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60 Cards in this Set
- Front
- Back
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Impetigo
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-most common skin infx in kids
-Staph aureus, strep pyogenes -late summer and fall -peak incidence 2-5 -usually on: face, extremities -very contagious |
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bullous impetigo
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-staph
-lesions bullous (raised), may see satelittle lesions -thin crust |
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nonbullous impetigo
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-Strep and staph
-thick honey colored crusting -painless but very pruritic -regional adenopathy may occur -heals more slowly |
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impetigo tx
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-fewer lesions: topical; mupriocin (bactroban) 3x/day
-large numbers of lesions: oral abx to cover both staph and strep: dicloxacillin or 1st gen cephalosporin if think MRSA, Ceph 2 if think strep, TMP-SMX if MRSA -good hygiene! |
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Ecthmyma
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-like impetigo only deeper to SQ, shallow ulcers
-strep and staph -may cause scarring -treat with oral abx to cover both staph and strep |
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Folliculitis
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-pustular infx of hair follicle
-staph most common -treatment included heat, topical abx (bacitracin) -Hot tub folliculitis: pesudomonas, usually resolved spontaneously, fluoroquinolone if severe |
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Furuncle
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-extension of folliculities to SQ
-painful inflammatory nodule with an overlying pustule through which a hair emerges -warm compresses, topical abx |
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Carbuncle
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-confluence of durincles
-deeper extension, more systemic sx -usually need oral abx -if fluctuant, I&D |
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Abscesses
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-localized collection of pus, usually staph
-may be assoc with localized erythema and lymphangitis -fever rare, think deeper infx |
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abscesses etiology
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-extremities: minor trauma
-head, neck, axilla & perineum: obst of apocrine and sebaceous glands -perirectal: bacterial spread from anal cysts -vulvovaginal: obst of bartholin cysts - |
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CA-MRSA
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-outbreaks of furunculosis
-families: nasal carrier of staph -sport teams:inadequate personal hygiene, contact with furuncles/fomites -IV drug users -previous hx of MRSA -becoming prominent STI |
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presentation of CA-MRSA
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-folliculities,furuncles, "spider bite"
-may progress to form abcesses or cellulities -may also progress to necrotizing fasciitis, TSS |
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Abscesses mgmt
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-I&D, culture
-consider Xray to r/o FB -no abx needed if nml host, abscess <5cm and no surrounding cellulitis -check tetanus status -elevation, warm compresses, f/u in 24-48hrs, if no improvement consider MRSA |
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abscess tx
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1. <5cm, afebriel, otherwise healthy
-I&D -cx -warm compresses -close f/u 2. >5cm, febrile, no other co-morbidities -I&D -cx ?blood -PO abx: TMP/SMZ: 2tabs BID -warm compresses, close f/u |
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post Rx decolonization
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-Mupirocin ointment intranasally +/- under fingernails twice a day for 5 days
-Hibiclens showers q 24hrs X 3 days; then 3 times a week |
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paronychia
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-nail bitting, trauma
-staph -early infx: warm soaks and abx -I&D -Cx: MRSA -tetanus status -+/- xray: FB, >10-14 days think osteomyelitis -f/u in 24-48 hrs -ask about occupation |
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Felon
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-infx of pulp space of digits
-usually staph -pt c/o severe, throbbing pain -tense, tender pulp on exam -xray r/o osteo or FB -I&D, cx -oral abx for MSSA and MRSA -tetanus statis -close f/u in 24 hrs |
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Cellulitis
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-skin and superficial subcutaneous tissue
-S. pyogenes, S.aureus -predisposing factors: trauma, previous surgery, vascular insufficiency, lymphedema, DM, ETOH, malnutrition -erythema, not distinct demarcations, mild pain and/or tenderness, swelling warmth -most commonly in lower leg |
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cellulitis hx
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-age of pt
-onset: gradual/sudden -systemic sx: fever, chills, AMS, polyuria, polydipsia, extreme pain -precipitating event -PMH -meds: steroids, chemo, abx, antipyretics, allergies -SH |
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cellulitis PE
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-should focus on determining the depth and extent of the cellulitis
-pts appearance -VS -inspection- look b/t toes/soles -palpation:pain out of proportion to appearance of cellulitis → think ischemic tissue; remote pain → progressive infection -crepitus: subcut emphysema -ascending LAD -sensory -ROM: dec or painful suggest deep tissue involve -mental status |
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cellulitis mgmt
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-fingerstick/WBC
-cultures not indicated unless assoc abscess -xray: to r/o gas, FB, bony involvement -abx for staph and strep or guided by hx -analgesics: NSAIDs/tylenol -heat, elevation, immobilization, mark borders, dont forget ot check tetanus status! |
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cellulitis outpt therapy
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-healthy pts
-superficial infxs -abx converage for staph & strep, 10-14 days; consider CA-MRSA -mark borders -close f/u in 24-48hrs with good discharge instructions |
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cellulitis inpt mgmt
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-septic pts/signs of ascending or deep infx
-IC pts -specific types of cellulitis -oral abx treatment failure -pts unwilling or unable to comply with tx - Antibiotic therapy depends on location of cellulitis, PMH, previous antibiotics. General management principles still apply. |
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Erysipelas
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-acute superficial midface cellulitis
-now more commonly seen on extremities -s>pyogenes classically, however may also see staph aureus, CA-MRSA -when on face can lead to cavernous sinus thrombosis |
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erysipelas hx
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-intensely painful
-origin may be sinus or nasal lesion: recurrent URI/sinusitis; Peds-nasal FB -DM, venous statis, lymphedma |
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erysipelas PE
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-pt toxic appearing
-VS -sharply demarcated, raised borders |
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erysipelas tx
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-admission when midface
-CT to r/o abscess -IV abx for strep, staph, MRSA -if IC, cover for other organisms, fungus -check tetanus status |
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periorbital cellulitis
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-preseptal or postseptal
-need CT -staph, strep, H.flu, anaerobes -common in kids, IM |
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preseptal cellulitis
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-ant to orbital septum
-hx -PE: usually well appearing, eyelid swelling with erythema and warmth, -vision and pupil nml, no pain on EOM -look for nasal FB -mgmt: Ct, outpt therapy with close f/u, abx, tetanus status |
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orbital cellulitis
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-infx of orbital soft tissye
-pts ill appearing -VS -dec vision -proptosis, chemosis, injection -dec ocular motilitu with pain on EOM -ocular pain and inc ICP -dec sensation along ophthalmic and maxillary branches of CNV -CT -IV abx -ophth consult -may need I&D |
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Ludwig's angina/parapharyngeal abscess
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-cellulitis of the submandibular, sumental, sublingual space and neck
-oral flora: strep, Hflu, anaerobes, eikenella -can invade fascia and muscle -usually follows dental work or dental abscess; FBs, fish bones -very serious: elevation of tongue leads to resp distress |
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ludwings angina hx and PE
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Hx: prior dental procedure/abscess, tongue piercing
PE: -toxic appearance -dysphagia, neck pain -dysphonia -fever, tachycardia, tachypnea -boardlike swelling "bull neck" -trismis, drooping -elevation or protrusion of tonguel |
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ludwigs mgmt
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- Constant observation, cric tray at bedside, emergent ENT consult, ICU admission
- IV antibiotic coverage for strep, H flu, anaerobes, eikenella -may need operative drainage -CT |
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Necrotizing infxs
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-progressive inflamm and necrosis of the tissues, may include skin, fat, fascia or muscle
-caused by a variety of bacteria: gram positives, gram neg, anaerobes -index of suspicion: host factors: 1. compromised host 2. post-op 3. obesity 4. PVD 5. malnutrition 6. concomitant varicella |
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necrotizing infx- index of suspicion-wound factors
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1. soft tissue trauma
2. post surgical procedure 3. decubitus ulcer 4. intestinal perforation, strangulated hernias 5. perirectal abscess, phymosis. paraphymosis 6. IV injection of illegal drugs 7. devitalized, necrotic tissue 8. rapid onset/spread 9. spread despite abx tx |
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necrotizing infx most impt sx
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-pain out of proportion to the size and type of the wound/infection!!
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necrotizing infx PE
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-simple cellulitis but ill appearing pt
-pain out of proportion -to massive edema, erythema, crepitus, bronze/ecchymotic skin, blebs, gangrenous areas, anesthesia of overlying skin; unstable pt -high fever, tachycardia, tachypnea -hypotension -AMS -dec urine output |
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necrotizing infxs PE-what to do
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-undress completely
-inspect for lymphadenitis, palpate for tenderness, crepitus -sensory exam - paresthesias -ROM: pain/dec think muscle involvemet -cap refill/pulses |
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necrotizing infxs tx
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-fluid resuscitation ,resp and iontropic support
-empiric broad abx converage: Gram +, -, anaerobes, MRSa -emergent surgical consult |
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Toxic shock syndrome
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-produced by some strains of staph secondary to exotoxin production
-produced by some strains of step pyogenes -bypass macrophages and directly stimulates T cells "superantigen" |
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Fournier's gangrene
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-necrotizing subcutaneous infx of the perineum
-insidious onset -pain or itching that is rapidly followed by fever, chills & impressive perineal swelling with crepitus -pt toxic, tachypneic, tachycardiac, febrile -caused by infx or trauma to the perineal area -gram +, gram -, anaerobes -resuscitation, broad spectrum coverage, emergent surgical consultation/debridement |
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Tetanus
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-results from infx with clostridium tetani- elaborates a neurotoxin at the site of the injury
-found in soil, manure, dust, clothing, skin -most cases in nonimmunized or partially immunized people >60 -lacerations/punctures -infected chronic wounds/abscesses -burns -IVDU |
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tetanus prone injuries
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1. crush injuries
2. devitalized tissue/ischemia 3. contaminated wounds 4. wounds >24 hours old 5. deep wounds |
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tetanus immunization
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- Pts primarily immunized with full series and last Td was < 5 years - dont require booster
- Pts primarily immunized with full series and last Td was >5 years - Tetanus/diptheria/pertussis booster: Active immunity -DTap: given to infants and children to 6 yrs of age -Tdap: given to children 7 yrs of age to adults < 64 yrs of age one time booster instead of Td |
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tetanus: pts who were never immunized, or did not complete series
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- Tetanus immune globulin: passive immunity: 250 international units IM
- Also start or complete Td series: active immunity: 0.5 ml IM (Tdap for first dose, Td for subsequent) repeat booster 6 wks, 6 months |
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Bites
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-what animal caused the bite?: risk of infx, rabies, Hep B, Hep C, HIV
-when did the injury occur? -PMH including tetanus status -wound care -cosmetic concerns |
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Dog bites
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-80% of al bites
-crushing, tearing, avulsions, punctures -staph, strep, pasteurella multocida, capnocytophaga -relatively low infx rate .5-10% - Literature doesn’t support “prophylactic” abx for simple, uncomplicated bites (except hand) but in practice, everyone prescribes them for 3 to 5 days -abx prophylaxis for 3-5 days |
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dog bites mgmt
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-meticulous wound care: debridement & irrigation
-xray - ? rabies prophylaxis -+/- suturing: depends on type of bite & location, NEVER SUTURE HANDS -abx: staph, strep, pasteurella, multocida - Augmentin! -tetanus status -cultures only indicated in infected wounds -close f/u 24 hrs |
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Cat bites
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-5-15% of all bites
-deep punctures -pasteurella multocida, strep, staph -80% incidence of infx -DONT SUTURE -always get abx, even just for scrathes |
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cat bites mgmt
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-meticulous wound care: debridement if possible and irrigation
-xray -? rabies prophylaxis -don't suture! -abs: Augmentin -close f/u |
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Rabies
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-viral infx transmitted by the saliva of infected mammals
- Encephalomyelitis in host that is almost always fatal -incubation: 20-90days -bats, raccoons, skunkts, foxes -rare in rodents, rabbits - |
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Rabies postexposure prophylaxis (PEP)
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-immediate and meticulous wound care: irrigation and debridement
-passive immunity: HRIG: human rabies immune globulin -active immunity: HDCV: human diploid cell vaccine |
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Human bites
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-punctures, abrasions, avulsions
-Eikenella corrodens (anaerobes), strep, staph -Hep B and C -? HIV -meticulous wound care, abx in high risk areas: Augmentin -suturing decision case by case basis -tetanus status -PEP, Hep B, ?HIV |
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Tenosynovitis
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-acute synovial space infx
-Kanavel signs: 1. fusiform swelling of digit 2. digit help in flexed position 3. pain on passive extension 4. tenderness along course of flexor tendon |
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Clenched fist injury
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-xray: r/o fx, Fb
-meticulous wound care -no suturing -be aware of possible tendon injury! - Antibiotics: staph, strep, eikenella, anaerobes |
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tenosynovitis mgmt
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-xray
-abx: staph, strep most common -admission, hand consult, possible OR -elevation, bulky dressing -tetanus |
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rat bites
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-spirillum minus, streptobacillus monligormis
-augmentin -rabies not indicated |
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spider bites
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-Have patient bring in spider when possible
-Most cause local reaction, may abscess -Most cause local reaction, may abscess -analgesia -antihistamines |
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brown recluse spider bites
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-mainly in south central and desert SW of US
-non infectious; necrotic arachnidism -initially painles -erythematous lesion that heald days to weeks -local urticaria, N/V, rash -rest, elevation, ice packs -most pts do not have severe rxns -no lab test available to confirm |
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black widow spider
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-not infectious
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