Schoenwald Flashcards
what do you think when you see bone/joint pan and elevated APR
osteomyelitis
what are the 2 types of osteomyelitis
acute
chronic
suspect osteomyelitis if (2)
- bone can be probed w. swab from wound site
- wound > 6 weeks duration
what are 2 imaging choices for osteomyelitis
- plain film xray
- MRI if xray negative and high suspicion for osteomyelitis
osteomyelitis is __ or
__ infxn of the bone
bacterial
fungal
what are the 3 sources of osteomyelitis
- hematogenous
- invasion from contiguous focus of infxn
- skin breakdown
what are 5 hematogenous sources of ostomyelitis
- bacteremia
- sickle cell anemia
- elderly
- IVD users
- DM
a diabetic foot infxn is an example of which source of osteomyelitis
invasion from contiguous focus of infxn
vascular insufficiency or trauma is an example of which type of osteomyelitis
skin breakdown
what bacteria is associated w. SSA and osteomyelitis
salmonella
what test do you order for definitive confirmation of osteomyelitis
bone culture
what is the main organism associated w. osteomyelitis in non SSA patients
s. aureus
osteomyelitis in DM pt’s is often
polymicrobial
what bacteria would you suspect if a pt had osteomyelitis from a nail through the foot
pseudomonas
MRI will usually show infxn how long after clinical symptoms
7-15 days
what do you think when you see an MRI w. cortical erosion, periosteal rxn, lucency, or osteolysis
osteomyelitis
what are the treatment steps for osteomyelitis
- debridement of bone
- minimum 6 weeks abx targeted to organism
what is the minimum amt of time for abx in osteomyelitis
6 weeks
what is the empiric abx of choice for osteomyelitis
vanco 1 gm IV q 12 hr +/- Rifampin
PLUS
Cefriaxone 2 gm IV q 24 hr
after cultures, what abx should you use for MSSA
Nafcillin 2 gm iv q 4 hr
OR
Cefazolin 2 gm IV q 8 hr
what is the abx of choice if culture shows MRSA
vanco 1 gm IV q 12 hr +/- rifampin 300-400 mg po tid
what is the abx of choice if osteomyelitis culture shows pseudomonas
Cipro
must also check for foreign body and do tetanus prophylaxis if nail
what is the abx of choice for mild osteomyelitis
doxycycline → good bone penetration
how should you treat osteomyelitis in DM pt
- debride and get cultures
- no empiric therapy → wait for culture to preserve kidneys
what labs should you order for continued monitoring for osteomyelitis
- CBC
- CMP
- APR
what is the mc affected bone in brodie’s abscess
tibia
what is brodie’s abscess
abscess walled off by body’s immune system for years
what are 3 symptoms of brodie’s abscess
- pain
- +/- outward drainage externally
- red and swollen around bone
what is the pathogen associated w. brodie’s abscess
s. aureus
what is this showing
brodie’s abscess
what might brodie’s abscess look like on xray
small luscent area
what are the 3 causes of infectious arthritis (septic arthritis)
- direct inoculation of joint space by bacteria
- contiguous spread
- bacteremia
- previously damaged joint
what is the most common cause of infectious (septic) arthritis
bacteremia
what 2 pt populations are vulnerable to infectious (septic) arthritis from a previously damaged joint
- RA
- prosthetic joint
what joints are mc in infectious (septic) arthritis
knee
hip
shoulder
spread of infectious arthritis is usually
monoarticular
what are 4 symptoms of infectious (septic) arthritis
- fever
- pain at joint
- erythema of joint
- impaired ROM
- monoarticular
what is the most common cause of infectious (septic) arthritis in young, healthy, sexually active pt’s
gonorrhea
what is the op tx for infectious (septic) arthritis
doxycycline
OR
Bactrim
→ to cover MSSA and MRSA
what is the tx for infectious (septic) arthritis if only MSSA isolated
Nafcillin
OR
Keflex
besides abx, how else should you treat infectious (septic) arthritis
fluid drainage
what is reactive arthritis
rxn to infectious arthritis outside of the active infxn
what kind of process is reactive arthritis
delayed inflammatory
reactive arthritis is more common in what pt population
HLAB27 (ankylosing spondylitis)
what are the 3 most common bacteria in reactive arthritis
- chlamydia
- trachomatis
- various GI bugs
what GI bugs are commonly seen in reactive arthritis
salmonella
yersinia
campylobacter
c.diff
what are the 2 tx options for reactive arthritis
- NSAIDs
- smoldering infxn: continue abx
what are 4 cardinal symptoms of gonococcal septic arthritis
- fever
- arthralgias of multiple joints
- asymmetric tenosynovitis
- skin pustules
where doe infectious gonococcal arthritis usually begin
hands
what are 3 diagnostic tests for gonococcal septic arthritis
- fluid aspirate and culture
- blood cultures
- xray
how is gonococcal septic arthritis spread
disseminated from bacteria from cervix, urethra, or pharynx
what is the tx for gonococcal septic arthritis
- ceftriaxone
- fluid drainage
what are the 6 considerations in wound assessment
- tissue type
- wound exudate
- periwound condition
- pain level
- size
what are 4 wound tissue types
- necrotic
- infective
- granulation
- maceration
periwound area is any area that extends __ cm from the edge of the wound
4 cm
many people with wounds have __ wound sensation
poor
when documenting a wound, note the __
and __
size
depth
what does optimal wound tissue look like
beefy red granulation
escar around the edges of a wound may indicate
necrosis
what is wound maceration
lightening of skin
bumpy/wrinkled
epithelization means
tissue healing
slough is __
and must be __ for healing
remnants of WBC
debrided
where do pressure ulcers occur
areas of bony prominences → ankles, elbows, tailbone
what are the stages of pressure ulcers
1-4-unstageable
stage 1 pressure ulcer
nonblanchable erythema of intact skin
stage 2 pressure ulcer
partial thickness skin loss w. exposed dermis
stage 3 pressure ulcer
full thickness w. skin loss
stage IV pressure ulcer
full thickness and tissue loss
unstageable pressure ulcer
obscure full thickness skin and tissue loss
deep tissue pressure injury
persistent, non blanchable
deep red, maroon, purple
what are 4 rf for nonhealing wounds
- smoking!!
- endocrinology problems → DM, hypothyroidism
- hematologic problems → polycythemia
- CVD issues → CVD, COPD
what is the mc location for venous ulcerations (venous stasis)
gaiter area of leg → 95%
usually medial
venous ulceration usually have __ edges
sloping
what are 5 characteristics of venous ulcerations (venous stasis)
- edema
- hemosiderin staining
- hair loss of extremity
- weeping → exudate
- itching
what are 5 rf for venous ulcerations (venous stasis)
- varicose veins
- DVT
- chronic venous insufficiency
- poor calf muscle fxn
- obesity
when should compression stockings be used for venous ulceration/stasis
if caused by edema
when should compression stockings be avoided for venous ulcerations/stasis
if arterial flow is compromised → poor pulse
what is the mc location for arterial ulcers
toes, foot, ankle
what do the edges of an arterial ulcer look like
punched out
what are 3 characteristics of arterial ulcers
- painful even w.o inflammation
- exudate rare
- edema uncommon
what are 3 rf for arterial ulcers
- PVD
- DM
- SSA
ulcer appears punched out w. well demarcated edges; pale, necrotic base; surrounding skin dusky or shiny; hairless
arterial ulcer
what is hyperemia
pinkish-red skin
what type of ulcer is caused by decreased arterial blood supply to LE, tissue hypoxemia, and damage
arterial ulcer
what are 5 tx for arterial ulcers
- restore arterial fxn if possible
- usually surgery
- medications not helpful
- wound tx
- smoking cessation
what test is useful to determine the extent of PVD
ankle brachial index (ABI)
how do you measure ABI
measure systolic bp in both brachial and then both dorsal pedis/posterior tibial arteries → then divide
what should the pt do for 10 min before ABI
rest
supine
what is nl for ABI
1.0 - 1.4
what does an ABI >4 indicate
noncompressible calcified vessel
what does an ABI <0.9 indicate
dx of PAD
what does an ABI 0.5-0.8 indicate
moderate arterial dz → refer to specialist
what does an ABI < 0.5 indicate
severe arterial dz → refer to specialist
you should refer pt to specialist if ABI is
0.8 or lower
name 3 ways that negative pressure wound therapy (wound vac) enhances healing
- reduces edema
- increases rate of granulation tissue
- stimulates circulation
wound vac is a __ system
that removes __ and
promotes __
sealed
fluid
circulation
you should not use wound vac on
infected areas
what are 4 contraindications for wound vac
- malignancy of wound → ex melanoma
- untreated osteomyelitis
- placement of dressings in contact w. exposed bv, organ, or nerve
- nonenteric or unexplained fistulas
what are 7 indications for wound vac
- chronic wounds
- acute wounds
- traumatic wounds
- partial thickness
- dehisced (open) wounds → reopened
- diabetic ulcers
- pressure ulcers
what are indications for growth factors/skin graft substitutions
small area
not much skin to use
what are 2 examples of growth factors
- apligaf
- dermagraft
what are 3 types of debridement
- enzymatic
- mechanical
- sharp
what is enzymatic debridement
chemical agents that eat away dead tissue
most enzymatic debridement agents have been
taken off market
ex Santol
why are enzymatic debridement agents harmful
can’t discern good tissue from bad tissue
what is mechanical debridement
wet to dry dressings (gauze) → applied to wound → takes away tissue when pulled off
peroxide and iodine are considered __ debridement
but can be __ to tissue
mechanical
destructive
what is sharp debridement
surgical/scalpel to remove tissue
what are 3 considerations for wound follow up
- close monitoring
- weekly visits
- careful documentation!!
