Special Operations Forces Medical Handbook

4-13

changes with body position, as in going from supine to upright or vice versa, is indicative of a pleural effusion
or empyema. Pain severe enough to cause the patient to lie on the affected side for hours is suggestive of
an empyema – see Empyema section.)

Objective: Signs
Using Basic Tools: Vital Signs: Fever over 101°F, Respiratory rate over 14, Resting Pulse over 90
beats/min
Inspection: Cyanosis (bluish skin color may be normal in some dark pigmented people, especially around the
lips and nails); splinted respirations; lying with pleuritic side down.
Palpation: Warm over dull-sounding area - empyema
Auscultation: Rales indicates an infiltrate; rhonchi indicate airway secretions; dullness may indicate lobar
consolidation, collapsed lung, or a pleural effusion.
Using Advanced Tools: Pulse oximetry: < 90% Lab: WBC < 4000 (atypical pneumonias or immunocompro-
mised patients) or > 30,000; Hematocrit <30; Creatinine over 1.2 mg/dl or BUN over 20 mg/dl (if available);
Sputum: Gram stain (> 15 WBC/HPF indicates infection);
CXR (if available): findings other than single-lobe involvement (i.e. multiple lobes, cavitation, and rapid
progression from a prior film, or the presence of a pleural effusion).

Assessment:
Differential Diagnosis
Lobar (typical) pneumonia, viral pneumonia (see Common Cold and Flu, Adenovirus), mycoplasma pneumo-
nia, tuberculosis (see TB Section), other atypical pneumonias.
Atelectasis can resemble pneumonia but is caused by a mechanical airway obstruction, chest wall abnormality
or a loss of normal lung space. The treatment for atelectasis focuses on opening up the alveoli with aerosol
bronchodilators, cough induction, and antibiotics if infection is present. Untreated atelectasis is a signicant
risk factor for developing pneumonia.

Plan:
Treatment: Always check for medication allergies!

1. Outpatients on po antibiotic: Generally preferred: macrolides, uoroquinolones, or doxycycline
   Azithromycin: 500 mg po, then 250 mg po qd x 4 days (safe and effective – children and pregnant women)
   Erythromycin: 250-500 mg/day po qid for 10 days (30% have gastrointestinal side effects)
   Levooxacin: 500 mg po qd x 7 – 10 days
   Doxycycline: 100 mg po bid x 10 days (not in children under 12 years or pregnant women)


2. Hospitalized Patients on Intravenous Antibiotics: Start treatment as soon as possible. Change to single
   agent oral therapy 24 hours after the patient clinically improves.
   CeftriaxoneA 1 gm IV qd, plus azithromycinB 500 mg IV qd (separate IV infusions, children: 15
   mg/kg/day)
   Alternatives: levooxacinC 500 mg IV qd – single agent, CefuroximeA 750 – 1.5 g (children 50-100
   mg/kg/day) IV plus erythromycinB 500 mg IV (1 g for Legionella)
   A – Beta lactam: second or third generation cephalosporin;
   B – Macrolide: only azithromycin and erythromycin are IV;
   C – Fluoroquinolone: must be broad spectrum: levooxacin, omnioxacin, grepaoxacin

Supplemental oxygen
Postural drainage and frappage (systematic, forceful percussion of back) to help remove secretions.

Patient Education
General: Stop smoking.
Medication: Complete a full course of the appropriate antibiotic therapy.
Activity: Bedrest while on IV antibiotics. Limited activity for one to two weeks (temporary prole, T-2).
Prevention: Vaccinate all personnel for inuenza and adenovirus, and vaccinate those without spleens for
pneumococcus and haemophilus.
No Improvement/Deterioration: Return if symptoms do not resolve or improve in 48 hours.