In addition to aggressive fluid resuscitation and urgent surgical intervention, the initiation of appropriate antimicrobial therapy is crucial in the setting of a NSTI.
Which of the following represents an appropriate antibiotic regimen for the given clinical situation?
Correct Answer: B
When a patient presents with signs and symptoms of an aggressive infection and associated systemic toxicity, concern for an aggressive NSTI must be high. In addition to intravenous fluid resuscitation and urgent surgical consultation, initiation of broad spectrum antibiotic therapy is prudent. Initial coverage with broad spectrum antibiotic therapy is recommended given that infections may be polymicrobial (Type 1 NSTI) or monomicrobial (Type 2 NSTI) in nature. Initial coverage includes vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem. Addition of Clindamycin provides antitoxin coverage should the pathogen include a toxin-producing strain of streptococcus or staphylococcus. Of the choices above, Answer B provides appropriate broad coverage, which can later be de-escalated based on culture data. Although the vignette in Answer E raises concern for Vibrio vulnificus, which would be appropriately covered with Doxycycline, it would be remiss to not empirically treat for a polymicrobial infection until further culture data are obtained.
Reference:
A 34-year-old female with a history of IV substance abuse presents to the hospital via EMS after being found down for some unknown amount of time. While in the ED, she was treated with naloxone for presumed IV heroin overdose. On further examination, she was noted to have stigmata of recent IV drug use, and her right forearm is significantly swollen with tense compartments. When asked to move her fingers she is able to do so, but reports decreased sensation over the dorsal aspect of her hand as well as significant pain in her forearm with passive range of motion of her wrist. All of the following statements regarding the diagnosis and management of acute compartment syndrome (ACS) are true EXCEPT:
Correct Answer: E
Acute compartment syndrome (ACS) of an extremity occurs when elevated pressures within a fascial compartment result in compromised circulation and muscle death. The causes of ACS of the extremity are varied, but include trauma, specifically following long bone fractures, ischemia-reperfusion injuries, thermal burns, and crush injuries, among others (Answer A). The resultant muscle necrosis and breakdown can be measured by increases in serum CK (Answer B). The diagnosis is clinical, and an early high index of suspicion is critical. Early signs and symptoms include pain out of proportion that is worsened with passive range of motion and swollen, tense compartments. Decreased sensation and muscle weakness are later findings, suggestive of nerve and muscle ischemia. The “classic findings” associated with ACS, the “five Ps” are overall inaccurate, and waiting for these symptoms before intervention will result in irreversible damage and morbidity (Answer E). Instead, diagnosis is made by performing serial physical exam and may be aided by the measurement of compartmental pressures, specifically when used to calculate extremity perfusion pressures rather than used as an absolute number (Answer C). Management involves early surgical consultation for compartmental decompression and fasciotomies (Answer D).
References:
A 20-year-old male presents with a closed fracture of his left tibia and fibula sustained while playing basketball. He undergoes splinting by Orthopedic Surgery and 3 hours later he begins to complain of pain in his distal lower extremity. His pain is worsened with passive range of motion, and he notes decreased sensation over the dorsal aspect of his foot. His pulse examination is symmetric over bilateral lower extremities but his capillary refill time is delayed.
What is the most appropriate next step in the management of this patient?
The patient above is presenting with acute compartment syndrome (ACS) of his lower extremity following a closed, traumatic fracture. Although rare, it is important to remember that these patients are at risk of developing ACS and delays in diagnosis can result in irreversible damage, morbidity, and potential limb loss. The patient above has developed increased pain hours after splinting of his lower extremity, which is not relieved by pain medication and is worsened with passive range of motion. These signs, in conjunction with his decreased sensation and prolonged capillary refill time, are all clinical signs concerning for the development of ACS. It would be inappropriate to treat his symptoms with increased doses of narcotic pain medication, which may mask his symptoms and does not address the underlying problem (Answer A). Similarly, elevating the extremity will not address the underlying problem, and although serial examinations are important for monitoring, the patient above requires more aggressive intervention to avoid irreversible damage (Answer E). Invasive measurement of compartment pressures may aid in the diagnosis when it is not clinically apparent and should not delay surgical intervention in cases where clinical suspicion is sufficiently high (Answer C). There is no role in this clinical situation for obtaining a CTA and doing so would only delay the necessary intervention (Answer D).
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