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7/30/2019 0 Comments

Skin and Soft Tissue Infections

Skin and Soft Tissue Infections

Epidemiology

Cellulitis 2.3 million visits in the ED annually
15% get admitted
Up to 30% of diagnosed cellulitis is really a “cellulitis mimic”

Important Aspects of your History

Travel? Water exposure?
Recent trauma or bug bite?
Recent antibiotics?
Immunocompromised? Diabetes w/ complications (neuropathy, sugar uncontrolled, etc)?

The Mimics

Venous stasis
PAD
DVT or superficial thrombophlebitis
Dermatosclerosis
Diabetic myonecrosis
Lymphedema
Contact dermatitis
Necrotizing fasciitis

Workup

Good history and physical exam
Always ultrasound to look for purulence or abscess
Labs largely unhelpful

Treatment

Simple cellulitis w/out purulence = Keflex (consult local antibiogram)
Cellulitis w/ purulence = Keflex plus Staph Aureus coverage
Abscess – Drain and only give antibiotics in special circumstances

“Special” cellulitis

Perichondritis
- Needs coverage for pseudomonas
Bites – think Pasteurella
- Augmentin
Water exposure
- Vibrio– doxycycline
- Aeromonas– Rocephin, Bactrim, or a fluoroquinolone.
Orbital cellulitis
- IV abx, CT scan
Unvaccinated children
- H. influenzacellulitis associated with 90% bacteremia
Abscess
- Needs drainage
- Bactrim if abscess > 5cm, patient immunocompromised, in axilla or groin

Necrotizing fasciitis +/- Toxic Shock Syndrome

When patient presents in extremis, the diagnosis is easy
Helpful physical exam findings
- Pain out of proportion
- Pain outside the margin of the rash
- Bullae, skin necrosis, pallor, hypoesthesia, crepitus are late findings
Labs are unhelpful and cannot be relied upon until it is too late
Resuscitate and give Vancomycin, Zosyn, and Clindamycin
- Clindamycin needed for decreased toxin release in setting of toxic shock syndrome. Always give with first wave of antibiotics if you are treating necrotizing fasciitis
Imaging is not universally helpful
Very tough diagnosis, you need a high index of suspicion
Consult surgery quickly if suspicious, you will need source control

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7/21/2019 0 Comments

Pediatric "Difficult" Airway Review

Republished with Permission from www.PedEMMorsels.com

Difficult Airway: Basics

Defining “Difficult Airway” is challenging, so studies are not strictly comparable (we all know it after we have dealt with it though).
Some separate “Difficult Airway” from “Difficult Intubation.” [Belanger, 2015]
- Difficult Airway – unable to provide adequate gas exchange despite BVM, airway adjuncts, or combination of the two.
- Difficult Intubation – 3 or more attempts by an experienced clinician

The incidence of difficult intubations in children vary from <0.1% to 9%[Graciano, 2014; Heinrich, 2012]
Difficult intubations is associated with higher incidence of oxygen desaturations below 80% and adverse events. [Graciano, 2014]

Difficult Airway: Important Differences
Anatomic and physiologic differences influence how the oral, pharyngeal, and tracheal axes align as well as how the respiratory mechanics function and how the child compensates to physiologic stress.
The differences are most prominent in children < 2 years of age and more adult anatomy evolves as children progress to 8 years of age.

Anatomic Differences:

Relatively larger head (particularly occiput)
- Need for shoulder roll instead of head elevation to align external auditory meatus with sternal notch (which helps align the three axes).
Smaller and compressible nasal passages
- More easily occluded by mucous
- Easily obstructed by poorly positioned facemask.
Relatively larger tongue
- More difficult to control with laryngoscope blade.
- Occupies more mouth and posterior pharyngeal space.
Larynx location is more cranial
- Adult’s larynx located around C4-5
- Child’s larynx located around C3-4, but can be even higher (C2-3).
- Makes for more of an “anterior” airway and acute angle from pharyngeal axis to tracheal axis.
Epiglottis is longer and more floppy
- Softer cartilage and more pliable tissues
- Can be more difficult to retract away from glottic opening.
Trachea is more compressible
- Softer cartilage and more pliable tissues
- Can be easily compressed by a “helpful” person performing cricoid pressure (don’t let this happen).
Ribs are horizontal
- Contribute less to the work of breathing
- Diaphragm does most of the work of breathing.
Low functional residual capacity
- Due to smaller airways and less dead space
- Smaller reservoir from which the apneic child can draw oxygen
Smaller number of alveoli
- Less oxygen absorption surface area.

Physiologic Differences:

Higher metabolic rate
- Consumes oxygen at more than twice the adult rate
- Combined with low functional residual capacity, leads to rapid desaturations.
Low glycogen stores
- High metabolic rate and low glycogen stores leads to hypoglycemia.
- Hypoglycemia is a common SYMPTOM of the critically ill child.

Difficult Airway: Predictive Factors

Adult-based tools (ex, LEMON, Mallampati, thyromental distance) are notpredictive in young children. [Belanger, 2015]
There are patient factors that are associated with difficult intubation. [Karsli, 2015; Belanger, 2015]
- History of difficult airway (duh) [Graciano, 2014]
- Less than 1 year of age
- Signs of Upper Airway Obstruction (duh) [Graciano, 2014]
- Congenital/Genetic Syndromes w/ altered anatomy
  - Down Syndrome
  - Pierre Robin Sequence
  - Treacher Collins
  - Cleft Palate
  - Mucopolysaccharidosis (ex, Hunter, Hurler)
- Physiologic stress [Graciano, 2014]
  - Hypotension, ventilation failure, etc

Difficult Airway: Assume the Worst

Most pediatric airways can be secured by experienced clinicians, but the potential for discovering a difficult airway after meds have been pushed is a perilous position to be in. [Belanger, 2015]
Absence of predictive factors for difficult airway does not mean it will be an easy airway. [Karsli, 2016; Graciano, 2014]
- One study found 1 in 5 Difficult Airway cases were NOT anticipated.[Karsli, 2016]

Moral of the Morsel

Pediatric patients are a special population and warrant special considerations.
Anatomy and Physiology matter! There are numerous differences that need to be considered… even when it is “easy.”
Anticipate the Worst! 1 out of 5 is a concerning number – All pediatric patients should be considered to have a Difficult Airway until you successfully intubate them… then you can hit the “easy” button.
There are no “easy airways” in the ED, regardless of age. Patients that require intubation in the ED have, be definition, stressed physiologic systems and, as such, should be considered difficult until proven otherwise.

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7/13/2019 0 Comments

Transition of Care (Sign-Out) in the ED

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EMGuideWire

From the J. Lee Garvey Innovation Studio in the
Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC

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Skin and Soft Tissue Infections

Pediatric "Difficult" Airway Review

Transition of Care (Sign-Out) in the ED

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