William W. Forgey, MD
Body System Symptoms and Management - Fever/Chills, Lethargy, Pain, Itch, Hiccups and Headache
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Symptoms are indicators of problems. Fever, pain, and itch can sometimes aid you in determining exactly what is wrong with the patient. The various decision tables in this book use one or more symptoms to help identify a diagnosis and plan a treatment.
It is also useful to know how to minimize some of these symptoms. Why itch when you can treat it? The cause of an itch may vary from poison plant dermatitis to an insect bite to liver disease. Regardless of the cause, what can you do to alleviate it?
The best method for reducing symptoms is to successfully treat the underlying problem. Sometimes definitive treatment cannot be accomplished. At other times, the symptom remains after the injury is past, and the symptom becomes the greatest part of the problem. Table 3-1 provides a guide to general symptom care.
For a discussion of symptoms localized to a particular body part, refer to table 3-2 for the anatomical or body location and symptom cross-referenced in the Clinical Reference Index, starting on page 300.
Evaluation and management of symptoms relating to injuries and environmental exposure can also be found through the Clinical Reference Index on page 300.
The average oral temperature of a resting individual is 98.6°F (37°C); in active individuals, it is 101°F (38°C). Rectal temperatures are 0.5 to 1.5°F higher. A tympanic temperature (taken by an infrared sensor placed in the ear) will range from equaling to being 0.5 to 1°F higher than an oral temperature. An axillary (armpit) reading ranges from 0.5 to 1°F lower than oral. Forehead or temporal readings are, in my opinion, all over the map, depending on ambient temperature, sweating, technique, and expense/accuracy of the device, but they are generally considered equal to oral. Certainly, they are useful when checking a large number of persons rapidly and provide a good estimate. A 1°F temperature rise above normal in a human will result in the heart rate increasing 10 beats per minute over the patient’s normal resting heart rate. This is a useful field method of judging temperature, if everyone knows what his resting pulse is. Some diseases cause a peculiar drop in heart rate, even in the face of an obviously high temperature. The most notable of these are typhoid fever (see page 242) and yellow fever (see page 244).
Although injury and exposure can cause elevated body temperature, fever is usually the result of infection. The cause of the fever should be sought and treated. If pain or infection is located in the ear, throat, or elsewhere, refer to the appropriate anatomical area listed in the Clinical Reference Index on page 300.
If other symptoms beside fever are present (diarrhea, cough, etc.), see the cross-references listing for these symptoms in the Clinical Reference Index to provide treatment to alleviate the suffering due to these conditions. This may diagnose the underlying disease, which will have a specific treatment indicated in the text.
The prepper approach to therapy may be quite different from that used in clinical medicine. When off the grid and in doubt about whether a fever is due to viral, bacterial, or other infectious causes, treat for a bacterial infection with an antibiotic from your Rx Medication Modules. Initially give the patient Levaquin 500 mg, 1 tablet daily, and continue until the fever has broken for an additional 3 days. This will conserve medication while providing adequate antibiotic coverage for a suspected bacterial infection.
If it is possible that the patient has a strep throat, give Zithromax rather than Levaquin, as described on page 285. If you are not carrying the Rx kit, then treat the symptoms using the medications described in your non-Rx Medication Modules. In either case, rest is important until the patient is again free of fever and has a sense of well-being.
Chills are a kind of shivering, accompanied by a feeling of coldness (not related to hypothermia; see page 247). Chills, also called rigors, usually occur when the body temperature is 102°F (38.9°C) or the person has had a sudden rise in body temperature. Chills frequently indicate the onset of a bacterial infection, which should be treated with an antibiotic as described above. In tropical countries, serious infections such as malaria must be considered (see page 229). People tolerate fevers quite well, and it is possible that elevated temperatures enhance the immune response to infections. However, persons with a history of febrile seizures or a history of heart problems should certainly be treated to lower an elevated temperature. Generally, it is best to use Tylenol (acetaminophen), but usually ibuprofen and aspirin are safe. Aspirin should be avoided in children with chicken pox or other viral illness due to an increase in Reye’s syndrome (a disease of progressive liver failure and brain deterioration) with its use. The Non-Rx Oral Medication Module contains three products useful in treating fever: ibuprofen, aspirin, and Percogesic. As these are all over-the-counter products, the dosage will be listed on the product containers. The Rx Oral/Topical Medication Module contains the nonsteroidal anti-inflammatory drug (NSAID) meloxicam, and its use is described in that section (see page 284).
Lethargy, or prolonged tiredness or malaise, is a non-localizing symptom such as fever or muscle aches (myalgia). Pain, however, is a localizing symptom that points to the organ system that may be the cause of such things as lethargy, fever, or a general ill feeling. Frequently after a few days of lethargy—or at times even hours—localizing symptoms develop, and the cause of the lethargy can be determined to be an infection of the throat, ear, or elsewhere.
Sometimes a chronic condition is the source of the lethargy, such as anemia, leukemia, low thyroid function, occult or low-grade infection, mental depression, or even physical exhaustion. The latter we would expect to be obvious from the history of the preceding level of activity, and strength should return within a few days.
Anemia can be present due to chronic blood loss from ulcers, menstrual problems, inadequate formation of iron, leukemia, or other cancers in the bone marrow, and so on. Chronic anemia can be identified by looking at the color of the skin inside the lower eyelids. Pull the lower lid down, look at it, and compare to another person. Normally this thin skin is very orange colored, even if the cheeks are pale. If the color is a blanched white, anemia is very likely. Another good indication of anemia is an increase in the pulse rate of more than 30 beats per minute in the standing position when compared to a recumbent position.
Malaise or lethargy can be a presenting complaint of acute mountain sickness, but this would be unusual below 6,000 feet (1,800 meters). If other symptoms are present, such as nausea, one must think of hepatitis (see page 225) or, if preceded by a severe sore throat, infectious mononucleosis (see page 60).
Lethargy is one of the most common presenting complaints that I see in my office. An accurate diagnosis requires careful evaluation, sometimes aided by laboratory tests. If the problem is not depression, then regardless of the cause, the person needs rest, proper nutrition, and adequate shelter.
Adequate pain management can involve a mixture of proper medication and attitude—the attitudes of both the victim and the medic are crucial. A calm, professional approach to problems will lessen anxiety, panic, and pain. Pain is an important symptom that tells you something is wrong. It generally “localizes” or points to the exact cause of the trouble, so that pain in various parts of the body will be your clue that a problem exists, and that specific treatment may be required to eliminate it. Refer to the Clinical Reference Index (page 300) under specific areas of the body (such as ear, abdomen, etc.) to read about diagnoses and specific treatments of the causes of pain.
An application of cold water or ice can frequently relieve pain. This is very important in burns, orthopedic injuries, and skin irritations. Cold can sometimes relieve muscle spasm. Gentle massage and local hot compresses are also effective treatments for muscle spasm.
The alleviation of pain with medication calls for a step-wise increase in medication strength until relief is obtained. Throughout this book you will be referred to this section for adequate pain management. Use discretion in providing adequate medication to do the job, without overdosing the patient. Remember that a pill takes about 20 minutes to begin working and is at maximum therapeutic strength in about 1 hour. If possible, wait an hour to see how effective the medication has been. But use common sense. If the injury is severe, give a respectable initial dose.
For mild pain, from the Non-Rx Oral Medication Module, provide the victim with ibuprofen, 200 mg, 1 or 2 tablets every 4 hours. Meloxicam in the prescription kit is particularly good for orthopedic injuries, or whenever muscle sprains and contusions are encountered. It is also ideal for menstrual cramps and tension headache, and it is relatively safe to use in head injuries. It can also be used for the muscle aches and fever from viral and bacterial infections.
Meloxicam, ibuprofen, and aspirin have anti-inflammatory actions that make them ideal for treatment of tendinitis, bursitis, or arthritic pain.
For severe pain you may have to rely on providing the maximal dose of ibuprofen (800 mg every 6 hours) or meloxicam 15 mg once daily. This can be augmented by giving the victim 1 or 2 Atarax 25 mg tablets every 4 to 6 hours.This medication helps eliminate any associated nausea, and from my experience also potentiates the pain medication so that it works more effectively.
The Rx Oral/Topical Medication Module also contains nasally inhaled Stadol (butorphanol tartrate). This very powerful pain medication is about ten times stronger per milligram than morphine. It is taken as a spray up one nostril, followed by another spray in the other nostril 5 to 20 minutes later, if necessary. This may be repeated every 3 to 4 hours. This medication is as powerful as any injectable product available. (See a full discussion of this medication on page 289.) Its rate of onset is rapid; within 5 minutes relief should start, reaching its maximum effect within 20 minutes. As there are no needles required to administer this drug, it should be easier to take on foreign trips than injectable medications. You might consider keeping it with your toothpaste until across the border. At least I do.
If you are carrying the Rx Injectable Medication Module, severe pain can be treated with an injection of 10 mg of Nubain (nalbuphine). This amounts to 0.5 ml of the strength listed in the kit. This can be potentiated with Vistaril (hydroxyzine), 25 mg or 50 mg, also by injection. These two drugs can be mixed in the same syringe. They both sting upon injection.
Local pain can be eliminated or eased with cold compresses or ice, as mentioned above. Applying dibucaine 1% ointment will help skin surface pain, such as from sunburn and abrasions. Applying a cover of Spenco 2nd Skin dressing provides cooling relief due to the evaporative action of the water from this safe-to-use gel pad. Deep cuts and painful puncture wounds can be injected with lidocaine 1% from the Rx Injectable Medication Module. This technique is described on page 292.
As itch is a sensation that is transmitted by pain fibers, all pain medications can be used in alleviating itch sensations. Itch also indicates that something is awry and may require specific treatment. The most common causes are local allergic reactions, such as poisonous plants, fungal infections, and insect bites or infestations (or look under specific causes in the index). General principles of treatment include further avoidance of the offending substance (not so easy in the case of mosquitoes). Avoid applying heat to an itchy area, as this makes it flare up worse. Avoid scratching or rubbing; this also increases the reaction. If weeping blisters have formed, apply wet soaks with a clean cloth or gauze. While plain water soaks will help, making a solution with regular table salt will help dry the lesions and alleviate some of the itch. Make a solution approximately 10% weight to volume of water. Cream-based preparations work well on moist lesions, while ointments are more effective on dry, scaly ones. The Topical Bandaging Module contains 1% hydrocortisone cream, which, while safe to use, is generally not very effective against severe allergic dermatitis. For best results, one should apply it 4 times daily and then cover the area with an occlusive dressing, such as cellophane or a piece of plastic bag. The Rx Oral/Topical Medication Module contains Topicort (desoximetasone) 0.25% ointment, which is strong enough to adequately treat allergic dermatitis with light coats applied twice daily. Athlete’s foot and skin rashes in the groin or in skin folds are generally fungal and should not be treated with these creams. They may seem to provide temporary relief, but they can worsen fungal infections. For possible fungal infections, apply clotrimazole cream 1% twice daily from the Topical Bandaging Module.
Oral medications are frequently required to treat severe skin reactions and itch. The Non-Rx Oral Medication Module contains Benadryl (diphenhydramine), 25 mg. Take 1 or 2 capsules every 6 hours. It is one of the most effective antihistamines made, but there are less sedating ones now sold without prescription, such as Claritin, Zyrtec, and Allegra. The Rx Oral Topical Medication Module contains Atarax (hydroxyzine), 25 mg. It is very effective both in treating the symptom of itch and as an antihistamine.Take 1 or 2 tablets every 6 hours. These medications are safe to use on all sorts of itch problems. If one is suffering from an asthma attack, however, they should not be used, as they tend to dry out the lung secretions and potentially make the illness worse. Patients with a history of asthma should use the newer antihistamines mentioned above.
Hives are the result of a severe allergic reaction. Commonly called welts, these raised red blotches develop rapidly and frequently have a red border around a clearer skin area in the center, sometimes referred to as an annular lesion. As these can and do appear over large surfaces of the skin, treatment with a cream is of little help. Use the diphenhydramine or hydroxyzine as indicated above. Extensive urticaria or allergic dermatitis lesions frequently need to be treated with an oral steroid. The Rx Oral/Topical Medication Module has Decadron (dexamethasone) 4 mg tablets; 1 tablet should be taken twice daily after meals.
It should be noted that the Vistaril recommended for the Rx Injectable Module is also hydroxyzine, as is the oral Atarax. This same module also has an injectable form of the dexamethasone. For treatment of rash, the oral medications should suffice.
In case of a concurrent asthmatic condition or the development of shock, treat as for anaphylactic shock (see page 193). In case of suspected tick bite, an annular or circular lesion may be a sign of Lyme disease (page 228). If fever is present, one must consider that a rash and itch have resulted from an infection. A diagnosis may be impossible in the bush, so treatment with an antibiotic is appropriate on expeditions expected to last longer than several more days. Use doxycycline, 100 mg twice daily, from the Rx Oral/Topical Medication Module as a field-expedient solution to the problem. Treat fever as described on page 29.
Hiccups can start from a variety of causes and are generally selflimited. Persistent hiccups can be a medically important symptom requiring professional evaluation and help to control. Several approaches to their control when off-grid may be tried. Have the victim hold his breath for as long as possible or rebreathe air from a paper sack. These maneuvers raise the carbon dioxide level and help stop the hiccup reflex mechanism. Drinking 5 to 6 ounces of ice water fast sometimes works; one may also close one’s eyes and press firmly on the eyeballs to stimulate the vagal blockage of the hiccup. The other vagus nerve stimulation maneuvers described under Rapid Heart Rate (page 25) can be tried.
If these maneuvers do not work, from the Non-Rx Oral Medication Module, you may give diphenhydramine, 25 mg, or from the Rx Oral/Topical Medication Module you may give Atarax, 25 mg, 2 tablets. The Rx Injectable Medication Module includes Vistaril, the injectable form of Atarax. This medication may be given in a dose of 50 mg IM. These doses may be repeated every 4 hours. Let the patient rest and try to avoid bothering him until bedtime. If still symptomatic at that point, have him rebreathe the air from inside a sleeping bag to raise the carbon dioxide level in his bloodstream and, if nothing else, to muffle the sounds.
A variety of situations can cause a headache; refer to table 3-3. Too much sun exposure, dehydration, withdrawal from caffeine, stress, high altitude illness, dental or eye problems—the list is almost endless. Be sure to consider the possible underlying problems mentioned above as they are the most common.