Morning Report

Chief Residents

You are working the 9p-7a ER shift Outgoing resident signs out an axillary abscess in Bed 9, ready for I & D

You go back in to take your own history

History

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One liner and plan

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To prescribe, or not to prescribe

Mixed Data
Retrospective study: 531 MRSA cases
Improved outcomes in those tx with Abx Multiple observational and retrospective studies Comparable cure rates in those +/- Abx

Treat if:

Abscess >5cm Multiple lesions Extensive surrounding cellulitis Co-morbidities Immunosuppresion Systemic signs and sxs Inadequate response to I&D

Antibiotic Selection

As you gather your supplies

Doc, I thought Id update you on your patients vitals:
HR: 158 RR: 28 BP: 93/48 Temp: 40.6 O2 Sat: 99% RA

Physical Exam
HR: 158 RR: 22 BP: 93/48 Temp: 40.6 O2 Sat: 99% RA

HEENT:

NCAT, PERRL, EOMI, bilaterally injected conjuctivae w/ purulent drainage, TMs erythematous, OP erythematous w/ bilateral tonsillar exudates

Neck: Ant and post cervical LAD CV: Tachycardic rate, no murmurs.
crackles NL s1 and s2

Resp: Tachypnic, clear breath sounds, good air movement, no wheeze, no Abd: Soft, NT/ND. No masses, no HSM, NABS GU: NL female genitalia, Tanner V Ext: R axillae: 2x2 cm boggy, erythmatous pustular lesion, +fluctuant, slightly
tender, no active drainage

Skin: Diffuse erythroderma w/ erythema on B palms, cap refil ~3 seconds,

bounding pulses in all 4 ext

Neuro: Sleepy but arousable, AO x3, delayed answer to questions but appropriate

Im waiting for orders, Doc. What is your plan?

 Randomized-Control Trial
n= 263 (Pts <17 excluded from this study)

In hospital mortality: 30% for EGT vs 46% for ST

EGT

130 Early Goal-Directed Therapy 133 Standard Thearpy

Higher central mean venous oxygen saturation

In ER:

Placement of central venous catheter Crystalloid and colloid fluids Vasoactive agents PRBC transfusion Ionotropes

Lower lactate Lower base deficit Higher pH Decreased CV collapse and

death & improve morbidity.

1. Developmental differences in hemodynamic

response

2. Activated Protein C 3. Thrombocytopenia associated multi-organ failure 4. Gemophagocytic Lymphohistiocytosis

Developmental Differences
Transitional circulation
Sepsis induced hypoxia & acidosis Increased PVR PPHN

Treatments directed at decreasing PVR

Differing presentations Children compensate for decreased CO with elevated SVR rather than increased HR Adults: Warm shock
Low SVR, Low BP Elevated HR , Children: Severe hypovolemia and cold shock High SVR (until late stages), High BP Elevated HR ,

QI project: ED protocol for recognition and management

of sepsis

Imaging
Axillary US:
A hypoechoic slightly heterogeneous collection
measures 2.5 x 2.8 x 3.0 cm in the right axilla just anterior to the axillary artery and vein. The skin is swollen superficial to the fluid collection.

Axillary Culture:
Many MSSA, pan susceptible

Putting it all together

TOXIC SHOCK SYNDROME

Epidemiology
First described 1978
1980: 817 cases reported (all menstruating F)

Menstrual Cases
Associated w/ highly absorbent and polyacrylate rayoncontaining tampons

Nonmenstrual
50% of TSS cases Post-surgical, post-partum, mastitis, septorhinoplasty,
sinusitis, osteo, arthritis, burns, abscesses.

3% mortality 30% recurrence rate in non treated cases

Nelson, 2007

5396 cases 74% associated with menstruation 91% in 1971 59% in 1996 Case-fatality rate 5.5% in 1979 1.8% in 1996

Etiology
Staph
Exotoxins
TSST-1 producing
strains of MSSA and MRSA Food poisoning SSS TSS C, D, E and H

Strep Exotoxins
M protein
Indicates virulence of
strep species

M type 1, 3, 12 and 28
associated w/ shock

A, B and C

Activate immune system by bypassing the usual antigen-mediated immune response release of large quantities of inflammatory cytokines

Diagnostic Criteria for Toxic Shock

Staph

vs.

Strep

Major (all req)

T >38.8 Hypotension Rash (erythroderma)

Major (all req)

Isolation of GAS from a sterile site Hypotension

Minor (2 or more)

Renal impairment Coagulopathy Liver involvement ARDS Erythematous macular rash Soft tissue necrosis

Minor (any 3)

MM inflammation Vomiting / Diarrhea Liver abnormalities Renal abnormalities Muscle abnormalities CNS abnormalities Thrombocytopenia

Exclusion Criteria
Absence of another explanation Neg BCx

If GAS is isolated from a nonsterile site but the patient fulfills the other criteria noted above, a probable diagnosis of GAS TSS can be made if no other etiology for the illness is identified.

Treatment
Supportive
Fluids Pressors

Antibiotics: 10-14 days

Vancomycin Clindamycin, rifampin, erythromycin, quinolones
Inhibit protein synthesis

Additional Therapies
IVIG (400 mg/kg once)
Logical therapy if theory of TSS resulting from lack of Ab
production Proven success with strep TSS, no proven success with staph TSS

Corticosterioids (10-30 mg/kg/day)

Under investigation, not recommended

Long term sequelae

Desquamation of palms and soles 1-2 wk after
onset of illness

Prolonged muscle weakness Fatigue Amputation of digits Reversible hair or nail loss

Objectives - eview management of an R abscess - eview the approach to R sepsis in the ER - Review the etiology, pathogenesis, clinical symptoms and treatment of Septic Shock

Citations
Epidemiology, clinical manifestations, and diagnosis of streptococcal toxic shock
syndrome: http://www.uptodateonline.com/online/content/topic.do? topicKey=gram_pos/5335&selectedTitle=2%7E80&source=search_result content/topic.do?topicKey=gram_pos/ 4986&selectedTitle=1%7E80&source=search_result Med 1996; 334:240.

Staphylococcal toxic shock syndrome: http://www.uptodateonline.com/online/

Bisno, AL, Stevens, DL. Streptococcal infections in skin and soft tissues. N Engl J Kliegman et al. Nelson Textbook of Pediatrics. 18th Edition Rivers et. Al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and
Septic Shock. N Engl J Med 2001; 345:19