Burns summary

Burns

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Common finger injuries: tendons and ligaments

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Normal anatomy

Extensor mechanism

  • Central slip that extends the PIP (attaches to dorsal middle phalanx)
  • 2 lateral bands that extend the DIp (attaches to dorsal distal phalanx)

Flexor mechanism

  • Flexor digitalis superficialis flexes the PIP (attaches to base of middle phalanx)
  • Flexor digitalis profundus flexes the DIP (attaches to base of distal phalanx)

There are also collateral ligaments (at the side) and volar plate (at base) providing support for the fingers.

Common finger injuries involving tendons & ligaments

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Evaluating FDP injury: profundus & superficialis test

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Evaluating collateral ligament injury: valgus & varus test


Types of splint used:

Extension splint for extensor tendon injuries

Untitled.pngNote that patient should keep finger in extension for 6 weeks.

  • Splinting has to be restarted if patient flexes the finger.
  • Hyperextension can cause circulatory impairment. A blanched finger = too much extension. Allowing the skin to “breathe” for 10 to 20 minutes between splint changes minimizes the risk of maceration.

Buddy splint for collateral ligament injury

Progressive extension splint for volar plate injury (using dorsal aluminium splint)

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Reference:

JEFFREY C. LEGGIT, CHRISTIAN J. MEKO. Acute Finger Injuries: Part I. Tendons and Ligaments. Am Fam Physician
2006;73:810-6, 823

Pulmonary Embolism

Evaluation of PE (ACP 2015)

5 things to remember

  • Use validated clinical prediction rules to estimate the pretest probability (Simplified Well’s, modified Well’s or traditional Well’s, Geneva’s score)
    Modified WellSimplified Well
  • Low pretest probability + meet all PERC criteria = no D-dimer
  • Intermediate pretest probability or low risk but does not meet all PERC criteria = D-dimer is needed
  • Age adjusted D-dimer threshold (10 X age) for patients > 50 yo. If d-dimer below the age adjusted threshold, no further imaging studies.
  • For high pretest probability, obtain CTPA or VQ scan if CTPA is c/i or not available. Do not get a D-dimer.

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** Alternative approach can be used if patint has symptoms of DVT – doing LE venous ultrasound. However, a single negative US should not be used to exclude subclinical DVT.

Common question: what is the fetal radiation risk of CTPA vs VQ scan?

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Treatment of PE (BTS 2003)

5 things to remember:

  • Massive PE or imminent cardiac arrest = 50 mg alteplase
    Non massive PE, thrombolysis should not be used as first line.
  • Intermediate/high risk of PE = the first important thing is to give heparin (BEFORE imaging)
  • Oral anticoagulation only after you confirm the diagnosis.
  • Target INR is 2-3, discontinue heparin after target is reached.
  • Duration of treatment
    – 6 weeks for temporary reversible RF
    – 3 months for first idiopathic, then reassess at the end of 3 months.
    – At least 6 months for others

**SC LMWH is recommended over IV UFH unless rapid onset eg in massive PE is needed. Dose adjustment of LMWH is needed in renal failure.

Other things to consider

  • Consider testing hemophilia in <50 yo with recurrent PE or positive family history.
  • Cancer investigation only when it is suspected clinically.
  • IVC filter can be done as temporarizing measure until anticoagulation can be started.
  • Pregnancy: warfarin is teratogenic and should not be used until after delivery. Breast feeding is okay with warfarin.
    – Approaching delivery, UFH should be substituted
    because its anticoagulant effect can more easily be reversed if
    necessary
    – There are different views about whether it should be
    discontinued or the dose reduced 4–6 hours before the
    expected time of delivery.
    – Continue anticoagulation for 6 weeks post-partum or 3 months,      whichever is longer.
  • Cancer: Same anticoagulation but remember that higher risk of recurrence and bleeding.
    – Duration is arbitary due to lack of good evidence.
    – Recurrent PE: higher target INR OR long term LMWH (both increase bleeding risk) or IVC filter (questionable value)

  1. Uae validated clinical prediction rule. If low risk, use PERC score to determine whether to get a D-dimer.
  2. If patient has symptoms of DVT, use LE ultrasound. Single negative US does not exclude subclinical PE.
  3. Thrombolysis only in massive PE.
  4. IV UFH or SC LMWH in intermediate/high probability of PE before the dx is confirmed. Oral anticoagulation after the dx is confirmed.
  5. Duration is 6 weeks with reversable RF, 3 months with first idiopathic and 6 months with the others.
  6. In pregnancy, warfarin is contraindicated BUT is okay after delivery and does not preclude breast feeding. Anticoagulation for 6 wks PP or 3 months, whichever is longer.
  7. Cancer patient has higher risk of bleeding and recurrence. Recurrent PE in malignancy is very difficult to be managed with poor evidence supporting one over another. (increase target INR vs long term LMWH vs IVC filter).

Reference

Evaluation of Patients With Suspected Acute Pulmonary Embolism:
Best Practice Advice From the Clinical Guidelines Committee of the
American College of Physicians

British Thoracic Society guidelines for the management of
suspected acute pulmonary embolism. Thorax 2003;58:470–484

IDSA SSTI guideline 2014

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Recommendations on impetigo and ecthyma

  • Culturing the exudates is helpful, but treatment can be done without culturing.
  • Impetigo: oral/topical abx; if outbreaks/numerous lesions oral form is preferred.
    – Topical muciprocin or retapamulin bid for 5 days
  • Ecthyma: oral is preferred.
  • Oral therapy for impetigo and ecthyma is dicloxacillin/cephalexin for 1 week (normally MSSA). if MRSA, doxycycline/clindamycin/TMP-SMX.

Recommendations for purulent skin infections

  • Treatment without culture is reasonable.
  • Culture & stain from inflamed epidermoid cysts are not recommended.
    – Inflammation and purulence are a reaction to cyst wall rupture and contains skin flora.
  • I &D is the recommended treatment.
  • Abx only in the presence of SIRS criteria. Abx should cover MRSA.

Recommendations for recurrent skin abscesses

  • Look for local causes eg hidradenitis suppurativa, pilonidal cyst etc.
  • If begin in childhood, the adult should be evaluated for neutrophil disorders,
  • Should be drained and cultured. Treat with 5-10 days abx against the pathogen isolated.
  • Consider a 5 day decolonization regimen bid of intranasal muciprocin, daily chlorrhexidine washed and decontamination of personal items. (weak evidence)

Recommendations for cellulitis and erysipelas

  • Cultures are not routinely needed, unless malignancy on chemo, neutropenia or other forms of immunodeficiency.
  • Typical cellulitis: oral abx against Streptococci. MRSA is unusual cause.
  • Cover for MRSA and streptococci if the cellulitis is associated with penetrating trauma, IVDU, purulent drainage, MRSA infection evidence elsewhere, or SIRS (severe non purulent).
  • Chck the interdigital toe spaces as treating fissuring or maceration may eradicate colonization with pathogens.
  • Treatment duration is 5-10 days. Elevation of the affected limb is recommended.
  • Weak evidence supporting use of systemic corticosteroids in non diabetic adult patient with cellulitis. Clinician must ensures NF is absent.

Recommendations for recurrent cellulitis

  • Identify predisposing conditions eg venous insufficiency or toe web abnormality.
  • Weak evidence supporting prophylactic abx (eg oral penicillin for 4-52 weeks or IM benzathine penicillin every 2-4 weeks) in patients with 3-4 episodes of cellulitis per year.

Recommendations for surgical site infections

  • Suture removal + incision and drainage is most important therapy.
  • Only give abx if there are systemic symptoms.
  • Cover for MRSA if there are RFs eg recent abx/hospitalization or prior MRSA infection.
  • Cover G- and anaerobes in GI and GU infections (cephalosporin/FQ + metronidazole).

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Recommendations for NF

  • Prompt surg.consultation.
  • Broad empiric abx as the etiology can be polymicrobial eg vanco + zosyn or + ceftriaxone/FQ & metronidazole or + carbapanem)
  • For documented Strep.A NF, penicillin + clindamycin is recommended.

** Consider NF if

  1. Pain out of proportion, edema and tenderness extending beyond the erythema
  2. Systemic intoxication
  3. Failure to respond to initial abx
  4. Presence of crepitus, bullous lesions or skin necrosis.

Most with NF should return to OR 24-36 hours after first debridement and daily thereafter until surgical team finds no further need for debridement. These wounds can discharge copious amount of fluid so aggressive fluid therapy is needed. Abx is continued until no further debridement is needed or patients improve clinically.

Recommendations for pyomyositis

  • MRI is the recommended imaging modality.
  • Culture should be obtained from the abscess material and blood (only 5-30% of blood culture will be positive).** Serum CK can be normal.
  • Vancomycin is recommended for initial empirical therapy. Add abx that covers for G- bacilli in open trauma/immunodeficient patients.
  • Like purulent skin lesions, drainage should be performed early.
  • Repeat MRI if there is persistent bacteremia (identify undrained foci)
  • For MSSA infection, use cefazolin or antistaphy penicillin.

Recommendations for gas gangrene

  • Urgent surgical debridement.
  • broad spectrum empiric therapy in the absence of definitive etiology.
  • HBO therapy is NOT recommended as it has not been proven as a benefit to the patient.

Recommendations for animal and human bite wounds

  • Prophylactic abx only for high risk wounds eg immununocompromised, asplenia, adv.liver disease, mod-severe injuries, especially to hands & face.
  • PEP for rabies maybe indicated.
  • Cover for both aerobic and anaerobic pathogens eg augmentin or cefuroxime or other 2nd & 3rd gen cephalosporin + clindamycin/metronidazole
    ** Other options: SMX-TMP/FQ + clinda/metro
    ** Do not use macrolides due to variable activity against P.multocida and fusobacteria.
  • Give tetanus toxoid in patients without vaccination within 10 years.
  • Do not perform primary closure on wounds except face (weak evidence).

Recommendations for immunocompromised patients

  • Consider other ddx eg Sweet’s syndrome, GVHD, leucocytoclastic vasculitis. Always perform biopsy/aspiration to obtain material for histological and microbiological evaluation.
  • Determine whether the current fever & neutropenia is recent, persistent (after 4-7 days) or recurrent.
  • Risk stratify the patients. High risk = prolonged (>7 days) neutropenia (ANC < 100 cells/uL) or with MASCC score <21.
  • For initial fever + enutropenia: vancomycin + antipseudomonal abx eg zosyn, cefepime is recommended. Duration of tx 1-2 weeks.
    ** For low risk patients, augmentin + ciprofloxacin can be used.
    ** levofloxacin has better G= coverage but less potent against P.aeruginosa than cirpofloxacin.
  • CSF therapy should not be routinely used.
  • For recurrent/persistent fever and neutropenia: yeasts and molds are the main cause.
    – Candida: echinocandins for 2 weeks, lipid formulation amphotericin B with fluconazole is acceptable alternative
    – Aspergillus: voriconazole or lipid formulation amphotericin B/posaconazole/echinocandins for 6-12 weeks.
    – Mucor: amphotericin B or posaconazole
    – Fusarium: voriconazole or posaconazole
    – Also if suspect HSV/VZV, add IV aciclovir.
  • Sens of single serum fungal antigen test eg (galactomannan or 1,2 B-D glucan) is low.

Other organism-specific recommendations

  • Cat scratch disease: azithromycin
  • Erysipeloid: penicillin or amoxicillin for 7-1 days
  • B.mallei (aerobic, gram negative): ceftazidime, gentamicin, doxycycline, ciprofloxacin or imipenem based on in vitro efficacy.
    ** Known as glanders: ulcerating nodular lesions caused by B.mallei, humans because accidental host by inhalation of contact with horses/mules

5 take home messages

  • Routine cultures of blood and tissues is not recommended for skin infections, except with systemic signs, immunosupression, malignancy or animal bites.
    ** In animal bites, blood culture only when there is systemic signs.
    (http://emedicine.medscape.com/article/881171-treatment)
  • For abscess, if no systemic signs, no abx is indicated.
  • CA-MRSA is very unlikely in typical cellulitis, so in typical cellulitis only Streptococci coverage is needed. This is in contrast in purulent infection (empirical should cover CA-MRSA).
  • Cover for MRSA if the cellulitis is associated with penetrating trauma, purulent discharge, IVDU or evidence of MRSA infections elsewhere. In surgical site infection, cover for MRSA if there is recent exposure eg prior hospitalization/abx use or history of MRSA infxn.
  • Examine inter-digital toe spaces for fissuring/maceration. Abx treatment can reduce colonization.

5(+2) abx therapy to remember:

  • Impetigo: topical muciprocin or retapamulin OR oral cephalexin/dicloxacillin; ecthyma: oral cephalexin/dicloxacillin
    ** If MRSA: doxycycline/clinda/TMP-SMX
  • Cellulitis:
    – Mild-moderate: penicillin or cephalosporin (PO in mild, IV in mod)
    – Severe: vanco + Zosyn or carbapenem
  • Surgical site infection
    – Not GI/GU: cefazolin or vancomycin if MRSA is suspected
    – GI/GU: 3rd gen cephalosporin/FQ + metronidazole (G- & anaerobes)
  • NF or gas gangrene: vanco + broad spectrum eg Zosyn/carbapenem
  • Animal bites: augmentin or 2nd or 3rd gen cephalosporin + metronidazole/clindamycin
    ** DO NOT use azithromycin

  • Pyomyositis: Vanco, if immunocompromised/open trauma add gram negative coverage
  • Immunocompromised (need to cover MRSA + PSA + fungal/viral etc)
    – Mild: cipro (for P.aeruginosa) + augmentin
    – Severe: vanco + Zosyn/cefepime/carbapenems
    – Persistent/recurrent: add antifungals/antivirals

Reference:

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America.

 

Liquid nicotine intoxication

E-liquid can have nicotine concentration as high as 100 mg/mL, which are diluted prior to use. When ingested in high concentration and in sufficient volume (1 vial = 15 mL) patients can develop significant nicotinic toxicity. Recently a case of cardiac arrest has been reported after ingesting two 15 ml vial (100 mg/mL).

Clinical manifestation of toxicity (similar to cholinergic toxidrome) is biphasic with early central stimulation followed by depression. Can involve GI (N&V, diarrhea), cardio (hypertension, tachycardia –> bradycardia), respiratory (bronchorrhea, tachypnea –> apnea), CNS (agitation, seizure –> somnolence, coma) etc.

No specific antidote. based on organ specific dysfunction eg cholinergic toxidromes = atropine, seizure = BZ

Reference:

Chen BC et al. Death following intentional ingestion of e-liquid. Clin Toxicol 2015;53:914-916.

Kim JW et al. Liquid nicotine toxicity. Pediatr Emer Care 2015;31:517-524

Revision of NRP 2010 Guidelines

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Some main points

  • Compared to ACLS, NRP focuses on hypothermia prevention & effective ventilation (bilateral chest sounds and movements) in newborn.
  • Avoid hypothermia by placing the baby in radiant warmer or using plastic wrap.
  • Always try to reposition the baby’s head and adjust the mask (to have a good seal) if baby is not improving (still gasping or HR <100). Intubation should be the last thing you think in newborn resuscitation.

For summary on the update in 2015 AHA guideline for CPR and ECC:
https://medicalrojak.wordpress.com/2015/10/19/aha-2015-update-for-cpr-and-ecc-neonatal-resuscitation/