmonella, Hepatitis A
2) Cholera, Norovirus
What are some examples of diseases that result from vector borne transmission?
1) Malaria, Dengue
2) Lyme disease, Tick-borne encephalitis
Describe Airborne transmission
1) Aerosolized droplet nuclei

2) Small dust particles

3) Less than 5 um in size

4) Carried by air currents
What are some example of diseases caused by Airborne Transmission?
1) TB, Measles, Varicella

2) SARS, Influenza
This is the continuous presence of disease within a given "geographic" area. It is also the background or "expected" rate of a disease in an area
Endemic
This is an increased occurrence of a disease in a community or region which is clearly in excess of normal expectancy
Epidemic
This is a global or extensive epidemic
Pandemic
What are the determinants of disease outbreaks?
1) Infectivity & virulence of an agent

2) Susceptible population

3) Efficiency of transmission

4) Timely identification

5) Effectiveness of control measures
T or F. Determinants of disease outbreaks are depended on the balance between the number of susceptible persons and the number immune to a disease
True
This is the resistance of a group to invasion and spread of an infectious agent, based on the resistance to infection of a high proportion
Herd immunity

(If a large enough proportion of the group is immune, the entire group is protected)
What are the various prevention & control measures for communicable disease?
• Immunizations
• Medication prophylaxis
• Contact investigation
• Practices/Procedures/Inspections
• Education & Behavior modification
• Communicable disease reporting
• Vector & animal control
• Environmental sanitation
• Disease surveillance
• Outbreak investigation
• Quarantine & Isolation
This applies to Healthy (Asymptomatic) patients,it is during the Incubation period, the patient can stay Home, and there is minimal enforcement (Police PRN)
Quarantine
Why don't we like to use quarantine?
Because it results in loss of personal freedoms
This is used for Sick (symptomatic) patients, during the Communicable period, they are admitted to Hospital as a common standard precaution
Isolation
What is the single most effective way to prevent disease in deployed troops?
Access to clean potable water
Section 5
Diseases of Military & Public Health Importance
This is a disease that will have a significant impact on a unit's ability to complete its mission
Show-Stopper
What is the key factor of a show stopper?
Total lost soldier-days
- Short duration diseases in large numbers
- Longer duration diseases in small numbers
Describe how severity can play a role in diseases that are considered show-stoppers
1) There can be a high level of care required (ICU)

2) High morbidity/high mortality
What is not a show stopper?
1) Diseases that are unlikely to occur in significant numbers
- Minimal exposure (Ebola/anthrax)
- Very inefficient transmisson (Hantavirus pulmonary syndrome)

2) Very mild disease not causing lost work (gonorrhea)
What are the major exposure categories of infectious diseases in a military setting?
1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted
Worldwide, what is the biggest potential show stopper?
Food and Water Borne diseases
How is the military exposed to Food and Water Borne diseases?
1) Eating on the local economy

2) Improper food procurement procedures

3) Dining facility problems

4) Person-to-person spread in field conditions
What is the most common Food and Water Borne disease?
Bacterial diarrhea (early treatment is essential)
Can we often identify the organism that caused bacterial diarrhea if a lab is present?
Yes
What population is viral diarrhea most common?
Adults
Of the causes of viral diarrhea, what is the most common virus?
Norovirus
T or F. Hepatitis A (HAV) and Hepatitis E (HEV) are Food and Water Borne diseases
True
Both HAV and HEV will leave soldiers sick for 30 days or more. Which one has a vaccine?
Hepatitis A (HAV)

**There is no vaccine for Hepatitis E (HEV)
T or F. Parasitic/Protozal diarrhea is common
False
T or F. It is easy to diagnose Parasitic/Protozal diarrhea in the field
False
What is the longest lasting and most severe cause of Parasitic/Protozal diarrhea?
Giardia
What are the methods for preventing food & water-borne diseases?
1) Absolute control over food and water

2) Proper field sanitation and hygiene

3) Eating on the economy
- Can be prohibited when necessary
- Education to lower the risk

4) Routine vaccination (Hepatitis A, typhoid)
What are the major exposure categories of infectious diseases in a military setting?
1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted
In "some" areas, what is the biggest potential show stopper?
Vector Borne (Mosqutoes, Sand flies, Ticks, Mites, Flies)
What are some major vector borne causes of diseases that have operational impact?
1) Malaria (Night mosquito, Rural)

2) Dengue Fever (Day mosquito, Urban)
What is the most severe case of Malaria?
Falciparum
What is the vaccine and specific treatment for Dengue fever?
There isn't one
What do the following vector borne disease have in common:

1) Chikungunya

2) Rift Valley Fever

3) Yellow Fever

4) Japanese encephalitis
They are all mosquito borne infections
What do the following vector borne disease have in common:

1) Leishmaniasis (disease of the tropics)

2) Bartonellosis

3) Sand Fly Fever
They are all Sand fly-borne disease
What do the following vector borne diseases have in common:

1) Crimean-Congo hemorrhagic fever

2) Tick-borne encephalitis
They are tick-borne diseases
What do the following vector borne diseases have in common:

1) Murine typhus

2) Plague
They are flea borne disease
What vector causes scrub typhus?
Mites
What vector causes Endemic typhus?
Louse
How are vector borne diseases prevented?
1) Personal protective measures (PPM) such as Permetherin and bed netting
- The "only" protection in most cases
- "Always" the first line of defense

2) Chemoprophylaxis and vaccines (malaria pills, yellow fever vaccine)
What is one of the largest vulnerabilities of contracting a vector borne disease?
Neglect of PPM
Is vector control practical in the places we deploy to?
NO
* Who is responsible for enforcing PPM and prophylaxis?
The COMMAND!
What are the major exposure categories of infectious diseases in a military setting?
1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted
With regards to water contact diseases, do you have to drink the water to get sick?
No
What type of field operations may involve getting wet (and possibly sick)?
1) Fording rivers, streams

2) Crossing rice paddies

3) Recreational exposure

4) Flooding
This is a disease caused by a spirochete that can penetrate skin or mucous membranes. It is shed by animals (particularly rodents) in urine and we get it from water sources
Leptospirosis
This is a disease that is caused by a parasitic worm (flat worm or fluke) that has free swimming larvae which can penetrate the skin. It causes chronic infection, also acute fever similar to dengue
Schistosomiasis
What is the main way for preventing water contact diseases?
1) Avoid swimming, bathing, or washing in stagnant pools or sluggish streams

2) Protective clothing

3) Survey bodies of water
What are the major exposure categories of infectious diseases in a military setting?
1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted
How is the military vulnerable to diseases from soil contact?
1) Sleeping on the ground

2) Breathing in the dust
How can soil contact spread diseases?
Pathological organisms, particularly viruses can be suspended in dust
What is the main disease caused by contact with the soil?
Hantaviral diseases (Very severe---require ICU)
How are soil contact diseases prevented?
1) Avoid setting up camp in heavily rodent-infested areas

2) Rodent control where feasible
- Use traps ans eliminate possible nesting sites & food sources

3) Minimize dust inhalation
- use of masks
- wet down roads and floors if feasible
- No sleeping on bare ground
What are the major exposure categories of infectious diseases in a military setting?
1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted
Although most Soldiers have limited contact to diseases that are spread by animals, which Soldiers have a higher risk?
1) SOF

2) MPs

3) Veterinarians
How are regular Soldiers often times exposed?
Mascots (must be controlled by the command)
What diseases are associated with animal contact?
1) Rabies (which is a significant threat if bitten/exposed to Saliva) --It is nearly always fatal

2) Anthrax

3) Q-Fever
What part of the body does rabies virus affect?
The Central Nervous System
What kind of animal is the major vector for rabies in developing countries?
Dogs
What kind of animal is the major vector for rabies in the United States?
Wild animals (Skunks, Raccoons, Bats, and foxes)
What is the prevention for rabies?
1) Avoid all strange or wild animals

2) No mascots or pets

3) Immunization: pre and post exposure wound cleaning
Does pre exposure vaccination eliminate the need for post exposure vaccination?
No
Ok so exacerbates respiratory diseases in deployed settings?
1) Overcrowding

2) Close contact with locals
Most respiratory diseases in deployed settings are NOT show stoppers but a few are, what are they?
1) Influenza (definite show stopper) --> routine vaccination is essential and required

2) Meningococcal meningitis (Rare but severe)
How are respiratory diseases prevented?
1) Avoid overcrowding

2) Proper ventilation in enclosed spaces

3) Proper hygiene and sanitation with strict hand washing for disease control

4) Isolation of cases if necessary

5) Vaccination appropriate and required in some cases
STDs rates are historically high in troops. But are STDs show stoppers?
No
What are the STDs that can cause a high impact?
1) HIV

2) Hepatitis B (part of routine vaccinations now)
How are STDs prevented?
1) Education
- Abstinence
- Condoms
- Hepatitis B vaccine for high risk

2) Command climate determines success
Section 6
Introduction to Humanitarian Operations
This is a human disaster that follows war & civil strife, characterized by:

1) Displacement of large populations

2) Near total loss of existing infrastructure

3) Continuing concerns for personal security

"Persons of Concern"
Complex Emergency
What are persons of concern?
Those leftover from a complex emergency

1) Refugees

2) Internally Displaced Person (IDP)
This person is described as the following:

1) Cross the border out of their country

2) Entitled to protection under UN and international law
Refugee
This person is described as the following:

1) Move but do not cross their border

2) Not afforded protection under the law, and therefore more difficult to assist
Internally Displaced Person (IDP)
What are the 5 leading causes of death in humanitarian emergencies?
1) Diarrhea & dehydration

2) Measles

3) Malaria

4) Acute Respiratory Infections

5) Malnutrition (only non-infectious cause of death)
Who are the most vulnerable individuals in a given population during disaster?
1) Children (orphaned/unaccompanied)

2) Women (head of household, Pregnant/Lactating, Victims of sexual violence)

3) Elderly/Disabled
What are the phases of an emergency?
Developing Country Model:
o Acute Emergency Phase
• High crude mortality rates (CMR)
• High case fatality rates (CFR)
• Outbreaks of communicable diseases
• Severe malnutrition

- Developed Country Model:
o High war-related trauma
o Malnutrition in the elderly
What are the 10 essential emergency relief measures?
(ICE PIPE PRO)


1) Institute a diarrhea control program

2) Coordinate activities

3) Establish primary care medical treatment (based on local population)

4) Provide adequate food - 2100 kcals/person/day; equitable distribution; target supplemental and therapeutic feeding programs

5) Immunization against measles & provide Vitamin A supplements (prevent measles)

6) Provide elementary sanitation & clean water - 3-5 L/person/day

7) Establish disease surveillance and a health information system

8) Provide adequate shelter & clothing

9) Rapid health assessment

10) Organize human resources
What are the advantages to military involvement in humanitarian operations?
1) Speed

2) Security

3) Transportation

4) Logistics

5) C3

6) Self-sufficiency

7) Specialty units (Engineers, Civil Affairs, PM),

8)Deployable field hospitals

9) MEDEVAC
What are the disadvantages to military involvement in humanitarian operations?
1) Medical training (oriented towards combat, not disaster victims)

2) Logistics (supplies not appropriate for disaster)

3) Focus (short-term)

4) Political (extension of the US government, never purely humanitarian)

5) Expense (Ethiopian airlift)
Section 7
Medical Response to Chemical Terrorism
What are the physical properties of Nerve Agents?
1) Clear, colorless liquids

2) Tasteless, most are odorless

3) Volatility (Persistence is inversely related to volatility. The more volatile a substance is, the less persistent it is and vice versa)
-GB (Sarin) > GD (Soman) > GA (Tabun) > GF >>VX

4) Penetrate skin and clothing
What is the MOA for Nerve agents?
Inhibits Enzyme (AChE) Acetylcholine Esterase
- Does not destroy Ach


- Then, then excess ACh continues to stimulate organs (organ overstimulation)
As a result of organ over stimulation, what would you expect to see in a patient that has been exposed to nerve agents?
D-D-U-M-B-B-B-E-L-S

1) Diarrhea

2) Diaphoresis

3) Urination

4) Myosis

5) Bronchorrhea

6) Bronchospasm

7) Bradycardia

8) Emesis

9) Lacrimation

10) Salivation
What are the heart rate effects of Nerve Agents?
May be high, low or normal

1) Muscarinic (Vagal) decreases HR

2) Nicotinic (Ganglionic) increases HR

3) Hypoxia: (decrease oxygen) increase HR
What is the FIRST and MOST important step in managing patients with nerve agent exposure?
Protect self/ Medical Facility
AFTER, you have protected yourself and the medical facility, then what?
For patients:

1) ABCs

2) Drugs (Nerve agent antidotes)

3) Decontamination

4) Supportive care

5) Anticonvulsant therapy

(Not neccesarily in this order)
This drug blocks excess acetylcholine
Atropine
How is atropine given?
1) Starting dose: 2 mg or 6 mg (depends on exposure)

2) Continue 2 mg every 5-10 minutes until
- Secretions dry up
- Ventilation improves
What is the usual dose of atropine?
1) 15-20 mg (severe casualty)

2) 1000s of mg in insecticide
What are the endpoints for STOPPING atropine?
1) Reduction in secretions

2) Reduction in chest tightness

3) *Patient able to breathe comfortably on his/her own
What should I NOT titrate atropine to?
1) Heart rate

2) Miosis (may persist for up to 6 weeks)

3) Twitching or fasciculation
This drug removes agents from AChE (unless aging has occurred)
2-PAM Cl
What is the starting dose for 2-PAM Cl?
1) One or three combo pens; repeat in one hour (Nerve Agent Antidote Kit (NAAK) or Mark I contains 600 mg

2) IV: One gram slowly (20 to 30 min)' repeat in one hour
if aging of the nerve agent has occurred, what is the only drug that will work?
Atropine (2-PAM Cl will not work)
How is Decontamination of "vapor" taken care of?
1) Removal of clothing

2) Washing of hair (soap and water)
How is decontamination of liquid exposure taken care of?
1) Vigorous washing of exposed skin and hair

2) Soap and water is "as effective as sodium hypochlorite" and no contamination from run off

*The solution to pollution is dilution*
This anticonvulsant is given after severe nerve agent exposure, or if seizures continue after antidotes are given
Diazepam
What considerations need to be made in regards to RTD?
1) Vision (Infantry guy needs to be able to shoot and cant function with Miosis)

2) Minor, subtle mental effects
What are vesicants?
Blister agents
What are the blister agents?
1) Mustards
- Sulfur
- Nitrogen

2) Lewisite

3) Phosgene Oxime
This substance is classified as the following:

1) Oily liquid

2) Light yellow to brown

3) Vapor heavier than air

4) Liquid heavier than water

5) Low volatility; persistent
Mustard
What is the MOA of Mustard?
1) Penetrates through skin surfaces in 2 minutes (If it is wiped off before 2 minutes it is not so bad)
- Quickly cyclizes in tissue
- Alkylates cell components (DNA proteins)

2) DNA damage leads to:
- Cell death (This is why its used in chemotherapy)
- Mutation
When does chemical cell damage occur in Mustard?
1 to 2 minutes
When do we see "clinical" effects of mustard?
2 to 48 hours (usually 4 to 8 hours)
What does mustard have the ability to damage?
1) Skin

2) Eyes

3) Airways

4) Systemic
- Bone Marrow
- GI tract
- CNS
- Lymphoid tissue
What are the signs of mustard on the skin?
1) Erythema

2) Small vesicles; later coalescence

3) Blisters/bulla

4) Possible coagulation necrosis with liquid exposure
What must often times be done to protect the airway of a patient that has been exposed to mustard (especially if they have hoarseness and stridor)?
they need to be intubated
What is usually the cause of death if it occurs within 24 hours of mustard exposure?
Pulmonary (This is why they need to be intubated)
What is usually the cause of death if it occurs within 3-6 days of mustard exposure?
Pneumonia
What is usually the cause of late death if when associated with mustard?
Sepsis (depressed immune system- Bone marrow)
Again what is the first thing in regards to a patient and mustard exposure/
Protect self!
What is the management of a patient that has been exposed to mustard?
Treat as a burn patient

1) General supportive care

2) Debridement of burns

3) Frequent irrigation

4) Antibiotics: Topical/Systemic (Cellulitis)

5) Systemic analgesics

6) Appropriate IV fluids and electrolytes

7) Burn unit in severe cases
What must be avoided in the eye for mustard burns?
Topical analgesics
What is the management of the eye with mustard burns?
1) Irrigate, irrigate, irrigate

2) Homatopine or other anticholinergic ointment

3) Topical antibiotic ointment

4) Vaseline or bacitracin to the lid edges
What is the management of the airway for a patient exposed to mustard?
1) Steam, cough suppressants

2) Oxygen

3) Bronchodilators

4) Early intubation

5) Assisted ventilation

6) Antibiotics AFTER organism identified
What is the management of the bone marrow after being exposed to mustard?
1) Reverse isolation

2) Blood component replacement
- RBC, WBC, platelets

3) Granulocyte Colony stimulating factor

4) Marrow transplants
What are the long term affects of mustard?
1) Carcinogen

2) No evidence of human reproductive toxicity

Chronic exposure:

1) Respiratory cancer

2) Unclear: bronchitis, emphysema
This is a rapidly acting chemical poison that is naturally occurring, present in combustion, and fumigant/pest killer
Cyanide
What are the non-military uses of cyanide?
1) Poisonings (terrorists, executions, homicides, suicides)

2) Industry ( Electroplating, Plastics processing, Gold and Silver extraction, Fumigation, Photography, Metallurgy)
What are the characteristics of cyanide?
1) Liquid, gas, or salt

2) Volatile (boiling point 60-80 degrees F)

3) Bitter almond to biting, purgent odor

4) Strong affinity for metals especially ferric iron
What are the manifestations of cyanide poisoning?
1) Rapid onset

2) Brief period of tachypnea

3) Loss of consciousness

4) Convulsions

5) Apnea WITHOUT cyanosis

6) Asystole

7) Death
How is the diagnosis of cyanide poisoning made?
1) History of exposure

2) Rapid onset of symptoms

3) Cherry red skin; odor of bitter almonds

4) Respiratory depression

5) Labs (Methahemoglobin levels, Whole blood or tissue cyanide or thiocyanate level, metabolic acidosis)
What is the first thing in the medical management of a cyanide case?
Protect yourself
What must be done for the patient with cyanide poisoning
1) Eliminate further exposure

2) Decontamination (soap and water)

3) General supportive therapy
- ABCs
- 100% oxygen
- Correct metabolic acidosis/ manage seizures
- Gastric lavage with activated charcoal (ingestion)

4) Specific antidotal therapy

5) Observation fo at least 24-48 hours
What is the antidote therapy for cyanide poisoning?
1) Cyanide antidote kit
- Methehemoglobin Formers (Amyl Nitrite, Sodium Nitrite)

- Sulfur Donor (Sodium Thiosulfate)
What are the pulmonary agents used in chemical terrorism?
1) Chlorine

2) Phosgene
What is similar about Chlorine and Phosgene?
1) Mass produced and transported

2) Seen in industrial accidents

3) Used in domestic terrorism

4) Related compounds
- Oragnofluoride polymers (PFIB)
- Oxides of nitrogen
- HC smoke
This pulmonary agent is described as the following:

Mild exposure:

- suffocation, choking sensation
- ocular, nasal irritation
- chest tightness, cough
- exertional dyspnea

Moderate exposure:
- above symptoms + hoaresness and stridor
- pulmonary edema within 2-4 hours
Chlorine
This pulmonary agent is described as the following:

Mild exposure:

- mild cough
- dyspnea
- chest tightness,

Moderate exposure:
- above symptoms + ocular irritation, lacrimation
- smoking tobacco produces bad taste
Phosgene
What are the clinical effects of Choline under severe exposure??
1) Severe dyspnea at rest

2) May cause pulmonary edema within "30-60 min"

3) Copious upper airway secretions

4) Sudden death may occur from laryngospasm
What are the clinical effects of Phosgene under severe exposure??
1) Severe dry cough

2) Onset of pulmonary edema with "4 hours"

3) May produce laryngospasm

- Latent period (S/S onset more rapid with higher exposure)

- exacerbated by exercise
This pulmonary agent is an Organoflouride polymer (PFIB)
- polytetrafluoroethylene "Teflon"
- Many commerical uses
- Used in armor vehicles and aircraft

*Toxic combustion by products
PFIB
What is 10 times more potent than Phosgene?
PFIB (but patients will have a latent period of 1-4 hours, followed by dyspnea and edema. These patients usually recover within 72 hours w/o sequela
What are the Properties/characteristics of HC Smoke?
Obscurant smoke with many combustion products
What happens with mild exposure to HC smoke?
1) Dyspnea

2) Lab findings normal (monitor x 4-6 hours)
What happens with moderate exposure to HC smoke?
1) Initial severe dyspnea, resolves spontaneously in 4-6 hours

2) Return of symptoms within 24-36 hours

3) CXR initially clear, later dense infiltrates

4) Hypoxia

5) Bronchopnuemonia may lead to interstitial fibrosis
What happens with severe exposure to HC smoke?
1) Rapid onset; severe dyspnea

2) Paroxsymal cough with bloody sputum

3) Hemorrhagic ulceration of upper airway

4) Rapid onset pulmonary edema

5) Laryngeal edema/spasm, death
Describe ways to be exposed to nitrogen oxide (NOx)
1) High temp combustion (arc welding)

2) Nitrate-based explosives (enclosed spaces)

3) Disel engine exhaust
What are the clinical effects of Nitrogen Oxide(NOx)?
1) Similar to HC Smoke
- May remit spontaneously
- Exacerbated by exertion

2) Long latent period
- may be asymptomatic for 2-5 weeks

3) Fibrotic changes may occur
- Pulmonary Function Tests (PFTs) may show chronic airway obstruction


***Young person exhibiting COPD symptoms? ---> Think NOx exposure
What is the general therapy for pulmonary agents?
1) Terminate the exposure

2) Rescucitate- ABCs

3) Maintain strict bed rest

6) Observe for 6 hours
- If abnormal, assess for additional 24 to 36 hours
- provide supportive care
Section 8
CBRNE (Medical Response to Bioterrorism)
What are the key features of biological weapons?
1) Availability or ease of production

2) Incapacitation and lethality

3) Appropriate particle size in aerosol

4) Ease of dissemination

5) Stability after production (as opposed to some volatile chemical weapons)

6) Susceptibility and Non-Susceptibility
What are the advantages of biological weapons?
1) Potentially deadly or incapacitating effects

2) Self-replicating capacity

3) Relative low cost

4) Insidious symptoms

5) Difficult to detect

6) Spares property and surroundings
What are the disadvantages of biological weapons?
1) Can affect aggressor force

2) Dependence on weather for dispersion

3) Effects of temperature, sunlight, etc on organism

4) Environmental persistence

5) Generation of secondary aerosols

6) Unpredictable morbidity and mortality

7) Relatively long incubation periods

8) Publics aversion to their use
What are the indications of a possible biological attack?
M-A-S-H A L-L-U-M-P

• Military & civilian casualties
• Apparent aerosol route of infection
• Sentinel dead animals
• High morbidity or mortality
• Absence of natural vector
• Low attack rates in special populations
• Localized illness
• Unusual disease entity
• Multiple diseases in the same patient
• Point source outbreak
This category of the CDC's Critical Biological Agents is characterized as the following:

1) "Easily transmitted" or spread from person to person

2) "High Mortality", potential major public health impact

3) Might cause public panic and social disruption

4) Require special attention for public health readiness
Category A
What are some examples of "Category A" CDC Critical Biological Agents?
1) Variola Major (Smallpox)

2) Bacillus Anthracis (Anthrax)

3) Yersinia Pestis (Plague)

4) Clostridium Botulinium Toxin (Botulism)

5) Francisella tularensis (Tularemia)

6) Filoviruses

7) Arena viruses
This category of the CDC's Critical Biological Agents is characterized as the following:

1) Moderately easy to disseminate

2) Cause "Moderate morbidity and low mortality"

3) Requires special enhancements's of CDC's diagnostic capacity and enhanced disease surveillance
Category B
What are some examples of "Category B" CDC Critical Biological Agents?
1) Coxiella burnetti (Q-fever)

2) Brucella species (Brucellosis)

3) Burkholderia Mallei (Glanders)

4) Alphavirses - VEE, EEE, WEE

5) Ricin toxin from Ricinus Communis (Castor Beans)

6) Epsilon toxin of Clostridium Perfringens

7) Staphlococcus enterotoxin B

8) Food or Waterborne (Salmonella species, Shigella dysenteriae, E-Coli O157:H7, Vibrio Cholerae, Cryptosporidium Parvum
This category of the CDC's Critical Biological Agents is characterized as the following:

-Emerging pathogens that could be engineered fro mass dissemination in the future
Category C
What are some examples of "Category C" CDC Critical Biological Agents?
1) Nipah virus

2) Hantavirus

3) Tickborne hemorrhagic fever viruses

4) Tickborne encephalitis viruses

5) Yellow fever

6) MDR Tuberculosis
What are the principles of consequence management?
1) Containment

2) Isolation and Quarantine

3) Mass patient care

4) Mass logistics

5) Mass prophylaxis

6) Mass fatalities
Describe "Containment"
1) Overt release
- Decon on site
- Control access to "hot zone"

2) Covert Release
- Protect facility and personnel
- Notify Federal authorities
What are the considerations that need to be made with "Isolation and Quarantine?'
1) Is it warranted?

2) Is it feasible?

3) Benefits outweigh consequence?
What factors are included in "Mass patient care"?
1) Transport

2) Triage

3) Infection control

4) Surge capability (Patient transfers, Isolation wards, and cohorting, Ancillary care centers)
What are the factors of "Mass logistics"?
1) Local stock piles

2) Strategic National Stockpiles
What factors need to be considered with "Mass Prophylaxis"?
1) May be needed to be distributed in large numbers

2) It is the responsibility of every public health jurisdiction in the country to develop and maintain the capability to respond to bioterrorism events, dispense antibiotics, and carry out vaccination campaigns tailored to its local population
Who is involved in managing "Mass Fatalities"?
1) Healthcare organizations

2) Local medical examiners

3) Coroners
What are the general medical management principles of dealing with a potential biological casualty?
1) Maintain a healthy index of suspicion

2) Protect yourself

3) Save the patient's life (primary assessment)

4) Disinfect/Decontaminate as appropriate

5) Establish a diagnosis (secondary assessment)

6) Provide prompt therapy

7) Institute proper infection control measures

8) Alert the proper authorities

9) Conduct an epidemiological investigation (& manage psychological aftermath of attack)

10) Maintain a level of proficiency
Emerging infectious diseases are among the most important future threats facing both military & civilian populations. Future threats are difficult to predict, but should include:
1) Molecular biology

2) Resurgence of old diseases

3) Genetic engineering
Section 9
CBRNE (Radiation)
What are the unique challenges of radiation events?
1) Medical Response infrastructure untested for major radiological events in the U.S

2) Clinician inexperience with radiation injuries

3) Could be an exceptionally large number of casualties

4) Large numbers of concerned people with little or no exposure

5) Fear of radiation exposure expressed by public and caregivers
What are the different types of ionizing radiation?
1) Alpha - Internal hazard (toxic if swallowed), can be stopped by paper & skin

2) Beta - Internal & external hazard, can be stopped by clothes (e.g. ACUs/BDUs), skin burns may result from high dose/rate

3) Gamma & x-ray - External hazard, highly penetrating (need lead shielding)

4) Neutron - External hazard, highly penetrating (need better-than-lead shielding)
What are potential radiation terrorist scenarios?
1) Target attack on a nuclear installation

2) Radiological Exposure Device (RED), e.g. hidden radioactive source

3) Radiological Dispersal Device (RDD), e.g. "Dirty Bomb

4) Detonation of an Improvised Nuclear Device (IND)
This is a radioactive device "stolen from industrial facilities/hospitals"

- Potential to expose people to lethal doses of radiation by hiding sources

- Tens to hundreds of people could present with symptoms of acute radiation syndrome (ARS)

- Thousdands could require monitoring
Radiological Exposure Device (RED)
This is usually detonated by a conventional explosive laced with radioactive material "dirty bomb"

- Significant radiation exposures not likely unless trapped near the source

- Tens to hundreds could present with conventional traumatic injury, external contamination, and potential internal contamination

- Hundreds to thousands could present for radiological screening, counseling on health effects, or psychosocial trauma
Radiological Dispersal Device (RDD)
This could cause an "Immediate national emergency" and spreads radiation by the "Detonation of a stolen warhead"

-kills tens of thousands

- Hundreds of thousands could be displaced
Improvised Nuclear Device (IND)
What type of injuries can nuclear weapons cause?
Radiation injuries, PLUS:

1) Blast injuries (eardrum rupture, lung damage,, crushing, missiling, & translational injuries)

3) Thermal pulse injuries (flash burns, flame burns, flash blindness, retinal burns)
What are the physics of nukes?
1) Blast

2) Overpressure

3) Fallout

4) Radiation
This is described as the following:

- Similar to other high explosives

- Flying debris become secondary missiles

- May throw humans around like rag dolls
Blast
This may cause rupture of TM and hollow organs
Overpressure
This type of radiation can affect the whole body or partial body (This is not a threat to healthcare providers)
External irradiation
This is radiation deposited on the skin and is a threat to healthcare providers
"External" contamination by radioactive material
This is radiation that is inhaled, swallowed, absorbed through skin, or introduced through wounds
"Internal" contamination by radioactive material
This is radiation uptake by body cells, tissues, or organs (bone, liver, kidney, etc)
"Incorporation" contamination by radioactive material
This is any combination of external irradiation, or external, internal, or incorporation contamination
Combined injury
This is "residual radiation" produced by unused fissionable materials or debris carried aloft in the fireball and activated
Fallout
Does Fallout decay rapidly or slowly?
Rapidly
Can the location and time of arrival of fallout be predicted?
Yes; therefore it is possible to avoid exposure
This is radiation produced by the fission and/or fusion reactions during detonation
Prompt (initial) radiation
T or F. Radiation is highly penetrating
True
Is radiation partially absorbed or scattered by air?
Both
How fast does radiation travel?
At the speed of light
This travels at the speed of light but in a straight line
Thermal pulse
Can the thermal pulse be reflected or shaded?
Both
T or F. A thermal pulse is 30 times more intense than the noon sun
True
Radiation is highly penetrating, what about a thermal pulse?
A thermal pulse has very little penetrating power
Radiation is partially absorbed or scattered by air, what about a thermal pulse?
Easily absorbed and attenuated
What are the 3 thermal injuries?
1) Flame burns

2) Flash blindness (Dazzle)

3) Retinal burns
This thermal injury is caused by secondary fires and has a MAJOR impact on response operations
Flame burns (Think of Nagasaki)
This is a bright light flash that temporarily "bleaches light-sensitive" elements of the retina
Flash blindness
How long does Flash blindness last?
Seconds to minutes
Should a person exposed to flash blindness be expected to recover?
Yes (Full recovery)
With Flash blindness, scattered light may induce effect; does a person's eyes have to be focused on the flash to have injury?
NO
This occurs when retinal tissue is heated excessively by light "focused" on the retina
Retina burns
Describe the damage caused by retina burns
Permanent
This is described as a group of symptoms that develop after total body irradiation greater than 1 Gy (100 cGY)
Acute Radiation syndrome (ARS)
Does ARS occur from internal or external radiation?
Both
What are the 4 important factors to consider with Acute Radiation syndrome (ARS)?
1) High dose

2) High dose rate

3) Whole body exposure

4) Penetrating radiation
What are the 4 phases of Acute Radiation syndrome (ARS)?
1) Prodrome - time of onset related to total dose of radiation; can begin minutes to hours after exposure

2) Latent - Lasts days to weeks (progression of organ failures)

3) Illness - phase when overt illness develops

4) Recovery/Death - Can take weeks to months from initial exposure
This is caused by radiation over 1 Gy (100 cGY)
Hematopoietic Syndrome
What happens in Hematopoietic Syndrome?
Bone marrow is suppressed
What are the symptoms of Hematopoietic Syndrome?
1) Leukopenia

2) Purpura

3) Thrombocytopenia

4) Hemorrhage

5) Infection

6) Epilation (Balding)
This is caused by radiation over 6 Gy (600 cGY)
Gastrointestinal Syndrome
What happens in Gastrointestinal Syndrome ?
Gastrointestinal endothelial cells
What are the symptoms of Gastrointestinal Syndrome?
1) Hematopoietic signs and symptoms

2) Nausea and vomiting with 2-4 hours

3) Diarrhea, electrolyte imbalance

4) Sepsis, opportunistic infections (Gram - Sepsis)
What is the management of Gastrointestinal Syndrome?
-Hematopoietic measures

- Electrolyte management
This is caused by radiation over 20 Gy (2000 cGY)
Circulatory/CNS Syndrome
What are the signs and symptoms of Circulatory/CNS Syndrome?
1) Convulsions

2) Tremors

3) Ataxia

4) Lethargy

5) Coma
What is the average to death with Circulatory/CNS Syndrome?
48 hours
What is the treatment of Circulatory/CNS Syndrome?
1) Analgesics

2) Sedatives
What is the only ARS syndrome whose patients can be considered "expectant" for triage purposes?
Circulatory/CNS Syndrome
What is the treatment of ARS?
1) IV Fluids

2) Blood and Platelet Transfusions

3) Infection prevention

4) Other supportive care as necessary

5) Cytokines (Stimulate production of white blood cells and decrease maturation time; Increase viability of mature cells)

6) Stem cell transfusion, bone marrow transplant, limited indication)

7) Selective gut decontamination
What is the prognosis of Hematopoietic syndrome?
Survival Probable: < 2 Gy

Survival Possible: 2-8 Gy
What is the prognosis of Gastrointestinal Syndrome?
Survival Unlikely: 8-20 Gy
What is the prognosis of Circulatory/CNS Syndrome?
Survival not possible: > 20 Gy
What is the hallmark of acute radiation syndrome (ARS)?
Nausea and vomiting
What is a rough estimate of exposure and outcome associated with acute radiation syndrome (ARS)?
Time to emesis
What is highly suggestive of a poor prognosis with acute radiation syndrome (ARS)?
Onset of vomiting within 1-2 hours
Radiation + Trauma =
Higher mortality rate
Other than emesis, what else can be used as a marker for acute radiation syndrome (ARS)?
Rise in core body temperature
Wound and burn care, surgery, and orthopedic repair should be done in the first 48 hours. If they cannot, how long should it be delayed?
2-3 months
In combined injury (ARS + Trauma) what are the top treatment priorities?
Resuscitation and Stabilization/ABCs (TOP Priority)

NOT DECONTAMINATION!
What are the treatment decision of ARS based upon?
The prodromal phase
- Nausea, vomiting, fever, (onset, severity)
- Absolute lymphocyte counts
What are the labs that need to be ordered in a ARS patient?
1) Baseline CBC with differential (Track absolute lymphocyte count)

2) Serum Amylase q24 hours

3) Type and cross match (If transfusions needed, use irradiated blood products)

4) Collect and save additional blood samples in heparinized tubes for later analysis

5) 24 hour urine sample collection (monitor excretion of radioactivity)
Section 10
Basic Nutrition: Obesity Causes and treatment
How do you calculate BMI?
Weight in pounds x 4.88
_________________________

Height in feet (squared)
CLASSIFICATION SIDE
BMI SIDE
Underweight
< 18.5
Normal weight
18.5 - 24.9
Overweight
25 - 29.9
Obesity (Class 1)
30 - 34.9
Obesity (Class 2)
35 - 39.9
Extreme/Morbid Obesity
≥ 40
**What is as predictive of disease (obesity) waist-to-hip ratio?
Waist Circumference
What is considered a high waist circumference in both males and females?
Males: > 40 inches (102 cm)

Females: > 35 inches (88cm)
**What is an independent risk factor for diseases such as: HTN, Cardiovascular disease, & Diabetes?
Excess abdominal fat
What are some weight loss goals?
1) Reduce & maintain lower body weight

2) Loss of 1-2 pounds per week
**What is the main initial weight loss goal?
Not greater than 10% of body weight over 6 months
There are several therapies for the treatment of obesity, what is the best approach?
A COMBINED APPROACH to include:

1) Diet therapy

2) Physical therapy

3) Behavior therapy

4) Pharmacology

5) Weight loss surgery
Carbohydrate =
4 kcal/g
Protein =
4 kcal/g
Fat =
9 kcal/g
Alcohol =
7 kcal/g
**How many kcal is in 1 pound of fat (adipose tissue)?
3500 kcal
**What will enable a patient to have a weight loss of 1-2 pounds/week?
A daily intake of 500-100 kcal BELOW estimated expenditure
If I were to change my whopper with cheese meal and "large" drink and fry to "diet" soda or "medium" drink and fry, how much less calories am I consuming?
330 less calories
If I were to change a McDonald's "Crispy Chicken" Bacon Ranch salad to "Grill" chicken, how much less calories am I consuming
100 less calories
If I were to eat a "Sausage", Egg, & Cheese' wich to Change "Bacon", Egg, & Cheese Crossan'wich, how many less calories am I consuming?
-160
**What are the behavior therapies that can impact food intake and energy expenditure?
1) Self monitoring

2) Stimulus control

3) Cognitive Restructuring

4) Stress Management

5) Social Support

6) Physical Activity

7) Relapse Prevention
How can a patient prevent weight gain?
Physical activity of 150-200 min/week
(Equal to 1200-2000 kcal/week)
How much weight loss will <150 min of physical activity yield?
Minimal
How much weight loss will >150 min of physical activity yield?
2-3 kg
How much weight loss will >225-420 min of physical activity yield?
5-7.5 kg
How can a patient maintain their weight loss?
200-300 min/week
What will physical activity and diet result in?
Weight loss if energy restriction is not severe
When is a patient prescribed medicine for weight loss?
High risk patients only

1) BMI > 30

2) BMI > 27 with comorbidities
How long should a patient try lifestyle modifications before using pharmacotherapy for weight loss?
6 months
What medication is prescribed for short term use?
Phentermine (appetite suppressant/anorexiant)
What medications are used for long term use?
1) Silbutramine (appetite suppressant)
- May increase BP and HR, cause insomnia, constipation, and dry mouth

2) Orlistat (pancreatic lipase inhibitor/reduces fat absorption by 30%)
- reduces absorption of fat-souluble vitamins/nuteients
- May cause GI distress (incontinence/flatulence)
**When is surgery an option for weight loss?
For clinically severe obesity

1) BMI > 40

2) BMI > 35 with serious co-morbid conditions
What are the surgical procedures available?
1) Restrictive Malabsortive (Gastric Bypass)

2) Restrictive Surgical (Gastric Banding)
- Decreases the size of the stomach and is adjustable
What are the risks associated with Restrictive Malabsortive (Gastric Bypass)?
1) Causes dumping syndrome

2) Results in more significant nutrient deficiencies
What nutritional deficiencies can be caused by surgical intervention for weight loss?
1) Vitamin B12

2) Calcium

3) Iron

4) Protein

5) fluid

6) Potassium
Which one causes more weigh loss, Restrictive Malabsortive (Gastric Bypass) or Restrictive Surgical (Gastric Banding)?
Restrictive Malabsortive (Gastric Bypass)
Section 11
Fueling for Optimal Performance
**When does thermoregulation become impaired in an athlete or soldier?
When he loses 2% of body water due to dehydration

- ≤ 2% loss will have minimal impact on performance

- ≥ 2% loss will negatively impact endurance performance
**Increased Energy needs + Decreased Food and Fluid intake =
Increased Muscle Wasting
**How much fluid should soldier/athlete drink 2-3 hours BEFORE exercise?
400 to 600 mL (14-20oz)
**What is the optimal strategy to maintain fluid balance DURING exercise?
Individual sweat rate
How can I calculate the individual sweat rate?
- Weight before - Weight after exercise (lbs) = A

- A * 16 (changes pounds into ounces

- A + ounces consumed during exercise = B

- B/minutes exercised = oz/minute
**How much fluid should soldier/athlete drink 2-3 hours AFTER exercise?
- More than the amount of sweat lost (150-200%)

- The amount depends on the sodium content of the beverage
What are 3 ways to improve fluid intake?
1) Cool (palatability, maintain core temp)

2) Flavored

3) Contain Sodium (avoid hypohydration) or drink plain water with food
What is the best way to assess hydration status?
1st morning void and color of urine
**What is the normal range for urine specific gravity?
1.002 - 1.028
**What is the specific gravity for minimal dehydration?
1.020 - 1.029 (1-3% of body water)
**What is the specific gravity for severe dehydration?
> 1.030 (> 5% loss of body water)
The goals for Pre-exercise supplements is to arrive fueled & hydrated, what does it include?
o Food should be consumed 2-6 hours prior to event

o Food should be high carb, low fiber & fat, moderate protein

o Liquids can be consumed 1 hour prior to event, best if hydrated with 400-600mL 2-3 hours prior
The goals of supplements during exercise should be to prevent/delay fatigue & hydration, what does it include?
o Fluid consumption to maintain fluid balance (average 6-12 oz/15-20min)

o Exercise < 1 hour only requires fluid replenishment

o Exercise > 1 hour requires fluids, 30-60g carbs/hour, & Sodium/electrolyte replacement

o Exercise > 3 hours requires fluids, up to 90g carbs/hour (multiple transportable carbs)
The goals of Post-exercise supplements are to replenish & repair the body, what are they?
o Consuming carbs & protein after a hard workout will enhance recovery
• Carbs - Glycogen replenishment, increase insulin levels
• Protein - Halt protein degradation, May enhance protein synthesis, May assist with glycogen replenishment when carb intake is inadequate

o Fluids should replace weight lost during workout (24oz- 32oz for every pound)
If a soldier asks me what is the maximum amount of protein that they should consume in one sitting, what should I tell him?
20-25g. Anything more will be oxidized
Section 12
Medical Preparation for deployment
What is deployment readiness processing?
The verification of an individual service member's readiness for deployment (NOT just a medical process)
What are the purposes of Medical/Dental Processing?
• To ensure that soldiers are "fit to deploy"

• To ensure that all "preventive measures" have been completed

• Establish a pre-deployment "medical baseline"

• For "forensic" purposes

• To "identify" any soldiers who are medically or dentally "non-deployable"
What are the conditions required for deployment of soldiers with pre-existing medical conditions?
• The condition is stable and NOT expected to be impacted by deployment conditions

• Unexpected worsening of the condition will NOT result in a medically grave outcome

• On-going health care needs & medications are available in theater and require no special handling or storage

• No duty limitations or accommodations required
What is the requirement for completing a pre-deployment health questionnaire and what is it called?
• DD Form 2795 - Pre-Deployment Health Assessment requirements @ Home Station/Processing Station
o Completed/signed 30 days prior to deploying; MUST BE REVIEWED AND SIGNED BY PROVIDER; Positive responses MUST BE REFERRED to a health care provider for appropriate follow-up.
What is the immunology process and its relation to immunizations?
When can 2 or more "inactivated" vaccinations be administered?
They can be administered at the same time, or at any interval
When can 1 live & 1 inactivated vaccine can be administered?
They can be administered at the same time, or at any interval
When can 2 live vaccines be given?
They must be administered simultaneously, or have a 4 week (minimum) interval
Describe how PPD and live vaccines are given
- They can be administered on the same day (must apply PPD first)

- If live vaccine administered first, wait 4-6 weeks for PPD
What is the Vaccine Adverse Events Reporting System (VAERS)?
It is a national vaccine safety surveillance program that is co-sponsored by the CDC and FDA
What is the function of Vaccine Adverse Events Reporting System (VAERS)?
It is a early warning system (signal detection) for potentially clinically serious vaccine adverse events or health outcomes
Can anyone file a VAERS?
Yes
When is filing a VAERS mandatory?
o Hospitalization due to vaccine

o 24hr loss of duty from illness/injury/reaction to vaccine

o Event is on VAERS reportable events table

o Event is on the NVCIP vaccine injury table

o Contamination of vaccine lot is suspected

o Adverse Event results in a permanent medical exemption (MR)
What are Robust Take +/- systemic symptoms?
o Onset usually 8-10days

o Symptomatic treatment with rest, analgesics

o Usually resolves in 24-72 hours

o Not a reason to exempt from future vaccination
What are Local and Systemic Reactions?
1) Local reactions are the most frequently noted reactions among vaccines

2) Common systemic reactions
• fever, headache, muscle aches

3) Usually responsive to symptomatic therapy (NSAIDS) within 72 hours
Describe Vaccine Hypersensitivity
History is crucial - Must meet immunologic criteria

- Usual "suspects"
• Gelatin
• Egg protein
• Antibiotics
• Latex
Describe a bacterial infection with a Vaccinia-Specific adverse event (bacterial infection) "Vaccinia refers to the vaccination that eradicated smallpox"
1) Systemic Infection
• Staph and strep are most likely culprits
• Super infection of the Vaccination Site or Regional Lymph Nodes (< 0.5%)
• The frequency is not truly known
• Historically more common in children than adults
• When in doubt, culture it

2) Robust Take
• Robust Take seen in up to 15%
• Onset typically 8-10 days
• May be a viral cellulitis (NOT bacterial) due to viral replication while the immune system mounts a response
• Majority "cellulitis" cases are robust takes
Describe satellite lesions from Vaccinia
o Frequency varies from 2.4-6.6%
o Probably more frequent, but often mild so not documented
o Follow normal healing progression
o No special attention needed
o Ask about site care
• Patient using anything topically (which they should not) that might have spread some virus locally?
How should contact lesions be treated from vaccinia?
They need o be covered like a primary site vaccination
When does Non-Viral Pustulosis occur?
In primary vaccines; It is pruritic and usually occurs 7-14 days post vaccination. No evidence of vaccinia
Is Non-Viral Pustulosis contagious?
No!
Describe the symptom associated with Non-Viral Pustulosis?
It can be VERY Pruritic
How is Non-Viral Pustulosis treated?
With antihistamines
How does Non-Viral Pustulosis resolve?
It resolves spontaneously, but secondary infection due to scratching
What are Benign Papulovesicular Eruptions?
- They are eruptions that occur 10-18 days post vaccination and resolve in 14-70 days
What is the key clinical point with Benign Papulovesicular Eruptions?
The patient has other systemic symptoms indicating virus spread through the blood stream
Are Benign Papulovesicular Eruptions contagious?
No
What are the symptoms associated with Benign Papulovesicular Eruptions?
Itching; but no fever
Is myopericarditis common with smallpox?
No but it can happen
Section 13
Occupational Health
What are the "role"s for Occupational Health in the military setting?
1) ****To "protect DoD civilian workers" (contract workers are typically covered by their emplyer)

2) To protect the Soldiers, Sailors, and Airmen

3) Focuses on prevention

4) Public Health
What are the "reasons" for Occupational Health in the military setting?
1) Compliance with "laws", regulations, & exectutive orders

2) Maintain healthy workforce

3) Maintain productivity

4) Decrease organzation costs
What type of treatment is given in the "Program elements of Occupational Health"?
"Occupational" illness and injury
When is "Respiratory Protection" required?
It is required for "ANYONE" wearing a respirator
What are the elements of the Respiratory Protection Program?
1) Evaluation of workplace for respiratory hazards

2) Initial and annual evaluation and clearance for respirator use
- OSHA mandated questionnaire
- Spirometry and/or CXR if needed
- "Use Test" if need

3) Recommendations fro hazard abatement
Describe the OSHA questionnaire
- If all elements (Question 1 to 9) are negative, no further evaluation is nexessary

- If questions are answered "yes' they must be addressed by the health care provider
In the Respiratory Protection Program, are PFTs, CXR or labs "required"?
NO! Use only if clinical judgement indicates
What makes the final decision in the Respiratory Protection Program?
The "USE TEST"
What is the "Use Test"?
Put the worker in the type of respirator to be used, with the same filters, and work them for 15 to 30 minutes
Again, what is the gold standard for the Respiratory Protection Program?
The "Use Test"
Who must be enrolled in the Hearing Convervation Program?
ALL personnel routinely exposed to "Hazardous noise" shall be placed in a hearing conservation program

- > 85 dB, 8 hour Time weighted average (TWA)
- > 140 dB peak
DoD components shall be issued personal hearing protectors free to those personnel
What must be included in the "written" Hearing conservation plan?
1) Noice exposure computation
2) Monitoring
3) Abatement
4) Hearing protectors
5) Hearing protector attenuation
6) Training
7) Audiometric Testing Requirements
8) Audiometric test rooms
9) Audiometers
10) Calibration of audiometers
11) Record keeping
12) Program Evaluation
What is done for a person enrolled in the Hearing Conservation Program?
1) Initial and annual audiogram
2) Hearing protection fitting and issue
3) Referral to audiology as needed
4) Evaluation of workplace for noise hazards
5) Recommendations for noise abatement
6) Education
* When should a Reference (Initial) audiogram be administered of initial exposure to hazardous noise?
Within 30 days
How long must a patient not be exposed to noise prior to the Reference (inital) audiogram?
14 hours
How often is an audiogram required for all personnel routinely exposed to hazardous noise level?
Annually (All military personnel and Civilian workers)
When should a "termination" audiogram shall be conducted on each worker?
When the worker is about to stop working in designated "hazardous noise areas"
What is the primary purpose of medical surveillance program?
Prevention of disease
What is the workman's compensation for government employees (civilian)?
Federal Employee Compensation Act (FECA)
What are the benefits afforded to employees under FECA?
1) The worker is entitled to care by agency provider or by personal physician at worker's discretion.

2) FECA pays all hospital, physician, and medication bill

3) PLUS 75% of base pay "TAX FREE" while off work
What is the Primary Care Physician's role in FECA claims?
1) Initial evaluation

2) Fill out CA-16 (this authorizes treatment)

3) Follow up care if patient selects you as his/her primary physician

*NOTE* The Department of Labor DOES NOT accept PA signatures. All of the notes must be co-signed by a physician (MD or DO)
Section 14
Healthy People 2020 Putting Prevention into Practice
Explain the development of Health People 2020
It is "national agenda" that communicates a vision for improving health, has a set of specific & "measurable objectives", and these objectives are organized within distinct "Topic Areas".
What are the most recent topic areas for Healthy People 2020?
• Adolescent health
• Blood disorders & safety
• Childhood (early & middle)
• Dementias (including Alzheimer's)
• Genomics
• Global health
• Healthcare-associated infections
• Quality of life, Health-related
• Lesbian, Gay, Bisexual, & Transgender health issues
• Older adults
• Preparedness
• Sleep health
• Social determinants of health
What are the goals of Healthy People 2020?
1) Attain high quality, longer lives free of preventable disease, disability, injury and premature death

2) Achieve health equality, eliminate disparities, and improve the health of all groups

3) Create social and physical environments that promote good health or all

4) Promote quality of life, healthy development and healthy behaviors across all life stages
What are the objectives of Healthy People 2020?
1) Represent quantitative values to be achieved over the decade

2) Organized within the topic areas

3) Managed by lead Federal agencies

4) Supported by scientific evidence

5) Address population disparities

6) Data driven and prevention oriented
What are some of the ways that healthcare providers can use Healthy People to improve population health?
1) Contribute to national progress on the Healthy People objectives by offering patients relevant counseling, education, and other preventative services

2) find objectives that pertain to your specific areas of specialization
- Understand how your patient population compares with the U.S. Population as a whole
- Learn about key issues within each topic area that are important to address on a national level
This is defined as improving the delivery of appropriate clinical preventative services with tools and resources to support healthcare organizations and engage the entire healthcare delivery system
Put Prevention into Practive (PPIP)
What is Put Prevention into Practive (PPIP)?
An Implementation program derived from recommendations of U.S. Preventative Services Task Force
What is the purpose of Put Prevention into Practive (PPIP)?
1) increase awareness of prevention

2) Increase appropriate use of clinical preventative services (screening tests, counseling, immunizations)
Why is Put Prevention into Practive (PPIP) needed?
1) Vast majority of premature death is preventable

2) Strong evidence shows that clinical preventative services can prevent some of the leading causes of death

3) Combat barriers to the effective delivery of preventative care
How was Put Prevention into Practive (PPIP) developed?
1) Lanched in 1994 to increase implementation of USPSTF recommendations

2) Management transferred to AHRQ in 1998

3) Cooperation of many public and private groups

4) Based on research-tested interventions for improving delivery of preventative services in primary care settings

5) Focused group tested with clinicians, office staff, patients

6) Ongoing consultation with users and potential users
What are the "patient barriers" to delivering clinical preventative services?
1) Lack of knowledge

2) Anxiety about procedures and results

3) Inconvenience

4) Costs
What are the "clinical barriers" to delivering clinical preventative services?
1) Lack of prevention training and knowledge

2) Lack of confidence that prevention makes a difference

3) Lack of time

4) Inadequate reimbursement
What are the "office barriers" to delivering clinical preventative services?
1) Lack of knowledge

2) Lack of motivation, not ready for change

3) Lack of effective teamwork

4) Clinical setting focused on illness and treatment rather than wellness and prevention

5) Inadequate systems for delivery, tracking and followup for preventative services
Section 15
Nutritional Management of Individuals in Humanitarian Circumstances
These are measurements to quantify the severity of the nutritional situation to allow planning and implementation of an appropriate response
Anthropometrics
What are the measurements of Anthropometrics?
1) Weight for Height % of median - Main indicator of acute malnutrition (<70% - severe malnutrition; 70-79% - moderate malnutrition)
- Weight - Composite indicator for long-term & current malnutrition (Stunting & Wasting)
- Height - Indicator of chronic malnutrition (Stunting)

2) Z-score - used in screening osteoporosis via DEXA scan; compares pt score to a young adult

3) Mid-upper arm circumference (MUAC)

4) Body mass index (BMI)
What is most common evidence of chronic malnutrition?
Stunting
How will a patient that has "Stunting" Present?
1) Normal height/weight

2) No evidence of clinical malnutrition

3) Growth grossly retarded
This program adds foods and nutrients to an existing diet; non-targeted or targeted to vulnerable groups
Supplementary Feeding Program (SFP)
This program provides a carefully balanced and intensively managed complete dietary regimen accompanied by medical intervention to a severely malnourished child
Therapeutic Feeding Program (TFP)
In this program, the majority of the severely malnourished are treated at home; Uses outreach teams & aims to build community capacity; Provides therapeutic foods containing the right mix of nutrients; Ready-to-use Therapeutic Foods (RUTF) can be locally manufactured
Community Therapeutic Care (CTC)
What vitamin deficiency causes "Xerophthalmia"?
Vitamin A deficiency
What puts a person at risk for having a Vitamin A deficiency?
No fresh fruits, low fat
****What are the clinical manifestations of a Vitamin A deficiency?
1) Night blindness; Conjunctival, then corneal xerosis; Biots spots (Dry, dull, cloudy cornea); corneal ulceration; keratomalacia (Softening and subsequent ulceration and perforation of the cornea); Phrynoderna AKA "Toad Skin" (Marked follicular hyperkeratotic eruption on the arm)

- Once a patient has kertomalacia, it cannot be treated with vitamin A and the patient will lose their eye

2) Poor growth, impaired immunity, increased risk of persistent diarrhea

*****3) Measles more severe in a Vitamin A deficiency (because it depletes Vitamin A stores)
What vitamin deficiency causes Beri-Beri?
Vitamin B1 (Thiamine) Deficiency
What puts a person at risk for having a Vitamin B1 (Thiamine) Deficiency?
Polished rice
What is the clinical presentation of "Dry" Beri Beri?
Bilateral peripheral polyneuritis evolves to flaccid paralysis
What is the clinical presentation of "Wet" Beri Beri?
Cardiovascular syndrome with edema and heart failure, sudden death
What vitamin deficiency causes Pellagra?
Vitamin B3 (Niacin)
What puts a person at risk for a Vitamin B3 (Niacin) deficiency?
Maize-Based; Low protein diet
What is the clinical presentation of Pellagra?
1) Diarrhea

2) Dementia

3) Dermatitis: dark, dry skin lesions in sun-exposed areas

4) Glossitis
What puts a person at risk for Vitamin B6 (pyridoxine) deficiency?
Isoniazid (Pyridoxine antagonist)
What are the clinical manifestations of a Vitamin B6 (pyridoxine) deficiency?
1) Dermatitis

2) Glossitis

3) Cheilosis

4) Peripheral neuritis

Infants: Irritability, Convulsions, Anemia
What vitamin deficiences cause gloassitis?
1) Iron

2) Niacin (B3)

3) Thiamine (B1)

4) Riboflavin (B2)

5) B12

6) Zinc

7) Vitamin B6 (Pyroxidine)
What vitamin deficiency causes Scurvy?
Vitamin C (Ascorbic acid)
What puts a person at risk for a Vitamin C (Ascorbic acid) deficiency?
No/few fresh fruits and vegetables
What are the clinical manifestations of a Vitamin C (Ascorbic acid) deficiency?
1) Swollen, bleeding gums with loss of teeth

2) Swollen, painful joints

3) Internal hemorrhage
What vitamin deficiency cause Rickets?
Vitamin D deficiency
What puts a person at risk for a Vitamin D deficiency?
1) Little sunlight

2) Dark skin

3) Breast feeding

4) Poor diet
What is the clinical presentation of Vitamin D deficiency?
1) Rickets

2) Osteomalacia
What vitamin deficiency causes anemia?
Iron Deficiency
What puts a person at risk for an Iron deficiency?
1) Few animal products in diet

2) Parasitic Infection

3) Concomitant vitamin C or folate deficiency
What is the clinical manifestation of Iorn deficiency?
1) Fatigue, Pallor, Infection susceptibility

2) Lead poisoning

3) Poor learning and work capacity
What puts a person at risk an Iodine deficiency?
Food Grown in iodine deficient soil
What is the clinical manifestation for Iodine deficiency?
1) Goiter

2) Reproductive failure to include increased risk of spontaneous abortion and stillbirth

3) Cretinism in children born to iodine-deficient mothers
What is the risk of a Zinc deficiency?
Low meat (low zinc), high grain (high phytate) diets

THIS IS A VAST PROBLEM
What are the effects of a Zinc deficiency?
1) Lower immune competence

2) Increases risk of: Diarrhea and Respiratory infection
What is the clinical manifestation of a Zinc deficiency?
1) Role in protection of cell membrane integrity" may be protective aganist free radical injury

2) Acrodermatitis enteropathica (Scaling plaques)

3) Alopecia, Glossitis, Nail dystrophy

4) Lethary, Anorexia
What are the benefits breast feeding?
1) Known nutritional and immunologic advantages

2) Maintain normal infant growth

3) Promote bonding

4) Maternal sense of empowerment, self esteem, and stress reduction

5) Conserve food within a household

6) Contributes to sustainable development and food security
What are the risks of bottle feeding?
1) High infection loads

2) Contaminatino of water supply

3) Lack of fuel for formula preparation

4) Disruption of the supply of commercial formula products
Can women breastfeed under stressful emergency conditions?
Yes!

- Milk "production" is adequate under stress
- MIlk "release" may be affected by stress
If a malnourished mother is breast feeding, who do we supplement? The mother or the infant?
Supplement the mother (supplementing the infant decreased suckling and milk production)