3-10
better cosmetic result. Keep the incision small, only large enough to allow entrance of your 5th digit. Do
not cut deeply into the breast tissue, but start superficially and advance carefully. Make your incision deeper
until the cavity is just reached and pus begins to drain. Insert your 5th digit into the wound to break up any
loculations and to ensure complete drainage. Irrigate the wound, and if possible place a Penrose drain, pack
with 2x2 dressings and cover with 4x4 dressings.
Follow-up care: Remain at bedrest, continue warm soaks and hydrate well. Continue antibiotic therapy with
Augmentin (amoxicillin/clavulanate) po bid if 875/125 mg or tid if 500/125 mg for 10 days after resolution of
the abscess. Engorgement of the breast will interfere with healing. Feed infant or empty the affected breast
on a regular basis, every 2-2 1⁄2 hours. The milk is clean as long as the abscess drains to the outside (through
the skin). Nursing can continue when the abscess is surgically drained as long as the incision and drainage
tube are far enough from the areola. If the drain is too near the areola for the infant to nurse, the breast still
must be emptied by manual expression or pumping. Milk may drain from the incision during breastfeeding.
Apply pressure over the incision while breastfeeding to minimize leakage. If the patient cannot do this herself,
her spouse or another person may hold light pressure over the incision.
Follow-up Exam: 24 hours and as needed thereafter. Change the dressings and advance the drain at each
visit. The breast should heal well from the inside out within 3-5 days.
Referral Criteria: Persistent fever despite treatment; worsening pain; increased size of abscess.
What Not To Do:
Do not make incision any deeper than necessary.
Do not make the incision too close to the areola to avoid compromising breastfeeding.
Do not allow the skin to close over the incision until the abscess has healed from the inside out to the
surface.
Symptom: Chest Pain
CAPT Kurt Strosahl, MC, USN & COL Warren Whitlock, MC, USAIntroduction: Chest pain can arise from any of the structures within the chest or be referred from outside
of the chest (from the cervical spine or abdominal organs). Immediate, life-threatening causes of chest pain
include: acute coronary ischemic syndromes, pericardial tamponade, pneumothorax, arterial gas embolism,
pulmonary embolism, aortic dissection, esophageal rupture, and perforated ulcer. A high level of suspicion for
these diagnoses is necessary to institute potentially life saving therapy. The history and physical examination
and basic tests may be insufficient to exclude these diagnoses in the field, so many patients may be treated
“unnecessarily.” A prior history of any of these diseases should lead to a presumptive diagnosis in favor of
recurrence. Other causes of chest pain may not be life threatening if they are misdiagnosed. These include
musculoskeletal chest wall pain, decompression sickness, hiatal hernia with reflux disease or dyspepsia,
herpes zoster (shingles), bronchitis or pneumonia, gall stones, mitral valve prolapse, subacromial bursitis,
mastitis, pancreatitis. (See appropriate portion of the Handbook for detailed discussion of these conditions).
Heart attacks occur in healthy twenty year olds. Most heart attack victims die in the first 1-4 hours due to
ventricular fibrillation, asystole, myocardial rupture or cardiogenic shock. There is very little to be done in the
field to prevent this! Heparin helps acute coronary ischemia and pulmonary emboli but harms esophageal
rupture, pneumothorax, tamponade, and aortic dissection.
Subjective: Symptoms
Focused History: Quality: Is the pain sharp? (Musculoskeletal pain is sharp, localized to a finger point area,
and lasts seconds to minutes. Cardiac pain is better described as a discomfort, localized to the inside of the
chest, builds in intensity over several minutes and lasting 5 minutes or more. Pneumothorax pain is sharp,
localized to the inside but can be stopped by holding the breath. GI pain is sharp or a discomfort but is
relieved by antacids, swallowing liquids, and located centrally under the breastbone or in the upper abdomen.
Aortic dissection is a severe, tearing pain that starts suddenly, builds rapidly, moves into the back and causes