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Definition

The term triage, derived from the French word meaning “to sort,” in its military application involves prioritizing victims into categories based on their severity of injury, likelihood of survival, and urgency of care.

The goal of civilian prehospital triage is to identify high-risk injured patients who would benefit from the resources available in a trauma center.

Goal

The ideal tool to accomplish these two divergent tasks does not exist. Assessment must be made quickly, often under difficult conditions with limited resources, and current schemes are of limited accuracy.

Although it is easy to identify patients with severe injuries based on abnormal physiology, a more difficult problem is identification of high-risk patients whose initial physiologic status is normal.

Perhaps the most useful currently available system is that advocated by the Committee on Trauma of the American College of Surgeons, which assesses four components simultaneously:

1. Physiologic response

2. Injury anatomy

3. Injury biomechanics

4. Comorbid factors.

The goal of a trauma system is to prevent unnecessary death, and thus a certain degree of over-triage is acceptable and even desirable.

Under-triage, however, is always to be avoided because the benefits of trauma center care are withheld from a patient who is thus misclassified. Many studies have tried to determine and adjust the optimal ratio of under- and over-triage. Conventional wisdom suggests that a 50% over-triage rate may be required to minimize under-triage.

Triage can take on differing forms as the situation demands. As medical care resources become limited, alternative triage schemes may be used so that the greatest number of patients may be treated.

Such schemes may be seen in situations of multiple or mass casualties. In these cases the “most good is applied to the greatest number of patients.” This is different from our present triage scheme, whereby the most seriously injured patient receives the majority of the medical care while the less seriously injured wait for care.

Classification

The military uses a triage scheme in which patients are classified for transport as immediate, delayed, or expectant.

The method of triage widely used by municipalities is the START triage scheme, which stands for simple triage and rapid treatment. This is accomplished by color tagging of patients.

· The color red is first priority and signifies a critical patient.

· Yellow (urgent) is second priority.

· Green (minor) is a third-priority patient.

· Black represents expectant or dead patients.

The initial triage assessment components include the ability of the patient to :

· Ambulate

· Respiratory function

· Systemic perfusion

· Level of consciousness.

Patients are classified into transport categories on the basis of these assessments.

Definition

Cysts within the breast are fluid-filled, epithelium-lined cavities that may vary in size from microscopic to large, palpable masses containing as much as 20 to 30 mL of fluid.

Clinical Manifestation

· A palpable cyst develops in at least 1 in every 14 women, and 50% of cysts are multiple or recurrent. The pathogenesis of cyst formation is not well understood. However, cysts appear to arise from destruction and dilation of lobules and terminal ductules.

· Cysts are influenced by ovarian hormones, a fact that explains their variation with the menstrual cycle. Most cysts occur in women older than 35. The incidence of cyst development steadily increases until menopause and sharply declines thereafter. New cyst formation in older women is generally associated with exogenous hormone replacement.

Laboratory Findings

· A palpable mass can be confirmed to be a cyst by aspiration or ultrasound. Cyst fluid can be straw colored, opaque, or dark green and may contain flecks of debris. Given the low risk for malignancy within a cyst, if the palpable mass disappears completely after aspiration and the cyst contents are not grossly bloody, the fluid need not be sent for cytologic analysis.

· If the cyst recurs multiple times (more than two times is a reasonable rule), cytology is justified.

· Microscopic studies have shown that fibrosis at or near the lobule, combined with continued secretion, results in unfolding of the lobule and expansion of an epithelium-lined cavity containing fluid.

Treatment

· Aspiration

· Surgery

Surgical removal of a cyst is usually indicated if the cytologic findings are suspicious or the cyst recurs multiple times.

Definition

Herpes zoster is the recidivans form of varicella-zoster virus infection. The primary infection varicella or chickenpox most commonly occurs as an acute childhood exanthem.

The virus establishes latent infection in sensory ganglia at the base of the brain and spinal column. As the cell-mediated immune response conferred at the time of primary infection wanes, the disease increases in incidence. Certain provoking factors and concomitant illness are associated with attacks.

Onset

• Zoster attacks may occur in children and young adults, but are quite rare.
• Severe or prolonged attacks, especially in young persons, should raise concern about concomitant illness and immune status.

Provoking Factors

• Immunosuppression, whether iatrogenic or secondary to disease.
• Hemorrhagic zoster lesions or zoster of unusual severity in a young host should raise suspicion of underlying disease such as lymphoma, hematologic malignancies, or HIV disease.
• Physical trauma to infected sensory ganglia, and occasionally to peripheral nerves, can trigger attacks.
• Radiation therapy of solid tumors and spinal manipulation are among the other common causes.

Clinical Manifestation

• Most cases of herpes zoster present with pain that is variously described as shock-like or a continuous burning sensation with hyperalgesia. Other patients experience less intense but equally uncomfortable crawling or pruritic parasthesias, and find that even fabric touching the area is intolerable.
• Within 2 or 3 days, and rarely as long as a week, skin lesions develop within the anatomic area of the involved nerve segment. These lesions, like those of herpes simplex virus (HSV), consist of tightly grouped vesicles on an erythematous, urticarial base. The lesions are usually more extensive than those of HSV and may be continuous or, more often, exhibit skip areas within the neurologic segment.
• Mild constitutional symptoms of fatigue and lassitude may precede the skin lesions, but fever is rare.
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• Uncomplicated zoster in children usually is mild and often painless. It can run its entire course in 2 weeks or less, and normally clears without sequelae. In young adults, the average course is 2 to 3 weeks long, pain is mild to moderate, and sequelae are rare.

The following anatomic locations are most frequently involved:

· Thoracic dermatomes 53%

· Cervical dermatomes 20%

· Trigeminal nerve 15%

· Lumbosacral dermatomes 11%

Dermatologic Physical Exam

Primary Lesions

1. Erythematous urticarial plaque or plaques within a dermatome segment or contiguous dermatomes.

2. Grouped 3- to 5-mm vesicles that evolve and often umbilicate.

3. Pustules that replace vesicles as the lesions mature.

Secondary Lesions

1. Erosions as blisters and pustules rupture.

2. Crusting as pustules dry and shrink or due to secondary infection.

3. Hemorrhage into vesicles.

4. Necrosis and gangrene in severe lesions having an active vascular component.

5. Postinflammatory hyperpigmentation, common even in uncomplicated zoster.

6. Scarring, more common in older patients or in zoster that is associated with underlying systemic disease.

Distribution

Microdistribution: None.

Macrodistribution: Follows a dermatome segment or contiguous neural segments.

Laboraotry studies

Tzanck Smear

· A smear of material from a fresh ruptured blister base is placed on a glass slide and immediately stained with Giemsa or some similar stain.

· A positive smear will show herpesvirus effect by the presence of keratinocytes with balloon nuclei and multinucleated giant cells with similar changes.

· This test is rapid and inexpensive, and can be performed with equipment that is readily accessible.

· Sensitivity, in experienced hands, from a fresh vesicle approaches or exceeds 70%.

Biopsy

· Biopsy of a zoster lesion shows pathognomonic features, but is usually done only to investigate a lesion that is clinically atypical.

· Biopsy does not distinguish HZV from HSV- 1 or HSV-2, and adds nothing if the lesions are clinically diagnostic.

Complement Fixation Tests

· These titers rise rapidly following onset, and are useful in atypical infections.

Viral Culture

· Although culture is very specific and will distinguish HZV from HSV-1 and HSV-2, sensitivity is low (50% or less).

· Cultures may be used to confirm the diagnosis in unusual cases. In otherwise clinically typical cases, culture is unnecessary and the diagnosis can usually be confirmed by Tzanck smear or RIF test.

Rapid Immunofluorescence Test (RIF) for Herpes

· This test employs a monoclonal antibody system and exhibits a sensitivity of about 65%.

· In addition to speed, RIF can distinguish among HZV, HSV-1, and HSV-2.

· The specimen consists of a smear from a blister, and the test is practical and reproducible. Results are available in 1 hour or less after receiving the specimen.

Polymerase Chain Reaction (PCR)

· PCR testing performed from blister specimens shows a sensitivity of 97%, which is superior to culture.

· PCR is rapid and can distinguish HZV from HSV-1 and HSV-2.

· It is positive when performed from crusts and material from involuting lesions where culture, Tzanck, and RIF results are less reliable.

· The technology is expensive and not universally available at present.

Complications

Generalized zoster

In addition to the problems associated with the special forms reviewed above, one of the most serious complications is generalized herpes zoster. Many patients will develop a few scattered lesions that are out of the primary neurologic segment. When extensive lesions occur along with fever and systemic toxicity, however, it is an indication of general viremia.

Postherpetic neuralgia (PHN)

It is the most common complication of herpes zoster. The incidence peaks in patients in their sixth and seventh decades, probably due to more severe attacks and lowered capacity to regenerate after nerve injury.

Pain or altered nerve function persisting more than 30 days after the onset of skin lesions is considered PHN. Of those with persisting pain or altered sensation, a large number gradually improve and clear over several months. Lancinating pain, hyperalgesia, and crawling dysesthesias are most common.

Other rare complications:

• Encephalitis
• Myelitis
• Cranial/peripheral nerve palsies
• Delayed contralateral hemiparesis
• Acute retinal necrosis

Therapy

· Analgetic : NSAID (e.g. mefenamic acid 500 mg, indometasin 25 mg three times a day or ibuprofen 400 mg three times a day)

· Phenol-zinc lotion for vesicular phase.

· Acyclovir 800 mg five times a day for one week on early phase. Or another anti viral (e.g famcyclovir, valacyclovir).

· Antibiotic : for secondary infection

Postherpetic neuralgia (PHN) :

· Fenol 3-5% cream 2-6 times a day.

· Amitriptilin 10-25 mg/night or gabapentin 100-300 mg/day.