Special Operations Forces Medical Handbook

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car’s gear shift knob, are more likely ACD; not all sites exposed to an allergen will always erupt; look for
patterns - if the skin is flared up around the sites of the elastic bands in underwear (beltline and proximal
thighs), think of the “Bleached Rubber Syndrome”, which results from contact of elastic with household
bleach, creating a sensitizing chemical not present in new underwear unexposed to bleach. The patient
must throw away all underwear that has been bleached, and buy new undergarments, never exposing them
to bleach. If the agent is also a systemic allergen (e.g., latex), dyspnea, wheezing and other respiratory
symptoms may be seen (this is very rare).

Assessment:

Differential Diagnosis - other dermatitides such as atopic, seborrheic, xerotic, and stasis dermatitis, as
well as tinea, impetigo, erysipelas, cellulitis, or even Bowen’s disease (carcinoma in situ). (See appropriate
sections of this book).

Plan:
Treatment:

1. AVOIDANCE IS KEY! Protective clothing can help, but a change of occupation, hobby or substances
   used may be necessary.


2. Topical steroids are very useful, in higher potencies (fluocinonide or triamcinolone ointment), in order
   to calm the skin while identifying offending agent.


3. For exudative, weeping areas, a soothing astringent (drying) treatment such as Domeboro compresses
   bid/tid can help. Minimize wet-dry cycles and avoid over-cleansing the skin. In generalized cases, bathe
   just every other day, with lukewarm water for less than 5 minutes. Use only a mild cleanser like Cetaphil
   lotion or Dove Sensitive Skin soap. Avoid scrubbing the affected areas.


4. Bland emollients like white petrolatum (Vaseline) or Crisco vegetable shortening will help to moisturize
   and protect.


5. Oral antihistamines like Atarax (hydroxyzine) in doses of 25-50 mg tid/qid, or up to 100mg at bedtime
   can alleviate much of the itch. The antipruritic effects of Atarax last 24 hours and the drowsiness usually
   only lasts 8-10 hours, a decided advantage over Benadryl.


6. Oral steroids can be needed in the most severe cases, used in a tapering fashion for 3 weeks, starting at
   60 mg each morning for a week, then 40 mg for a week, then 20 mg for the last week. Reserve oral
   steroids for the most widespread or bothersome cases. Three weeks of treatment is very important in
   order to outlast the hypersensitivity reaction in the skin.

Evacuation/Consultation Criteria: Evacuation is not necessary, except with systemic allergic symptoms.
Consult as needed.

Chapter 7: Gastrointestinal (GI)

GI: Appendicitis

COL (Ret) Peter McNally, MC, USA

Introduction: Appendicitis is the most common abdominal surgical emergency. Between 5-10% of people
develop this condition in life (lower percentage in developing world). Appendicitis can occur at ANY AGE,
but is most common during from 20-40. Consider the diagnosis of appendicitis in anyone with an appendix
that develops acute abdominal pain..

Subjective: Symptoms
Classic sequence: (1) generalized abdominal pain; (2) anorexia, nausea or vomiting; (3) localized pain over
the appendix; (4) fever (Low-grade). Initially, the pain is usually colicky, vague and not severe. It reaches
a peak at 4 hours only to gradually subside, and then reappear as a severe pain localized to the right
lower quadrant (RLQ). The shift in pain from generalized to the RLQ (McBurney’s March) is a diagnostic
clue. About 95% of patients have anorexia, nausea or vomiting. Hunger or persistent eating is atypical in