Extremity Pain - Exam 3 Flashcards
______ usually involves the upper dermis. What is the MC pathogen?
erysipelas
MC group A strep
_____ involves the skin and subq tissues. What is the MC pathogen?
cellulitis
MC staph
What are the risk factors for cellulitis and erysipelas?
skin fissuring
maceration
burns
venous stasis
lymphedema
malnutrition
______ involves the upper dermis. What is the MC pathogen
erysipelas
group A strep
_____ involves the skin and subcutaneous tissue. What is the MC pathogen?
cellulitis
Staph
What are the risk factors for cellulitis and erysipelas?
skin fissuring
maceration
burns
venous stasis
lymphedema
malnutrition
How will cellulitis and erysipelas presentation be different?
cellulitis: ill defined borders, NOT a clear margin of transition
erysipelas: will have prodromal s/s, bright red painful indurated plaques with WELL DEFINED borders
What are the indications to order labs on a pt with cellulitis or erysipelas?
Systemic symptoms or extensive skin involvement
Immunosuppression or multiple comorbidities
Immersion injury or infected animal bite
Failed outpatient therapy
aka not everyone needs labs!! only if cormorbid or systemic symptoms
_____ can be ordered on pts with concern for a deep abscess vs cellulitis
bedside US
What imaging should you order if you have concerns for osteomyelitis or necrotizing soft tissue infection?
xray: bone
CT: bone, soft tissue (CT with IV contrast for necrotizing soft tissue infection)
How long does it take for osteomyelitis to show on the xray?
2 weeks
What is the tx for cell/erysipelas?
no MRSA risk: cephalexin
MRA risk: bactrim or (doxy PLUS amox)
supportive therapy: rest, cool compresses, elevation
What are the return procautions in cellulitis and erysipelas? When do they need to follow up?
return: if any s/s of abscess formation, sepsis
draw circle around swelling and if swelling extends past 2 inches then need to return to PCP/ER
follow up in 48-72 hours
What are the indications for admission in cell/erysi? What is the inpt tx?
systemic toxicity or signs of sepsis
No MRSA Risk - IV cefazolin
MRSA risk - add IV vancomycin
What are the s/s of sepsis that would indicate admission in cellulitis/erysipelas?
**What are the MRSA risk factors? When would you use them for this test?
When deciding what abx to use in cell/erysipelas
What are the risk factors for cutaneous abscess? What is the MC pathogen?
trauma (abrasions or shaving)
skin foreign bodies
insect bites
IV drug abuse
MC pathogens - S. aureus, MRSA
Will a pt with a cutaneous abscess have systemic symptoms?
NOT usually but if present consider bacteremia
What dx should you order in an cutaneous abscess? When would you order an xray?
dx are NOT necessary but can order US if you want to differentiate from cellulitis
if concerned about radiopaque FB or osteomyelitis
What is the management of an cutaneous abscess?
(I&D) - requires informed consent
What are the step by step procedure to I&D an abscess? When does the pt need to come back?
need to culture the pus to make sure the abx are approperiate
need to follow up in 2-3 days for packing removal or replacement
What are the indications to rx abx after the abscess has been I&D?
lesion > 2 cm
multiple abscesses
extensive surrounding cellulitis
immunosuppression or signs of systemic infection
What is the abx of choice for pt with cutaneous abscess? What about severe presentations, IC or signs of sepsis?
PO: bactrim, doxy or clinda
severe:
IV vancomycin
Add cefepime or meropenem if signs of sepsis
What is the tx for a large/deep abscess?
drain in the OR
When do you need to consult a specialist in an abscess?
Consult specialist for abscesses affecting the:
palms
soles
nasolabial folds or areas of cosmetic concern
What do you need to do first in a pt that is high risk for endocarditis and has an abscess?
Patients at high risk for endocarditis need abx prophylaxis prior to I&D¹
Abx given 60-120 minutes before incision
bactrim, clinda, vanc, cefepime, meropenem (NOT doxy) are all appropriate choices
**What 2 questions should you ask your pt before draining an abscess to determine if they are a high risk for endocarditis or not?
**Any hx of heart valve problems?
** Any current or past hx of IV drug use?
What is the disposition for an abscess?
admit those who require IV abx
everyone else can go home
What are the pt education wound care instructions for an abscess? **When do you need to return for a packing removal/change?
Wound care instructions - do not get wet, do not remove the dressing or packing
Specific return precautions - “worsening in symptoms, fever, vomiting”
**Return to ER or PCP in 2-3 days for packing removal/change
DVT of the UE extremity is usually due to _____
indwelling catheter
Unilateral extremity pain, swelling, or cramping
+/- Erythema, warmth and tenderness
+ Homan’s sign
What am I?
**What should you measure? What is a concerning finding?
DVT
**A difference of ≥2 cm in diameter between right and left leg measured 10 cm below the tibial tubercle
What are 2 skin changes that would indicate a large PROXIMAL DVT?
Phlegmasia alba dolens
Phlegmasia cerulea dolens
_____ swollen, painful, pale or white limb
Phlegmasia alba dolens
______ swollen, painful dusky or blue color limb
Phlegmasia cerulea dolens
What are the different scoring options for Well’s for DVT score?
- Score of 0 or less - D-dimer
- Score of 1-2 - high sensitivity d-dimer
- Score of 3 or higher - US
What are some common causes of an elevated d-dimer?
thromboembolism: MI, stroke, acute limb ischemia, DVT, PE
DIC
Covid 19
severe infections
sepsis
sx/trauma
liver dz
kidney dz
vascular disorders
malignancy
thrombolytic therapy
pregnancy
What is considered a proximal vs distal DVT?
What are the absolute CI to anticoagulation in DVTs?
What is the tx for DVT w/o limb ishcemia?
DOAC(preferred) or LMWH/warfarin (alt.)
What is the tx for DVT with limb ishcemia or CI to anticoag?
consult vascular sx for surgical thrombectomy with IVC filter placement
VS
Catheter directed thrombolysis followed by anticoagulant (aka tPA directly into clot)
What are the admission criteria in a DVT?
Proximal DVT
Concurrent symptomatic pulmonary embolism (PE)
“High risk of bleeding”
Comorbid conditions or other factors that warrant in-hospital care
______
renal insufficiency, hemodynamically unstable, social concerns
^ these were NOT directly stated the slides but inferred
What do you want to ask your DVT pt about before sending them home?
any s/s of chest pain or SOB? then these pts CANNOT go home because they potentially could be having a PE
claudication that is progressive over time
atypical leg pain
chronic non-healing wounds
Hyperpigmented skin with hair loss
What am I?
chronic PAD
not an emergency
sudden onset, severe constant pain, doesn’t improve with rest
What am I?
What are the 6 Ps? Which ones are later to show up?
acute arterial occlusion
pain (out of proportion)
pallor
poikilothermia (cold)
_______
below are last to occur:
paresthesias
paralysis
pulselessness
What is the progression of skin changes seen in arterial limb ischemia?
skin pallor, mottling/cyanosis, petechiae/blisters, necrosis
_____ is used to assess pulses at bedside in arterial limb ischemia along with ABI. What is abnormal? What is severe?
hand-held doppler
<0.9 is abnormal
<0.4 suggest severe disease
How do you calculate ABI?
_____ is the initial modality of choice for arterial limb ischemia. ______ is utilized if dx is uncertain after US or for presurgical planning
duplex US is initial
CT angiography, MR angiography
(Elkins said, CTA with “run off” into the legs)
Why do you want to get an EKG in a pt with arterial limb ischemia? What other non-routine labs would you want to order?
because of K, that could cause an new arrhythmias
CK, myoglobin, lactic acid, UA
What are the major differences between the classifications of acute limb ischemia? What is the name of the scale?
I
IIa
IIb
III
**I and IIa have NO motor deficit and no/minimal sensory deficits (IIa)
**IIb and III will have motor and sensory deficits
What is the management of stage I and IIa arterial limb ischemia?
Stage I and IIa: Perform diagnostic vascular imaging before treatment
What is the management of stage IIb arterial limb ischemia?
immediate consultation with vascular surgery about revascularization prior to additional diagnostic imaging
What is the management of stage III arterial limb ischemia?
irreversible damage and will likely require amputation
How will Elkins tell us the pt has weakness present in a question about arterial limb ischemia?
document the pt has strength 3/5 instead of strength is 5/5 bilateral like for a normal pt
What is the management of an arterial limb ischemia
