Rosen & Barkin's 5-Minute Emergency Medicine Consult (625 page)

• Neurovascular compromise or injury requiring surgical repair
  
• Concomitant infection or necrosis
  
• Investigation of abuse and or neglect
  

Successful band removal with restoration of circulation.

Wounds at high risk for infection should have close follow-up in 1–2 days.

Return to the ED for increasing pain, numbness, tingling, redness, swelling drainage, fevers, or other changes in clinical presentation.

• Failure to completely examine the fingers, toes, and genitalia of the irritable infant
  
• The hair causing a hair tourniquet may be obscured by edema and heaped up tissue and skin.
  
• Rings must be removed early after trauma to the distal extremity.
  

• Hoffman RJ, Wang VJ, Scarfone RJ.
  Fleisher and Ludwig’s 5-minute Pediatric Emergency Medicine Consult
  . Lippincott Williams & Wilkins; 2011.
  
• O’Gorman A, Ratnapalan S. Hair tourniquet management.
  Pediatr Emerg Care.
  2011;27(3):203–204.
  
• Peckler B, Hsu CK. Tourniquet syndrome: A review of constricting band removal.
  J Emerg Med
  . 2001;20(3):253–262.
  
• Rosen P, Chan TC, Vilke GM, et al.
  Atlas of Emergency Procedures.
  St. Louis, MO: Mosby; 2001.
  
• Sung S, Hsu CK, O’Rouke K. Resident training in constricting band removal: Motorized cutting.
  Ann Emerg Med.
  2007;50(3):Sup:S76.
  

CODES

• 959.5 Finger injury
  
• 959.7 Knee, leg, ankle, and foot injury
  

BASICS

Rickettsial invasion of small blood vessels:

• Causes direct vascular damage
  
• Superimposed additional vascular damage/vasculitis due to immunologic phenomena
  

• Acute infection by
  Rickettsia rickettsii
  via tick vector:
  
  • Dermacentor andersoni
    (wood tick) in the western states
    
  • Dermacentor variabilis
    (dog tick) in the eastern states
    
• Reported in all states; 1/2 of cases occur in 5 states (NC, SC, TN, OK, AR), as well as parts of Central America and South America
  
• More common April–September, but can occur any month
  
• More common in males and in individuals 40–64 yr of age
  

DIAGNOSIS

• Tick bite reported within 14 days of rash in 60% of patients
  
• Incubation varies 2–14 days with median 7 days
  
• Exposure to ticks, often in rural environment
  

• Rash:
  
  • Initial rash (3–5 days)
    
    • Macular, red, and flat
      
    • Blanches under pressure
      
    • 1–4 mm diameter
      
  • In hours to days:
    
    • Becomes darker, papular, dusky, and palpable
      
  • In 2–3 days:
    
    • Petechial or purpuric
      
    • Positive Rumpel–Leede test
      
    • May coalesce or ulcerate
      
  • In severe disease, necrosis of dependent peripheral parts may occur.
    
  • Location:
    
    • Begins in flexor surfaces of wrist and ankles, rapidly spreading to palms and soles
      
    • Spreads centripetally involving extremities; may involve trunk and face
      
    • 15% with centrifugal spread to palms and soles
      
    • 10% of patients do not have rash
      
    • Often not identified when patient initially presents for care
      
• Pulmonary:
  
  • Nonproductive cough
    
  • Chest pain
    
  • Dyspnea
    
  • Rales
    
• GI:
  
  • Often associated with fatal Rocky Mountain spotted fever
    
  • Secondary to vasculitis
    
  • Nausea/vomiting
    
  • Abdominal pain/distention
    
  • Ileus
    
  • Hepatosplenomegaly
    
• Neurologic:
  
  • Focal or generalized neurologic manifestation in 2/3
    
  • Meningismus
    
  • Severe, unremitting headache
    
  • Encephalitis
    
• Other:
  
  • Generalized edema
    
  • Dehydration
    
  • Malaise
    
  • Myalgia
    
  • Retinal hemorrhage and conjunctivitis
    
• Complications:
  
  • Disseminated intravascular coagulation (DIC)
    
  • Noncardiogenic pulmonary edema
    
  • Acute renal failure
    
  • Severe or fatal in advanced age, male sex, African American, chronic alcohol abuse, glucose-6-phosphate dehydrogenase deficiency
    

Clinical diagnosis supplemented by confirmatory lab findings such as hyponatremia, anemia, and thrombocytopenia

• Serology:
  
  • Diagnose by single titer >1:64 or 4-fold increase. Antibody may not be detected in the 1st few days of symptoms
    
  • Methods:
    
    • Immunofluorescent antibody (sensitivity of 95%)
      
    • Complement fixation
      
    • Indirect hemagglutination test
      
    • Indirect immunofluorescence assay is reference standard.
      
• CBC:
  
  • Normal WBC count
    
  • Thrombocytopenia
    
  • Anemia
    
• Electrolytes, BUN/creatinine, glucose:
  
  • Hyponatremia <130 mEq/L
    
• Liver profile:
  
  • Elevated aspartate aminotransferase
    
  • Lactate dehydrogenase
    
• Arterial blood gas for:
  
  • Hypoxia
    
  • Respiratory alkalosis
    
• Coagulation profile if DIC suspected
  
• Microbiology:
  
  • Immunohistologic antibody stain of skin biopsy
    
  • Isolation of
    R. rickettsii
    (time-consuming/ expensive)
    
  • Polymerase chain reaction assay
    
• CSF:
  
  • Pleocytosis and increased protein
    

• Chest radiograph for pulmonary edema, pneumonia
  
• Echocardiography:
  
  • Decreased left ventricular contractility
    

Skin biopsy may be confirmatory if immunohistologic antibody studies available.

• Other tick-borne diseases:
  
  • Ehrlichiosis: Older adults
    
  • Relapsing fever
    
  • Lyme disease: Erythema chronicum migrans
    
  • Tularemia
    
  • Babesiosis
    
  • Colorado tick fever
    
• Infectious diseases:
  
  • Meningococcemia—late winter, early spring; maculopapular or petechial rash
    
  • Measles—late winter, early spring; severe prodrome
    
  • Rubella—palms and soles spared
    
  • Varicella—does not have rash in extremities
    
  • Viral exanthem
    
  • Infectious mononucleosis—palms and soles spared
    
  • Disseminated gonococcal infection—pustular lesions
    
  • Typhus—rash starts at trunk with centrifugal spread
    
  • Secondary syphilis
    
  • Scarlet fever
    
  • Kawasaki disease—red, cracked lips
    
  • Toxic shock syndrome
    
  • Gastroenteritis
    
  • Staphylococcal sepsis
    
• Inflammatory causes:
  
  • Allergic vasculitis
    
  • Thrombotic thrombocytopenic purpura
    
  • Collagen vascular disease
    
  • Juvenile rheumatoid arthritis
    
• Heat illness
  

TREATMENT

Stabilize as appropriate

• ABC management
  
• 0.9% NS IV fluid bolus for dehydration
  
• Oxygen for hypoxia
  

• Correct fluid and electrolyte deficits.
  
• Initiate antibiotic therapy immediately based on clinical and epidemiologic findings. Should not be delayed until lab confirmation is obtained:
  
  • Doxycycline—drug of choice
    
  • Chloramphenicol in pregnant and allergic patients
    
  • Sulfonamides make infection worse.
    
• Administer acetaminophen for fever.
  
• Consider high-dose steroids for severe cases complicated by extensive vasculitis, encephalitis, or cerebral edema (controversial).
  
• Better outcome in children if treatment begins before day 5 of illness
  
• Treat complications:
  
  • DIC
    
  • Adult respiratory distress syndrome
    
  • CHF
    
• Medication