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!!

Thanks for your time!

djogovic@ualberta.ca