Special Operations Forces Medical Handbook

3-63

6. Provide analgesia:
   a. Acetaminophen: up to 1gram po qid prn
   b. Severe joint pain may require narcotics (codeine or oxycodone) until patient can be transported for
   further evaluation.
   c. Nonsteroidal Anti-inammatory drugs (NSAIDs) will also decrease inammation at full strength and
   regular dosing.

1. Ibuprofen 800 mg po tid


2. Naproxen 500 mg po bid (often provides better compliance with less frequent dosing)


3. Piroxicam 20 mg po qd (better compliance but slower onset)


4. Indomethacin 50 mg po tid (preferred for intense inammation as in gout or
   spondyloarthropathy)


5. Tolectin DS 400 mg op tid (good alternative if indomethacin not tolerated due to CNS side
   effects)

7. Consider muscle relaxants, which may reduce muscle spasm and back pain associated with sacroiliitis, and
   may improve sleep disturbances and early morning pain and stiffness. Flexeril (cyclobenzaprine) 10 mg
   po tid, or q hs for sleep effects.


8. Aspirate knees for comfort and to assist ambulation.

Septic joint:

1. Immobilize joint and allow no weight bearing or exercise until infection treated.


2. Antibiotics: 2 – 3 week course (GC responds rapidly)
   Gram positive cocci: Nafcillin 9gm IV daily, dosed q 4 hrs
   Gram negative organisms: Ceftriaxone 1-2 gm IV daily
   Gram stain negative: Ceftriaxone 1-2 gm IV daily prophylactically

Gout:

1. Current preferred treatment is indomethacin 50 mg po tid, or other NSAID as above.


2. Alternatively, use colchicine 1 mg po q 2 hours prn until pain is relieved, or until diarrhea or vomiting
   presents. No more than 7 mg should be given in 48 hours for a given attack. On average, about 5 mg
   is required.


3. Obtain consultation before initiating chronic therapy with probenecid or allopurinol to prevent attacks
   (suppress serum uric acid levels).

Other Inammatory Arthritis (non-infectious):

1. Prednisone 40 mg given once in the morning tapered (decrease 5 mg/day) over a week to 15 mg daily.
   The Medrol dose-pack does this over a 5-day period.


2. If evacuation is delayed, prednisone can be further tapered by 2.5 – 5 mg per week as tolerated.


3. Rheumatoid and lupus patients often respond well to 5-15 mg daily.


4. Once the patient has been on prednisone for more than a week it should be tapered slowly and not
   stopped suddenly.


5. Do not give steroids in trauma or for ankylosing spondylitis.


6. Steroids may benet some patients with peripheral joint inammation by improving their ability to function
   and ambulate until they can be transported for denitive care.


7. Alternate taper: Prednisone 40 mg X 5 days, then 30 mg X 5 days, then 20 mg for 5 days etc.


8. Patients with potentially life threatening illnesses like systemic lupus erythematosus, allergic reactions
   with anaphylaxis, and drug hypersensitivity reactions (serum sickness like responses) need high dose
   steroids (Prednisone 1 mg/kg po in split dose, example: 20 mg tid – qid) and immediate transport.

Patient Education
General: Discuss appropriate illness with patient.

1. Natural history of gout: attacks of 7 – 10 days average duration with multiple recurrences.


2. Acute polyarthritis: May be the reaction to an infection or an exposure; frequently resolves within weeks
   with unknown cause. If it is symmetric, involves small joints of the hands and wrists and persists >6 weeks,
   it may be rheumatoid arthritis.