Infection Flashcards
Spread of odontogenic infections
- Source
- Spread in cancellous bone
- Breakthrough into cortical bone
- Infection of local soft tissue
- Spread to facial planes and spaces
Pathogenesis of abscess
- Aerobic bacteria invade and cellulitis starts
- Aerobic bacteria create acidic environment and hypoxia
- Anerobic bacteria invade and breakdown tissue
- Purulence develops
Trachestosmy
- Initially we are going to ramp the patient with a shoulder roll
- Prep and drap.
- Palpate and mark out landmarks (Thyroid cartilage, cricoid cartilage, trachea, sternal notch), incision midway between cricoid cartilage and sternal notch.
- 3cm horizontal incision through skin & Sub q
- Retract the strap muscles and anterior jugular veins.
- Divide the thyroid isthmus with bovine cautery
- Ask the anesthesiology to lower the Fi02, bovine through the pretracheal fat and fascia
- Using two 2-0 nylon sutures secure the 2nd tracheal cartilage and place cricoid hook
- Ask the anesthesiologist to let down the ballon
- Bjork flap incision through the 2/3 tracheal rings.
- Ask the anesteisologist to withdraw the tube until past the tracheal opening
- Advance the 6.5mm ET tube, inflate the ballon
- Check for ventilation and chest risk
- Secure the ET to the chest.
Oral Bacteria
Aerobes
- G+ cocci: Strep viridans, staph, eikenella
- G- rods: Haemphilus
Anerobes
- G+ cocci: Step & peptostrep
- G- rods: Prevotella, porphymonas, bactericides, fusobacterium
Sepsis, SIRS
Bacteremia causing systemic immune response
Tachycardia >90BPM
Tachypnea >20BPM
Hyper or hypothermia >38.1 or <36
leukocytosis or leukopenia: >12,000 or <4,000/mm3
Septic shock
Distributive shock with low BP and organ failure from systemic immune response to bacteria and toxic factors from bacteria. Vasodilation, renal failure, ARDS, DIC
Compromised host
DM
End stage liver or kidney failure
HIV
Malnutrition
Sickle cell anemia
Leukemia
Lymphoma
Chemotherapy
Immunologics
Chronic corticosteroids
Criteria for inpatient management
Fever >38.1
Failed antibiotic management
Airway insult
Immunocomprimised host
Trismus
Secondary space involvement
Toxic appearance
Rapid progression
Penicillin, Amoxicillin
B- lactam antibiotic- Interferes with cell wall synthesis (bactericidal)
Penicillin VK: 500mg QID, or 25-50mg/kg QID pediatrics
Amoxicillin: 500mg BID, 25-50mg/kg BID pediatrics
Ideal antibiotic
Narrow spectrum, low cost, bactericidal, oral formulation, low toxicity
Augmentin, Unasyn
B-Lactam & lactamase inhibitor
Amoxicillin and clavulonic acid- oral 875/125mg BID, 80-90mg/kg/day
Unasyn and sulbactam- 3g q6h
Clindamycin
Interferes with bacteria protein production at the 30s subunit
At low dose it is bacteriostatic, at hight does it is bactericidal
150-600mg QID adults, 15-30 mg/kg QID pediatrics
Does not cross BBB, good abscess penetration
Carbapenums
Cell wall lysis
Serious G+/- aerobic or aerobic infection
Vancomycin
Inhibits cell wall synthesis
Moxiflocacin
400mg /24 hours
Blocks DNA gyrase
fluoroquinolone
Doxycycline
Tetracycline
Inhibits binding at the 30s ribosomal subunit
100mg BID
Azithromycin
Inhibits binding at the 50s ribosomal subunit
Emissary Veins
Areas where superficial vein penetrates the intracranial cavity
- Deep facial vein to pterygoid plexus to Vesalius vein to cavernous sinus
- Facial vein to ophthalmic vein to cavernous sinus (Danger zone)
Cavernous sinus thrombosis
Inflammation, thrombosis intracranial endovascular cavernous sinus (ascending)
- Headache, vision changes, fever, malaise, proptosis, photophobia
- CN III,IV, V1, V2, IV changes (Opthalmopeligia, eyelid ptosis, and pupillary defect)
Txt- Antibiotics, anticoagulation, and steroids
Afferent pupillary defect
Optic nerve to EdingerWestfall nucleus to ciliary ganglion and to iris sphincter muscle via short ciliary nerve (CNIII parasympathetic) Marcus gun pupil
Oculocardiac reflex or trigeminocardiac reflex
Trauma, infection or surgery
Trigeminal nerve to vagus nerve (Bradycardia)
Necrotizing fasciitis
Necrosis of the fascia and subcutaneous tissues
ill defined borders, skin is erythematous, dusky and might have crepitus
Gas forming bacteria- Strep progenes and Staph aureus
Wide local excision, with serial debridements and washouts
Broad spectrum antibiotics, ID consult and supportive care
Osteomyelitis
Inflammation and increased intramedullary pressure causing vascular compromise and bone necrosis
Risks- Vascular insufficiency (DM), immune dysfunction, pagers or fibro-osseous disease
Acute > 4 weeks
Chronic < 4 weeks
Symptoms- Acute: Pain (deep and boring), swelling, truisms, parethesia, fever, malaise
Chronic- mild or asymptomatic (Supporitive or non supportive)
Increase ESR, CRP and leukocytosis
Streptococcus, staph aureus and epidermis 80-90%
E.coli, Action, eikenella 20%
Tecnetium 99m: show bone inflammation (Scintigraphy)
CT or MRI:
Treatment:
Correct host defenses
Remove source: Sequestration, saucerization and decortication (Small defects)
Resection for large lesions
HBO for refectory cases
Surgical drainage, culture and tailor antibiotics to bacteria
Reconstruction
Acute suppurative
Chronic suppurative
Chronic non-suppurative
Sclerosis osteomyelitis (Diffuse or focal)
SAPHO- CRMO - Children, NSAIDs
Osteoradionecrosis
Meyer theory suggested that a triad of radiation, trauma and infection lead to necrosis
Marx theory of hypocellularity, hypovascualrity and hypoxia lead to necrosis
Delanian theory free radical production lead to activation and dysregulated fibroblast activity and decrease osteoblast activity.
Marx classification:
I- Superficial exposed bone with minimal soft tissue ulceration
II- Localized mandibular involvement, exposed cortex and medullary bone
III- Diffuse mandibular involvement including lower border, fracture or orocutaneous fistula
Txt-
Prophylactic:
Extraction of all necessary teeth prior to radiation, fluoride therapy
After radiation 20/10 HBO dives
Early stage: Conservative therapy with long term antibiotics, chlorohexidine mouth rinses, and superficial debridement, pentoxyfillene and vitamin E (tocopherol)
Refactory stage: 30 dives before resection and 10 after
Advanced: 30 dives before resection, and 10 after consider soft tissue coverage and free tissue transfer.
MRONJ (Medication related osteonecrosis of the jaws)
Diagnosis: Exposure to biphophates, RANKL-i receptor activator of nuclear kappa B ligand inhibitor, antiangiogenic medications. No hx of radiation and exposed bone for >8 weeks
Pathogenesis- Bone remodeling suppression through inhibition of osteoclasts and antiangiogenisis
Bisphosphonates
Reclast- Zolendronic acid IV
Fosamax- alendronate
Actonel- risedronate
Boniva- ibandronate
Anti-angiogenic mediations
Axitnib (Inlyta)
Beacizumab (Avastin)
Cabozantinib (Cometriq)
Everolimus (Afinitor)
RANKLi (Receptor activator of nuclear kappa b ligand)
Xgeva- denosumab IM every four weeks
Prolia- denosumab IM every six months
