Lower Extremity Pain the ED Flashcards
lecture only
- An acute infection of the skin and subcutaneous tissue resulting from a break in the skin barrier
- involves the upper dermis
dx? MCC?
Erysipelas
MC - group A Strep
- An acute infection of the skin and subcutaneous tissue resulting from a break in the skin barrier
- involves the skin and subcutaneous tissues
dx? MCC?
cellulitis - staph
RF for Cellulitis & Erysipelas
- skin fissuring
- maceration
- burns
- venous stasis
- malnutrition
- lymphedema
- erythema
- painful/tender swelling
- ill defined borders
- warm to touch
Cellulitis
- prodromal fever, chills, malaise and nausea
- bright red painful, indurated plaques
- well-defined borders (demarcated)
- warm to touch
Erysipelas
Indications for serology for Cellulitis & Erysipelas
CBC, CMP, blood cx
- Systemic symptoms or extensive skin involvement
- Immunosuppression or multiple comorbidities
- Immersion injury or infected animal bite
- Failed outpatient therapy
what can help differentiate cellulitis from abscess
Cellulitis & Erysipelas
Bedside US
Concern for DVT vs cellulitis/erysipelas, do what w/u?
Venous doppler US
If Concern for osteomyelitis or necrotizing soft tissue infection, use what w/u?
- X-ray - bone
- CT - bone, soft tissue
Outpatient Management for Cellulitis & Erysipelas, No MRSA Risk
cephalexin, dicloxacillin, or clindamycin
tx for Cellulitis & Erysipelas - MRSA risk
- Bactrim
- doxy
- clinda
general mgmt for Cellulitis & Erysipelas
- rest, cool compresses, elevation of the affected area
- Patient education to watch for complications and return precautions
- Follow up in 48-72 hours
Inpatient Management for Cellulitis & Erysipelas
- IV ceftriaxone, cefazolin, clindamycin, or nafcillin
- If MRSA risk add - IV vancomycin or daptomycin
Indications for Cellulitis & Erysipelas admission
systemic toxicity or evidence of sepsis:
- T > 100.4°F (38°C)
- HR > 90
- RR > 20
- WBC < 4k or > 12k
- SBP < 100
- AMS
- Lactic acid > 2
- Immunocomp
Sepsis - ≥ 2
RF for MRSA infection
- Health care-associated: recent hospitalization, residence in long-term care, recent surgery, hemodialysis
- HIV, IVDU, h/o abx use
- factors associated with outbreaks: incarceration, military service, sharing sports equipment, sharing needles, razors, and other sharp objects
A collection of purulent material within the dermis or subcutaneous space - often progresses from a local superficial cellulitis
Cutaneous Abscess
RF for Cutaneous Abscess
- trauma (abrasions or shaving)
- skin foreign bodies
- insect bites
- IV drug abuse
MCC Cutaneous Abscess
- S. aureus
- MRSA
- Fluctuant, tender, erythematous nodule, often with surrounding erythema
- Spontaneous drainage may be present
- Systemic symptoms are rare - if present consider bacteremia
Cutaneous Abscess
w/u for Cutaneous Abscess
- MC unnecessary
- POCUS - may help rule out FB, differentiating deep abscess from cellulitis
- X-ray - if concern about radiopaque FB or osteomyelitis
mgmt for Cutaneous Abscess
- I&D
- pack wound w/ iodoform, cover with sterile dressing
- f/u 2-3 d
how to I&D cutaneous abscess
- IC
- use povidone iodine and drape in sterile fashion
- Anesthetize wound around abscess, infiltrate deep into abscess if inadequet numbing
- Icise with no. 11/15 blade
- +/- irrigation w/ saline
- types of complicated cutaneous abscess cases?
- tx?
- Large or deep abscess - drain in OR
- palms, soles,nasolabial folds or areas of cosmetic concern - consult specialist
- what type of pt is in need of abx prophylaxis prior to I&D cor cutaneous abscess?
- what abx?
- high risk for endocarditis
- IV Clindamycin or vancomycin 30-60 min before I&D procedure
high risk features for endocarditis
cutaneous abscess
- prosthetic heart valves
- prosthetic material used for valve repair
- h/o previous infective endocarditis
- unrepaired cyanotic congenital heart disease
- repaired congenital heart defect with prosthetic material or device
- repaired congenital heart disease with residual defects
- cardiac transplant recipients with valve regurg d/t structurally abnormal valve
mgmt for Mild cases of cutaneous abscess?
I&D alone
indications for abx for moderate to severe cases of cutaneous abscess
lesion > 2 cm, multiple abscesses, extensive surrounding cellulitis, immunosuppression or signs of systemic infection
adjuvant antibiotics for moderate to severe cutaneous abscess
- Oral therapy if moderate presentation with immunocompetence: Bactrim, doxycycline, clindamycin
- Parenteral therapy for severe presentations, immunocompromised or signs of sepsis: IV vancomycin, linezolid or clindamycin
- Add piperacillin-tazobactam (Zosyn) or meropenem if signs of sepsis
disposition for cutaneous abscess
- Admit those requiring parenteral abx
- Otherwise discharge home
- Wound care instructions - do not get wet, do not remove the dressing or packing
- Specific return precautions - “worsening in symptoms or vomiting”
- Return to ER or PCP in 2-3 days for packing removal/change
s/s of DVT
- Unilateral extremity pain, swelling, or cramping
- +/- Erythema, warmth and tenderness
- A difference of ≥ 2 cm in diameter between right and left leg measured 10 cm below the tibial tubercle
- (+) Homan’s sign - low sensitivity and specificity
presentation of large proximal DVT
- Phlegmasia alba dolens - swollen, painful, pale or white limb
- Phlegmasia cerulea dolens - swollen, painful dusky or blue color limb
pretest probability for DVT?
Wells
- Score of < 0 - D-dimer
- Score of 1-2 - high sensitivity d-dimer
- Score of > 3 higher - US
a product of cloth breakdown, released upon degradation of polymerized crosslinked fibrin.
D-dimer
causes of high plasma D-dimer
- thromboembolism
- inflammation
- surgery/trauma
- liver disease
- kidney disease
- vascular disorders
- malignancy
- thrombolytic therapy
- pregnancy
3 steps of mgmt for DVT
- determine location
- bleeding risk
- develop tx plan
difference between clots based on its location in DVT?
- proximal - larger
- distal (below knee) - smaller
scoring for low, mod, and high risk for DVT?
- Low risk - 0 risk factors
- Moderate risk - 1 risk factor
- High risk - ≥ 2 risk factors
mgmt for Proximal DVT without limb ischemia (e.g. phlegmasia)
- High bleeding risk: IVC filter w/o anticoagulation, consult surg
- Moderate/low risk: DOAC (preferred) or LMWH/warfarin (alt.)
mgmt for Proximal DVT with limb ischemia
consult surg
- High bleeding risk: Surgical thrombectomy with IVC filter placement
- Moderate/low risk: Catheter directed thrombolysis followed by anticoagulant
mgmt for Distal vein involvement only - High bleeding risk
IVC filter placement
mgmt for symptomatic Distal vein involvement only - Moderate/low bleeding risk
DOAC (preferred) or LMWH/warfarin (alt.)
mgmt for asx Distal vein involvement only - Moderate/low bleeding risk
Is there concern for risk of proximal extension of clot?
- “Yes” - same as symptomatic
- “No” - serial US qwkly x 2-4 weeks - If evidence of extension start anticoagulant
Admit if any of the following for DVT:
- Proximal DVT
- Concurrent symptomatic pulmonary embolism (PE)
- High risk of bleeding
- Comorbid conditions or other factors that warrant in-hospital care
Discharge home if all are present:
DVT
- Doesn’t meet any admission criteria
- Hemodynamically stable
- No renal insufficiency
- No social concerns: good living conditions, caregiver support, phone access, understanding and ability to return to the hospital should deterioration occur
- Classic claudication - progressive over time; location is reflective of location
- Atypical leg pain - ischemic rest pain
- Chronic non-healing wounds, hyperpigmented skin with hair loss
- May be asymptomatic
Chronic Peripheral Artery Disease (PAD)
- sudden onset of severe constant pain that doesn’t improve with rest
- followed by the 6 P’s
Acute arterial occlusion
Artery-Specific Claudication Sites?
- Iliac - Buttock/thigh
- Common femoral - Thigh
- Superficial femoral - Upper ⅔ of calf
- Popliteal - Lower ⅓ of calf
- Infrapopliteal - Foot
6 p’s of arterial occlusion
- pain (out of proportion)
- pallor
- pokilothermia
- paresthesias
- paralysis
- pulselessness
One or more are present in acute arterial ischemia of an extremity.
progress of skin changes of arterial limb ischemia?
- pallor
- mottling/cyanosis
- petechiae/blisters
- necrosis
w/u for arteria limb ischemia
- Bedside hand-held doppler < 0.9; < 0.4 severe
- noninvasive vasular imaging - duplex US; CT/MR angiography if dx uncertain
- Labs - CBC, BMP, PT, PTT, INR, CK, myoglobin, lactic acid, UA; EKG - new arrhythmia
mgmt for RUTHERFORD I?
viable - Urgent evaluation
mgmt for RUTHERFORD - Marginally threatened (IIa)
Urgent revascularization
mgmt for RUTHERFORD - Immediately threatened (IIb)
Emergent
revascularization
mgmt for RUTHERFORD- Nonviable (III)
Amputation
When to order diagnostic testing for Stage I and IIa
Perform diagnostic vascular imaging before treatment
When to order diagnostic testing for Stage IIb
immediate consultation with vascular surgery about revascularization prior to additional diagnostic imaging
when to order diagnostic testing for Stage III
PAD
irreversible damage and will likely require amputation
tx for Arterial Limb Ischemia
- UFH - 60-80 u/kg bolus followed by 12-18 u/kg/hr maintenance; Initiate as soon as Classification is determined; Do not delay tx for imaging
- Pain control
- Prepare for surgery: NPO, IV fluids
