SELF CARE

HEADACHES Exclusion criteria: Severe Persist 10 days Last trimester of pregnancy <8 yoa (<12yoa avoid naproxen, 15- yoa with viral sx avoid salicylates) High fever/serious infection Liver disease, 3+ alcoholic drinks daily Secondary headache Migraine sx but no diagnosis Dosing: Pediatric (mg/kg) APAP 10-15 IBU 7.5 Naproxen sodium (>12yoa) 220-440mg q8-12hrs (MAX 660 mg/d) Aspirin 10-15 Adult APAP 325-1000mg (4000mg) IBU 200-400mg (1200mg) Aspirin 650-1000mg (4000mg) Mg salicylate 650mg q4 or 1000mg q6 (4000mg) Notes: -Avoid salicylates/NSAIDS if asthma and nasal polyps, chronic/recurrent GI ulcers, gout, coagulation disorders/anticoagulant therapy, HBP, CHF, kidney disease, aspirin allergy - Drug interx Asprin INCREASES valproic acid concentration (use naproxen instead) NSAIDS INCREASES digoxin concentration NSAIDS/salicylates inhibit antihypertensive meds and may cause hyperkalemia with ACEi and K sparing diuretics NSAIDS/salicylates INCREASES MTX Salicylates and sulfonylureas: hypoglycemia -alternative meds: butterbur 50+mg/d for migraine: belching, avoid during pregnancy/lactation, avoid with UPA products feverfew-migraine: rebound, mouth ulceration, anticoagulant effect peppermint oil-tension HA: irritation, avoid during pregnancy/lactation CoE Q10 150mg/d for migraine: avoid during pregnancy/lactation, GI disturbances Mg 20mmol/d for prevention of migraine, IV during acute attack: diarrhea, GI Riboflavin 400mg/d for migraine frequency: diarrhea, polyuria

FEVER Exclusion Criteria: Notes: Fever definition: 100 F, 37.8 C Hyperthermia: malfunctioning of normal thermoregulatory process at hypothalamus Malignant hyperthermia >104 F (40 C), muscle rigidity, metabolic acidosis Drug induced hyperthermia 102-104 F ( 38.8-40 C), as high as 108 F Most common mechanism is hypersensitivity (rash, urticarial, eosinophilia) Usually happens week after, 48 hrs if vaccine-induced Hyperpyrexia: >106 F 41.1 C results in mental and physical consequences Avg temp 97.5-98.9 F, 36.4-37.2 C (set point: physiologic/behavioral mechanisms NOT activated) Peak temp 4pm-6pm, Lowest 6am (consistent rhythm after 2 yoa, pronounced in children) Variation 1.8 F (1 C) in adults, 2.58 F (1.48 C) in children Phenothiazines, TCA, anticholinergic: Decrease sweating [decrease heat dissipation] Sympathomimetics (amphetamines,cocaine, epinepheine): vasoconstriction [heat dissipation] Thyroid hormones: increase metabolic rate [increase heat generation] Neuroleptic Malignant Syndrome: high temp, muscle rigid, abnormal body movement, sweating, tachycardia, high/low BP, incontinence, altered consciousness. YOUNG MALE on neuroleptic meds (phenothiazines, butyrophenones, thioxanthenes)

MUSCULOSKELETAL INJURIES AND DISORDERS Exclusion Criteria: Moderate/severe Persist >2wks (7days after tx) Increased intensity or change in character Pelvic/abdominal other than dysmenorrhea N/V/fever or other s/s system infection/disorder Visually deformed joint, abnormal movement, limb weakness, fracture 3rd trimester of pregnancy <2yoa Notes Sprains (ligaments) Grade I: excessive stretching Grade II: partial tear Grade III: complete tear Carpal tunnel syndrome: sense of heat/cold/swollen when not, weakness, drop things *sx persist during sleep OA: pain does not measure damage Hip and knee: APAP 1st line Guarding: overly contracted, develop tight band of muscle tissue trigger point, happens if do not Mobilize area after rest/healed Ice <15min 3-4x/d closest to time of injury, vasoconstriction reduces vascular clearance of inflammatory mediators Heat 15-20min 3-4x/d 48+h AFTER injury or will exacerbate vascular leakage and tissue damage Use as warm wet compress, heat pad, water-bottle. Do NOT use with topical agents or broken skin Heat wraps should be worn over clothing if 55y and NOT during sleep

TRVP1 receptor- activation by menthol and capsicum produces heat Counterirritant- apply up to 3-4x/d up to 7 days nerve stimulation vs. depression of pain Indicated for temporary relief of minor aches/sprains of muscle/joints FDA approved Cat I Rubefacients Allyl isothiocyante 0.5-5% Ammonia water 1-2.5% Methyl salicylate 10-60% Turpentine oil 6-50% Cooling Camphor 3-11% Menthol 1.25-16% >1% anesthetic 1.25% counterirritant

prolong PT with warfarin tonic-clonic after 10min, LETHAL in children 5ml of 20% (resp dep, status epilepticus) LETHAL 2g

Vasodilator Histamine dihydrochloride 0.025-0.1% Methyl nicotinate 0.25-1%

inactive topically, drop BP/HR, syncope

Irritant w/o rubefaction but equipotent Capsicum/Capsicum oleoresin/capsaicin 0.025-0.25% MOA: deplete substance P (slow/unmyelinated type C neuron, released In response to endogenous stress or exogenous trauma/injury Capsaicin selective for process centers in type C fibers in skin DOA: 4-6h, pain relief in 14days, delay 4-6wks Regular use 3-4x/d to keep pain from returning, recontinue ok Tachyphylaxis No action on BV so not rubeficient Reduce pain NOT inflammation Penetration enhancer *** >1% ->neurotoxicity and hyperalgesia *** >0.025% -> cough

COUGH Exclusion criteria: FDA ADVISES AGAINST Pharmacological tx for <2 yoa****** (labeling <4) Thick yellow sputum/green phlegm Fever >101.5 F (38.6 C) Unintended weight loss Drenching nighttime sweats Hemoptysis

Hx/Sx chronic underlying related disease (asthma, COPD, CHF, chronic bronchitis) Foreign object aspiration Drug associated cough (ACEi) Persist >7 days Worsens or new sx with self-tx Notes: 3 phases: inspiratory, compressive, expulsive Acute (usually upper, viral) <3weeks, Subacute 3-8 wks, chronic 8+wks Re-evaluate 7 days Dry cough- antitussive (central acting) American College of Chest Physician cough guidelines 2006 Viral URTI- use combo 1st gen antihist with decongestant, (codeine/DM ineffective) Codeine/DM- short sx relief of acute/chronic bronchitis, subacute postinfectious cough Naproxen may reduce viral cough (increased upper airway afferent nerve sensitivity) Guaifenesin not recommended for any indication Honey- botulism in <1y Codeine 10-20mg q4-6h (120mg), PEDS 6-12y adult, 2-5y 1mg/kg/d in 4 divided acts centrally on medulla to increase cough threshold well absorbed orally, 15-30min onset, 4-6hr DOA hepatic metabo into morphine SE: N/V/dizziness, sedation, constiplation LETHAL DOSE 0.5-1g, respiratory depression, cardiopulmonary collapse CI: codeine hypersensitivity, premature birth Pregnancy category C (resp dep), in breast milk but still compatible AAP Dextromethorphan 10-20mg q4h or 30mg q6-8h (120mg), PEDS 6-12y , 2-5y 2.5-5mg q4h or 7.5 q6-8h (30mg) Equipotent to codeine, similar indication, onset, DOA SE drowsiness, N/V, stomach discomfort, constipation Overdose- confusion, excitation, nervous, irritability, restlessness, drowsiness, severe N/V, depression Abused for phencyclidine-like euphoric effect, psychosis/mania Blocks serotonin re-uptake (MAOi combination within 14 days ->serotonin syndrome: inc BP, hyperpyrexia, arrhythmia, myoclonus) Pregnancy category C, unknown if in breast milk and no recommendations Diphenhydramine HCl 25mg q4h (150mg), PEDS 6-12y , 2-5y citrate 38mg, 19mg, 9.5mg Centrally, medulla to increase cough threshold, 1st gen only, nonselective (heavy sedation/anticholinergic) well absorbed, 15min onset, hepatic metabo paradoxical excitability in children and elderly SE drowsiness, discoordinated, resp dep, blurred vision, urinary retention, dryness Overdose CNS depression, hypotension, CNS stimulation (hallucination/convulsions) Caution: narrow angle glaucoma, elevated intraocular pressure, stenosing PU, pyloroduodenal obstruction, sx prostatic hypertrophy, bladder-neck obstruction, asthma, LRTI, hyperthyroidism, CV disease, HTN CI hypersensitivity Pregnancy category B, in breast milk so may cause excitation and irritability and decrease flow Protussive (Expectorants) Guaifenesin Indicated for sx relief of ACUTE and INeffective productive cough (thins mucus inc productiveness)

Little data supports efficacy esp at non-Rx dosage SE N/V/D, headache, dizziness, rash, drowsiness, stomach pain Topical antitussives Camphor 4.7-5.3% and menthol 2.6-2.8% (both only FDA-approved) Steam inhalants 6.2% camphor or 3.2% menthol Lozenges 5-10mg menthol Local anesthetic sensation and sense of improved air flow, stimulate sensory nerve endings in nose and mucosa Little data supporting efficacy LETHAL: 4 teaspoons of 5% camphor ingestion by children

COLDS Nasal decongestants Phenylephrine HCl 10mg q4 (60mg), PEDS 6-11y , 2-5y Phenyephrine bitartrate 15.6mg q4h (62.4mg), PEDS 6-11y , NOT for <6y Pseudoephedrine 60mg q4-6h (240mg), PEDS Local anesthetics q 2-4h, local antiseptic cetylpyridinium chloride or hexylresorcinol, menthol & camphor (efficacy not well documented) Benzocaine Diclonine HCl Exclusions: Fever 101.5 (38.6) Chest pain SOB Worsening or additional sx during tx Underlying chronic cardiopulmonary diseases (asthma, COPD, CHF) Immunosuppressed Frail, old age <9mos hypersensitivity Notes Upper respiratory: pharynx, nasopharynx, nose, cavernous sinusoids, paranasal sinuses Peak viral conc 2-4days, present 16-18days in nasopharynx Viral infection ends when enough neutralizing antibodies IgA and IgG leaked into mucosa RF smoking, allergies, dense population, sedentary, less diverse social network, chronic (1+month) stress

Complications sinusitis, mid ear infections, bronchitis, bacterial pneumonia, asthma/copd Exacerbations Effective ingredients ethyl alcohol 62-95%, benzalkonium chloride, salicylic acid, pyroglutamic Acid, triclosan Direct acting on adrenergic receptors: phenylephrine, oxymetazoline, tetrahydrozoline Indirect: ephedrine (displace NE from storage vesicles, depletion-> tachyphylaxis), slow acting but longest DOA Mixed: pseudoephedrine and phenylephrine Ophthalmic: naphazoline, oxymetazoline, phenylephrine, tetrahydrozoline INS non-Rx decongestants Short-acting: ephedrine, epinephrine, levmetamfetamine, naphazoline, phenylephrine Propylhexedrine, tetrahydrozoline Intermediate: xylometazoline Long: oxymetazoline Systemic decongestants metabolized by COMT and MAO in mucosa, liver, GI Pseudoephedrine well absorbed, PE low F Both peak conc at 0.5-2h Non-Rx decongestants not FDA approved for sinusitis Rhinitis medicamentosa contributed by short-acting, long duration, and benzalkonium chloride preservative 3-5days is current accepted duration of therapy

Pump nasal sprays: prime before 1 use, tilt head forward, gently insert, sniff deeply, press once Nasal inhalers: warm in hand, gently insert, sniff deeply while inhaling, DISCARD after 2-3mos Nasal drops (preferred for small children): squeeze bulb to release med, lie on bed with head tilted back over side of bed, drop, tilt head side to side, lie for couple min, do NOT rinse dropper Coricidin HBP is marketed for HTN patients, does NOT contain decongestant Pseudoephedrine sale limited to 3.6g/d, 9g/month per patient FDA 2007 petition PE 10mg to 25mg q4h Decongestants *Overdose: excessive CNS stimulation, paradoxical CNS depression, CV collapse, shock, coma -only supportive TX *SE: elevated BP, arrhythmia, CNS stimulation *CI concomitant MAOi Pregnancy cat B/C, theoretically decrease fetal blood flow (Pseudoephedrine-abdominal wall defects in newborns), decrease milk production, drink more water Oxymetazoline preferred (poor absorbtion) PE and pseudoephedrine compatible with breast-feeding, avoid xylometazoline and naphazoline Concomitant drug use with decongestants MAOis, methyldopa- increase BP Phenelzine, tranylcypromine, isocarboxazid, furazolidone, procarbazine TCA- increase BP, decrease decongestant activity Antacids/alkalinizers- decrease elimination of pseudoephedrine (potassium acetate, sodium acetate, sodium bicarbonate, sodium citrate, lactate, potassium citrate, citric acid)

st

sodium

with antihistamines CNS depressants MAOis- anticholinergic/CNS depressive, decrease BP with dexchlorpheniramine Phenytoin- decreased elimination with chlorpheniramine Ketoconazole, erythromycin, cimetidine- increased loratadine plasma concentration Theophylline >400mg increased cetirizine plasma concentration Complementary therapies Butterbur-hepatoxic and renal, GI Echinacea- hepatoxic, aggravate immune disorders, immunosupp with prolong use English Ivy- N/V, uterine contract, skin irritation Ephedra- Tachycardia, HTN, heart attack, stroke, seizure Ginseng- insomnia, restlessness, hotflash Zinc may block adhesion of rhinovirus to nasal epithelium, may inhibit viral replication by disrupting viral capsid SE headache, nasal tenderness, dry mouth, nasal sting/burn, ANOSMIA Lozenges SE GI Vitamin C >2g/d high dose, 4g/d- diarrhea, prophylaxis effective in marathon runners Larch arabinogalactan (probiotic, increase activity of natural killer cells)

ALLERGIC RHINITIS Exclusions <12y pregnant/lactating non-allergic sx otitis media, sinusitis, bronchitis, any other INFECTION undiagnosed/uncontrolled asthma, COPD persistent/unresponsive to tx unacceptable SE Notes nd Antihistamine- 2 gen, non-sedating, peripherally selective Well absorbed, peak 1.5-3h CI in breast-feeding (otherwise take hs after last feeding) Pregnancy: IN Cromolyn(cat B) 1st line <12y: REFER, Loratidine, cetirizine elderly: Loratidine and IN cromolyn

DRUG TESTING Drugs impairing in the workplace (in order of most to least): Alcohol > marijuana > cocaine > opiates > amphetamines/benzodiazepines/barbituates Drug tests do not measure level of intoxication or use patterns Immunoassay to screen out negative tests, gas chromatography/mass spectrometry to confirm Antibody binding proportional to concentration, possible similar substances may have false positive: Amphetamines- nasal decongestant/ephedrine Opiates- dextromethorphan or negative to other impairing products: morphine- oxycodone, meperidine Benzoyl ecgonine is metabolite of cocaine only (novocaine argument) Sensitivity-how long drug/metabolites detectable Most drugs can be detected in urine for up to 3 days, methaqualone and phenobartbital 2-3 wks Amphetamines/secobarbital so quick may show up negative Reasons for drug testing: Pre-employment Appear high, involved in accident possibly caused by drugs Safety on-the-job Return to service physical exams, follow-up, promotions into sensitive positions Random testing to identify and discourage future use (impaired professionals in recovery) Universal testing in a workplace Screening test technologies: Radioimmunoassay, enzyme immunoassay, florescence polarization immunoassay, partial immunoassay Detection in urine: Ethanol: 2-12h Propoxyphene: 6-48h

Amphetamine: 48h Opiates: 2d Methadone: 3 d Cocaine metabolite/benzoyl ecgonine: 2-4d Barbituates: 24h (short-acting), 2-3wks (long-acting) Benzodiazepines: 3d-yrs Cannabinoids: 4-5d (moderate 4x/wk), 10d (daily), 20d (chronic) Phencyclidine: 14d Methaqualone: 2 wks PDT-90: marijuana, cocaine, opiates (heroin), methamphetamines, PCP Signs of drug use parents should use: Low grades/poor school performancy Aggression, rebellion Excessive peer influence Lack of parental support/guidance Behavior problems at early age Alert to alcohol and other drug use