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Co-Director, University of Connecticut School of Medicine

Other signs of atropinization includingflushing,drymouthanddilatedpupils; tachycardia (pulse of 140 per minute) may occur. Early in therapy, monitor for improving blood pressure and heart rate (above 80 beats/ minute), normal pupil size and drying of the skin and axillae. As with adults, double the dose every 5 minutes until pulmonary secretions are controlled. Signs of atropinization,including:flushing,drymouth,dilatedpupils and heart rates vary depending on age of child, with young toddlers having a rate approaching 200. Crackles in the lung bases nearly always indicate inadequate atropinization, and pulmonary improvement may not parallel other signs. Continuation of, or return of, cholinergic signs indicate the need for more atropine. Reversal of muscarinic manifestations, rather than a specific dosage, is the object of atropine therapy. If these signs appear and become the predominant clinical effects, atropine administration should be discontinued, at least temporarily, while the severity of poisoning is reevaluated. Save a urine sample for metabolite analysis if there is need to identify the agent responsible for the poisoning. Consider pralidoxime in cases of mixed carbamate/organophosphate poisoning and cases of an unknown pesticide with muscarinic symptoms on presentation (see Chapter 5, Organophosphate Insecticides, subsection Treatment, item 5, page 49. Decontaminate concurrently with whatever resuscitative and antidotal measures are needed to preserve life. Contamination of the eyes should be removed by flushing with copious amounts of clean water. For asymptomatic individuals who are alert and physically able, skin decontamination should occur as previously outlined in Chapter 3, General Principles. Attending personnel must take precautions including rubber gloves to avoid contamination. Contaminated clothing should be promptly removed, bagged and laundered before returning, and items such as shoes, boots and headgear should be discarded. Consider gastrointestinal decontamination if N-methyl carbamate has been ingested in a quantity sufficient to cause probable poisoning. If the patient has presented with a recent ingestion and still asymptomatic, adsorption of poison with activated charcoal may be beneficial. In significant ingestions, diarrhea and/or vomiting are so constant that charcoal adsorption and catharsis are not included. Observe patient closely for at least 24-48 hours to ensure that symptoms (sweating, visual disturbances, vomiting, diarrhea, chest and abdominal distress, and sometimes pulmonary edema) do not recur as atropinization is withdrawn. The observation period should be longer in the case of mixed pesticide ingestion, because of the prolonged and delayed symptoms associated with organophosphate poisoning. As the dosage of atropine is reduced over time, check the lung bases frequently for crackles. Atropinization must be reestablished promptly if crackles are heard or if there is a return of miosis, sweating or other signs of poisoning. Monitor pulmonary ventilation carefully, particularly in poisonings by large doses of N-methyl carbamates, even after recovery from muscarinic symptomatology, to forestall respiratory failure. Give adrenergic amines (n-morphine, succinlycholine, theophylline, phenothiazines and reserpine) only if there is a specific indication, such as marked hypotension. Otherwise, they are probably contraindicated in N-methyl carbamate poisoning cases. Treat cases in which liquid concentrates of some carbamates formulated in a petroleum product base have been ingested as acute respiratory distress syndrome. Do not administer atropine prophylactically to workers exposed to N-methyl carbamate pesticides. Prophylactic dosage may mask early symptoms and signs of carbamate poisoning and thus allow the worker to continue exposure and possible progression to more severe poisoning. Atropine itself may enhance the health hazards of the agricultural work setting, impairing heat loss (due to reduced sweating) and impairing the ability to operate mechanical equipment due to blurred vision caused by mydriasis. Acute fatal poisoning by methomyl caused by inhalation and transdermal absorption. Evaluation of the decarbamylation process of cholinesterase during assay of enzyme activity.

Provide usual pre-arrival instructions (porch light, control animals, gather medications, etc. Change to standard precautions guideline if no significant concern for special pathogen. Put on face shield: Put on full face shield over the surgical mask to protect the eyes, as well as the front and sides of the face. For cut or tear, inspect skin for injury and report potential exposure immediately to supervisor. Remove the face shield (and head cover/hood if used) by tilting the head slightly forward, grabbing the rear strap, and pulling it over the head, allowing the face shield to fall forward. Pull gown away from body, rolling inside out and touching only the inside of the gown. Unzip or unfasten coverall completely before rolling down while turning inside out. Avoid contact with outer surface of coverall during removal, touching only the inside of the coverall. Remove the surgical mask by tilting the head slightly forward, grasping the elastic straps, and pull the straps off the ears and/or top of head to release the mask allowing it to fall forward off the face. Remove and discard gloves, taking care not to contaminate bare hands during removal process. Put on impermeable boots, pull coverall material over top of boot and tape (leaving tab). Assure inner hood (if present) is tucked into coverall and outer hood drapes over shoulders. Remove and discard outer gloves, taking care not to contaminate inner gloves in the process. For cut or tear, inspect skin for injury and report any potential exposure immediately to supervisor. Remove and discard gloves, taking care not to contaminate bare hands during removal. Note that cardiac arrest early in the illness may be due to electrolyte imbalance and may be survivable. Handle any needles and sharps with extreme care and dispose in puncture-proof, sealed containers that are specific to the single patient. Do not dispose of used needles and sharps in containers that have sharps from other patients in them. This location will likely be pre-determined by facilities and chosen to minimize environmental exposure at the facility and prevent exposure of unprotected staff, patients, and visitors. For example, consider not obtaining vital signs if patient is "dry," has no visual evidence of distress or shock, and transport time is not prolonged. When in doubt, consider them contaminated and package as appropriate for transport by ambulance personnel. If any concern for stretcher contamination, transfer patient to hospital cart upon exit from ambulance. Transfer waste to hospital or appropriate agency as previously arranged and in accordance with applicable regulations. If the ceiling is a flat impermeable surface, the agency may elect not to apply plastic to the ceiling. A third person should also be available as a trained observer and to assist as needed. It is important that all drape materials are in sections that are small enough to facilitate the insertion of the biohazard bags into an autoclave or pre-determined Category A infectious substance packaging for disposal. This should include attention to proper contact time and particular detail for high-touch surfaces such as door handles and steps using care to limit mechanically generated aerosols.

Crossover Trial A clinical study in which subjects receive two or more drugs separated by drug-free periods. Diabetes Mellitus A group of metabolic diseases characterized by chronic hyperglycemia with disturbances in carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both. This can result in structural and functional abnormalities including changes in vascular permeability and gene expression in the retina. Diarrhea A symptom characterized by loose or unformed stools, frequently accompanied by other gastrointestinal symptoms. It is nearly always a symptom of another disease or condition, rather than a disease in its own right. It is considered acute when it lasts for less than 4 weeks (typically associated with a bacterial or viral infection) and chronic when it persists for more than four weeks. Secretory diarrhea is caused by an increase in active secretion or an inhibition of absorption. Exudative diarrhea is characterized by the presence of blood and/or pus in the stool. Usually the comparison is between an experimental drug and a placebo or a standard comparison agent. Double-Dummy A research testing method in which patients in all treatment groups receive medication of the same appearance, one of which is inactive (placebo) and the other active. See also Upstream Dysplasia Pathological abnormality of development such as an alteration in size, shape and organization of adult cells. E Effectiveness the therapeutic effect of an intervention as demonstrated or observed in the real-world setting. See also Efficacy Efficacy the therapeutic effect of an intervention as demonstrated or observed in a controlled setting, such as a clinical trial. See also Effectiveness Emesis Emesis is the complex reflex consisting of ejecting the contents of the stomach through the mouth. Also known as vomiting, this reflex can be triggered by various endogenous or exogenous factors. Epithelium the cellular avascular tissue layer that covers all free cutaneous, mucous and serous surfaces. G G-Protein One of several mediators of activated cell surface receptors and their enzymes and ion channels. They are responsible for the signal transduction pathways which alter the concentration of intracellular second messengers. These second messengers in turn regulate the behavior of other intracellular target proteins, leading to the desired cellular response. G-Protein-Coupled Receptor Cell surface receptors that are coupled to G proteins. They have seven membrane spanning domains and have been divided into two subclasses: those in which the binding site is in the extracellular domain. Activation can result in potent anti-inflammatory activity as well as regulation of several cardiovascular, metabolic, immunologic and homeostatic responses. Glucocorticoids A family of steroid hormones generally synthesized and secreted by the adrenal medulla which affect intermediary metabolism such as hepatic glycogen deposition. Cortisol (also known as hydrocortisone) is the most potent naturally occurring hormone in this class. It regulates several cardiovascular, metabolic, immunologic and homeostatic responses. Headache Diffuse pain experienced in various regions of the head, not limited to the area of distribution of any single nerve. Hemagglutinin A membrane glycoprotein (550 amino acids) of the influenza virus type A involved in receptor binding and fusion. The name is derived from its capacity to agglutinate red blood cells at neutral pH. There are 15 hemagglutinin (H) subtypes of which only 3 (H1, H2 and H3) are associated with human illness.

Note: In the event of a military aircraft crash, body recovery may be the responsibility of local law enforcement or military authority, depending on the circumstances and location of the mishap. In most circumstances it is best to leave the bodies in position until investigating authorities arrive and survey the site. If the bodies must be moved prior to arrival of the investigative authority, every attempt should be made to record the exact location where the body was found, and the exact position it was in (photographs from multiple angles are helpful). Page 17 Refusal of Medical Care and/or Transport: In general, Active Duty military members may not refuse life-saving medical care. Mentally competent adult civilians (including dependents, spouses and retired military members) may refuse medical care, even if refusing medical care endangers their lives. If the patient is unconscious, or unable to make a rational decision (secondary to head injury or any other cause of altered mental status) the principal of Implied Consent assumes that a normal, rational person would consent to life-saving medical treatment. If the patient is a minor or mentally incompetent adult, permission to treat must be obtained from a parent or guardian before treatment can be rendered. If a life-threatening condition exists, and the parent or guardian is unavailable for consent, treatment shall be rendered under the principal of implied consent, as noted above. If an alert, oriented patient with normal mental status refuses medical care, then care cannot be rendered. Note: the statement must be signed and dated by the patient, and countersigned by a witness. The medical record should completely document that the patient is awake, alert, oriented and has normal mental status. Page 18 Chapter 3: Trauma Assessment Trauma patients are not definitively treated in the field, only critical interventions are made. Based on the environmental threat, Pararescuemen need to judge the extent of patient assessment to be accomplished during initial contact. A more thorough assessment can be accomplished once the patient is removed to a secure area. Alert: Patient is Alert & Oriented to person/place/date/time Verbal: Patient responds properly to verbal stimuli Pain: Patient responds to painful stimuli (withdraws from stimulus) Unresponsive: Patient is unresponsive to all stimuli Pupils Equal Round Reactive to Light Glasgow Coma Scale Spontaneous 4 To voice 3 To pain 2 None 1 Oriented 5 Confused 4 Inappropriate sounds 3 Incomprehensible sounds 2 None 1 Obeys Command Localizes pain Withdraws (pain) Flexion (pain) Extension (pain) None 6 5 4 3 2 1 Eye Opening Verbal Response Motor Response Score of 8 or less, or deteriorating score indicates severe head injury in trauma patients. Page 21 Chapter 4: Shock Shock is defined as tissue perfusion that is not adequate to meet metabolic needs. There are several types of shock, but all are based on the underlying mechanism causing inadequate perfusion. The major types of shock that Pararescuemen are concerned with are: Hypovolemic, Cardiogenic, Anaphylactic, Septic, and Neurogenic. Hypovolemic/Hemorrhagic Shock: the treatment of hemorrhagic shock with large amounts of fluids in the field is controversial. In cases where bleeding is internal (abdominal or chest wounds), fluid resuscitation prior to surgical control of bleeding may actually make things worse. In cases where the bleeding has been controlled (for example extremity wounds), then fluid resuscitation to higher blood pressures is acceptable. Two personnel independently verify blood type O, product identification number and number of units at pick up and just prior to transfusion. If reaction is only allergic reaction and Benadryl relieves symptoms may restart transfusion Page 23 Cardiogenic Shock Signs & Symptoms: Abnormal pulse: Irregular, rapid and/or weak pulse Decrease in blood pressure 30mmHg or more from normal (less than 90mmHg systolic) Chest pain Nausea and vomiting Pallor, cold clammy skin Muscular weakness Treatment: 1. Anaphylactic Shock Signs & Symptoms: Hives Apprehension Hyperventilation Laryngeal edema Reddened skin or numerous blotchy red areas Itching Angioedema Tachycardia Wheezing Respiratory distress Hypotension Airway obstruction/shock Treatment: See Protocol Algorithm Next Page How to Make 1:10,000 Epi Concentration: Put 1 mL of 1:1,000 Epi into 9 mL of Normal Saline To Make an Epinephrine Drip for Treatment of Severe Anaphylaxis: 1. Caution: Neurogenic shock may mask intra-abdominal, pelvic and lower extremity injury. A careful survey of the entire patient is mandatory in patients with this condition. Page 26 Chapter 5: Spinal Injuries Guidelines and Considerations: If the patient is unconscious, assume spinal injury. Use correct technique (in-line stabilization) and enough people to move the patient without manipulating the C spine. Clinical Clearing of the Spine: In some rescue or combat situations, the risks incurred by taking the time to do complete cervical spine immobilization, or of transporting an otherwise ambulatory patient with C-spine precautions are significant.