Page 138 - 2022 Ranger Medic Handbook

Insomnia
DEFINITION: Primary insomnia is sleeplessness not caused by another sleep, medical, psychiatric disorder, medica-
tions, or other substances. Secondary insomnia is a result of one of the above causes. Common in deployed setting
with changes of > 4 time zones.
S/Sx: Perceived reduction of sleep time; difficulty initiating sleep on schedule; daytime sleepiness or tiredness; difficulty
concentrating; anxiety; moodiness.
MANAGEMENT:
1. Practice consistent sleep hygiene of a sleep/wake schedule in a cool, dark, quiet environment (if possible). The CBT-I
app should be used/offered as initial therapy. Cognitive behavioral therapy for insomnia is the first line and mainstay
of treatment.
SECTION 3 3. Encourage a 30-minute “wind down” time before attempted sleep and decreased electronic screen stimulation for
2. Reduce intake of stimulants, especially caffeine or energy drinks, and avoid heavy late-night meals or high-calorie
snacks before bedtime. Also avoid working out 2–3 hours before bedtime.
2 hours prior to bed (TV, cell phones, tablets etc.).
4. The use of first generation antihistamines can be used if initiation of sleep is the biggest complaint. Dosing consists
of 25–50mg. Consider melatonin 3mg PO approximately 30–120 minutes before bedtime OR in consultation with a
medical provider, Zolpidem 5–10mg PO at bedtime or eszopiclone 2mg immediately at bedtime. Do not use these
agents for longer than 2 weeks, abuse potential and side-effect profile are high. Any choice of pharmacotherapy
should not be used for more than two weeks.
DISPOSITION: Evacuation not required unless individual’s performance becomes a risk to mission, self or others.
SPECIAL CONSIDERATIONS:
1. Ensure differential diagnosis from sleep apnea, psychiatric or behavioral disorders and other medical reasons.
2. The body’s circadian rhythm generally takes 1 day per time zone traveled to adjust to the new time zone or activity
schedule.
3. Sleep management medications are intended to assist in adjustment of sleep schedule and not as a convenience
during long travel.

Joint Infection
DEFINITION: Bacterial joint infection, infected bursitis, septic arthritis, septic joint; may result from penetrating trauma
(e.g., animal bites or shrapnel).
S/Sx: History of adjacent penetrating trauma or infection; single red, swollen joint; fever; pain with axial load; inability
to straighten/flex joint.
MANAGEMENT:
1. IMMOBILIZE THE JOINT.
2. Gain IV access.
3. For septic joint: ceftriaxone 2g IV/IM bid OR ertapenem 1g IV/IM qd. For septic bursitis: treat per Cellulitis Protocol
with clindamycin.
4. Treat per Pain Management Protocol.
DISPOSITION: Priority evacuation
SPECIAL CONSIDERATIONS:
1. May result from penetrating trauma (especially animal or human bites), gonorrhea, or iatrogenic causes (i.e., at-
tempted aspiration of joint effusion).
2. Consider also an acute joint effusion due to blunt trauma or overuse (usually less red and no fever).

124 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL