Conference Notes 4-17-2012
PAQUETTE STUDY GUIDE SPECIAL PATIENTS
One year risk of death after a fall in the elderly is 50%.
Heroin users: Cotton fever is due to unknown pyrogen effect. Thought to be due to particulate matter from cotton or gram neg endotoxin. However, even patients who don’t use cotton to filter their heroin get cotton fever. So cause is unknown. Fever resolves spontaneously.
Patients over 65yo account for 30% of trauma deaths even though they only account for 20% of total trauma patients.
Patients over age 80 have chest pain as the presenting complaint for AMI less than 50% of the time. SOB is more common.
Myositis ossificans (heterotpic ossification) usually found in chronically immobilized patients. Can be painful. Usually around the hip/knee/femur/shoulder.
Post traumatic syringomyelia: ascending spinal cord lesion in a patients who’s neuro deficit had been previously stable.
STRASBURGER HIV EMERGENCIES
1.2 million people in US are living with HIV infection. 1/5 people are unaware of their HIV infection.
17,000 people died from AIDS in 2009.
HIV deaths peaked around 1995.
AIDS: CD4 count less than 200 or an AIDs defining illness.
CD4 count >500 is an immunocompetent patient. CD4 200-499 is indeterminate so look for AIDS defining illness and consider CD4 %.
CD4% is a more reliable measurement than the CD4 count because it varies less. Normal CD4% is 32-68%.
www.aidsmeds.com is a good reference website for side effects and drug interactions of ART (anti-retroviral therapy). UCSF post exposure prophylaxis hotline can help you make decisions for starting prophylactic therapy after body fluid exposure. Other good website hivinsite.ucsf.edu.
General approach to HIV/AIDS patient: Find out CD4 count, CD4 trend, viral load, opportunistic infections/medication side effects.
AIDs patients who need CT: CD4<200, fever and nuero findings or stiff neck. Follow CT with LP. If patient has a CD4 count >200 you can do LP without prior CT if no focal deficits or headache. Absolute lymphocyte count= WBC count X %lymphocytes=>2000 then CD4 count is most likely over 200. If less than 2000 CD4 count may be less than 200. Have low threshold for doing LP in pt’s with neuro complaints.
Toxoplasmosis may have ring enhancing lesions on head CT.
Cryptococcus Neoformans: usually CD4 count is <100 but not always. Have chronic meningitis picture or prolonged headache. CT is usually unremarkable. Serum cryptococcal antigen is 95% sensitive and may be useful in the patient refusing LP. CSF cryptococcal antigen is 100% sensitive and specific. India ink staining is only 60-80% sensitive. Treat with amphoB and flucytosine.
Respiratory infections: most common are bronchitis or uri. Keep guard up for bacterial pneumonia and PCP pneumonia. Bacterial pneumonia due to strep pneumo is most common. PCP is the most common opportunistic infection.
PCP pneumonia: chronic cough, hypoxia with exertion. Walk them on a pulse ox and see if their sats drop. ABG can help if paO2 is <70 or AA gradient is >35 signifies severe PCP. Serum LDH can help identify PCP pneumonia. 1/3 of patients will have a nl CXR. Can also have a focal infiltrate. CT that does not show ground glass appearance is unlikely to be PCP.
Diarrheal illness: Get stool sample for lab testing. CD4>200 and labs look ok, and they look well, they can go home on cipro/flagyl. If not then admit.
CMV retinitis: CD4 count usually less than 50. Blindness in 30%. Fundoscopy shows cotton wool like findings. ART does not reverse disease but just slows it down.
Retinal varicella zoster can also occur in patients with very low CD4 counts
HIV patients have accelerated progression of coronary heart disease. HIV should be considered a CAD risk factor.
Immune Reconstitution Inflammatory Syndrome (IRIS): Rapid CD4 cell count increase or rapid decrease in viral load. Can happen within several weeks of starting ART. Due to underlying infection that the immune system was previously not responding to. Treat infection like PCP prior to starting ART. Steroids also can diminish the symptoms of IRIS.
Health Department Clinics can provide free HIV testing for patients.
ANGELA ROMERO PERFECT SERVE
Elder abuse: 4 felony convictions in and Kane and Cook counties in past 18 months for physical abuse and neglect.
NH Abuse: Psychiatric patients and and sexual felons in NH population. 2 elderly alzheimers got into fight and one died. The NH owner and staff are being prosecuted for murder/manslaughter. NH cannot give psychiatric meds (geodon) for dementia.
Case #1: Is withdrawing care the same as murder? The right of a competent individual to refuse any form of care is absolute. Power of attorney also has the right to refuse care for a patient. In some states, surrogates have similar power to refuse care. We have a withdrawl of care form to use in ED if you want to withdraw care. Need terminal condition, permanent unconsciousness, incurable or irreversible condition. So answer is no, withdrawing care is not the same as murder. Withdrawing care is not the cause of death but rather returning patient to condition of illness that will result in death. In a DNR situation, there is no difference in not initiating treatment and withdrawing treatment.
Case #2 13 yo girl with vaginal bleeding and dangling umbilical cord with no fetus. Pt will not say where baby is. Baby was in garbage dumpster. To whom do you have a duty as an ER doc? You have duty to patient and to baby both ethically and legally. Long discussion on this case but consensus felt probably smart move would be to place mom in psychiatric care rather than sending her directly to jail.
Case#3 How do we manage patients with chronic pain issues and drug seeking behavior? 10% of general population has substance abuse problems. Top 3 medical specialties with substance abuse are EM, anesthesia, and psychiatry. Oak Forest Hospital has a free urgent care 24/7. This clinic can give patients access to Cook County Clinics (pain clinic).
WILLIAMSON NEXT LECTURE FISH TOXINS
Anaphylactic Shellfish Reaction: Type 1 IGE immune mediated response. Can patients with shellfish allergy get IV contrast? Yes very safe. Shellfish allergy is to the shell not to iodine.
Shellfish poisoning: 4 syndromes diarrheal/ amnestic reaction/neurotoxic/paralytic (sodium channel blockade) multiple cases identified in Alaska. Pt’s have to be intubated sometimes.
Scromboid: Bacterial overgrowth in improperly stored fish producing histidine. Can be indistinguishable from allergic reaction. Tx with antihistamines.
Ciguatera: activation of sodium channels. Onset 3-6 hours after ingestion. Symptoms are paresthesias, dental pain and paradoxical temperature reversal. Iv mannitol can be tried.
Fugu: Tetradotoxin binds sodium channels resulting in ascending paralysis. Supportive care and charcoal decontamination of gut are treatments.
Stingray: Venom has no specific antidote. Get an xray for retained fb. Give prophylactic levoquin.
Mercury: Fish consumption is most common cause. Symptoms include fatigue, sensory impairment. Dimercaprol is treatment.
PATEL SAEM CPC CASE PRESENTATION
Neuromuscular causes of weakness: Brain, Cord, NM junction, Muscle disorders.
Periodic Paralysis causes acute weakness due to channelopathy.
Familial Hypokalemic Periodic Paralyssis: white race,
Thyrotoxic Periodic Paralysis: Acquired disorder, age 20-50, Asian males. Carbo load can precipitate an acute episode. Ekg may show U waves. Treat with beta blockers and possibly potassium. Hypokalemia and labs c/w hyperthyroidism confirms diagnosis.