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Paquette      Study Guide     Special Patients

Black tar heroin mixed with lemon juice may harbor fungus that when injected can result in fungal chorioretinitis.

50% of elderly patients hospitalized after a fall die within a year.   Falls represent a sentinel event and are not a normal part of aging.

*Trench Foot is stratum corneum breakdown due to continuous water exposure.  This is commonly seen in homeless persons forced to wear wet shoes and socks for prolonged time periods. Treatment is dry socks and dry shoes.

Treat maggots with ethyl chloride.  The topical Freezing Spray (ethyl chloride spray) works well to kill maggots.   A recent study showed that a yankaur suction device works well to remove maggots.

To optimally visualize the airway in obese patients, use RAMP positioning.  The goal is to line up the external auditory meatus with the sternal notch. 

*RAMP positioning

Cotton fever is due to a gram negative rod that exists on cotton balls. This gram negative rod can get into heroin when the cotton is used as a filter.   The fever is due to an exotoxin from the gram negative rod and is self-limited.  No treatment other than antipyretics is indicated for cotton fever.  However, this provides little help because it will be hard to differentiate cotton fever from sepsis when the patient first presents to the ED.

The right heart valves are more prone to endocarditis than left side heart valves.  Injection cocaine use is more likely to cause endocarditis than injection heroin use because cocaine has a shorter half life resulting in more injections and cocaine causes direct damage to the valves.

Obese patients tend to have EKG’s with low voltage and inferior t-wave flattening/inversions.  These changes are thought to be due to increased chest wall thickness and possible shift of the normal axis.

Trauma patients over age 50 account for 30% of Trauma deaths.  Trauma patients of advanced age have less physiologic reserve to withstand severe injury. 

Subdural hematoma is more common in elderly patients.

*Subdural vs. Epidural Hematomas

In patients over 80 years of age, chest pain is not the most common symptom of AMI.  Dyspnea and weakness are more common presenting complaints.

Downs syndrome patients have chronic atlanotaxial instability

*Atlanto-axial Instability

“Parents have brought a child with Down’s Syndrome ‘walking funny’ to an emergency department for evaluation,” Dr. Bull recalled. “And then the ED would X-ray the child’s hips and say nothing is wrong. But they were not aware of the importance of evaluating the cervical spine.”

The neurologic manifestations of symptomatic AAI include easy fatiguability, difficulties in walking, abnormal gait, neck pain, limited neck mobility, torticollis (head tilt), incoordination and clumsiness, sensory deficits, spasticity, hyperreflexia...and (other spinal cord) signs and symptoms. Such signs and symptoms often remain relatively stable for months or years; occasionally they progress, rarely even to paraplegia, hemiplegia, quadriplegia, or death. Trauma rarely causes the initial appearance or the progression of these symptoms. Nearly all of the individuals who have experienced catastrophic injury to the spinal cord had weeks to years of preceding, less severe neurologic abnormalities..."

During intubation of a Down’s patient, Great care must be taken to maintain the

neck in a neutral position. This may be accomplished

by placement of a soft collar after induction of anes-

thesia to avoid extreme neck flexion, extension, and

rotation. Leaving the collar in place may also serve as

a valuable reminder to all caring for the patient dur-

ing the perioperative and postoperative period that

cervical instability may exist

*Autonomic Dysreflexia can be seen in spinal cord injured patients who have a uti, constipation, pressure ulcer or constricting clothing below the spinal cord level of their injury.  The patients don't feel discomfort from these problems but develop HTN, flushing, sweating, and headache. 

Asokan     Interpreting the Chest Xray

We are responsible for everything on the X-ray, not just the aspects that we are interested in.  Be sure to look at the neck, axillae, and abdominal areas of a CXR.

Pathologic densities in the lung show up as a white density signifying abnormal fluid.

*Normal CXR

If you see an abnormality, look for a second or third less obvious abnormality.  Your eyes get stuck on the most obvious abnormality.

Consolidation is when the alveolar space is filled with inflammatory exudate.  Consolidations have air bronchograms.

Consolidation with air bronchograms

*Upright film shows a pleural effusion with a curved upper meniscus.

When looking for pneumothorax, look between the ribs for the pleural line.

*Pneumothorax. Note the pleural line between the ribs on the right.

*CHF Findings

*More views of peribronchial cuffing

*Small Bowel Obstruction

*Coffee Bean Sign of Volvulus

Jamieson     M&M

Life Lesson #1:  Don’t use dermabond around the eye.   If you need to disolve glue on an eyelid or your finger gets glued to the skin,  use erythromycin ointment.   It doesn’t break glue down immediately but it will over a relatively short time.

Life Lesson #2:  In order to figure out  what is going on with non-verbal nursing home patients, it may require a call to the nursing home.   Steve described the case of a nonverbal nursing home patient who otherwise was well appearing. He called the nursing home and learned that the patient was normally quite talkative. He proceeded to CT scan the patient and identified an intra-cerebral hemorrhage.

Life Lesson #3: Beware the back hallway bias.  This anchoring bias can cause you to downplay a patient’s acuity and symptoms.   Just because a patient is in the hallway and not in a critical care room doesn’t mean they can’t have a critical illness.

Life Lesson #4: Intubating obese trauma patients can be risky.  Expect O2 desaturation to occur more quickly than expected.  Be sure you have maximized your  pre-oxygenation.  Place the patient in RAMP position.  Use high flow continuous nasal oxygenation during the pre-oxygenation and intubation periods.  Have video laryngoscopy ready as either your first device or back up device.  Have an LMA ready to use as a rescue device.   Be sure to check that your oxygen source is working properly.  You can use ketamine as an induction agent to perform delayed sequence intubation; you can preoxygenate and evaluate the airway prior to neuromuscular blocking.

Htet/Meyers/Faculty       Orthopedic Exam Lab