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Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
Seminar 4   soft tissue infection
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Seminar 4 soft tissue infection

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Soft Tissue Infection …

Soft Tissue Infection
1. Gas Gangrene
2. Necrotizing Fasciitis

Published in: Health & Medicine
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  • Clostidium perfringens is a Gram-positive, rod-shaped, anaerobic, spore-forming bacterium of the genus Clostridium
  • impending doom - feel as though something extremely bad is going to happen but you are not sure
  • bleb - is an irregular bulge in the plasma membrane of a cell
  • Transcript

    • 1. Soft Tissue Infection Nashrul Hadi
    • 2. GAS GANGRENE • Gas gangrene also known as "Clostridial myonecrosis", and "Myonecrosis" • It is a bacterial infection that produces gas in tissues in gangrene.
    • 3. Epidemiology •demographics – Male : female ratio • no sexual predilection •location – buttocks, thigh, perineum
    • 4. • risk factors – Posttraumatic (associated with C perfringens) • • • • • MVA (most common) crush injuries gunshot wounds with foreign bodies burns and frostbite IV drug abuse – Postoperative • bowel resection or perforation • biliary surgery • premature wound closure – Spontaneous • colon cancer (associated with C. septicum) • neutropenia
    • 5. • Pathophysiology – Clostridial species • Clostidium perfringens (most common), Clostridium novyi, Clostridium septicum • found in soil and gut flora • gram-positive obligate anaerobic sporeforming rods that produce exotoxins (e.g. C. perfringens alpha toxin) – causes muscle necrosis and vessel thrombosis – can cause hemolysis and shock • incubation period <24h • gas produced by fermentation of glucose – main component is nitrogen – other bacteria include E. coli, Pseudomonas aeruginosa, Proteus species, Klebsiella pneumoniae
    • 6. • Prognosis – overall 25% mortality – 50% mortality if bacteremic – 100% mortality if treatment is delayed – poorer prognosis for older patients with comorbidities.
    • 7. Clinical Features • History – recent surgery to GI or biliary tract • Symptoms – Triad • suddent progressive pain out of proportion to injury – from thrombotic occlusion of large vessels • tachycardia not explained by fever • feeling of impending doom
    • 8. • Physical exam – sweet smelling odor – swelling, edema, discoloration and ecchymosis – blebs and hemorrhagic bullae – "dishwater pus" discharge – crepitus – altered mental status
    • 9. Investigation Radiographs •Findings – linear streaks of gas in soft tissues
    • 10. • Labs – Elevated LDH – Elevated WBC – Metabolic acidosis and renal failure • Histology – Gram stain reveals Gram-positive bacilli – absence of neutrophils • lack of acute inflammatory response is hallmark of gas gangrene • Culture – blood culture rarely grows Clostridial species • DDx – Necrotizing Fasciitis
    • 11. Treatment • Nonoperative – high dose IV antibiotics • 1st line is penicillin G and clindamycin • alternative treatment is erythromycin, tetracycline or ceftriaxone – clindamycin and tetracycline inhibit toxin synthesis – hyperbaric O2 • indications – useful adjunct • outcomes – effectiveness of HBO2 is inconclusive • Operative – radical surgical debridement with fasciotomies • indications – 1st line treatment is surgical
    • 12. Complication • Shock • Renal failure – both mediated by TNF alpha, IL-1, IL-6
    • 13. NECROTIZING FASCIITIS INTRODUCTION: •Necrotizing fasciitis is a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the sub cutaneous tissue. •It is a life threatening infection that spreads along soft tissue planes.
    • 14. • Risk factors – immune suppression • diabetes • AIDS • cancer – bacterial introduction • • • • • IV drug use hypodermic therapeutic injections insect bites skin abrasions abdominal and perineal surgery – other host factors • obesity • Associated conditions – cellulitis • overlying cellulitis may or may not be present
    • 15. • Prognosis – life threatening infection • mortality rate of 32% • mortality correlates with time to surgical intervention
    • 16.  Necrotizing Fasciitis Classification Type Organism Characteristics Type 1 Polymicrobial Typical 4-5 aerobic and anerobic species cultured: • non-Group A Strep • anaerobes including Clostridia • facultative anaerobes • enterobacteria • Synergistic virulence between organisms • Most common (80-90%) • Seen in immunosuppressed (diabetics and cancer patients) • Postop abdominal and perineal infections Type 2 Monomicrobial • Group A β-hemolytic Streptococci is most common organism isolated Type 3 Marine Vibrio vulnificus (gram negative rods) Type 4 MRSA • 5% of cases • Seen in healthy patients • Extremities • Marine exposure
    • 17. Clinical Features • Symptoms – early • localized abscess or cellulitis with rapid progression • minimal swelling • no trauma or discoloration – late findings • severe pain • high fever, chills and rigors • tachycardia
    • 18. • Physical exam – skin bullae – discoloration • ischemic patches • cutaneous gangrene – swelling, edema – dermal induration and erythema – subcutaneous emphysema (gas producing organisms) • DDx – Gas Gangrene
    • 19. Investigation • Radiographs – not required for diagnosis or treatment • Biopsy – only method of definitive diagnosis – surgical intervention should not be delayed to obtain
    • 20. • LRINEC Score – score > 6 has PPV of 92% of having necrotizing fasciitis – CRP (mg/L) ≥150: 4 points – WBC count (×103/mm3) • <15: 0 points • 15–25: 1 point • >25: 2 points – Hemoglobin (g/dL) • >13.5: 0 points • 11–13.5: 1 point • <11: 2 points – Sodium (mmol/L) <135: 2 points – Creatinine (umol/L) >141: 2 points – Glucose (mmol/L) >10: 1 point
    • 21. Management • Operative – Emergency radical debridement with broadspectrum IV antibiotics   • indications – whenever suspicion for necrotizing fascitis • operative findings – – – – liquified subcutaneous fat dishwater pus muscle necrosis venous thrombosis • technique – hemodynamic monitoring with systemic resuscitation is critical – hyperbaric oxygen chamber if anaerobic organism identified
    • 22. – antibiotics • initial antibiotics – start empirically with penicillin, clindamycin, metronidazole, and an aminoglycoside • definitive antibiotics – penicillin G » for strep or clostridium – imipenem or doripenem or meropenem » for polymicrobial – add vancomycin or daptomycin » if MRSA suspected 02/05/14
    • 23. – Amputation • indications – low threshold for amputation when life threatening
    • 24. Reference • Orthobullet 02/05/14

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