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Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC

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.

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Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC

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  1. Skin and Soft Tissue EmergenciesDennis Djogovic MD, FRCPC

  2. Financial Disclosures • None to declare

  3. Objectives • When should skin infections be of special concern? • Differential? • Treatment priorities?

  4. 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

  5. Non systemic cellulitis • PO Abx • Evidence based choices are poor • Retrospective analyses

  6. 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

  7. Make sure you cover for Strep and Staph • Staph • Do you need to worry about MSSA or MRSA?

  8. 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

  9. 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

  10. Incidence of MRSA in Different Settings MRSA per Ward, MSSA (N=818); MRSA (N=295) CAN-WARD

  11. MRSA tips • Age <2 • First nations • Close proximity to many people • Athletes • Prisons • Military • Hospital • Skin breaks • IVDU • Skin disorders • Known colonizers

  12. 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

  13. What is the ideal parenteral therapy?

  14. 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

  15. Linezolid • Bacteriostatic • Inhibits at ribosomal level • Excellent tissue bioavailability • IV or PO

  16. Linezolid • Adverse effects • Thrombocytopenia • Anemia • Lactic acidosis • Above mostly in the prolonged use setting • Serotonin syndrome • Reversibly binds MOA, if added to serotonin agent

  17. VancovsLinezolid • 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

  18. Case 3 • 62yr old female presents with triage complaint of “blisters” • Groan…

  19. 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

  20. Blisters- Bad or just gross? • Acuity? • Sick? • Localized or widespread? • Mucus membranes? • Patient • Sick? • Immunocompromised? • Age? • New meds? • Blisters: tough or fragile?

  21. Mucous Membranes? • HSV • SJS/TENS • Pemphigusvulgaris • Pemphigusparaneoplastic • Mucus membrane pemhigoid • type of BullousPemphigoid

  22. 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%

  23. Risk Factors • Any viral infection prior to triggering exposure, notably HIV+ • Medication exposures • Active malignancy • Southeast Asian Ethnicity

  24. 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)

  25. SCORTEN Prognostic Score

  26. 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.

  27. UAH Burn Unit-Suspected Trigger - **Viral serology was sought on all patients with a diagnosis of SJS/TENS and was all non-contributory.

  28. Observations on Triggers • The average time from onset of rash to stopping of medication was 10 days (range 2-30)

  29. Case 4 • 86 yr old male • Dementia • 2 week onset of blisters on arms, legs (creases) • A few have popped/leaked over past day

  30. BullousPemphigoid versus PemphigousVulgaris • PemphigoiD = Deep • VulgariS = Superficial • OR • Vulgaris = vulgar = ugly = sick and bad!

  31. 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?!)

  32. 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

  33. Necrotizing skin infections • Necrotizing • Fasciitis • Myositis • Cellulitis • In common • all of these patients are SICK • Only the OR can really tell the difference

  34. Imaging? • Ultrasound • Not too helpful • Can find abscess • MRI • Obtained from the ER?? • May overexaggerate soft tissue involvment

  35. 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!

  36. Treatment • OR • Antibiotics • Pen G and Clindamycin • +/-IVIG

  37. Take home points • A few ideas on antibiotic choices • Blisters, rashes, lesions • Quick? • Sick? • Tick, tick, tick!!

  38. Thanks for your time! • djogovic@ualberta.ca

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