skin and soft tissue emergencies dennis djogovic md, frcpc
TRANSCRIPT
![Page 1: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/1.jpg)
Skin and Soft Tissue Emergencies
Dennis Djogovic MD, FRCPC
![Page 2: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/2.jpg)
Financial Disclosures
None to declare
![Page 3: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/3.jpg)
Objectives
When should skin infections be of special concern?
Differential?
Treatment priorities?
![Page 4: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/4.jpg)
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
![Page 5: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/5.jpg)
Non systemic cellulitis
PO Abx
Evidence based choices are poor Retrospective analyses
![Page 6: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/6.jpg)
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
![Page 7: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/7.jpg)
Make sure you cover for Strep and Staph
Staph Do you need to worry about MSSA or MRSA?
![Page 8: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/8.jpg)
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
![Page 9: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/9.jpg)
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
![Page 10: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/10.jpg)
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%
![Page 11: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/11.jpg)
MRSA tips
Age <2
First nations
Close proximity to many people Athletes Prisons Military Hospital
Skin breaks IVDU Skin disorders Known colonizers
![Page 12: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/12.jpg)
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
![Page 13: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/13.jpg)
![Page 14: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/14.jpg)
What is the ideal parenteral therapy?
![Page 15: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/15.jpg)
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
![Page 16: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/16.jpg)
Linezolid
Bacteriostatic Inhibits at ribosomal level
Excellent tissue bioavailability IV or PO
![Page 17: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/17.jpg)
Linezolid
Adverse effects Thrombocytopenia Anemia
Lactic acidosis
Above mostly in the prolonged use setting
Serotonin syndrome Reversibly binds MOA, if added to serotonin agent
![Page 18: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/18.jpg)
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
![Page 19: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/19.jpg)
Case 3
62 yr old female presents with triage complaint of “blisters”
Groan…
![Page 20: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/20.jpg)
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
![Page 21: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/21.jpg)
Blisters- Bad or just gross?
Acuity?
Sick?
Localized or widespread?
Mucus membranes?
Patient Sick? Immunocompromised? Age? New meds?
Blisters: tough or fragile?
![Page 22: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/22.jpg)
Mucous Membranes?
HSV
SJS/TENS
Pemphigus vulgaris
Pemphigus paraneoplastic
Mucus membrane pemhigoid type of Bullous Pemphigoid
![Page 23: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/23.jpg)
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%
![Page 24: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/24.jpg)
Risk Factors
Any viral infection prior to triggering exposure, notably HIV+
Medication exposures
Active malignancy
Southeast Asian Ethnicity
![Page 25: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/25.jpg)
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)
![Page 26: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/26.jpg)
SCORTEN Prognostic Score
SCORTEN Score Mortality
0-1 3.20%
2 12.10%
3 35.30%
4 58.30%
5 or more 90%
![Page 27: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/27.jpg)
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.
![Page 28: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/28.jpg)
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.
![Page 29: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/29.jpg)
Observations on Triggers
The average time from onset of rash to stopping of medication was 10 days (range 2-30)
![Page 30: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/30.jpg)
Case 4
86 yr old male
Dementia
2 week onset of blisters on arms, legs (creases) A few have popped/leaked over past day
![Page 31: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/31.jpg)
Bullous Pemphigoid versus Pemphigous Vulgaris
PemphigoiD = Deep
VulgariS = Superficial
OR
Vulgaris = vulgar = ugly = sick and bad!
![Page 32: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/32.jpg)
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?!)
![Page 33: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/33.jpg)
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
![Page 34: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/34.jpg)
Necrotizing skin infections
Necrotizing Fasciitis Myositis Cellulitis
In common all of these patients are SICK Only the OR can really tell the difference
![Page 35: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/35.jpg)
Imaging?
Ultrasound Not too helpful Can find abscess
MRI Obtained from the ER?? May overexaggerate soft tissue involvment
![Page 36: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/36.jpg)
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!
![Page 37: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/37.jpg)
Treatment
OR
Antibiotics Pen G and Clindamycin
+/-IVIG
![Page 38: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/38.jpg)
![Page 39: Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC](https://reader036.vdocuments.us/reader036/viewer/2022062716/56649dfe5503460f94ae65fc/html5/thumbnails/39.jpg)
Take home points
A few ideas on antibiotic choices
Blisters, rashes, lesions Quick? Sick? Tick, tick, tick!!