Lecture 12: LE Pain Readings Flashcards
Most severe presentations of DVT (2)
- Phlegmasia cerulea dolens (cyanotic)
- Phlegmasia alba dolens (Pale)
Alba = albino = white
If someone has a PE, whats the likelihood they might have clinical signs of a DVT?
50%
Well’s for DVT
- Active CA in past 6 months
- Paralysis/paresis of lower limb
- Bedridden > 3 d 2/2 surgery in past 12 weeks
- Localized tenderness along deep veins
- Entire leg swollen
- Unilateral calf swelling > 3 cm below tibial tuberosity
- Unilateral pitting edema
- Collateral superficial veins
- Prior hx
>= 3 = high risk
When is venous US slightly impaired in dx DVT?
- Pelvic DVT
- Isolated calf DVT
- Obese
Which physical exam sign is non-specific for DVT?
Homan’s sign
Calf squeeze
Management of DVT
- LWMH
- UFH
- Xa inhibitor
What DVT subtype requires immediate tx with neutral position?
Phlegmasia cerulea dolens
Also consider IR for thombectomy
Top RFs for PAD
- Smoking
- > 70 years old
MC arteries for arterial embolism
- Femoral
- Popliteal
What 4 arteries are most likely to lead to limb ischemia?
- Femoropopliteal
- Tibial
- Aortoiliac
- Brachiocephalic
6 Ps of acute arterial limb ischemia
- Pain (earliest)
- Pallor
- Poikilothermia (cold)
- Pulsenessness
- Paresthesias
- Paralysis
Define claudication
- Cramping pain/ache
- Brought on by exercise, relieved by rest
- Reproducible
- Reocccurs at consistent walking distances
MCC of arterial embolism
Underlying thromboembolic dz
What ABI ratio is extremely concerning for critical limb ischemia?
< 0.41
Gold standard for diagnosing arterial occlusion
Arteriogram
Identify anatomy & directs tx of the limb
First steps to managing acute arterial occlusion
- Fluids
- Pain meds
- Dependent positioning (idk, it just says improves perfusion pressure)
- EKG & consider echo
What rutherford criteria requires immediate tx for acute limb ischemia?
2b or higher (immediately threatened)
What rutherford criteria may suggest amputation as tx for acute limb ischemia?
3 (irreversible)
Preferred AC for acute limb ischemia
UFH 80U/kg bolus + UFH 18U/kg/hr
Discharge meds for chronic PAD without comorbidities and no immediate limb threat
- Baby asa
- Loading dose of 325mg before d/c
Rutherford criteria chart for acute limb ischemia
How do community acquired MRSA skin lesions present?
- Warm
- Red
- Tender
- Abscesses that spontaneously drain
Similar to a SPIDER BITE
Tx for community acquired MRSA abscesses in a normal immune system
I&D
No abx unless accompanying cellulitis or systemic
ABX post I&D for patient with community acquired MRSA abscess with comorbidities
- Clinda 300mg PO QID
- Bactrim DS 2 tabs BID + Keflex 500mg QID
- Vanco BID IV if admitting.
7-10 days!
Top 2 organisms for monomicrobial necrotizing soft tissue infections
- GAS
- S. Aureus
If you have bad hygiene, add clostridials
Classic presentation of necrotizing soft tissue infections
- Pain out of proportion
- Sense of heaviness
- Edema, brown, bullae
- Malodorous
- Crepitus
What suggests systemic toxicity 2/2 necrotizing soft tissue infections?
Mental status changes like delirium or irritability
Tx of necrotizing soft tissue infections
- Vanco BID +
- Meropenem Q8h
Zosyn alternative. Clinda can be added.
Tetanus if needed
What systemic condition are we scared of occurring with a necrotizing soft tissue infection?
Septic shock
Who do you consult as soon as you suspect a necrotizing soft tissue infection?
Gen surg
Who is cellulitis MC in? (3)
- Elderly
- Immunocompromised
- Peripheral Vascular Disease
How does cellulitis present?
- Localized tenderness
- Erythema
- Induration of skin
May have accompanying lymphangitis/lymphadenitis
Dx of cellulitis
Clinical
Outpatient tx of cellulitis that is unlikely to be MRSA
- Keflex QID
- Dicloxacillin QID
- Clinda QID
Inpatient tx of cellulitis
- Clinda IV Q8h
- Cefazolin Q8h
- Nafcillin Q4h
MCC of erysipelas
GAS
due to skin break
Clinical features of erysipelas?
- Sudden high fever
- Chills/malaise/Nausea
- Demarcated erythematous area with burning sensation
Dx of erysipelas
Clinical
How do you tx uncomplicated erysipelas?
Same as cellulitis:
- Keflex QID
- Dicloxacillin QID
- Clinda QID
Mainstay of tx for simple skin abscess
I&D
What is a Bartholin gland abscess?
- Unilateral painful swelling of labia
- Fluctuant 1-2 cm mass
Tx of Bartholin gland abscess
Only if sus of STD
- I&D
- Insertion of Word catheter for 4 weeks
- Sitz bath after 2d
What is hidradenitis suppurativa and the tx?
- Chronic skin infection of the apocrine sweat glands (axilla and groin)
- I&D
Surgeon if recurrent
What are infected epidermoid & pilar cysts and tx?
- Erythematous, tender, cutaneous, fluctuant nodules
- I&D and check in 2-3d
- MUST REMOVE CAPSULE TO PREVENT RECURRENCE
but you remove capsule at a secondary visit
What is a pilondial abscess and tx?
- Tender, swollen, fluctuant mass along the superior gluteal fold
- I&D and check in 2-3d
- Surgery is definitive tx
MCC of folliculitis
S. aureus
Tx of regular folliculitis
- Warm compresses
- Topical bacitracin
Tx of extensive/painful folliculitis
- Keflex
- Dicloxacillin
- Azithromycin
What causes sporotrichosis?
Sporothrix schenckii
How does fixed cutaneous sporotrichosis present?
- Takes 3 weeks to incubate!
- Crusted Ulcer or verrucuous plaque
How does local cutaneous sporotrichosis present?
Subcutaneous nodule or pustule with surrounding erythema
How does lymphocutaneous sporotrichosis present?
MC type overall of the 3
Painless subcutaneous nodules that migrate along lymphatic channels
Dx of sporotrichosis
Clinical
Tissue biopsies too but not useful in ED setting
Tx of localized or systemic sporotrichosis
Itraconazole PO for 3-6 months
Tx of pts with systemic symptoms or disseminated sporotrichosis?
Amphotericin B
A BOMB
