- Email: [email protected]
An adult female with furuncles and formication
Harrahill/JOURNAL OF EMERGENCY NURSING
T h e score r a n g e s from u n t e s t a b l e to 6: 6 = Follows a s i m p l e motor c o m m a n d 5 = Localizes p a i n - - a t t e m p t s to remove the source of p a i n or m o v e a w a y from it 4 = W i t h d r a w s from p a i n (a generalized, n o t localized response) 3 = Flexion b e s t response. Usually n o t i c e d in the u p p e r extremities. A r m s b e n d at the elbow a n d a d d u c t t o w a r d the c h e s t (with extension of lower extremities). K n o w n as decorticate p o s t u r i n g . 2 = E x t e n s i o n b e s t response. Upper extremities extend, i n t e r n a l rotation of shoulders a n d a r m s (will see b e n t knees). 1 = No response. U = Chemically paralyzed.
A
21-year-old w o m a n c a m e to the e m e r g e n c y dep a r t m e n t with l u m p s on the right u p p e r a s p e c t of her b a c k a n d arm. She s t a t e d t h a t the l u m p s h a d b e e n i n c r e a s i n g in size a n d were a s s o c i a t e d with a s e n s a tion of m o v e m e n t u n d e r the skin. The lesions were n o t painful. The p a t i e n t w a s afebrile a n d vital s i g n s were w i t h i n n o r m a l limits. E x a m i n a t i o n revealed two e r y t h e m a t o u s lesions, a p p r o x i m a t e l y 2 c m in d i a m e ter, with a central o p e n i n g . B u b b l e s of serous m a t t e r were e x u d i n g from the o p e n i n g . The w o m a n h a d visited South A m e r i c a 16 days before her visit to t h e e m e r g e n c y d e p a r t m e n t a n d h a d Mr. Anderson is staff nurse II, Emergency Services, Fletcher Allen Health Care, Burlington, Vermont. For reprints, write Robert N. Anderson, RN, CCRN, CEN, CFRN, AEMT-CC, 267 Goose Pond Rd., Fairfax, VT 05454. J EMERGNURS1996;22:83-4 Copyright 9 1996 by the Emergency Nurses Association. 0099d767/96 $5.00 + 0 18/1/69178
References 1. Harrahill M. Upper extremity nerve assessment: a quick review. J EMERGNURS 1995;21:360-2. 2. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;7:81-3. 3. Teasdale G, Jennett B. Assessment of coma after severe head injury. Lancet 1977;4:878-81.
C o n t r i b u t i o n s for this c o l u m n should be s e n t to M a u r e e n Harrahill, RN, MS, CEN, 1404 SE Malden, Portland, OR 97202; p h o n e (503) 494-7206.
r e t u r n e d to the U n i t e d States a b o u t 10 days later. She h a d no recall of trauma or i n s e c t b i t e s to the area. What do you suspect? Discussion A d i a g n o s i s of furuncular m y i a s i s w a s made; the m o s t likely c a u s a t i v e a g e n t w a s identified as the h u m a n botfly (Dermatobia hominis). T r e a t m e n t was i n i t i a t e d b y s e c u r e l y t a p i n g slices of r a w b a c o n over the lesions f o r 1 hour. The b a c o n w a s t h e n rapidly r e m o v e d a n d a small w h i t e t u b e w a s n o t e d p r o t r u d i n g from the central opening. The t u b e w a s g r a s p e d with forceps, a n d s t e a d y traction p r o d u c e d a small (5 mm), white, pyriform larva. The larva located in the arm w a s r e m o v e d b y i n c i s i o n of t h e skin, followed by copious irrigation, b e c a u s e r e t a i n e d f r a g m e n t s c a n c a u s e a n i n f l a m m a t o r y reaction with a s e c o n d a r y infection. T h e h u m a n botfly does n o t live in the U n i t e d States b u t is c o m m o n in parts of Mexico a n d Central
February 1996 83
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NURSING/Anderson
a n d S o u t h A m e r i c a . It is k n o w n to live b e t w e e n 25 d e g r e e s n o r t h l a t i t u d e a n d 32 d e g r e e s s o u t h latitude. T h e a d u l t fly is a b o u t t h e size of a b u m b l e b e e . Infest a t i o n is s p r e a d b y t h e a d u l t fly c a p t u r i n g smaller blood-sucking insects such as mosquitoes and attachi n g its e g g s to t h e m . The carrier i n s e c t t h e n l a n d s on a s u i t a b l e host, t h e e g g s i n s t a n t l y hatch, a n d e n t e r t h e s k i n t h r o u g h t h e bite. T h e larvae t h e n feed on t h e h o s t in a s u b d e r m a l c a v i t y for 5 to 10 w e e k s . T h e larvae are initially fusiform a n d later b e c o m e pyriform, a n d t h e n
O c c l u s i o n of t h e b r e a t h i n g h o l e w i t h m i n e r a l oil or nail polish may cause the larvae to e m e r g e e n o u g h to b e grasped with forceps.
c a u s e t h e larvae to e m e r g e e n o u g h to b e g r a s p e d w i t h forceps. The i n j e c t i o n of local a n e s t h e t i c at t h e b a s e of t h e lesions c a n c a u s e fluid p r e s s u r e to e x t r u d e t h e larvae. T a p i n g t h e a r e a w i t h d u c t t a p e or similar h e a v y t a p e , a n d t h e n r e m o v i n g t h e t a p e to pull t h e larvae from their c a v i t y is n o t r e c o m m e n d e d b e c a u s e this m e t h o d t e n d s to l e a v e i n f l a m m a t o r y f r a g m e n t s .
Section Editor's teaching points A s t h e United S t a t e s h a s b e c o m e i n c r e a s i n g l y u r b a n ized, a n d h y g i e n e h a s generally i m p r o v e d , p a r a s i t i c i n f e c t i o n s h a v e b e c o m e less c o m m o n . However, w i t h travel to l e s s - d e v e l o p e d c o u n t r i e s b e c o m i n g m o r e c o m m o n a n d t h e d e c l i n e of h e a l t h c a r e for s o m e s e g m e n t s of t h e A m e r i c a n population, t h e i n c i d e n c e of b o t h p a r a s i t i c a n d i n f e c t i o u s d i s e a s e s is i n c r e a s i n g . T r i a g e n u r s e s are in a particularly g o o d p o s i t i o n to exp e d i t e c a r e a n d p e r h a p s m i n i m i z e t h e s p r e a d of s u c h d i s e a s e s . Careful q u e s t i o n i n g a b o u t r e c e n t travel, livi n g conditions, a n d k n o w n e x p o s u r e s c a n help focus diagnosis and treatment. Suggested readings
ovoid to l e n g t h s of 15 to 20 mm. T h e y m a i n t a i n a hole in t h e s k i n for respiration. W h e n m a t u r e , t h e larvae e m e r g e d u r i n g t h e n i g h t or early m o r n i n g hours, d r o p to t h e soil surface, a n d p u p a t e . The a d u l t botfly e m e r g e s after a b o u t a m o n t h . T h e a d u l t s do n o t f e e d a n d a r e rarely seen. It a p p e a r s t h a t t h e only a d u l t f u n c t i o n is to m a t e a n d p r o p a g a t e t h e cycle. T h e t r e a t m e n t w i t h b a c o n is a n old folk r e m e d y t h a t w o r k s v e r y well. S o m e t i m e s small larvae m a y b e e x t r u d e d b y a p p l y i n g e x t e r n a l p r e s s u r e . O c c l u s i o n of t h e b r e a t h i n g hole w i t h m i n e r a l oil or nail polish m a y
Auerbach PS. Wilderness medicine management of wilderness and environmental emergencies. 3rd ed. St Louis: Mosby, 1995:755-6. Goddard J. Physician's guide to arthropods of medical importance. Boca Raton, Florida: CRC Press, 1993:150-2. C o n t r i b u t i o n s for this c o l u m n s h o u l d b e s e n t to Lisa Molitor, ARNP, MSN, CEN, CCRN, 8404 S.W. 28th Place, Gainesville, FL 32607; p h o n e (904) 3311781.
JOURNAL t h e m e i s s u e T h e JOURNALOF EMERGENCYNURSINGi n v i t e s s u b m i s s i o n s for its t h e m e i s s u e . T h e D e c e m b e r 1996 t h e m e i s s u e of t h e JOURNALwill be d e d i c a t e d to "The S p e c t r u m of C a r e - - E m e r g e n c y N u r s e s in Nontraditional Settings." Submit articles to Karen Halm, M a n a g i n g Editor, JOURNALOF EMERGENCYNURSING, 216 Higgins Rd., Park Ridge, IL 60068-5736. Call (800) 243-8362 for d e a d l i n e a n d s u b m i s s i o n information.
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Volume 22, Number 1
T h e score r a n g e s from u n t e s t a b l e to 6: 6 = Follows a s i m p l e motor c o m m a n d 5 = Localizes p a i n - - a t t e m p t s to remove the source of p a i n or m o v e a w a y from it 4 = W i t h d r a w s from p a i n (a generalized, n o t localized response) 3 = Flexion b e s t response. Usually n o t i c e d in the u p p e r extremities. A r m s b e n d at the elbow a n d a d d u c t t o w a r d the c h e s t (with extension of lower extremities). K n o w n as decorticate p o s t u r i n g . 2 = E x t e n s i o n b e s t response. Upper extremities extend, i n t e r n a l rotation of shoulders a n d a r m s (will see b e n t knees). 1 = No response. U = Chemically paralyzed.
A
21-year-old w o m a n c a m e to the e m e r g e n c y dep a r t m e n t with l u m p s on the right u p p e r a s p e c t of her b a c k a n d arm. She s t a t e d t h a t the l u m p s h a d b e e n i n c r e a s i n g in size a n d were a s s o c i a t e d with a s e n s a tion of m o v e m e n t u n d e r the skin. The lesions were n o t painful. The p a t i e n t w a s afebrile a n d vital s i g n s were w i t h i n n o r m a l limits. E x a m i n a t i o n revealed two e r y t h e m a t o u s lesions, a p p r o x i m a t e l y 2 c m in d i a m e ter, with a central o p e n i n g . B u b b l e s of serous m a t t e r were e x u d i n g from the o p e n i n g . The w o m a n h a d visited South A m e r i c a 16 days before her visit to t h e e m e r g e n c y d e p a r t m e n t a n d h a d Mr. Anderson is staff nurse II, Emergency Services, Fletcher Allen Health Care, Burlington, Vermont. For reprints, write Robert N. Anderson, RN, CCRN, CEN, CFRN, AEMT-CC, 267 Goose Pond Rd., Fairfax, VT 05454. J EMERGNURS1996;22:83-4 Copyright 9 1996 by the Emergency Nurses Association. 0099d767/96 $5.00 + 0 18/1/69178
References 1. Harrahill M. Upper extremity nerve assessment: a quick review. J EMERGNURS 1995;21:360-2. 2. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;7:81-3. 3. Teasdale G, Jennett B. Assessment of coma after severe head injury. Lancet 1977;4:878-81.
C o n t r i b u t i o n s for this c o l u m n should be s e n t to M a u r e e n Harrahill, RN, MS, CEN, 1404 SE Malden, Portland, OR 97202; p h o n e (503) 494-7206.
r e t u r n e d to the U n i t e d States a b o u t 10 days later. She h a d no recall of trauma or i n s e c t b i t e s to the area. What do you suspect? Discussion A d i a g n o s i s of furuncular m y i a s i s w a s made; the m o s t likely c a u s a t i v e a g e n t w a s identified as the h u m a n botfly (Dermatobia hominis). T r e a t m e n t was i n i t i a t e d b y s e c u r e l y t a p i n g slices of r a w b a c o n over the lesions f o r 1 hour. The b a c o n w a s t h e n rapidly r e m o v e d a n d a small w h i t e t u b e w a s n o t e d p r o t r u d i n g from the central opening. The t u b e w a s g r a s p e d with forceps, a n d s t e a d y traction p r o d u c e d a small (5 mm), white, pyriform larva. The larva located in the arm w a s r e m o v e d b y i n c i s i o n of t h e skin, followed by copious irrigation, b e c a u s e r e t a i n e d f r a g m e n t s c a n c a u s e a n i n f l a m m a t o r y reaction with a s e c o n d a r y infection. T h e h u m a n botfly does n o t live in the U n i t e d States b u t is c o m m o n in parts of Mexico a n d Central
February 1996 83
JOURNAL OF E M E R G E N C Y
NURSING/Anderson
a n d S o u t h A m e r i c a . It is k n o w n to live b e t w e e n 25 d e g r e e s n o r t h l a t i t u d e a n d 32 d e g r e e s s o u t h latitude. T h e a d u l t fly is a b o u t t h e size of a b u m b l e b e e . Infest a t i o n is s p r e a d b y t h e a d u l t fly c a p t u r i n g smaller blood-sucking insects such as mosquitoes and attachi n g its e g g s to t h e m . The carrier i n s e c t t h e n l a n d s on a s u i t a b l e host, t h e e g g s i n s t a n t l y hatch, a n d e n t e r t h e s k i n t h r o u g h t h e bite. T h e larvae t h e n feed on t h e h o s t in a s u b d e r m a l c a v i t y for 5 to 10 w e e k s . T h e larvae are initially fusiform a n d later b e c o m e pyriform, a n d t h e n
O c c l u s i o n of t h e b r e a t h i n g h o l e w i t h m i n e r a l oil or nail polish may cause the larvae to e m e r g e e n o u g h to b e grasped with forceps.
c a u s e t h e larvae to e m e r g e e n o u g h to b e g r a s p e d w i t h forceps. The i n j e c t i o n of local a n e s t h e t i c at t h e b a s e of t h e lesions c a n c a u s e fluid p r e s s u r e to e x t r u d e t h e larvae. T a p i n g t h e a r e a w i t h d u c t t a p e or similar h e a v y t a p e , a n d t h e n r e m o v i n g t h e t a p e to pull t h e larvae from their c a v i t y is n o t r e c o m m e n d e d b e c a u s e this m e t h o d t e n d s to l e a v e i n f l a m m a t o r y f r a g m e n t s .
Section Editor's teaching points A s t h e United S t a t e s h a s b e c o m e i n c r e a s i n g l y u r b a n ized, a n d h y g i e n e h a s generally i m p r o v e d , p a r a s i t i c i n f e c t i o n s h a v e b e c o m e less c o m m o n . However, w i t h travel to l e s s - d e v e l o p e d c o u n t r i e s b e c o m i n g m o r e c o m m o n a n d t h e d e c l i n e of h e a l t h c a r e for s o m e s e g m e n t s of t h e A m e r i c a n population, t h e i n c i d e n c e of b o t h p a r a s i t i c a n d i n f e c t i o u s d i s e a s e s is i n c r e a s i n g . T r i a g e n u r s e s are in a particularly g o o d p o s i t i o n to exp e d i t e c a r e a n d p e r h a p s m i n i m i z e t h e s p r e a d of s u c h d i s e a s e s . Careful q u e s t i o n i n g a b o u t r e c e n t travel, livi n g conditions, a n d k n o w n e x p o s u r e s c a n help focus diagnosis and treatment. Suggested readings
ovoid to l e n g t h s of 15 to 20 mm. T h e y m a i n t a i n a hole in t h e s k i n for respiration. W h e n m a t u r e , t h e larvae e m e r g e d u r i n g t h e n i g h t or early m o r n i n g hours, d r o p to t h e soil surface, a n d p u p a t e . The a d u l t botfly e m e r g e s after a b o u t a m o n t h . T h e a d u l t s do n o t f e e d a n d a r e rarely seen. It a p p e a r s t h a t t h e only a d u l t f u n c t i o n is to m a t e a n d p r o p a g a t e t h e cycle. T h e t r e a t m e n t w i t h b a c o n is a n old folk r e m e d y t h a t w o r k s v e r y well. S o m e t i m e s small larvae m a y b e e x t r u d e d b y a p p l y i n g e x t e r n a l p r e s s u r e . O c c l u s i o n of t h e b r e a t h i n g hole w i t h m i n e r a l oil or nail polish m a y
Auerbach PS. Wilderness medicine management of wilderness and environmental emergencies. 3rd ed. St Louis: Mosby, 1995:755-6. Goddard J. Physician's guide to arthropods of medical importance. Boca Raton, Florida: CRC Press, 1993:150-2. C o n t r i b u t i o n s for this c o l u m n s h o u l d b e s e n t to Lisa Molitor, ARNP, MSN, CEN, CCRN, 8404 S.W. 28th Place, Gainesville, FL 32607; p h o n e (904) 3311781.
JOURNAL t h e m e i s s u e T h e JOURNALOF EMERGENCYNURSINGi n v i t e s s u b m i s s i o n s for its t h e m e i s s u e . T h e D e c e m b e r 1996 t h e m e i s s u e of t h e JOURNALwill be d e d i c a t e d to "The S p e c t r u m of C a r e - - E m e r g e n c y N u r s e s in Nontraditional Settings." Submit articles to Karen Halm, M a n a g i n g Editor, JOURNALOF EMERGENCYNURSING, 216 Higgins Rd., Park Ridge, IL 60068-5736. Call (800) 243-8362 for d e a d l i n e a n d s u b m i s s i o n information.
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Volume 22, Number 1