Beruflich Dokumente
Kultur Dokumente
Chief Residents
You are working the 9p-7a ER shift Outgoing resident signs out an axillary abscess in Bed 9, ready for I & D
History
http://www.guymonortho.com/images/patient-forms.jpg
http://images.fanpop.com/images/image_uploads/Lightning-McQueen-disney-pixar-cars-772510_1700_1100.jpg
Treat if:
Abscess >5cm Multiple lesions Extensive surrounding cellulitis Co-morbidities Immunosuppresion Systemic signs and sxs Inadequate response to I&D
Antibiotic Selection
Physical Exam
HR: 158 RR: 22 BP: 93/48 Temp: 40.6 O2 Sat: 99% RA
HEENT:
NCAT, PERRL, EOMI, bilaterally injected conjuctivae w/ purulent drainage, TMs erythematous, OP erythematous w/ bilateral tonsillar exudates
Neck: Ant and post cervical LAD CV: Tachycardic rate, no murmurs.
crackles NL s1 and s2
Resp: Tachypnic, clear breath sounds, good air movement, no wheeze, no Abd: Soft, NT/ND. No masses, no HSM, NABS GU: NL female genitalia, Tanner V Ext: R axillae: 2x2 cm boggy, erythmatous pustular lesion, +fluctuant, slightly
tender, no active drainage
Neuro: Sleepy but arousable, AO x3, delayed answer to questions but appropriate
Randomized-Control Trial
n= 263 (Pts <17 excluded from this study)
EGT
In ER:
Placement of central venous catheter Crystalloid and colloid fluids Vasoactive agents PRBC transfusion Ionotropes
Developmental Differences
Transitional circulation
Sepsis induced hypoxia & acidosis Increased PVR PPHN
of sepsis
Imaging
Axillary US:
A hypoechoic slightly heterogeneous collection
measures 2.5 x 2.8 x 3.0 cm in the right axilla just anterior to the axillary artery and vein. The skin is swollen superficial to the fluid collection.
Axillary Culture:
Many MSSA, pan susceptible
Epidemiology
First described 1978
1980: 817 cases reported (all menstruating F)
Menstrual Cases
Associated w/ highly absorbent and polyacrylate rayoncontaining tampons
Nonmenstrual
50% of TSS cases Post-surgical, post-partum, mastitis, septorhinoplasty,
sinusitis, osteo, arthritis, burns, abscesses.
5396 cases 74% associated with menstruation 91% in 1971 59% in 1996 Case-fatality rate 5.5% in 1979 1.8% in 1996
Etiology
Staph
Exotoxins
TSST-1 producing
strains of MSSA and MRSA Food poisoning SSS TSS C, D, E and H
Strep Exotoxins
M protein
Indicates virulence of
strep species
M type 1, 3, 12 and 28
associated w/ shock
A, B and C
Activate immune system by bypassing the usual antigen-mediated immune response release of large quantities of inflammatory cytokines
Staph
vs.
Strep
Minor (2 or more)
Renal impairment Coagulopathy Liver involvement ARDS Erythematous macular rash Soft tissue necrosis
Minor (any 3)
MM inflammation Vomiting / Diarrhea Liver abnormalities Renal abnormalities Muscle abnormalities CNS abnormalities Thrombocytopenia
Exclusion Criteria
Absence of another explanation Neg BCx
If GAS is isolated from a nonsterile site but the patient fulfills the other criteria noted above, a probable diagnosis of GAS TSS can be made if no other etiology for the illness is identified.
Treatment
Supportive
Fluids Pressors
Additional Therapies
IVIG (400 mg/kg once)
Logical therapy if theory of TSS resulting from lack of Ab
production Proven success with strep TSS, no proven success with staph TSS
Prolonged muscle weakness Fatigue Amputation of digits Reversible hair or nail loss
Objectives - eview management of an R abscess - eview the approach to R sepsis in the ER - Review the etiology, pathogenesis, clinical symptoms and treatment of Septic Shock
Citations
Epidemiology, clinical manifestations, and diagnosis of streptococcal toxic shock
syndrome: http://www.uptodateonline.com/online/content/topic.do? topicKey=gram_pos/5335&selectedTitle=2%7E80&source=search_result content/topic.do?topicKey=gram_pos/ 4986&selectedTitle=1%7E80&source=search_result Med 1996; 334:240.
Bisno, AL, Stevens, DL. Streptococcal infections in skin and soft tissues. N Engl J Kliegman et al. Nelson Textbook of Pediatrics. 18th Edition Rivers et. Al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and
Septic Shock. N Engl J Med 2001; 345:19