Anterior Cruciate Ligament Tear

Outdoor and wilderness athletes put a lot of stress on their joints. Whether you are skiing, climbing, biking, hiking, running, or doing any other activity at which you are risk for deceleration, a fall, or a blow to the knee, there is a risk of injuring the joint. A common sports injury is a torn anterior cruciate ligament. This problem is succinctly reviewed by Drs. Kurt Spindler and Rick Wright in the Clinical Practice section of a recent issue of the New England Journal of Medicine. (N Engl J Med 2008;359:2135-42)

According to the authors, the anterior cruciate ligament (ACL) is the most commonly injured ligament in the body for which surgery is frequently performed. This probably underestimates the problem because of failure to make the diagnosis. Women in sports appear to have a higher incidence of injury than do men, perhaps due to differences in leg alignment (increased incidence of "knock knee"), less space within the knee joint for the ligment, hormonal factors that would weaken the ligament, and perhaps less overall joint control during vigorous activities. Regardless of whether a person is a male or female, the injury leads to an increased incidence of "premature" knee osteoarthritis.

ACL tear is very often accompanied by other injuries, including those to a meniscus, joint cartilage, bone, and other ligaments. When the injury occurs, sometimes it is obvious, because of the mechanism of injury and/or hearing an audible popping sound, swelling from bleeding into the knee, and lack of function. When the ligaments on the sides of the knees ("collateral" ligaments) are injured, they generally do not cause swelling, and meniscal tears show delayed swelling.

The diagnosis may be made by the history, supplemented by a Lachman test (in which the lower leg is pulled anteriorly against a fixed femur, to detect instability) and, when necessary, magnetic resonance imaging (MRI) examination. In the acute phase of injury, the victim may be able to walk normally and perform "straight-plane" activities, such as stair climbing, biking, and even jogging. However, if he or she is unstable in normal activities or wishes to resume activities that call for cutting motions and pivoting, or is engaged in a profession or activity in which complete stability of the knee is essential (and safe), then surgery may be required.

In the acute phase of injury, the knee should be treated as would any other ligament injury, with rest, ice compression and elevation. Bracing or taping the knee may be helpful. Surgery may not be advised for a period of weeks, until the bleeding has subsided and the joint swelling receded.

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

image courtesy of www.eorthopod.com

Tags: anterior cruciate ligament, injured ligament, knee injury, wilderness medicine, outdoor medicine, healthline

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Sam Pelvic Sling versus pelvicbinder

In response to my latest post, pelvicbinder, I received a communication from the originator of the Sam Pelvic Sling ®. He informed me, with the appropriate disclaimer that he has a significant financial interest in the Sam Pelvic Sling ®, that the pelvicbinder™ does not have automatic "force control," since the tightness with which it is applied is controlled entirely by the user during application of the device. In this regard, he stated, "The fact is, the 'pelvicbinder' has no more force control than a bed sheet. There is nothing on this device to restrict the amount of force applied. For example, five different people of differing strengths would likely apply five different levels of force. The Sam Pelvic Sling ® is the only pelvic circumferential compressive belt containing a patented auto-stop device that limits the force to a scientifically proven, safe and effective range. Their levels of training and experience not withstanding, five different individuals applying the Sam Pelvic Sling® will always apply the same safe (and effective) force. This unique characteristic of our device allows it to be safely and effectively applied by untrained individuals at the scene of an accident, which is particularly relevant in a wilderness medicine scenario."

These are interesting comments and should be taken into consideration when deciding what to purchase, and to determine the necessary degree of training needed to properly apply any device.

If anyone wishes to offer an opinion or further commentary on this topic, please do so as a comment to this post.

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pelvicbinder

Fracture of the bony pelvis usually occurs if there is considerable force applied to the body, such as occurs with a fall or significant crush injury. Because there is a rich blood supply throughout the inner surfaces of the pelvis and many large blood vessels that traverse the muscles and organs housed within this part of the body, bleeding can be severe.

If (gently) pressing inward on the victim’s hips or downward on the pubic bone causes pain, suspect a fracture of the pelvis, and immobilize the victim from his waist on down. In the case of a suspected fracture of the pelvis, walking is prohibited. A pelvic fracture is frequently associated with severe internal injuries and bleeding, so rapid evacuation is a high priority. Be prepared to treat the victim for shock.

In order to keep any fractured bones of the pelvis in alignment, it is useful to wrap, or "bind," the pelvis in such a way as to compress the bones together and minimize their motion. In an improvised fashion, this may be done by wrapping the pelvis (hips and buttocks) very snugly with a sheet(s) or large towels, and tying them off or using adhesive tape to keep them in place. Alternatively, a sleeping pad, jacket or large shirt may be used for the same purpose.

The pelvicbinder™ is a force-controlled circumferential pelvic sling belt for effective reduction and stabilization of pelvic fractures. "Developed by trauma surgeons for trauma surgeons," it is a single-use, disposable "one size fits all" binder that is easily trimmed to fit each patient. Three colors are available - desert camo, yellow, and green camo. It is applied snugly, enough to be able to insert two fingers between the device and the skin of the victim. Another excellent device, which is reusable, is the SAM Pelvic Sling™.

Pelvic immobilization hopefully diminishes instability, internal bleeding, and pain. Before applying any pelvic compression method, be sure to empty the patient’s pockets and remove his belt so that the external pressure doesn’t press any items against the pelvis. For transport, place padding between the victim’s legs and gently tie his legs together to minimize motion and improve comfort. Daily skin checks should be performed to be certain that the pressure is not eroding the skin. This is done by having one health care provider slide his or her fingers under the binder to hold the pelvis stable, while another person briefly loosens the binder in order to inspect the skin.

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

Tags: pelvicbinder, pelvis fracture, pelvic stabilization, wilderness medicine, outdoor medicine, healthline

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Thank You to Codeblog for Grand Rounds

Thank you to codeblog for including my post about handwashing technique in this week's Grand Rounds. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining.

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Travel to High Altitude with Children

In the current issue of High Altitude Medicine & Biology (volume 9, number 4, 2008), there is an excellent article entitled "Travel to High Altitude with Young Children: An Approach for Clinicians," authored by Michael Yaron and Susan Niermeyer.

This article is a brief review of the principles of altitude illness in children. I found it helpful in my practice and in the advice that I give to persons who seek my opinions. The article emphasizes the following:

1. Children experience the full range of altitude-associated illnesses, including acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), and high altitude cerebral edema (HACE).

2. AMS in children is characterized by fussiness, lack of playfulness, poor appetite, nausea, vomiting, and poor sleep. This is the most common altitude illness in children.

3. HAPE, which is often preceded by AMS, is caused by low blood oxygen content, and is manifested as shortness of breath, rapid breathing, blue discoloration of skin in the fingers, toes, around the lips and in the earlobes, reduced activity tolerance, cough, coughing blood, and fever.

4. HACE, which is often preceded by AMS, carries features of headache, unbalanced gait, behavioral changes, and altered mental status, randing from confusion to hallucinations or coma, as well as a variety of neurological deficits.

5. The approach to a child traveling to high altitude should focus on planning the ascent, management of altitude-associated illness(es), and diagnostic followup:

Planning the ascent:

A. Ascend slowly. Avoid difficult descents in which initial rapid ascent will be necessary. Do not bring children younger than 4 to 6 weeks to high altitude, because their circulatory system maturation may not be sufficiently complete to prevent an increased incidence of altitude-associated illness. Infants who required supplemental oxygen during the neonatal period are at particular risk. Avoid traveling to altitude with children who have suffered recent inflammatory processes, such as viral infection, or situations associated with pulmonary hypertension. Children with trisomy 21 are more prone to HAPE than are those with normal chromosomes.

B. Recommendations for management include slow, graded ascent, early recognition of symptoms combined with halting further ascent, and descent if rest and time do not diminish or eliminate symptoms. The Children’s Lake Louise Score can be used to recognize AMS in children modify activity, and/or provide treatment. Treatment of AMS should be initiated once symptoms develop. Descent is effective treatment, and further ascent is contraindicated. The dose of acetazolamide recommended to treat AMS in children is 2.5 milligrams per kg (2.2 pounds) of body weight given every 12 hours, with a maximum dose of 250 mg. If prophylaxis for AMS, which is not routinely indicated, is undertaken, the dose is 1.25 mg/kg of body weight every 12 hours, begun 24 hours prior to ascent and continued for 48 hours after the maximal altitude is attained.

C. Diagnosis of structural cardiopulmonary abnormalities should be considered after an episode of altitude-associated illness in a child.

There is a great deal more useful information in this article, and I highly recommend it for health care providers and for persons who will be responsible for bringing children to high altitude environments.

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

Tags: high altitude, children, acetazolamide, wilderness medicine, outdoor medicine, healthline

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Thank You to ACP Internist for Grand Rounds

Thank you to ACP Internist for including my post about nosebleed in this week's Grand Rounds. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining.

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Handwashing Technique

Last spring, there was a report in the press that disinfectant wipes may contribute to the spread of drug-resistant bacteria in hospitals. This information originated with findings presented at the American Society of Microbiology's annual meeting. According to a report distributed by Reuter's, researchers at the Welsh School of Pharmacy at Cardiff University explained that "[w]hile the wipes killed some bacteria, a study of two hospitals showed they did not get them all, and could transfer the so-called superbugs," including methicillin-resistant Staphylococcus aureus (MRSA), "to other surfaces."

In greater detail from United Press International, a team led by Jean-Yves Maillard, Ph.D. observed intensive care unit (ICU) "hospital staff using surface wipes to decontaminate bed rails, monitors, tables and key pads, and other surfaces touched by patients and staff." According to the BBC, while the researchers visited the Welsh hospitals, they observed that "it was common for a single wipe to be employed on more than one surface." The "wipes were quite good at picking up bacteria from the first surface, but were unable to kill off the bacteria they picked up swiftly."

I would agree with these observations, because we have all observed the same in a health care setting. How many of us have used a disinfecting wipe, or other cleansing wipe, in the proper manner, that is to use it for a single surface, then discard it? It's so much easier to use it until it is caked with dust and grime, not thinking that it has probably lost its disinfection potential after the first swipe over a filthy surface.

The most blatant extrapolation I witnessed of this concept in the outdoors was during a trek to Pheriche in Nepal. We were on our way to visit the Himalayan Rescue Association medical outpost. The group of a dozen trekkers would take great care before each meal to wash hands in water that had been boiled and then colored purple for disinfection purposes with potassium permanganate, only to share the same towel in order to dry our hands. By the time the towel was used by the last person, who knew how many bacteria and viruses had taken residence amongst the shed skin, shared wash water, and other assorted flecks of dirt and plant material that had been rubbed into the cotton pile. The only way that we could have more effectively shared our germs would have been to rub all of our hands together at one time.

If disinfection of a liquid or surface (e.g., eating utensil, bowl, towel, wound dressing) is important, it must be done properly and with full knowledge of the limitations of the method used. For wiping things down with disinfectant wipes, the best method is "one surface per wipe," and to use as many wipes as are necessary to achieve a clean appearance. That is no guarantee of disinfection, but it is better than leaving obvious dirt (and presumably, infectious agents) in place, and certainly better than moving the germs from one place to another.

photo courtesy of www.i.ehow.com

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

Tags: disinfection, hand washing, disinfecting wipes, wilderness medicine, outdoor medicine, healthline

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Nosebleed

Nosebleed (epistaxis) is classified as anterior or posterior, depending on where it originates within the nose. Most nosebleeds are anterior, and occur along the anterior nasal septum, which divides the nares ("nostrils"). Generally, anterior nosebleed is less serious, because the victim will usually drain blood outward through the nostrils. Posterior nosebleed (10% of nosebleeds), which occurs with a greater frequency in elders, is more difficult to control, and the victim often drains blood back into the throat, with coughing and potential choking. Anterior nosebleed is more common and can usually be managed outside of the hospital. If you suspect a posterior nosebleed (bleeding from the nose accompanied by brisk bleeding into the throat, so that a lot of blood is continually swallowed, particularly after the anterior bleeding has been controlled), immediately evacuate the victim to a hospital.

The most frequent cause of a nosebleed is a small bleeding blood vessel or cut on the inner mucosal surface of a nostril. This is more common at high altitudes and in cold weather (e.g., winter), because the drying effect causes the skin to become irritated and crack. One way to prevent nosebleeds is to keep the inside of the nose lubricated with an ointment such as mupirocin or bacitracin, or to spray regularly with saline solution (such as Ocean saline mist or drops with 0.65% sodium chloride). It is possible that nosebleeds are more common in persons whose blood pressure has risen out of control, although this has never been proven and is somewhat controversial. People on prescription anticoagulant drugs are prone to nosebleeds. Low-dose aspirin, garlic, ginkgo, or ginseng ingestion may contribute to an increased frequency of nosebleeds.

To control an anterior nosebleed, attempt simple maneuvers first. Have the victim blow his nose to remove all clots. Keep him upright (sitting leaning forward) and calm, and firmly press both nostrils closed against the nasal septum (middle cartilage). A common mistake is to apply pressure against the nasal bones, rather than to press the fleshy sides of the nose against the septum. Hold this position for 15 minutes without release; letting go prior to this time will only restart the bleeding, because it takes the small blood vessels and scratched surface a while to stop oozing. After 15 minutes, let go and see if the bleeding has stopped. If not, gently but firmly pack both nostrils with a gauze or cotton roll moistened with phenylephrine 0.25% (Neo-Synephrine 1/4%) or oxymetazoline (Afrin) and repeat the pinching maneuver for 20 minutes. Generally, this does the trick; if it doesn’t, repeat the packing without the phenylephrine or oxymetazoline. After the bleeding has stopped, leave the packing in place for 2 hours and then gently remove it. Sometimes, simply spraying phenylephrine or oxymetazoline inside the nose (as one would do for a common cold) at the beginning of the compression process is enough to terminate a nosebleed. Cold (low temperature) compresses applied to the bridge of the nose or a roll of gauze or cotton placed beneath the upper lip are of limited help when dealing with a brisk nosebleed.

Packing with absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel) may be helpful. Another hemostatic packing gauze is QuikClot NoseBleed gauze (Z-Medica Corporation). A useful device for packing the nose to stop a nosebleed is the Rhino Rocket (Shippert Medical Technologies), which is a compressed medical-grade foam sponge with applicator. The foam is guided into place, where it swells on contact with moisture (blood) to 8 to 10 times its compressed size. A string is attached to the sponge so that it can be easily removed. Weimert Epistaxis (nosebleed) Packing or Merocel hemoX uses a similar approach. Merocel is a polyvinyl alcohol nasal tampon that is inserted into the nose, whereupon exposure to a topical vasoconstrictor (e.g., phenylephrine 0.25%) and saline causes it to expand and create pressure over the bleeding point. The rapid RHINO nasal pack with Gel Knit uses a hemostatic carboxymethylcellulose fabric over an inflatable balloon to apply compression within the nose. In one study, this device was felt to be less painful to insert and easier to remove than the Rhino Rocket. NasalCEASE (Catalina Healthcare) is a bundle of fine fibers made from brown seaweed (active ingredient calcium alginate) extract that can be inserted into the nose to aid clotting.

If the nose is packed, administer an antistaphylococcal antiseptic (such as dicloxacillin or trimethoprim-sulfamethoxazole) for the duration of the packing. The nasal packing should be kept moist with sterile saline or oxymetazoline (Afrin) spray.

A relatively new product for doctors to use to control an anterior nosebleed is FloSeal Hemostatic Matrix, which is a proprietary combination of cross-linked gelatin granules and topical human thrombin. There is a mixing process that creates a gelatinous foam that is gently injected to fill the anterior nose and stop the bleeding. The patient winds up with a comfortable nose filled with foam that breaks done in 3 to 5 days and is completely disappeared in 5 to 7 days. This is a relatively expensive treatment, but quite effective when used properly.

Some of the information in this post was derived from an excellent article entitled "Epistaxis," by Rodney J. Schlosser, M.D. (New England Journal of Medicine 2009;360:784-9)

Photo Credit: Brad Pitt: Ambler/Knapik/Splash News

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

Tags: nosebleed, epistaxis, nose, wilderness medicine, outdoor medicine, healthline

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Coastal Solutions, Inc.

Coastal Solutions, Inc. of Savannah, Georgia promotes a line of products named "Jellyfish Squish, "Fire Ant Coolant," "Chigger Chaser," and "Bite Blaster," the active ingredient for all of these being the topical anesthetic 4% lidocaine hydrochloride (dissolved in water). The products are provided in Magic Marker-sized (0.24 fluid ounce or 7 milliliters) pump spray containers. Fire Ant Coolant, Chigger Chaser, and Jellyfish Squish also contain, among other compounds, aloe eucalyptus oil, methyl paraben, and propyl paraben. Bite Blaster does not contain eucalyptus oil.

Topical lidocaine is an effective anesthetic, and rarely causes adverse reactions. I asked the company to provide me with any data available to them to indicated the efficacy of lidocaine. I received a paper entitled "Jellyfish Sting Relief," authored by Peter Verity and Dick Lee of the Skidaway Institute of Oceanography, which is affiliated with the University System of Georgia. These investigators compared lidocaine, vinegar (acetic acid), household ammonia, meat tenderizer, and deionized water as topic remedies to treat stings on the arms of volunteers from the jellyfishes Chiropsalmus quadrumanus ("sea wasp") and Chrysaora quinquecirrha ("sea nettle"). Their observations were that lidocaine was helpful (e.g., alleviated the pain), whereas deionized water and papain were without effect, and vinegar and ammonia caused an initial increase in pain. Furthermore, they observed the stinging cells of the sea nettle under the microscope while being "treated" with these same remedies, and found that vinegar stimulated mass firing of nematocysts. The implication of this finding is not entirely clear, because it was not correlated with any particular clinical finding. Lidocaine was not seen to cause nematocysts to fire.

Lidocaine hydrochloride is a well-known and extensively tested topical (skin) anesthetic, which has long been known to be useful abrasions (scrapes), minor burns, small cuts, and insect bites. To this list can now probably be added jellyfish stings. The role of other topical agents, such as vinegar, ammonia, and baking soda, remains empirical, but supported by many experts based upon clinical observations of efficacy. For instance, vinegar is emphatically recommended by experts in Australia for stings from Chironex fleckeri, the dreaded box-jellyfish. I have used vinegar and rubbing alcohol, alone and in combination, to treat all varieties of jellyfish stings with great effect. This makes me continue to believe that all jellyfish are not absolutely identical in terms of their response to therapies, and that the nematocysts of different species may respond differently to different topical agents.

It makes perfect sense to me that topical lidocaine hydrochloride should be effective for jellyfish stings, chigger bites, and insect stings, as it is a non-specific anesthetic agent that is capable of numbing superficial skin no matter what the irritant. However, it should not be relied upon to abort an allergic reaction to a sting, nor to neutralize any venom that has been transferred in the envenomation or stinging process. I intend to carry a spray vial and to utilize it the next time I am bitten or stung, which is inevitable. It may also come in handy the next time I need to prepare (numb) a wound for cleansing, with the notation that this is not a sterile solution. Lidocaine toxicity should not be a concern when using a small amount of this spray.

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

Tags: Coastal Solutions, jellyfish, chigger, fire ant, wilderness medicine, healthline

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Thank You to Doc Gurley for Grand Rounds

Thank you to Dr. Jan "Doc" Gurley for including my post about sore throat in this week's Grand Rounds. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining. This week's host has taken Grand Rounds to a new level, and I am both incredibly impressed and grateful. Check it out!

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Sore Throat

Sore throat is a common problem at home and outdoors. Sore throat (pharyngitis) is a common complication of viral infections (the common cold, infectious mononucleosis), breathing dry air (“altitude throat”), or primary bacterial throat infection (“strep throat”). Symptoms of an infection include pain with swallowing, fever, swollen lymph nodes (“swollen glands”) in the anterior neck, red throat, swollen tonsils, pus over the tonsils and throat, headache, fever, abdominal pain, and nausea and vomiting.

Because the symptoms of a viral throat and tonsil infection and a bacterial strep (group A beta-hemolytic streptococcus [GABHS]) throat are frequently identical, it is hard to make the differentiation without a throat-swab “rapid strep test” or bacterial culture. Below the age of 3 years, a child rarely has a strep throat; in young adults, the presence of strep throat in the presence of classic symptoms (fever, pus, and swollen tonsils and lymph glands in the neck) is roughly 50%. However, because the potential complications (kidney or heart disease) of an untreated strep throat in a young person outweigh the complications of antibiotic use, it is advisable to treat a person who is outdoors and without a definitive diagnosis (e.g., on a camping trip) with penicillin (or amoxicillin), cefadroxil, or erythromycin for a full 10-day course, or with azithromycin or clarithromycin for 5 days. If none of these drugs is available, clindamycin or cephalexin can be used. Even if the victim improves after 2 to 3 days, the antibiotic should be taken for the full course.

Adjuncts to care include saltwater gargles (1/2 tsp, or 2.5 ml, of table salt in 1 cup, or 237 ml, of warm water), throat lozenges, warm fluids (to moisten and soothe the throat), and aspirin or acetaminophen to control fever. To avoid Reye syndrome (postviral encephalopathy and liver failure), do not use aspirin to control fever in a child under the age of 17.

If a person develops an acute sore throat that rapidly becomes extremely uncomfortable (severe pain, difficulty swallowing), a single dose of dexamethasone or its equivalent may be given along with an antibiotic, assuming the victim can swallow the medications. This may help decrease inflammation, but should not be given routinely for a “nontoxic,” or run-of-the-mill, sore throat (see below). If someone with a sore throat has a high fever associated with difficult or noisy breathing, altered (e.g. hoarse) or muffled voice (“like talking with a potato in his mouth”), drooling, stiff neck, or any visible swelling (bulging) in the back of the throat, he should be made as comfortable as possible and transported immediately to a hospital. Such a condition may indicate an abscess in the back of the throat or next to a tonsil, infection and inflammation of the epiglottis (epiglottitis), or massively swollen tonsils. Any of these may rapidly obstruct the airway.

If a person develops tender swelling under the tongue and/or under the chin, particularly associated with swollen lymph glands in the neck, fever, difficulty swallowing, and foul breath, this may indicate an infection in the floor of the mouth. Treat the victim with an antibiotic as for a strep throat and seek immediate physician consultation.

A sore throat can be caused by overgrown of the fungus Candida albicans, which leads to a condition known as “thrush.” This occurs most commonly in persons who are immunosuppressed, have recently taken broad-spectrum antibiotics, use inhaled or oral steroids, wear dentures or orthodontic appliances, have diabetes, or are elders. Symptoms include burning in the mouth and throat, white patches on the palate and in the mouth and throat, painful swallowing, heartburn, drooling, and loss of appetite. If thrush is suspected, it can be treated with nystatin (Mycostatin) oral suspension, swished and swallowed four times a day for 2 weeks, or with nystatin oral lozenges 4 to 5 times daily for two weeks.

In a paper entitled "Clinical efficacy of dexamethasone for acute exudative pharyngitis," A. Taser and colleagues from the Department of Emergency Medicine at Nazilli General Hospital in Nazilli, Aydin, Turkey reported their investigation about whether treatment with single-dose dexamethasone could provide relief of symptoms in acute pharyngitis. A prospective, randomized, double-blinded, placebo-controlled clinical trial was undertaken over a 3-month period, and included all consecutive patients between 18 and 65 years of age presenting with acute exudative (inflammation, redness, and pus) pharyngitis, sore throat, pain on swallowing, or a combination. Each patient was treated with azithromycin and acetaminophen for 3 days. The effects of placebo and a single dose (8 mg) intramuscular injection of dexamethasone were compared. The patients were asked to report the exact time to onset of pain relief and time to complete relief of pain. After completion of the treatment, telephone follow-up regarding the relief of pain was conducted. After certain patients were excluded, 42 patients were assigned to the placebo group and 31 were assigned to the intramuscular dexamethasone group. Time to perceived onset of pain relief was 8.06 +/- 4.86 hours in steroid-treated patients, as opposed to 19.90 +/- 9.39 hours in the control group (p = 0.000). The interval required to become pain-free was 28.97 +/- 12.00 hours in the dexamethasone group, vs. 53.74 +/- 16.23 hours in the placebo group (p = 0.000). No side effects and no new complaints attributable to the dexamethasone and azithromycin were observed. The conclusion was that sore throat and pain on swallowing in patients with acute exudative pharyngitis may respond better to treatment with an 8-mg single dose of intramuscular dexamethasone accompanied by an antibiotic regimen than to antibiotics alone. In an outdoor setting, where dexamethasone for intramuscular injection would likely not be available, an oral dose of dexamethasone or another equivalent steroid could be used. The precise dose of dexamethasone for oral administration for this indication has not been determined, but a low one-time therapeutic dose would be 0.6 milligrams per kilogram (2.2 pounds) of body weight, up to a maximum dose of 10 mg.

Recently, the American Heart Association (AHA) rewrote its recommendations for diagnosing and treating acute streptococcal pharyngitis, which is its first update since 1995. The statement, released online in the journal Circulation, notes that prevention of rheumatic fever depends on control of streptococcal infection.

Here are some of the AHA's recommendations:

A throat swab-and-culture is the standard method of diagnosing strep throat. Antigen ("rapid strep") tests have low sensitivity, and culture backup is likely necessary in children and adolescents to confirm negative results.

Oral penicillin V, amoxicillin, and injected benzathine penicillin G are the recommended treatments. Alternatives for patients allergic to penicillin include a narrow-spectrum oral cephalosporin, oral clindamycin, an oral macrolide antibiotic, or azithromycin.

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

Tags: strep throat, sore throat, pharyngitis, wilderness medicine, outdoor medicine, healthline

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Socorro Island Dive and Wilderness Medicine CME

I'm delighted to announce that I will be participating in an exciting continuing medical education (CME) adventure to benefit the Wilderness Medical Society (WMS).

The journey will be January 24 to February 2, 2010 to Socorro Island, Mexico for the Dive and Wilderness Medicine Continuing Medical Education program. Dr. Karen Van Hoesen of the University of California San Diego (UCSD) and I will deliver updates in Dive and Wilderness Medicine via a curriculum accredited by the WMS combined with an exciting eight day live-aboard scuba diving experience.

18.5 hours of AMA PRA Category 1 credits are accredited through the WMS along with Fellowship of the Academy of Wilderness Medicine (FAWM) credit hours. This CME/FAWM event will take place in an exceptional conference venue – The Nautilus Explorer - one of the world’s premier dive vessels. The 117-foot ship features a relaxed meeting space, gourmet meals and world-class accommodations. Only eighteen spots will be available for participants to enjoy eight days of educational sessions during this excursion to Socorro Island, a marine and nature preserve located 200 miles south of Cabo San Lucas.

The cost is $685 for CME tuition plus the package price of the scuba adventure accommodations selected by the participant. The CME curriculum will cover certain topics essential for attainment of Fellowship in the Academy of Wilderness Medicine, emphasizing dive and marine medicine, and related wilderness medical issues. The itinerary of this excursion includes potential encounters with giant manta rays, humpback whales, dolphins and five species of sharks. Additional details may be obtained at www.tandtadventures.com under the “ocean” tab or by calling toll free at 1.888.308.3007 or via email to jim@tandtadventures.com

I hope to see some of you aboard.

Tags: Socorro Island, CME, dive medicine, wilderness medicine, outdoor medicine, healthline

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Naturally Occurring Toxins 3

This is the seventeenth post based upon educational sessions and syllabus material presented at the Wilderness Medical Society Annual Meeting & 25th Anniversary held in Snowmass, Colorado from July 25 to 30, 2008. It includes information from a lecture entitled “Beautiful But Deadly: Naturally Occurring Toxins,” delivered by Edward J. (“Mel”) Otten, MD, FACMT, FAWM, who is Professor Of Emergency Medicine and Pediatrics, as well as Director of the Division of Toxicology in the medical center at the University of Cincinnati. Mel is also a past President of the Wilderness Medical Society.

VENOMOUS ANIMALS

Arthropods comprise the largest group of animals and contains 60% of all living species. Many arthropods are venomous. They may bite, sting or secrete venom through pores or hairs. Caterpillars, ticks, mites, water bugs, ants, bees, spiders, scorpions, centipedes, kissing bugs, millipedes and many others are included in this group.

Hymenoptera

The class Hymenoptera contains the most commonly encountered venomous animals and accounts for most of the morbidity and mortality. These are the bees, wasps, hornets, and ants. The amount of venom that is deposited is usually small and the serious clinical effects are related to manifestations of an allergic reaction.

The venom apparatus is a modified ovipositor and the venom, with the
exception of that of fire ants, is mainly protein in nature but also contains
various peptides, amines and other low molecular weight substances. Fire ant (Solenopsis invicta) venom is 99% alkaloid, which is unusual in the animal kingdom. The venom of Hymenoptera is deposited in the victim via the sting and may produce an immunoglobulin E (IgE) mediated antigen-antibody reaction and an acute anaphylactic (severe allergic) response in the victim. This is the usual cause of death and is not related to the toxicity of the venom, but rather to the immune response mounted by the victim.

Honey bee venom causes an increase in the amount of histamine released. There is only a small degree of cross reactivity with the venom of wasps and hornets. The honey bee has large barbs on her sting, which result in the entire venom apparatus being removed during the stinging process and the bee dying. This causes a release from the bee of a pheromone that attracts more bees. More stings may occur. The sting is usually painful and may become red and swollen. Some victims may have a diffuse reaction involving an entire limb that resembles cellulitis.

Antihistamines may be used to treat the symptoms. Victims who have an anaphylactic response may have airway spasm, a raised red rash (hives), very low blood pressure, coma and cardiac arrest. The treatment is epinephrine injection, oxygen and airway control, and fluid administration, and must be instituted as soon as possible after the sting(s) to be effective.

The Rule of Hymenoptera: It's not the toxin - it's the allergic reaction that is dangerous.

Arachnids

There are more than 20,000 species of spider in the world, and all of them are venomous. Fortunately for humans, only a few of these spiders have the ability to penetrate human skin. There are about 800 species of scorpion, and only a few of these cause serious envenomation in humans.

The two most dangerous spiders in the United States are the black widow (Latrodectus mactans) and the brown recluse (Loxosceles reclusa). Black widow venom causes patients to present with severe muscle spasms, high blood pressure, excessive salivation, seizures and coma. A horse serum-derived antivenom is available and should be used if benzodiazepines (e.g., diazepam [Valium]) and/or calcium gluconate are not effective.

Venom from Loxosceles species contains a number of proteins, including sphingomyelinase D, a rare enzyme even in venomous animals. There are no specific neurotoxins and most of the clinical signs are necrotic skin lesions or allergic reactions. There is no specific foolproof treatment, but oral dapsone has been advocated by some clinicians to limit the amount of tissue destruction.

The only dangerous scorpion in the United States is the Arizona bark scorpion Centruroides exilicauda. This is a small scorpion with a potent venom that enhances repetitive firing of axons by sodium channel
activation.

The Rule of Scorpions: The large the scorpion, the more local reaction; the smaller the scorpion the more dangerous from a generalized illness perspective.

Reptiles

Venomous snakes have always struck fear in the hearts of humans. Perhaps this is because man may have evolved on the plains of Africa, where reside some of the most dangerous snakes. There are about 3000 species of snakes, but only about 300 are venomous, and these are found in five families. Only two of these families are represented in the United States. These are the pit vipers (Crotalidae) and the coral snakes (Elapidae).

Pit vipers can be identified by a small heat sensitive pit found between the eye and the nostril. They cannot be identified by their shape or color pattern. This family includes the rattlesnakes, copperheads, water moccasins, and pygmy rattlesnakes. The Eastern coral snake can be identified by the pattern of the colored bands on its body. If a red band is next to a yellow band, the snake is venomous. The only venomous lizards in the world are found in the American Southwest in the form of Gila monsters or beaded lizards.

Reptile venoms are extremely complex and may contain several classes of compounds that act in a number of ways. For example, pit viper venom contains a number of enzymes that cause local tissue destruction and deranged blood clotting (e.g., excessive bleeding) as well as small polypeptides that are cardiotoxic and neurotoxic. The clinical presentation may vary depending on the species, and a number of victims suffer multi-system involvement.

Not all persons envenomed by pit vipers need to be given antivenom. Only snakebite victims with moderate to severe reactions should be treated with the horse serum-derived antivenin. The antivenin must be given intravenously, and the clinical response determines the dose. Prior to treatment, most intended recipients are skin tested for horse serum allergy, but a significant number of persons who test “negative” may still suffer an allergic reaction to antivenom. Therefore, it is mandatory that everyone receiving antivenom be monitored closely for anaphylaxis. Most patients receiving more that 7 vials of traditional antivenom develop a reaction known as serum sickness.

Coral snake venom is primarily neurotoxic. Most victims of coral snakebite will need to receive antivenin. A recent problem in the United States is the importation of extremely dangerous venomous snakes (cobras, kraits, mambas, adders) from foreign countries. These snakes are difficult for U.S. medical personnel to identify, and appropriate antivenom is not readily available. Local zoo professionals or herpetologists at universities may be helpful in identifying these snakes. The Antivenin Index from the Arizona Poison Control Center may be helpful in locating and obtaining antivenom.

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Thank You to Health Business Blog for Grand Rounds

Thank you to Health Business Blog for including my post about self esteem and mountaineering in this week's Grand Rounds. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining.

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