skin and soft tissue emergencies dennis djogovic md, frcpc
TRANSCRIPT
Skin and Soft Tissue Emergencies
Dennis Djogovic MD, FRCPC
Financial Disclosures
None to declare
Objectives
When should skin infections be of special concern?
Differential?
Treatment priorities?
Case 1
23 previously healthy male presents to the ED with “spider bites” to his left lower leg
Clinically stable vitals and appearance
Medical Hx: benign
Social Hx: lives at home. Competitive wrestler
Non systemic cellulitis
PO Abx
Evidence based choices are poor Retrospective analyses
O/E:
Chest/abd exam normal
Lower left leg Normal pulses, sensation, strength 10-20 small pustules (<1mm in size), mild
surrounding redness, non painful
Make sure you cover for Strep and Staph
Staph Do you need to worry about MSSA or MRSA?
PO Abx Choices
Keflex Strep and MSSA
Clinda Strep, MSSA, MRSA
Amoxicillin Strep
But not staph
Septra, Doxycycline Staph (MSSA and MRSA)
But not strep
Linezolid
MRSA background
Methicillin (B lactamase) in use since 1959
Outbreaks of MRSA since the 1960s
Hospital acquired Far more virulent
Community acquired Less virulent (usually)
Community prevalence increasing
MRSA per Ward, MSSA (N=818); MRSA (N=295)
CAN-WARD
Incidence of MRSA in Different Settings
WARD TYPE % OF ALL S. aureusICU 15.7%
Surgical Ward 9.2%
Medical Ward 27.8%
ER 24.2%
Outpatient Clinic 23.1%
Overall 26.5%
MRSA tips
Age <2
First nations
Close proximity to many people Athletes Prisons Military Hospital
Skin breaks IVDU Skin disorders Known colonizers
Case 2
23 previously healthy male presents to the ED with “spider bites” to his left lower leg
Treated with clindamycin, swab grew MRSA
5 days later, lesions not healing, and appears to have more cellulitis
Appears clinically unwell HR 115, 125/70, 38.9C
Erythema of lower leg Although not rapidly progressive
What is the ideal parenteral therapy?
Vancomycin
Inhibits cell wall synthesis
Fairly safe
Very effective For now
Greatest level of experience and knowledge
Achieving ideal dose levels not easy
MSSA cleared faster with B lactams than Vanc
Tissue penetration variable Bone, CSF
Linezolid
Bacteriostatic Inhibits at ribosomal level
Excellent tissue bioavailability IV or PO
Linezolid
Adverse effects Thrombocytopenia Anemia
Lactic acidosis
Above mostly in the prolonged use setting
Serotonin syndrome Reversibly binds MOA, if added to serotonin agent
Vanco vs Linezolid Linezolid versus vancomycin for the treatment of methicillin-resistant
Staphylococcus aureus infections. Stevens DL, Herr D, Lampiris H, Hunt JL, Batts DH, Hafkin. Clin Infect Dis. 2002;34(11):1481
hospitalized adults with known or suspected methicillin-resistant Staphylococcus aureus (MRSA) infections
linezolid (600 mg twice daily; n=240) or vancomycin (1 g twice daily; n=220) for 7-28 days. S. aureus was isolated from 53% of patients; 93% of these isolates were
MRSA. Skin and soft-tissue infection was the most common diagnosis,
15-21 days after the end of therapy, no statistical difference between the 2 treatment groups clinical cure rates (73.2% of linezolid group and 73.1% in vancomycin
group) microbiological success rates (58.9% linezolid group, 63.2% vancomycin
group)
similar rates of adverse event
Case 3
62 yr old female presents with triage complaint of “blisters”
Groan…
Case 3
62 yr old female
2 day duration Now also in her mouth
Rapidly worsening
HR 120, BP 105/50, 38.4C, RR 26/min
Blisters- Bad or just gross?
Acuity?
Sick?
Localized or widespread?
Mucus membranes?
Patient Sick? Immunocompromised? Age? New meds?
Blisters: tough or fragile?
Mucous Membranes?
HSV
SJS/TENS
Pemphigus vulgaris
Pemphigus paraneoplastic
Mucus membrane pemhigoid type of Bullous Pemphigoid
Stevens-Johnson Syndrome/ Toxic Epidermal Necrolysis Syndrome (SJS/TENS)
An acute, immunologically mediated desquamation disorder secondary to infectious or environmental exposure.
Very uncommon. (1/500000)
BUT it can lead to disastrous sequelae akin to a major burn. Mortality SJS – 10% Mortality TENS – 30%
Risk Factors
Any viral infection prior to triggering exposure, notably HIV+
Medication exposures
Active malignancy
Southeast Asian Ethnicity
Early Prognostic Markers
Age >40
Active Malignancy
Tachycardia (>120) at presentation
% TBSA desquamated
Serum Bicarbonate <20mmol/L at presentation
Uremia at presentation (>10mmol/L)
Hyperglycemia at presentation (>14mmol/L)
SCORTEN Prognostic Score
SCORTEN Score Mortality
0-1 3.20%
2 12.10%
3 35.30%
4 58.30%
5 or more 90%
Management
Prompt identification and withdrawal of trigger.
General principles of burn care. Appropriate fluid resuscitation Wound care/Debridement
Steroids**
IVIG**
Mucosal / Ophthalmological involvement require appropriate specialist involvement.
UAH Burn Unit-Suspected Trigger
Cefazolin 2Diltazem 1TMP-SMX 3Phenytoin 1Vancomycin 1Atorvastatin 2Lamogtridine 1Allopurinol 1Mycoplasma pneumonia 1
-
**Viral serology was sought on all patients with a diagnosis of SJS/TENS and was all non-contributory.
Observations on Triggers
The average time from onset of rash to stopping of medication was 10 days (range 2-30)
Case 4
86 yr old male
Dementia
2 week onset of blisters on arms, legs (creases) A few have popped/leaked over past day
Bullous Pemphigoid versus Pemphigous Vulgaris
PemphigoiD = Deep
VulgariS = Superficial
OR
Vulgaris = vulgar = ugly = sick and bad!
Refer early
Not many acute therapies in the ED Maybe IV steroids?
Make sure you are not missing infection!! If on a recent abx, use a different class (TENS?!)
Case 5
Healthy 32 yr female
Gardening yesterday, scratched left arm on fence
Nightime fever
Awoke with painful red rash on left arm Spreading
HR 130, BP 90/50, O2 sat 91%
VBG: 40/26/7.18/lactate 9
Necrotizing skin infections
Necrotizing Fasciitis Myositis Cellulitis
In common all of these patients are SICK Only the OR can really tell the difference
Imaging?
Ultrasound Not too helpful Can find abscess
MRI Obtained from the ER?? May overexaggerate soft tissue involvment
Imaging?
Non contrast CT Looking for air
If you see air, you have necrotizing infection
If you don’t see air, this could still be necrotizing infection
Get your surgeon to look Ideally in the OR!
Treatment
OR
Antibiotics Pen G and Clindamycin
+/-IVIG
Take home points
A few ideas on antibiotic choices
Blisters, rashes, lesions Quick? Sick? Tick, tick, tick!!
