Grand Round Juhaina

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Soft Tissue Injury
By Juhina
Jan 19th 2010

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Grand Round Juhaina

  1. 1. Dr. Juhaina Al-Moosawi Mentor : Dr. Salma Al-Mauwali
  2. 2. Introduction : Soft tissue infection : A group of disease that involve the skin , S/C , fascia or muscle . Localized / involve a large portion . Harmless if treated / life threatening even when appropriately treated .
  3. 3. Classification : • Localized/ superfecial infections  Cellulitis  Abscess  Impetigo • Lethal infections  Toxic shock syndrome  Necrotizing fasciitis  Myonecrosis
  4. 4. Superficial Deep
  5. 5. Cellulitis : A soft tissue infection of the skin & S/C .
  6. 6. Risk Factors : • H/O trauma • Skin injury . • Underlying disease (diabetes , impaired lymphatic drainage )
  7. 7. Clinical Feature : • Pain • Tenderness • Erythema • Swelling of the involved area • Local warmth
  8. 8. Causes : • Streptococcus pyogenes . • Staphylococcus aureus.
  9. 9. Diagnosis : • Clinical manifestations . • Fever is uncommon . • No workup in the following criteria:  Small area of involvement  Minimal pain  No systemic signs of illness (fever, dehydration, altered mental status, tachypnea, tachycardia, hypotension) .  No risk factors for serious illness .
  10. 10. workup in serious cases : • CBC • U&E • Blood cultures • Aspiration of the wound + ve collection .
  11. 11. Imaging Studies : • Plain XR unnecessary in uncomplicated cases. • Soft tissue XR or U/S : purulent material or foreing body. U/S guided aspiration of pus : shorten hospital stay .
  12. 12. Immobilization Antibiotic Elevation Management Analgesia Warm packs
  13. 13. Disposition : Cellulitis Out patient In patient Localized Systemic toxicity No fever Sever infection : Hand , feet ,head , Neck , perineum . Oral antibiotic Worsen cellulitis 48-72 h . Immunocompramised F/U 24-48 h Increase erythematus area Fever Paranteral antibiotic Systemic symptoms
  14. 14. Oral Therapy of Superficial Soft Tissue infection : Agent Dose Group A Streptococcus Penicillin V ( phenoxymethylpenicillin) 250 -500 mg qid First generation cephalosporin 250 -500 mg qid Erythromycin 250 -500 mg qid Azithromycin 500 mg x 1 dose Then 250 mg qd x 4 Clarithromycin 500 mg bid Staphylococcus aureus ( not MRSA ) Dicloxacillin 125 -500 mg qid generation cephalosporin 250 - 500 mg qid First 250 – 500 mg qid Cloxacillin 250 – 500 mg qid Erythromycin ( variable effectiveness ) Then 250 mg qd x4 Azithromycin 500 mg x 1 dose
  15. 15. Agent Dose Clarithromycin 500 mg bid Clindamycin 150 -450 mg qid Amoxicillin / clavulanate 875/125 mg bid Or 500/125 mg tid Ciprofloxacin 500 mg bid Haemophilus influenzae 250-500 mg tid Amoxicillin / clavulanate 250-500 mg tid Cefactor 160 mg TMP/800 mg Trimethoprin (TMP)/sulfamethazone smx bid (SMX) 500 mg x 1 dose Azithromycin Then 250 mg qdx4 500 mg bid Clarithromycin
  16. 16. Emergency Department Protocol for the Management of Cellulitis , Nova Scotia, Canad Cellulitis : Acute spreading inflammation involving the soft tissue, excluding muscle, characterized by recent onset soft-tissue erythema, warmth, swelling & tenderness, considered to be of infective origin, and acquired in the community. Department of Emergncy Medcine * and Pharmacy ^ Dalhousie University Halifax, Nova Scotia, Canad Journal of Emergency Primary Health Care (JEPHC)
  17. 17. • Excluded infected surgical wounds or previously treated (< 3 months) deep diabetic infections.
  18. 18. Cellulitis Grading scale : Grade Clinical features I  Symptoms/signs restricted to superficial swelling, erythema, warmth, mild lymphadenopathy, & mild pain; absence of systemic symptoms in patients without risk factors for poor outcome . II  dominant systemic signs – fever, chills lymphangitis &/or rapidly advancing edge.  mild cellulitis (as defined in grade I) in high-risk, non-neutropenic, splenic patients. III  severe facial, perineal or extensive skin involvement (i.e. if any dimension of the area of skin involved is greater than the distance between the patient’s median wrist and the point of the elbow).  failure to respond to >48 hrs of adequate oral Rx,  a history of episodes of cellulitis requiring prolonged intravenous therapy. IV  deep perineal, orbital, joint, or deep hand involvement.  cellulitis in neutropenic or asplenic patients.  suspicion of necrotizing, deep-seated infection or severe sepsis .
  19. 19. Cellulitis algorithm Suspicion of Appropriate Diagnosis Abscess ? surgical Infected bite of management. Cellulitis1 Avoid antibiotics unless surrounding area of cellulitis. Use the same grading system for disposition, but use Table I for antibiotic Consider the possibility of Yes choice. necrotizing infection ? NO Grade I Grade II Grade III Grade IV
  20. 20. Yes NO Grade I Grade II Grade III Grade IV Cephalexin 500 Initial dose of Probenecid Candidate for Immediately give mg QID po x 7 2g po & Cefazolin 1-2g 2,3 home IV therapy4 Clindamycin 900mg IV days or, and Ceftriaxone 2g IV Cloxacillin 500mg Cephalexin 500 mg and IMMEDIATE QID po x 7 days QID po x 7 days. Yes NO REFERRAL or, Azithromycin or, Cloxacillin 500mg 500 mg po QID po x 7 days followed by 250 or, Azithromycin Probenecid 2g IMMEDIATE mg/day x 4 days. 500 mg po followed by Cefazolin or po & Cefazolin CONSULTS: 250 mg/day x 4 days. Cloxacillin I.D. for all patients 1-2g IV2,3 1-2g IV2,3 Family doctor plus: and reliable Family doctor Necrotizing patient/family and reliable infection– surgery, Closely supervised Refer for Deep hand patient/family home therapy. infection– Plastic admission Yes NO Probenecid 2g po & Surg. Yes NO Cefazolin 1g IV q24 Orbital cellulitis– hrs. Change to P.O. Opthalmology.5 Follo Return regimen as for Grade I, w-up to ED in with Follow- Return to ED if Grade I features 36-48h if FP in no up with in 24-36h if obtained for > 24 hrs. 48- improve FP in no Reassessment by FP 72h ment 24-36h improvement in 5 days.
  21. 21. probenecid • Inhibit renal tubular reabsorption of uric acid which lower serum uric acid levels. • It is recommended for patients with gout. • Increase & prolong the serum level of the antibiotic.
  22. 22. Studies suggest that intravenous cefazolin 2 g and oral probenecid 2 g daily is an effective regimen in the treatment of SSTI. The Annals of Pharmacotherapy , 23 January 2004
  23. 23. Toxic shock syndrome (TSS) A shock syndrome caused by the inflammatory response to toxins produced by various bacteria .
  24. 24. Types of Toxic Shock Syndrome • Staphylococcus bacteria (TSS). • Group A Streptococcus bacteria (STSS)
  25. 25. Epidemiology : • Discovered in 1978 in 7 children aged 8-17 years who had shock from Staphylococcus aureus . • The peak incidence of TSS occurred in 1980 associated with increased vaginal tampons use in menstruating women ~ 2.4 – 16 cases / 100,000 population . • CDC reported 200 cases / year from 1994 – 2001 with a steady increase in strep TSS & decrease in incidence of staph TSS since highly absorbent tampons were withdrawn from the market . • Strept TSS was 1st described in 1987 when reported 2 cases of shock due to isolated Step.Pyogenes . • TSS remains as highly fatal disease with mortality rate 30%- 70%.
  26. 26. Principles of disease Staph . aureus Strep . pyrogenic exotoxin toxin entertoxine SPEA SPEB ( TSST-1) B Mononuclear Blood cells IL TNF cytokines System
  27. 27. PATHOPHYSIOLOGY TSS:  3 phases: 1. Growth and multiplication of the bacteria. 2. Production of the toxin. 3. Activation of the immune system.
  28. 28. PHASE 1 Menstrual blood enhances the growth of S.aureus by providing a growth medium for the micro- organism. The tampons contain fibres that inhibit the lactobacilli & diminish their ability to limit the growth of S.aureus.
  29. 29. PHASE 2 ; TOXIN PRODUCTION 1. High protein levels 2. Neutral pH 3. High oxygen levels • Menstrual blood increases the protein levels and provides a neutral pH which provides excellent conditions for toxin production. • Tampons helps in introducing oxygen into the vagina also increasing toxin production. • Tampons cause microtrauma and increase the risk of the exposure of the toxins to the blood..
  30. 30. Phase 3 superantigen toxin MHC II + T cell polyclonal T cell activation. • cytokine storm • TNF, (IL) www.AMDTelemedicine.com
  31. 31. TSS Criteria for diagnosis Fever of 38.9 c ( 102 F) or higher . Rash ( diffuse macular erythema )that resembles the rash of scarlet fever Desquamation of skin 1-2 weeks after onset of disease . Hypotension ( syst BP less than 90 mm Hg , orthostatic drop of 15 mm Hg or more or orthostatic dysness or syncope ) . Clinical or lab abnormalities in at least 3 organ system : GI : Nausea , vomiting , diarrhea . Muscular : myalgia , creatine phosphokinase x 2 times normal . Mucous membrane : vaginal oropharyngeal , conjunctival hyperemia . Renal : Blood urea , creat X 2 times normal level , pyuria greater than 5 cells / high power field . Hepatic : bilirubin , serum transaminases x 2 normal level . Hematologic : thrombocytopenia , less than 100,000/mm3 . Neurologic : disorientation or altered consciousness without focal findings Reasonable evidance for the absence of other cause of illness .
  32. 32. Definition of Streptococcal Toxic Shock Syndrom Must meet criteria from both 1 & 2 below : 1. Isolation of group A Streptococcus from : a. A normally sterile site such as blood or CSF is a definite cases. b. A normally nonsteriel site such as sputum or skin lesion is a probable case . 2. Hypotension & at least 2 of the following : a. Renal impairment . b. Coagulopathy . c. Liver involvement . d. Adult respitarory distress syndrome . e. Generallized erythematous macular rash that may desquamate f. Soft tissue necrosis .
  33. 33. Comparison of Staphylococcal & Strptococcal TSS: Feature Staphylococcal Streptococcal Age Primarily 15-35 yr 20-50 yr Sex Greatest in woman Either Sever pain Rare Common Hypotension 100% 100% Erythroderma rash Very common Less common Renal failure Common Common Bacteremia Low 60% Tissue necrosis Rare Common Predisposing facto Tampons ,paking , Cut , burns ,Bruises , Varicella , NSAID use ? Thrombocytopenia Common Common Mortality rate less 3% 30%-70%
  34. 34. Risk Factors for Toxic Shock Syndrome Use of superabsorbent tampons . Post operative wound infections . Post partum period . Nasal paking . Common bacterial infection . Infection with influanza A . Infection with varicella . Diabetes mellitus . Human immunodeficiency virus infection . Chronic cardiac disease . Chronic pulmonary disease . Nonsteroidal anti inflammatory use ( may mask symptoms rather than be a risk factor )
  35. 35. Complication : • ARDS . • SHOCK . • Gangrene . • Disseminated intravascular coagulation (DIC ). • Renal failure
  36. 36. DXD : • Rocky mountain spoted fever . • Streptococcal scarlet fever . • Staphylococcal scalded-skin syndrome . • Kawasaki syndrome . • Leptospirosis . • Viral illnesses
  37. 37. Managment : • Aggressive IV fluid resuscitation . • O2 • Removal of source of bacteria . • Early antibiotic : Recommended in strept TSS Clindamycine : 600-900 mg IV x8h • Wound debridement . • Hyperbaric oxygen therapy . • Vasopressor . • Immunoglobulin IV 400 mg/ Kg . • Corticosteroids if pt suspected of having Adrenal insufficiency related to underlying disease or chronic steroid use .
  38. 38. Necrotizing fasciitis Progressive, rapidly spreading, inflammatory infection located in the deep fascia, with secondary necrosis of the s/c .
  39. 39. • 1989 toxic shock syndrome and strep A necrotizing fasciitis reported. • The overall morbidity and mortality is 70- 80%. • Strep NF is frequently associated with STSS .
  40. 40. • A retrospective study showed that upper extremity necrotizing fasciitis has a high mortality rate. • In their review, about 35% of patients died. • A state of altered consciousness and respiratory distress at initial presentation were found to be statistically significant factors for eventual mortality emedicine.medscape.com Mar 25, 2009 Michael Maynor, MD, Clinical Assistant Professor, Department of Hyperbaric/Emergency Medicine, Louisiana State University School of Medicine
  41. 41. Types : • Type I NF Polymicrobial infection : anaerobes , non-group A Strep. • Type II NF Monomicrobial infection : group A beta hemolytic Strep
  42. 42. Clinical Features : Stages of NF progression • I (Early) Erythematus /warmth Tenderness Edema Fever
  43. 43. • II (Intermediate) • Bullae formation • Necrotic patches • Oozing
  44. 44. • III (Late) Crepitus Skin anesthesia Sever systemic reaction .
  45. 45. Risk factor : • Surgical procedures • ( intraperitoneal infections and drainage perianal abscesses ). • IM injections and IV infusions . • Insect bites . • Local ischemia and hypoxia (e.g., diabetes). • Alcoholics. • NSAIDs .
  46. 46. Diagnosis : • CBC • U&E • Ca • Blood c/s : +ve in GAS • Deep sample biopsy • Local XR : presence of gas • MRI differentiated between acute cellulitis from NF .
  47. 47. A risk score retrospectively devised in six common laboratory parameters : • CRP ≥150 mg/L (4 points) . • WBC 15,000 to 25,000/microL (1 point) or >25,000/microL (2 points) . • HGB 11.0 to 13.5 g/dL (1 point) or ≤11 g/dL (2 points) . • Na < 135 meq/L (2 points) . • Creatinine > 1.6 mg/dL (141 mmol/L) (2 points). • Serum glucose > 180 mg/dL (10mmol/L) (1point). Uptodate 2009
  48. 48. • A total score ≥6 should raise the suspicion for necrotizing fasciitis ( 7-10%). • score ≥8 was highly predictive (>75 %). • The score is only useful when severe soft tissue infection is strongly suspected.
  49. 49. Mangmnat : • Surgical debridement . • fluid resuscitation . • Antibiotic therapy : Type I : • ampicillin + clindamycin / metronidazole. Type II : • Clindamycin + penicillin . Uptodate 2009
  50. 50. Conclusion: Rapid identification and rapid treatment is essential for recovery from aggressive disease.

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