An approximately 40 year-old male with a history of aortic stenosis s/p mechanical aortic valve replacement (on Coumadin) as well as hypertension presented to the emergency department with a chief complaint of severe headache. The patient was in severe distress on arrival and was unable to provide detailed history, he complained of two days of severe left-sided headache while clutching his head and groaning. Examination was notable for sensory localization with directed movements of right hemibody, and no apparent response on the left. He was taken to emergently for CT head non-contrast.
CT Head non-contrast
57 mm right posterior parenchymal hemorrhage with intraventricular component. Moderate edema, mass effect and 9 mm of midline shift.
Admission INR was 2.9, the patient received 25 units/kg of PCC as well as vitamin K 10mg IV x1. Neurosurgery was consulted and the patient was taken to the operating room for management.
Management of Supratherapeutic INR and Complications of Anti-Coagulation
- Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s
34F with no reported medical history BIBA with severe burns after house fire with estimated 70% TBSA involvement. On arrival, the patient was hypoxic, striderous, and unable to provide history. She was intubated for airway protection with some difficulty. Examination revealed deep partial and full-thickness burns to 70% of total body surface area including circumferential burns to bilateral upper extremities and extensive neck and anterior chest involvement. Initial fluid resuscitation and warming measures were instituted. Emergent bedside bronchoscopy revealed copious carbonaceous material throughout with attempts at lavage. Urine output was minimal despite aggressive resuscitation. Critical care transport to local burn facility was arranged where the patient ultimately expired.
Algorithm for the Management of Severe Burns
Assessment of Burn Depth
|Blisters, moist, red
|Painful to temperature/air
Flame, oil, grease
|Blisters, waxy dry, white/red
Flame, steam, oil, grease, chemical, electrical
|Waxy white, leathery grey, black
Estimating Burn Surface Area
Image from UWHealth.org
- Trunk: 18% anterior, 18% posterior
- Lower extremity (each): 9% anterior, 9% posterior
- Upper extremity (each): 9%
- Head/neck: 9%
- Perineum: 1%
Burn Transfer Criteria
- Partial thickness > 20% TBSA
- Partial thickness > 10% TBSA for extremes of age (<10 or >50 years-old)
- Any full-thickness
- Burns involving face, hands, feet, genitalia, major joints
- Inhalation injury
- Medical comorbidities impacting management/healing
- Monafo WW. Initial management of burns. N Engl J Med. 1996;335(21):1581–1586. doi:10.1056/NEJM199611213352108.
- Hettiaratchy S, Papini R. Initial management of a major burn: I–overview. BMJ. 2004;328(7455):1555–1557. doi:10.1136/bmj.328.7455.1555.
- Singer AJ, Della-Giustina D. Thermal Burns: Rapid Assessment and Treatment. Emergency Medicine Practice; 2000.
- Rice, PL. Emergency care of moderate and severe thermal burns in adults. In: UpToDate, Moreira ME (Ed), UpToDate, Waltham, MA. (Accessed on March 29, 2016)
- Gauglitz, GG. Overview of the management of the severely burned patient. In: UpToDate, Jeschke MG (Ed), UpToDate, Waltham, MA. (Accessed on March 29, 2016)
40 year-old male with a history of diabetes presents with right foot pain and swelling. His symptoms began 3 days ago with pain on the lateral surface of his right foot, described as aching, non-radiating and exacerbated with walking. Yesterday, he noted more prominent swelling and redness involving 4th and 5th toes. He denies trauma, fevers, and discharge.
- Diabetes mellitus, diagnosed 8yrs ago
- Lives with wife and 2 children and works an office job.
- Ten year history of tobacco use, quit 3 years ago.
- No EtOH or drug abuse.
- Metformin 500mg p.o. b.i.d.
- Ibuprofen p.r.n. joint pain
||Obese male, pleasant and in no acute distress, lying in bed with right foot raised.
||PERRL, EOMI, dry mucous membranes.
||RRR, normal S1/S2, no extra heart sounds, no murmurs.
||Right lower extremity with 8x8cm area of erythema predominantly involving lateral aspect of foot, dorsum of foot and 3-5th digits. There is a shallow, 1x1cm ulcer on the plantar surface of foot near 5th MTP. Area is also notable for ecchymosis and palpable crepitus. There is minimal tenderness to palpation or with active/passive range of motion.
||The remainder of the skin exam is unremarkable.
- BMP: 134/4.3/104/26/18/1.4/206
- WBC: 27.3/13.1/40/189 (90% neutrophils)
- Lactate: 1.2
- CRP: [pending]
- Calf cellulitis and gas-producing cellulitis in the lateral foot and toes.
- Thigh and inguinal lymphadenopathy.
- Although gas is seen down to the level of the bone, no definite bony changes are identified to establish a diagnosis of osteomyelitis. Please note that MRI is more sensitive for detection of early osteomyelitis.
40M with DM and diabetic foot ulcer resulting in a necrotizing soft tissue infection as evidenced by gas on imaging. Recommended surgical debridement and started on broad-spectrum antibiotics including:
- vancomycin 1g i.v. q.12.h.
- cefepime 2g i.v. q.8.h.
- metronidazole 500mg i.v. q.8.h.
The patient underwent amputation of 3-5th digits with good surgical margins and was discharged on post-operative day three in good condition.
Skin and soft-tissue layers and their infections: 1
Necrotizing Soft-Tissue Infections (NSTI):2,3,4
- Comorbid conditions
- Early (non-specific)
- Late (non-sensitive)
- Tense edema outside affected skin perimeter
- Disproportionate pain
- Systemic signs (fever, tachycardia, hypotension)
- Surgical debridement
- Carbapenem, combination B-lactam B-lactamase
- Vancomycin, linezolid (MRSA coverage)
- Clindamycin (inhibit protein synthesis)
- Supportive therapy
LRINEC score 5
<5 Low risk, 6-7 Intermediate risk, >8 High risk
- Morchi, R. (2/18/14). Emergency Medicine Procedures Cadaver Lab. Clinical Clerkship at UCLA. Los Angeles, CA.
- Goldstein, E. J. C., Anaya, D. A., & Dellinger, E. P. (2007). Necrotizing Soft-Tissue Infection: Diagnosis and Management. Clinical infectious diseases, 44(5), 705–710. doi:10.1086/511638
- Headley, A. J. (2003). Necrotizing soft tissue infections: a primary care review. American family physician, 68(2), 323–328.
- McHenry, C. R., Piotrowski, J. J., Petrinic, D., & Malangoni, M. A. (1995). Determinants of mortality for necrotizing soft-tissue infections. Annals of surgery, 221(5), 558–63.
- Wong, C.-H., Khin, L.-W., Heng, K.-S., Tan, K.-C., & Low, C.-O. (2004). The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Critical Care Medicine, 32(7), 1535–1541. doi:10.1097/01.CCM.0000129486.35458.7D
14 year-old female, previously healthy, brought in by ambulance s/p auto vs. pedestrian.
Incident unwitnessed, paramedics report no LOC with GCS 15 at scene. GCS 10 upon arrival to ED, with 2min GTC seizure. Patient intubated for airway protection and CT head showed non-displaced frontal bone fracture and small frontal SAH. Patient self-extubated, returned to baseline mental status and was transferred to PICU.
- VS: 128/76mmHg, 120bpm, 22 R/min, 100% RA, 37.6°C
- General: Alert and responsive young female with multiple bandages on extremities
- HEENT: Right frontal hematoma, no bony defect palpated, multiple facial abrasions, no otorrhea, no rhinorrhea, TM clear b/l, no other ecchymosis.
- CV: RRR, normal S1/S2, no M/R/G
- Lungs: CTAB
- Abdomen: +BS, soft, NT/ND, no rebound/guarding, no flank ecchymoses
- Neuro: AAOx3, CN II-XII intact, sensation/motor/reflexes symmetric and intact.
- Extremities: Well-perfused with good pulses, no focal bony tenderness, no joint effusions, multiple abrasions on extensor surfaces of all four extremities.
Assessment & Plan:
14yo female, previously healthy, s/p auto vs. peds followed by GTC seizure and CT head showing small SAH and non-displaced frontal bone skull fracture. No evidence of basilar skull fracture on examination or imaging. Seizure likely 2/2 irritation from SAH. Patient was followed closely in PICU with q1h neuro checks with low threshold for repeat CT if change in mental status or more seizures occurred. The patient was eventually transferred to the general ward and was discharged with neurology follow-up and Keppra for seizure prophylaxis for 6mo.
Types of Skull Fractures: