Travel Med

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Travellers Diarrhoea ABx

Single dose
Axithromycin 1g
Cipro 500mg

3/7 dose
Axithromycin 500mg OD 3/7
Cipro 500mg BD 3/7

Motion Sickness Drugs

1) scopolamine 1st line
Transdermal: one patch applied to mastoid at least four hours before travel, then every 72 hours as needed
Oral: 0.4 to 0.6 mg one hour before travel, then every eight hours as needed
2) First gen antihistamines useful but can be sedating
Cinnarizine (mod effective, least sedating)
Adults and children older than 12 years: 30 mg two hours before travel, then 15 mg every eight hours as neededChildren five to 12 years of age: 15 mg two hours before travel, then 7.5 to 15 mg every eight hours as needed

Dimenhydranate: not very effective but at least not sedating. 50-100mg TDS-QDS
Children six to 12 years of age: 25 to 50 mg every six to eight hours as needed (maximum: 150 mg per day)
Promethazine (mod effective, quite sedating):
Adults: 25 mg 30 to 60 minutes before travel, then every 12 hours as neededChildren: 12.5 to 25 mg twice daily as needed

Practical advise for motion sickness

1) Reduce motion variance
- travel in good weather
- Choose location within the vehicle that minimizes motion
Airplanes: over the wing
Automobiles: driver’s or front passenger seat, facing forward
Boats: facing toward the waves, away from the rocking bow, near the surface of the water
Buses: near the front, at the lowest level, facing forward
Trains: at the lowest level, facing forward
2) Gradual increase of amt of stimuli
3) View true visual horizon
- Focus on a distant point on the horizon
Look toward the motion or direction of travel
Maintain a wide view of the horizon
4) Avoid noxious stimuli
- positive thoughts, good ventilation
5) Treat and reduce gastritis

Fitness to Fly - What cardiovascular CI are there?

1) Uncomplicated myocardial infarction within 7days
2) Complicated myocardial infarction within 4-6weeks
3) Unstable angina
4) Decompensated congestive heart failure
5) Coronary artery bypass graft within 10days
6) Cerebrovascular accident within 3days
7) Uncontrolled cardiac arrhythmia
8) Severe symptomatic valvular heart disease

Good test: Walk 50m/climb 1 flight of stairs w/o severe dypsnoea

Fitness to fly: Respiratory CI

1) PTX - absolute CI (residual air may expand due to high altitudes, causing tension PTX)
2)

Fitness to fly: Pregnancy CI

Twins: >32wks gestation
Singleton: >36wks gestation

Fitness to fly: Post surgery CI

1) Hb <9 (relative)
2) <10days post abdo surgery (abdo gas expands 30% in the air, dont want to tear sutures)
3) <7days after Neurosurgery procedure (expansion of intracranial gas not ideal)

Fitness to fly: Post Eye Injury/Operation

Ophthalmological procedures for retinal detachment also involve the introduction of gas by intra-ocular injections,which temporarily increase intraocular pressure.
Delay 2weeks if sulphurhexafluoride is used
Delay 6weeks if perfluoropropane is used.
Other intra-ocular procedures and penetrating eye injuries, wait 1 week

Fitness to Fly: Hematological

1) Anemia - Hb >8 ideal
2) Sickle cell Anemia: fly w supplemental O2

Travel Risk DVT

Risk of DVT
1) Thombophilia
2) Recent major surgery
3) Trauma.surgery of lower limbs
4) Fam hx DVT
5) Age >40yrs
6) OCP

Is Aspirin useful for DVT prophylaxis?

NOOO. benefit does NOT outweight risk

Differential Causes of fever without a focus in a returning traveller

Dengue fever
Malaria
Typhoid fever

How is Malaria Diagnosed?

Hx:
Spiking fevers, leukopenia, thrombocytopenia, and increased bands who have visited a malaria-endemic area and did not take prophylaxis

Inx:
thin blood smear (utilizing the Giemsa Stain)
[ low parasitemia may need multiple blood smears to produce a positive result]

How is Dengue diagnosed

Hx:
spiking fevers and leukopenia who have visited a dengue-endemic area. History of travel has to be within 14 day +/- rash

Invx:
Clinical Diagnosis - tourniquet test (petechiae after arm cuff)
Do Blood test

How is Typhoid fever Diagnosed

Hx: spiking fever and leukopenia who have visited a typhoid-endemic area and who have not received a typhoid fever vaccination. +/- diarrhoea
rose spots, hepatosplenomegaly, and relative bradycardia with fever spikes.

Ix: blood, urine, or stool cultures positive for Salmonella typhi

What is the pathogenesis of Malaria?

Four species of Plasmodium can infect humans:
P. falciparum, Plasmodium vivax, Plasmodium malariae,and Plasmodium ovale.

Malaria is acquired by bites from Anopheles mosquitoes, which are dusk to dawn feeders

Malaria sporozoites from the mosquito travel to the human liver, where they develop into merozoites and are released in the blood weeks to months later.

Why is P.falciparum important?

P. falciparum is the most common species that infects humans and is the only malaria species that causes ful-minant disease, due to high parasitemias and the ability to bind to capillaries and clog the microcirculation.

Symptoms:
Fever, headache, mal-aise, arthralgias/myalgias, nausea/vomit-ing, and abdominal pain.
Signs
Splenomegaly or jaundice occurs in less than 35% of patients.
Rarely, severe hemolysis with hemoglobinuria (also called blackwater fever) and dark red urine

Investigations:
FBC may show anemia (29%), thrombocytopenia (45%); white blood cell count of less than 5,000 per mm3 (5 × 109per L; 26%);
elevated bands (85%); positive thin blood smear (99%); and negative thin blood smear with positive thick blood smear (1%)

What is common for Malaria Prophylaxis? What are the S/E. what is the treatment?

Prophylaxis
1) chlorquine, mefloquine
- S/E: insomnia and vivid dreams
2) Doxycycline

Treatment:
Chloroquine (Aralen) is the treatment of choice for P. falciparum in areas where there is no resistance. Other medications, such as quinine plus tetracycline or mefloquine

What is the empiric treatment of choice for typhoid fever?

Cipro