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Emergency Medicine > Lower Extremity Pain the ED > Flashcards

Lower Extremity Pain the ED Flashcards

lecture only

1
Q
  • An acute infection of the skin and subcutaneous tissue resulting from a break in the skin barrier
  • involves the upper dermis

dx? MCC?

A

Erysipelas
MC - group A Strep

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2
Q
  • 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?

A

cellulitis - staph

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3
Q

RF for Cellulitis & Erysipelas

A
  • skin fissuring
  • maceration
  • burns
  • venous stasis
  • malnutrition
  • lymphedema
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4
Q
  • erythema
  • painful/tender swelling
  • ill defined borders
  • warm to touch
A

Cellulitis

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5
Q
  • prodromal fever, chills, malaise and nausea
  • bright red painful, indurated plaques
  • well-defined borders (demarcated)
  • warm to touch
A

Erysipelas

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6
Q

Indications for serology for Cellulitis & Erysipelas

A

CBC, CMP, blood cx

  1. Systemic symptoms or extensive skin involvement
  2. Immunosuppression or multiple comorbidities
  3. Immersion injury or infected animal bite
  4. Failed outpatient therapy
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7
Q

what can help differentiate cellulitis from abscess

Cellulitis & Erysipelas

A

Bedside US

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8
Q

Concern for DVT vs cellulitis/erysipelas, do what w/u?

A

Venous doppler US

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9
Q

If Concern for osteomyelitis or necrotizing soft tissue infection, use what w/u?

A
  • X-ray - bone
  • CT - bone, soft tissue
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10
Q

Outpatient Management for Cellulitis & Erysipelas, No MRSA Risk

A

cephalexin, dicloxacillin, or clindamycin

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11
Q

tx for Cellulitis & Erysipelas - MRSA risk

A
  • Bactrim
  • doxy
  • clinda
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12
Q

general mgmt for Cellulitis & Erysipelas

A
  • rest, cool compresses, elevation of the affected area
  • Patient education to watch for complications and return precautions
  • Follow up in 48-72 hours
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13
Q

Inpatient Management for Cellulitis & Erysipelas

A
  • IV ceftriaxone, cefazolin, clindamycin, or nafcillin
  • If MRSA risk add - IV vancomycin or daptomycin
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14
Q

Indications for Cellulitis & Erysipelas admission

A

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

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15
Q

RF for MRSA infection

A
  1. Health care-associated: recent hospitalization, residence in long-term care, recent surgery, hemodialysis
  2. HIV, IVDU, h/o abx use
  3. factors associated with outbreaks: incarceration, military service, sharing sports equipment, sharing needles, razors, and other sharp objects
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16
Q

A collection of purulent material within the dermis or subcutaneous space - often progresses from a local superficial cellulitis

A

Cutaneous Abscess

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17
Q

RF for Cutaneous Abscess

A
  1. trauma (abrasions or shaving)
  2. skin foreign bodies
  3. insect bites
  4. IV drug abuse
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18
Q

MCC Cutaneous Abscess

A
  1. S. aureus
  2. MRSA
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19
Q
  1. Fluctuant, tender, erythematous nodule, often with surrounding erythema
  2. Spontaneous drainage may be present
  3. Systemic symptoms are rare - if present consider bacteremia
A

Cutaneous Abscess

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20
Q

w/u for Cutaneous Abscess

A
  1. MC unnecessary
  2. POCUS - may help rule out FB, differentiating deep abscess from cellulitis
  3. X-ray - if concern about radiopaque FB or osteomyelitis
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21
Q

mgmt for Cutaneous Abscess

A
  1. I&D
  2. pack wound w/ iodoform, cover with sterile dressing
  3. f/u 2-3 d
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22
Q

how to I&D cutaneous abscess

A
  1. IC
  2. use povidone iodine and drape in sterile fashion
  3. Anesthetize wound around abscess, infiltrate deep into abscess if inadequet numbing
  4. Icise with no. 11/15 blade
  5. +/- irrigation w/ saline
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23
Q
  • types of complicated cutaneous abscess cases?
  • tx?
A
  1. Large or deep abscess - drain in OR
  2. palms, soles,nasolabial folds or areas of cosmetic concern - consult specialist
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24
Q
  • what type of pt is in need of abx prophylaxis prior to I&D cor cutaneous abscess?
  • what abx?
A
  • high risk for endocarditis
  • IV Clindamycin or vancomycin 30-60 min before I&D procedure
25
Q

high risk features for endocarditis

cutaneous abscess

A
  1. prosthetic heart valves
  2. prosthetic material used for valve repair
  3. h/o previous infective endocarditis
  4. unrepaired cyanotic congenital heart disease
  5. repaired congenital heart defect with prosthetic material or device
  6. repaired congenital heart disease with residual defects
  7. cardiac transplant recipients with valve regurg d/t structurally abnormal valve
26
Q

mgmt for Mild cases of cutaneous abscess?

A

I&D alone

27
Q

indications for abx for moderate to severe cases of cutaneous abscess

A

lesion > 2 cm, multiple abscesses, extensive surrounding cellulitis, immunosuppression or signs of systemic infection

28
Q

adjuvant antibiotics for moderate to severe cutaneous abscess

A
  1. Oral therapy if moderate presentation with immunocompetence: Bactrim, doxycycline, clindamycin
  2. 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
29
Q

disposition for cutaneous abscess

A
  1. Admit those requiring parenteral abx
  2. 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
30
Q

s/s of DVT

A
  • 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
31
Q

presentation of large proximal DVT

A
  1. Phlegmasia alba dolens - swollen, painful, pale or white limb
  2. Phlegmasia cerulea dolens - swollen, painful dusky or blue color limb
32
Q

pretest probability for DVT?

A

Wells

  • Score of < 0 - D-dimer
  • Score of 1-2 - high sensitivity d-dimer
  • Score of > 3 higher - US
33
Q

a product of cloth breakdown, released upon degradation of polymerized crosslinked fibrin.

A

D-dimer

34
Q

causes of high plasma D-dimer

A
  1. thromboembolism
  2. inflammation
  3. surgery/trauma
  4. liver disease
  5. kidney disease
  6. vascular disorders
  7. malignancy
  8. thrombolytic therapy
  9. pregnancy
35
Q

3 steps of mgmt for DVT

A
  1. determine location
  2. bleeding risk
  3. develop tx plan
36
Q

difference between clots based on its location in DVT?

A
  1. proximal - larger
  2. distal (below knee) - smaller
37
Q

scoring for low, mod, and high risk for DVT?

A
  • Low risk - 0 risk factors
  • Moderate risk - 1 risk factor
  • High risk - ≥ 2 risk factors
38
Q

mgmt for Proximal DVT without limb ischemia (e.g. phlegmasia)

A
  • High bleeding risk: IVC filter w/o anticoagulation, consult surg
  • Moderate/low risk: DOAC (preferred) or LMWH/warfarin (alt.)
39
Q

mgmt for Proximal DVT with limb ischemia

A

consult surg

  1. High bleeding risk: Surgical thrombectomy with IVC filter placement
  2. Moderate/low risk: Catheter directed thrombolysis followed by anticoagulant
40
Q

mgmt for Distal vein involvement only - High bleeding risk

A

IVC filter placement

41
Q

mgmt for symptomatic Distal vein involvement only - Moderate/low bleeding risk

A

DOAC (preferred) or LMWH/warfarin (alt.)

42
Q

mgmt for asx Distal vein involvement only - Moderate/low bleeding risk

A

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
43
Q

Admit if any of the following for DVT:

A
  • Proximal DVT
  • Concurrent symptomatic pulmonary embolism (PE)
  • High risk of bleeding
  • Comorbid conditions or other factors that warrant in-hospital care
44
Q

Discharge home if all are present:

DVT

A
  • 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
45
Q
  1. Classic claudication - progressive over time; location is reflective of location
  2. Atypical leg pain - ischemic rest pain
  3. Chronic non-healing wounds, hyperpigmented skin with hair loss
  4. May be asymptomatic
A

Chronic Peripheral Artery Disease (PAD)

45
Q
  • sudden onset of severe constant pain that doesn’t improve with rest
  • followed by the 6 P’s
A

Acute arterial occlusion

46
Q

Artery-Specific Claudication Sites?

A
  • Iliac - Buttock/thigh
  • Common femoral - Thigh
  • Superficial femoral - Upper ⅔ of calf
  • Popliteal - Lower ⅓ of calf
  • Infrapopliteal - Foot
47
Q

6 p’s of arterial occlusion

A
  1. pain (out of proportion)
  2. pallor
  3. pokilothermia
  4. paresthesias
  5. paralysis
  6. pulselessness

One or more are present in acute arterial ischemia of an extremity.

48
Q

progress of skin changes of arterial limb ischemia?

A
  1. pallor
  2. mottling/cyanosis
  3. petechiae/blisters
  4. necrosis
49
Q

w/u for arteria limb ischemia

A
  1. Bedside hand-held doppler < 0.9; < 0.4 severe
  2. noninvasive vasular imaging - duplex US; CT/MR angiography if dx uncertain
  3. Labs - CBC, BMP, PT, PTT, INR, CK, myoglobin, lactic acid, UA; EKG - new arrhythmia
50
Q

mgmt for RUTHERFORD I?

A

viable - Urgent evaluation

51
Q

mgmt for RUTHERFORD - Marginally threatened (IIa)

A

Urgent revascularization

52
Q

mgmt for RUTHERFORD - Immediately threatened (IIb)

A

Emergent
revascularization

53
Q

mgmt for RUTHERFORD- Nonviable (III)

A

Amputation

54
Q

When to order diagnostic testing for Stage I and IIa

A

Perform diagnostic vascular imaging before treatment

55
Q

When to order diagnostic testing for Stage IIb

A

immediate consultation with vascular surgery about revascularization prior to additional diagnostic imaging

56
Q

when to order diagnostic testing for Stage III

PAD

A

irreversible damage and will likely require amputation

57
Q

tx for Arterial Limb Ischemia

A
  1. 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
  2. Pain control
  3. Prepare for surgery: NPO, IV fluids

Emergency Medicine (20 decks)

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