Rosen & Barkin's 5-Minute Emergency Medicine Consult (474 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

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Imaging
  • Lateral neck radiograph to evaluate soft tissue injury and detect foreign bodies
  • Chest radiograph to detect hemopneumothorax, mediastinal air
  • Zone I:
    • Angiography: Gold standard to evaluate vessel injury, invasive
    • Helical CT angiography: Speed, noninvasive
      • Aware of streak artifact from shoulder, poor view of subclavian vessels
    • Esophagram with water soluble contrast or dilute barium:
      • Low sensitivity
      • Combine with esophagoscopy to exclude injury.
      • Indications: Wound approaches/crosses midline, SC air
  • Zone II:
    • Asymptomatic: Observation
    • Symptomatic: OR
  • Zone III:
    • Symptomatic: Angiography or CT angiogram
Diagnostic Procedures/Surgery
  • Bronchoscopy can be helpful in evaluating tracheal injury.
  • Surgical consult for all wounds that penetrate platysma muscle
    • Surgical exploration:
      • Expanding or pulsatile hematoma
      • Active bleeding
      • Absence of peripheral pulses
      • Hemoptysis
      • Horner's syndrome
      • Bruit
      • SC emphysema
      • Respiratory distress
      • Air bubbling through wound
DIFFERENTIAL DIAGNOSIS
  • Peripheral or CNS injury
  • Cervical spine injury
  • Associated head or thoracic trauma
TREATMENT
PRE HOSPITAL
  • Frequent suctioning to clear airway of blood, secretions, or vomitus
  • 2 large-bore IVs
  • High-flow O
    2
    should be provided
  • BVM should be avoided for potential distortion of neck anatomy and airway compromise due to forced air through tracheolaryngeal wound into tissues
  • Airway must be vigilantly monitored, as edema or expanding hematoma can progress to airway compromise.
  • Indications for early oral intubation:
    • Clinical signs of respiratory distress
    • Stridor
    • Air hunger
    • Labored breathing
    • Expanding neck hematoma
  • Nasotracheal intubation has not been proven to worsen penetrating wounds
ALERT
  • Occlusive dressings should be applied to lacerations over major veins to prevent air embolism.
  • Cervical spine immobilization in the absence of focal neurologic deficits is not indicated
    • Blocks direct visualization/palpation of neck; increases likelihood of missing life-threatening signs
INITIAL STABILIZATION/THERAPY
  • Emergent intubation is indicated:
    • Patients who are in respiratory distress or comatose.
    • Be aware of voice change or odynophagia
    • Patients who are stable without evidence of respiratory distress may be managed aggressively with prophylactic intubation or observed closely with airway equipment at bedside.
    • Orotracheal intubation with rapid-sequence induction is method of choice for securing airway in penetrating neck trauma.
    • Blind nasotracheal intubation is contraindicated with apnea, severe facial injury, or airway distortion.
    • Fiberoptic bronchoscopic intubation is advantageous as patient may stay awake, allows direct visualization of vocal cords and injuries.
    • Percutaneous transtracheal ventilation may be useful when oral or nasotracheal intubation fails:
      • This is contraindicated in cases of upper airway obstruction.
      • May cause barotrauma
    • Cricothyroidotomy contraindicated if significant hematoma overlying cricothyroid membrane
      • Tracheostomy is warranted in this setting
    • Breathing:
    • Zone I injury can cause pneumothorax or subclavian vein injury and hemothorax:
      • May require needle decompression and tube thoracostomy
  • Circulation:
    • External hemorrhage:
      • Control with direct pressure.
      • If failed, insert and inflate Foley catheter balloon within wound to tamponade bleeding
      • Blind clamping of vessels is contraindicated owing to risk of further neurovascular injury.
    • Uncontrolled bleeding or hemodynamic instability: Send directly to OR.
    • After intubation, throat can be packed with heavy gauze to tamponade bleeding.
    • Hemothorax: Tube thoracostomy
ED TREATMENT/PROCEDURES
  • Nasogastric tube should
    not
    be placed because of risk of rupturing pharyngeal hematoma.
  • Prophylactic antibiotics are recommended (cefoxitin, clindamycin, penicillin G + metronidazole).
  • Tetanus prophylaxis
MEDICATION
  • Cefoxitin: 2 g (peds: 80–160 mg/kg/d div. q6h) IV q8h
    or
  • Clindamycin: 600–900 mg (peds: 25–40 mg/kg/d div. q6–8h) IV q8h
    or
  • Penicillin G: 2.4 million U/d (peds: 150,000–250,000 U/kg/d) IV q4–6h, + metronidazole
  • Metronidazole: 1 g load, then 500 mg (peds: 30 mg/kg/d div. q12h) IV q6h
IN PATIENT CONSIDERATIONS
Admission Criteria
  • All patients with penetrating neck trauma should be admitted and observed for at least 24 hr.
  • Observation must take place in facility capable of providing definitive surgical care.
  • Patients with injuries suggesting airway or vascular injury must be admitted to ICU.
Discharge Criteria
  • Asymptomatic patients who have negative studies may be discharged after 24 hr of observation.
  • Patients with wounds superficial to the platysma may be discharged directly from the ED
PEARLS AND PITFALLS
  • Failure to anticipate difficulties in airway management
  • Failure to recognize impending airway compromise
ADDITIONAL READING
  • Múnera F, Cohn S, Rivas LA. Penetrating injuries of the neck: Use of helical computed tomographic angiography.
    J Trauma
    . 2005;58(2):413–418.
  • Ramasamy A, Midwinter M, Mahoney P, et al. Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma.
    Injury
    . 2009;40(12):1342–1345.
  • Tisherman SA, Bokhari F, Collier B, et al. Clinical practice guideline: Penetrating zone II neck trauma.
    J Trauma
    . 2008;64(5):1392–1405.
  • Woo K, Magner DP, Wilson MT, et al. CT angiography in penetrating neck trauma reduces the need for operative neck exploration.
    Am Surg
    . 2005;71(9):754–758.
  • Wolfson AB.
    Harwood-Nuss’ Clinical Practice of Emergency Medicine
    . Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
CODES
ICD9
  • 874.01 Open wound of larynx, without mention of complication
  • 874.8 Open wound of other and unspecified parts of neck, without mention of complication
  • 874.9 Open wound of other and unspecified parts of neck, complicated
ICD10
  • S11.011A Laceration without foreign body of larynx, initial encounter
  • S11.81XA Laceration w/o foreign body of oth part of neck, init encntr
  • S11.90XA Unsp open wound of unspecified part of neck, init encntr
NECROTIZING SOFT TISSUE INFECTIONS
Adam Z. Barkin
BASICS
DESCRIPTION
  • Necrotizing soft tissue infections (NSTI) are infections of any layer of the skin associated with necrotizing changes
    • Usually spreads rapidly along tissue planes
  • Characterized by:
    • Widespread fascial and muscle necrosis with relative sparing of the skin
    • High mortality
    • Systemic toxicity
  • Crepitant anaerobic cellulitis:
    • Necrotic soft tissue infection with abundant connective tissue gas
  • Progressive bacterial gangrene:
    • Slowly progressive erosion affecting the total thickness of skin but not involving deep fascia
  • Nonclostridial myonecrosis (synergistic necrotizing cellulitis):
    • Aggressive soft tissue infection of skin, muscle, SC tissue, and fascia
  • Fournier gangrene:
    • Mixed aerobic–anaerobic soft tissue necrotizing fasciitis of the skin of the scrotum and penis in men and the vulvar and perianal skin in women
  • Necrotizing fasciitis:
    • Progressive, rapidly spreading infection with extensive dissection and necrosis of the superficial and deep fascia
  • Accounts for 500–1,500 cases per year in US
  • Often difficult to recognize
  • Incidence increases with:
    • Age
    • Smoking
    • Chronic systemic disease:
      • Diabetes
      • Obesity
      • Peripheral vascular disease
      • Alcohol abuse
      • IV drug use
  • 24–34% mortality
  • Also high morbidity:
    • Amputations
    • Renal failure
ETIOLOGY
  • Conditions that lead to the development of NSTIs:
    • Local tissue trauma with bacterial invasion
    • Local ischemia and reduced host defenses:
      • More frequently in diabetics, alcoholics, immunosuppressed patients, IV drug users, and patients with peripheral vascular disease
  • Type I NSTI:
    • Polymicrobial
    • Anaerobic and aerobic
    • Include Fournier gangrene and Ludwig angina
    • After surgical procedures
    • Existing diabetes, peripheral vascular disease, chronic kidney disease, alcohol abuse
      • Compromised immune system
    • Represent 80% of NSTIs
    • Strep species are most common aerobes
      • Also staph, enterococci, and gram-negative rods
    • Bacteroides are most common anaerobes
  • Type II NSTI:
    • Monomicrobial
    • Typically aerobic Streptococcus
    • Often young, healthy patients
    • Most common cause of “flesh eating” disease
    • Methicillin-resistant Staphylococcus aureus (MRSA) species are becoming more common
  • Type III NSTI
    • Least common NSTI (<5%)
    • Rapidly progressive
    • Clostridial myonecrosis is an example
    • Usually following penetrating wounds or crush injuries
    • Also can be seen after black tar heroin injection, skin popping, intestinal surgery, obstetrical complications
  • Bacteria involved include:
    • Group A β
      2
      -hemolytic streptococcus (GABHS)
    • Group B streptococcus
    • Staphylococci
    • Enterococci
    • Bacillus
    • Pseudomonas
    • Escherichia coli
    • Proteus
    • Klebsiella
    • Enterobacter
    • Bacteroides
    • Pasteurella multocida
    • Clostridium sp.
    • Vibrio sp.
    • Aeromonas sp.
    • Fungi

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