5-102
Diet: High calorie, initially use tube or IV feeding.
Prevention and Hygiene: Use topical antibiotics to umbilical stump. Clean all wounds thoroughly. Maintain
current Tetanus immunization status (see Table 5-4):
Table 5-4
Tetanus Immunization Chart
Tetanus Immunization Status Minor clean wound / Major clean wound / Contaminated wound
Fully immunized recent Td* booster — — —
Fully immunized Td booster 5-10 years ago — Td Td
Fully immunized no booster >10 years Td Td Td
Unknown, none, or incomplete immunization Td Td and TIG* (250 U) Td and TIG (500 U)
Td is tetanus toxoid; ** TIG is Tetanus Immune Globulin
NOTE: Tetanus vaccination of mother gives her protection and protects the newborn in the first few weeks
of life.
Follow-up Actions
Wound Care: If needed, debride the wound to avoid secondary infection. See Procedure: Wound
Debridement.
Return evaluation: Those with natural tetanus do not develop immunity (not enough toxin exposure). They
need to be re-vaccinated at 4-6 weeks then one month later.
Evacuation/Consultation Criteria: The level of care requires transfer to hospital
ID: Tularemia
COL Naomi Aronson, MC, USAIntroduction: Francisella tularensis is a small gram-negative bacillus that can enter the body by ingestion
(eating undercooked meat, drinking contaminated water), inoculation (bites, skinning/ trapping animals),
inhalation or contamination. This organism can penetrate unbroken skin. It is common in rabbits, opossums,
beavers, water rats, raccoons, muskrats and feral cats. It is transmitted by ticks, and less commonly by
deer flies. This is primarily a disease of the Northern Hemisphere, where it often affects hunters. Symptoms
start 2-5 days after contact. There are six recognized forms of tularemia: ulceroglandular (most common),
typhoidal, oculoglandular, glandular, oropharyngeal and pneumonic.
Subjective: Symptoms
Constitutional: Acute (< 2 hr): Fever 101-104°F, chills, malaise, anorexia, fatigue Sub-acute (2-48 hr):
Fever Chronic (>48 hr): Fever, if untreated, can last up to 30 days; chronic debilitation for months.
Specific: Acute (< 2 hr): Tender adenopathy; oculoglandular: tearing, photophobia; pharyngeal: severe sore
throat; typhoidal: dry cough; pneumonic: Dry cough Sub-acute (2-48 hr): All: rash (35%); ulcer (skin);
typhoidal: abdominal pain, diarrhea; pneumonic: pleurisy, rare hemoptysis; Chronic (>48 hr): Suppuration
of lymph nodes
Focused History: Have you recently had a tick exposure? (typical transmission) Have you been hunting and
skinned/dressed/ate any small wild animals? (typical exposure) How long have you felt feverish? (Fever in
ulceroglandular tularemia can last 1 month if untreated.)
Objective: Signs
Inspection: Acute (< 2 hr): Fever to 104°F; relative bradycardia. Ulceroglandular form: papule; pharyngeal
form: exudative pharyngitis; oculoglandular form: purulent conjunctivitis, eyelid edema Sub-acute (2-48 hr):
sometimes develops membrane or oral ulcer; rash (35%): acneiform, E. Nodosum, E. multiforme, urticaria,
Diffuse maculopapular Chronic (>48 hr): Ulcer (skin)
Auscultation: Sub-acute (2-48 hr): Pneumonic form: rales
Palpation: Acute (< 2 hr): Swollen localized lymphadenopathy Sub acute (2-48 hr): Fluctuant regional
lymph nodes, typhoidal form: hepatosplenomegaly