MOC Exam 4 Study Guide - Environmental Emergencies PDF

MOC Exam 4 Study Guide Environmental Emergencies  Heat Cramps  Severe cramps in large muscle groups fatigued by heavy work.  S/S: brief & intense pain, nausea, tachy, pallor, weakness, & diaphoresis  Commonly occurs in healthy, acclimated athletes with inadequate...

MOC Exam 4 Study Guide Environmental Emergencies  Heat Cramps  Severe cramps in large muscle groups fatigued by heavy work.  S/S: brief & intense pain, nausea, tachy, pallor, weakness, & diaphoresis  Commonly occurs in healthy, acclimated athletes with inadequate fluid intake  Resolve w/ rest and oral or parenteral replacement of sodium & water  Education: Avoid exercise for 12 hours, Increase their fluid intake, make sure they emphasize their salt replacement during this period, and prevention  Heat Exhaustion  Prolonged exposure to heat over hours or days  Clinical syndrome characterized by:  Fatigue, N/V, extreme thirst, & feeling of anxiety.  VSS (3)  1) hypotension  2) tachycardia  3) elevated body temperature (mild to severe, range from 99.6 to 105.8)  Additional s/s: Dilated pupils, mild confusion, ashen color, and profuse diaphoresis  Interventions:  Correlate fluid replacement to clinical and lab findings.  Place moist sheet over patient to decrease core temperature  Hospital admission considered for: Older adults, chronically ill & those who don’t improve in 3 to 4 hours  Heatstroke  medical emergency, results from failure of hypothalamic thermoregulatory processes  Increased sweating, vasodilation, and increased respiratory deplete fluids and electrolytes, specifically sodium – normal 135 to 145  Sweat glands stop functioning  S/S:  Core temperature rises within 10 to 15 minutes; higher than 105.8° F (41° C)  Altered mental status;  confusion leading to coma.  Hypotension,  tachycardia,  tachypnea,  weakness,  hot, dry skin; absence of perspiration,  Circulatory collapse  Brain is extremely sensitive to thermal injuries; can lead to cerebral edema and hemorrhage.  Death is related to amount of the patient’s body temperature remains high   Prognosis is related to: Age, baseline health status, & length of exposure  Heatstroke Interprofessional Care (ABC)  Rapidly decrease core temperature to save brain and organs  Remove clothing  Cover with wet sheets  Place patient in front of large fan  Immerse in cool water bah  Apply ice packs to groins and axilla  Peritoneal lavaging  Treatment of heatstroke:  Closely monitor temperature,  control shivering: administer drugs to control shivering chlorpromazine (Thorazine) IV,  monitor for rhabdomyolysis: check urine for color (dark tea color), amount, pH, and myoglobin  Education: Avoid future problems. Proper hydration during hot weather and exercise. Early signs and interventions for heat-related stress  Utilize the table below to differentiate the symptoms of heat cramps, heat exhaustion, & heat stroke. Heat Cramps Heat Exhaustion Heat Stroke  Emergency  Lowest heat  Moderate heat  Altered mental severity severity status (confused -  Severe muscle  Altered mental coma) contraction in status (anxiety)  Hot and dry exerted muscles  Ashen, pale skin  Hypotension  Thirst  Extreme thirst  Tachypnea  Fatigue, weakness  Tachycardia  Hypotension  Temperature  Tachycardia > 105.8  Temperature  weakness elevation 99.6 to 105.8  Weak thready pulse  Profuse sweating  Frostbite  True tissue freezing that results in the formation of ice crystals in the tissues and cells. (Causes really more of localized effect, injury is localized to wherever may have been exposed to extreme temperature or potentially was not prevented from being exposed- example toes, fingers, tip of nose)  Accompanied by initial pain, numbness, pallor of affected area  Deep frostbite requires aggressive management in a medical facility  Superficial: Pale to blue skin to mottled, crunchy ski, tingling, numbness or burning  Big blisters formation. Handle blisters with care – do NOT squeeze, massage, rub these areas. Anything that causes that friction force can cause more tissue injury. Usually swelling can occur with thawing (defrosting) remove any jewelry that could ultimately become a tourniquet when swelling begins to occur.  Deep:  Involves muscle, bone, tendon  White, hard, insensitive to touch  Tx: rewarming (for both superficial and deep)– immersing that extremity in a temperature-controlled circulating water that is usually around 98.6 to 104 degrees F, debride blisters will cover with sterile dressing, avoid heavy blankets & clothing, analgesia (oral NSAIDS, or IV for severe frostbite) if treatment is unsuccessful requires amputation, can lead to gangrenous necrosis.  Hypothermia  Core temperature 10.5  Happens when too much calcium is released from the bone  Four types/ Etiology – this is not important for testing purposes!! Read it if you want…  Humoral hypercalcemia of malignancy  Local osteolytic hypercalcemia  Vitamin-D mediated hypercalcemia  Ectopic secretion of parathyroid hormone by tumor cells  Who does this happen to?  people with lung and breast cancer  hematologic cancers  Metastatic disease of the bone  Multiple myeloma  When parathyroid-like substance is secreted by the cancer cells (stimulates bone breakdown and resorption which releases calcium into the bloodstream) * Dehydration and immobility can exacerbate this condition  Manifestations  Confusion, lethargy, depression, or impaired concentration  Muscle weakness, decreased tendon reflex  Nausea, vomiting, constipation, anorexia  Polyuria, polydipsia, dehydration  Renal calculi development and renal failure  Can be asymptomatic!!  What monitoring should be performed? o EKG changes (mostly sinus bradycardia, prolonged PR and shortened QT intervals) o what are your interventions  put the patient on telemetry!! This helps identify any EKG changes  12 lead EKG  Monitor labs  Severe complications o With severe cases – seizure, ileus, pathologic fractures, cardiac arrest  Prevention/Treatment  Prevention: identify those at high risk (those with bone involved malignancies, mucositis, renal failure, immobility, taking thiazide diuretics -breast and lung cancers-)  Treat the cause!  Increase mobility as possible  Hydration o 3000 – 4000 ml daily (if able to tolerate oral fluids) to help promote renal excretion of calcium o In moderate to severe cases we can administer IV hydration (isotonic solution -normal saline-) – monitor for fluid overload!!!  Possibly administer meds to inhibit bone break-down or increase bone formation:  o Bisphosphonates – gold standard!  Take 2-4 days to reach maximum effect (pt. may need calcitonin injections or Prolia (Denosumab) – if severe - until this medication gets on therapeutic range)  Examples- pamidronate, zoledronic acid o Calcitonin: Calcitonin opposes the actions of the parathyroid hormone, which is a hormone that increases your blood calcium levels. Calcitonin is given in emergencies when bisphosphonates haven’t taken effect yet o Loop diuretics: Administered after the patient has been well hydrated to promote kidney excretion of calcium.  If these fail, what would the patient be on? – Prolia (Denosumab)  Hemodialysis – needed in SEVERE cases, especially those with renal impairment  Monitoring  Labs o BMP (calcium levels) o CMP (renal function)  Seizure precautions – seizures can happen in severe cases *Patients with decreased albumin are at greater risk for hypercalcemia. – it is important to check the ionized calcium levels (levels of calcium bound to albumin) 3. Tumor Lysis Syndrome-occurs when malignant cells are rapidly killed; intracellular contents are released into the bloodstream.  Caused by: chemotherapy, can also occur with radiation  Electrolyte abnormalities: (4 hallmark lab changes) – IMPORTANT!  1) Hyperkalemia  2) Hyperphosphatemia  3) Hyperuricemia (high uric acid levels)  4) Hypocalcemia (phosphorus and calcium are opposites, so, the more phosphorus there is, the lower the calcium. This can lead to cardiac dysrhythmias)  Who is at risk?  Patients receiving chemo and radiation  Lymphoma patients  Cancers with high growth factor or large/bulky tumors (large tumors excrete more toxins when broken down by chemotherapy)  Preexisting renal dysfunction  When is it most likely to occur? – 24-48 hours after chemo. Lasts for 5-7 days  Manifestations:  GI: nausea, vomiting, GI distress  Musculoskeletal: lethargy, weakness  Metabolic acidosis:  Cardiac: dysrhythmias  Complications: Occur due to electrolyte imbalances. Patient is at risk for cardiac arrhythmias, seizures, and renal failure.  Prevention & Treatment  Prevention in high-risk patients o Who is high-risk? – renal compromised patients  IV hydration o Accurate & frequent I&O is mandatory. o What is this patient at risk for with aggressive fluids?  Treatment for Hyperuricemia o Hypouricemic agents:  Alopurinol - used with INTERMEDIATE risk; will not decrease preexisting elevated serum uric acid (prevents future uric acid development)  Febuxostat – more expensive than allopurinol but less drug-drug interactions  Rasburicase – used in HIGH risk; reduces and prevents o IV Hydration: AGGRESSIVE hydration, but we must consider cardiac and renal function. Accurate and frequent I&O is mandatory – High risk for fluid overload!! o If patient has metabolic acidosis, how is this treated? - acetazolamide and/or sodium bicarb (if patient is not receiving rasburicase and if they are experiencing metabolic acidosis)  Nursing Support: o Monitor – labs every 4-6 hours  BUN  Creatinine  U/O  Renal consult!!! o Safety precautions  Seizure precautions  Cardiac telemetry o Dialysis  Lower threshold to start due to higher risk of rapid potassium release  Oliguria or anuria, severe fluid overload, intractable hyperkalemia  Treatment for Hyperkalemia o Potassium lowering agents (Patiromer), sodium polystyrene sulfonate (Kayexalate) o Glucose & insulin o Calcium gluconate (reduce risk for cardiac dysrhythmias) o Extreme situations may require dialysis  Treatment for Hyperphosphatemia o Aggressive Hydration o Phosphate binder therapy   What is an example? – calcium carbonate  Treatment for Hypocalcemia – only treat if symptomatic!! o Symptomatic:  What are symptoms of hypocalcemia? – dysrhythmias, Chvostek’s, Trousseau’s  Treatment: in patients with acute symptomatic hypocalcemia, intravenous calcium gluconate is preferred. o Asymptomatic:  Will resolve itself once phosphorus is corrected *Remember calcium and phosphorus have an inverse relationship. Meaning when the phosphorus is high, calcium will be low. When hyperphosphatemia is treated and corrected, the low calcium level will rise. 4. Syndrome of Inappropriate Antidiuretic Hormone  Who does this happen to?  Small cancers: small cell lung cancer  Lymphoid cancers: Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, and lymphocytic leukemia  Etiology  The cancer will make and secrete ADH which will stimulate the posterior pituitary to secrete ADH. When this happens, we have water reabsorption, blood dilution, and hyponatremia  Hyponatremia  What are your normal sodium levels? 135-145  Manifestations: range from asymptomatic to severe. Symptoms will usually start developing when sodium levels reach 120  Mild: anorexia, fatigue, weakness, N/V, excessive thirst  Moderate: oliguria, weight gain without edema, progressive neuro symptoms (decreased reflexes), diarrhea  Severe: cerebral edema, coma, and death  Patho Review:  Increase in ADH hormone → increase in water reabsorption in the renal tubules → increased intravascular fluid volume → delusional hyponatremia and decreased serum osmolarity  Labs:   Treatment: treat the cause  Fluids restrictions o 500-1000 mL/day o Educate your patient: They will be THIRSTY  Hypertonic saline – for SEVERE cases o Hypertonic saline: raise the sodium SLOWLY – 0.5-1 mEq/hr (no more than 10-12 mEq in first 24 hours) – NOT a bolus, but a slow and controlled rate  Monitoring  Seizure precautions  Telemetry  Frequent neuro exams (GCS) 5. Superior Vena Cava Syndrome  Obstruction or compression of superior vena cava leading to compromised venous drainage in head, neck, upper extremities, and thorax. Associated with late stage disease (tumor has spread)  Etiology:  The superior vena cava is responsible for returning all the blood from the head, neck, and upper extremities to the heart. In this condition, a tumor, trauma, or thrombosis is blocking that blood flow. This can have a slow or rapid onset.  Who does this happen to?  Patient with malignancies in their chest, head, and neck  Patients with central lines or pacemakers  Patients who’ve had previous radiation to the chest  Manifestations:  Early symptoms: o Dyspnea, nonproductive cough  o Neck, facial, and upper extremity swelling (periorbital edema), especially upon arising (when waking up in the morning) - More severe with rapid onset o Dysphagia (tightness sensation in the collarbone area) o Chest pain o Horner syndrome (constricted pupil in one eye)  Late symptoms: o Hypotension o Tachypnea o Tachycardia o Orbital edema o Blurred vision o Hemoptysis o Syncope o Cyanosis of upper body and face o Hemorrhage o Mental status changes o Decreased CO  Treatment- treat the underlying cause (death can happen if left unresolved!)  Chemo – for long term control  radiation  Thrombolysis – if caused by a clot  Stent/Surgery (rare) – metal stent placed in vena cava to reduce swelling  Nursing interventions:  Keep HOB elevated – gravity will help decrease some of the swelling and engorgement  Treat pain & anxiety  Oxygen if needed  Frequent assessments o What priority assessments would you perform? – cardiac assessment, respiratory, and GCS for neuro assessments  Complications to airway  Death can result 6. Spinal Cord Compression  Compression of the spinal cord due to malignant disease and/or collapsed vertebrae  EMERGENCY – neurologic dysfunction can be permanent and progress rapidly  Etiology – tumor compressing spinal cord  Who does this happen to?  any cancer in the CNS and those that spread to bone o prostate, lung, breast especially o GI, renal and melanomas o Lymphomas can also invade epidural space  Manifestations:   Back and/or neck pain o Localized o Often worse when lying flat o Vertebral tenderness  Loss of bladder and/or bowel function  Sensation and/or motor impairment  Diagnosis  Imaging o MRI is the gold standard o X rays have a high false negative rate  Treatment  Good prognosis – female, slow onset, radiosensitive tumors, lower vs. upper spine  Poor prognosis – urinary or bowel dysfunction present, rapid onset, paraplegia prior to treatment start  Glucocorticoids – high dose steroids  Radiation  Surgery  Bisphosphonates (make sure you know examples) – explained above!!  Pain – use of braces  Safety concerns  Mobility concerns (This condition can result in paralysis if not alleviated properly)  Complications  Paralysis. Can be fatal especially if it occurs in the cervical region 7. Febrile Neutropenia  Fever – one single oral temperature of 38.3C (101F) or 38C (100.4F) or greater over one hour (MUST REPORT)  ANC (absolute neutrophil count) < 1500 or 1000  Severe neutropenia = ANC < 500  ANC = (polys + bands) x WBC, THEN multiply the product by 10 – Don’t need to memorize this formula!!  What is your patient at risk for with a low neutrophil count?  Infection  Sepsis  Death  Nursing Implications  Monitor: o Monitor for any Fever – one single oral temperature of 38.3C (101F) or 38C (100.4F) or greater over one hour o Monitor ANC count o Fever – one single oral temperature of 38.3C (101F) or 38C (100.4F) or greater over one hour o Frequent hand washing!  What kind of precautions should this patient be on if hospitalized?  o Neutropenic precautions to protect them from the potential infections outside and from us (wear mask, gloves, and a gown) o Limit visitors o Can they have live plants? - NO  Treatment: treat the cause (antibiotics-bacteria, antifungals-fungal cause)  Complications: infection and mortality 8. Disseminated Intravascular Coagulation (DIC)  Etiology  Abnormal response to clotting cascade caused by an underlying issue  Systemic (simultaneous and alternating) clotting and hemorrhaging  Can be acute (life threatening), subacute or chronic  EXTENSIVE ABNORMAL CLOTTING – depletion of clotting factors and platelets leading to oozing and fatal hemorrhaging  Who does this happen to?  Causes (listed in the table below)  Knowing the cause is VITAL – treating the cause is the primary intervention  Manifestations  Acute: o BLEEDING!!!  Skin changes, petechiae, purpura, or ecchymoses  Petechiae - are pinpoint, round, flat, purplish red spots that appear on the skin as a result of bleeding (if you see this, let the provider know immediately, the patient may need a rapid infusion of blood products)  Purpura- purple-colored spots and patches characterized by ecchymosis or other small hemorrhages  Bleeding from invasive lines or hematomas  Hemoptysis, bleeding from nose or gums, or less obvious (hematuria or occult)  MASSIVE hemorrhaging in some instances o Thromboembolism and Shock   Ischemic tissue, Gangrene, paralytic ileus, oliguria, renal/hepatic damage  Cyanosis, PE, ARDS, ECG changes, and organ failure  Chronic- may be asymptomatic (it is compensated by the body, so the signs and symptoms are not obvious)  Diagnosis  What is a d-dimer? - D-dimer test is a blood test that measures D- dimer, which is a protein fragment that your body makes when a blood clot dissolves in your body. D-dimer is normally undetectable or only detectable at a very low level unless your body is forming and breaking down significant blood clots.  Why is it elevated with DIC? - D-dimer measurement is the best single laboratory test for DIC diagnosis. D-dimer concentrations are increased in patients with overt and nonovert (chronic) DIC  Remember: Acute DIC is often “diagnosed” by presentation – It is difficult to obtain and wait for lab results (you start treating)   Treatment of underlying cause  Sepsis = antibiotics  Malignancy = chemotherapy  Obstetrical complication = what kind and can we treat it (amniotic fluid embolus, HELLP, etc)  Trauma = stabilize (stop any bleeding and replace blood and fluids)  CNS injury = stabilize (maybe send them to the OR)  Supportive Care  Complications: hemorrhage and mortality Burns, Safety, Biohazard & Decontamination  Burns o Types of Burns  Thermal  Inhalation injury - Above or below glottis o Above is more serious- swelling and blisters in airway o Below the glottis is more carbon monoxide poisoning o Look for soot in nares. o Monitor airways.  Electrical  Complications from current o Shock burn o Monitor entry and exit point o i.e grabbing a line- the contraction can snap bone  Chemical  Alkaline, Acid or Organic  Tricky to treat due to source of chemical  Chronic  Chemo or radiation  SJS or GVHD o Can be due to virus, skin sloths off 2. Extent/Depth of Burn  1st degree (superficial)  Monitor at home do not pop blisters  2nd degree- pink shiny moist layer  Partial thickness- not all the way through layers of skin o Released home with silvodin or creams  Deep partial thickness- getting through skin, less shiny o Monitored for infection and healing. rd  3 degree (full thickness)- white waxy, black charred skin  Needs to be grafted and dressing changes  Subdermal burns  Can cause loss of body parts due to the loss of capillary circulation 3. Size of Burn  Calculate TBSA (total body surface area) using the Rule of Nines 2nd degree or greater  For smaller or scattered areas use their palm size as 1% 4. Parkland Formula  % TBSA burn x 2-4cc x kg = 24 hour total o Half received in first 8 hours o Half received over the next 16 hours Example: 180lbs with 5% TBSA 75x 4 x 82kg =24,600cc of LR for 24 hours 12,300 cc over 1st 8 hours (at rate of 1538cc/hr) Then decrease rate by half for next 16 hours 5. Assessment  Airway  No stridor  Edema  No Soot in nares  Breathing  3rd degree burns can cause constrictions in face or chest, making breathing harder  Circulation  Monitor their circulation and pulses!  Possible fluid resuscitation  Temperature/ Vital signs  Check temperature.  Not going into shock  Other Traumas  Extent of Burn  Look at characteristics, depth, sensation, pink on color or white  Size of Burn (Rule of Nines)  Fluid Resuscitation (Parkland Formula) 6. Assessment of Airway and Breathing  Edema occurs  Are they breathing?  3rd degree could cause swelling inward rather than outward.  Prepare for intubation  Facial or neck burns  Monitor closey  Assess periodically  Monitor or intubate?  If breathing or not 7. Assessment of Circulation  Edema & Reabsorption  Rapid 2-3 hours post burn  Moderate-severe  Reabsorption o Start peeing.  Their CVP is adequate (urine output)  BP, HR & UOP  If blood pressure Is low and HR is high that shows their vasculature does not have fluid,  Might need to find alternative for blood pressure cuff or try getting an arterial line, o Patients get so swelled bp is hard to get.   Evaluate Urine output  Do they have pulses?  Escharotomy o Done in 3rd degree burns, cut through escar that is tight to allow movement due to tightness from edema  Fasciotomy o Cutting through fascia to allow swelling to move outward  If you lose pulse it’s too late, we don’t want patient to lose perfusion 8. Treatments  Clean  Dressings  Surgery  Debridement  Grafting o Mesh graft  Run a donor skin graft through machine to “stretch” it out these covers more surface area and its porous to allow skin to breathe. o Sheet graft  Taken from donor and placed right no burn patient’s skin.  Donor site  PT  Pain Control  Acute pain o Initial and after surgery o Procedural  During dressing changes, give prn meds to help relieve pain o Breakthrough  Pain that can come through even after high doses of pain meds, and or lapse in med  Healing pain o Background  Rehab/remodeling Hazardous Materials o Regulated by US Occupational Safety and Health Administration) o Must have an MSDS (Material Safety Data Sheet)  Name of product  Potential risks  How to prevent  What to do if exposed  Procedures for:  Using  Handling  Disposal  Storing  B. Radiation Safety  Minimize time in patient’s room  Internal radiation- patients body fluids are contaminated  private room  prohibit activities  complete bed rest  visit 1 hour, at least 6 feet away from the client  Do not enter the room if pregnant C. Radiation Contamination  Evacuate the area  Remove outer clothing  Place clothing in a PLASTIC bag to contain radiation  WASH/SHOWER all exposed body parts D. DECONTAMINATION vs ISOLATION  PPE and handwashing  Decontamination  Physical or chemical means to remove, inactivate, or destroy  Room in ER to contain and clear people before treatment  Neutralize the chemical or issue and possible post exposure tx  Decontaminate equipment after patient use  Isolation  Contact, droplet, airborne, containment o Every facility had different names but same rules  Key take away  Use precautions and high importance of cleaning, disinfection, and sterilization E. Emergency Response Plans  External disasters  Tornados, cyclones, hurricanes, severe storm, and flooding  Acts of terrorism and bioterrorism  Internal disasters  Fires, utility failure, workplace violence, explosions, bomb threats  Disaster planning and drills  Acts of terrorism and bioterrorism F. FIRE SAFETY  R.A.C.E  R: step number one is rescue everyone in danger, get all clients and visitors out of danger by following the fire plan set up and established by the facility you work in  A: step number two is pulling the fire alarm  C: step number three is to contain the fire in the smallest possible area by closing all window and doors. This prevents fire from spreading to other areas of healthcare facility.  E: step number four Is extinguishing the fire   FIRE extinguishers  Types: o Type A: used to put out fires on common cold solid things like paper, mattress and cloth including clothing o Type B: used to fight oil, gasoline, and grease fires, including kitchen grease fires. o Type C: used to extinguish electrical fires. o Type AB: combines the uses of a type A and B. they can be used on solids, like paper, wood, cloth as well as oil, gasoline and grease o Type ABC: combines all- all use. Ideal for homes and most areas of health care facility  P.A.S.S. o Pull the pin on fire extinguisher o Aim at the bottom of fire o Squeeze the trigger on the fire extinguisher to release the spray and then o Sweep the spray from side to side over the base of the fire until it is extinguished.  Stop, Drop, and Roll if someone is on fire  If room is filled with smoke  GET LOW AND GO! G. Biohazardous Material Prevention  Single use equipment  Needless systems and safety devices  Everything is disposable  Proper handwashing  Red biohazard bins  PPE  Always wear appropriate gear based on nursing care  Neutral zones in surgical areas  Safe sharps disposal H. Medical Gas Containers By Color  White: the international color for oxygen  Yellow: air  Green: oxygen  Light blue: nitrous oxide  Red: ethylene  Orange: cyclopropane  Brown: helium  Brown and green: helium and oxygen  Gray: carbon dioxide  Gray and green: carbon dioxide and oxygen I. BOMB THREATS   If it comes via phone  Keep them on the line as long as possible  Alert others to the threat  Collect data o Callers gender o Where is the bomb o When is it to be detonated? o Anything you can hear in the background J. BIOTERRORISM  Dispensing nuclear, biological, or chemical agents as weapons  Prompt recognition and ID of health hazards are essential in preparedness of HCP  Chemical: categorized by target organ/effect  Sarin (nerve gas) or phosgene or mustard gas  Radiologic/Nuclear: RDD or dirty bombs  Explosion and radioactive material (e.g., uranium)  Blast, Crush, or Penetrating injury  Biologic: anthrax, smallpox, botulism, plague, tularemia, and hemorrhagic fever \ ANTHRAX a. Can be found naturally in soil b. Commonly affects animals around the world c. Humans can get 4 different types d. Not contagious human-to-human (GI or Inhalation) i. Cutaneous ii. GI iii. Inhalation iv. Injection e. TREATMENT i. Antibiotics for 60 days 1. Ciprofloxacin 2. Doxycycline ii. Report to health department immediately f. Vaccine available-people at risk (e.g., military) i. If 18-65 years old (not for pregnant or nursing women) ii. 3 shots over 4 weeks SMALLPOX g. No naturally acquired smallpox cases since 1977 h. Concern about use of smallpox virus as a bioterrorist agent i. Heightened concerns about diagnosis j. Clinicians lack experience with smallpox diagnosis k. Public health control strategy requires early recognition of smallpox case l. Incubation Period: 7-17 days i. Pre-eruptive Stage (Prodrome): fever and systemic  ii. complaints 1-4 days before rash onset iii. Would misdiagnose until day 4-5