Soft Tissue Injury By Juhina Jan 19th 2010

1. Dr. Juhaina Al-Moosawi
Mentor :
Dr. Salma Al-Mauwali

2. Introduction :
Soft tissue infection :
A group of disease that involve the skin
, S/C , fascia or muscle .
Localized / involve a large portion .
Harmless if treated / life threatening
even when appropriately treated .

3. Classification :
• Localized/ superfecial infections
 Cellulitis
 Abscess
 Impetigo
• Lethal infections
 Toxic shock syndrome
 Necrotizing fasciitis
 Myonecrosis

4. Superficial
Deep

5. Cellulitis :
A soft tissue infection of the
skin & S/C .

6. Risk Factors :
• H/O trauma
• Skin injury .
• Underlying disease
(diabetes , impaired lymphatic drainage )

7. Clinical Feature :
• Pain
• Tenderness
• Erythema
• Swelling of the involved area
• Local warmth

8. Causes :
• Streptococcus pyogenes .
• Staphylococcus aureus.

9. Diagnosis :
• Clinical manifestations .
• Fever is uncommon .
• No workup in the following criteria:
 Small area of involvement
 Minimal pain
 No systemic signs of illness
(fever, dehydration, altered mental status,
tachypnea, tachycardia, hypotension) .
 No risk factors for serious illness .

10. workup in serious cases :
• CBC
• U&E
• Blood cultures
• Aspiration of the wound
+ ve collection .

11. Imaging Studies :
• Plain XR unnecessary in
uncomplicated cases.
• Soft tissue XR or U/S :
purulent material or foreing body.
U/S guided aspiration of pus :
shorten hospital stay .

12. Immobilization
Antibiotic Elevation
Management
Analgesia
Warm packs

13. Disposition :
Cellulitis
Out patient In patient
Localized Systemic toxicity
No fever Sever infection :
Hand , feet ,head ,
Neck , perineum .
Oral antibiotic Worsen cellulitis
48-72 h .
Immunocompramised
F/U 24-48 h
Increase erythematus area
Fever Paranteral antibiotic
Systemic symptoms

14. Oral Therapy of Superficial Soft Tissue infection :
Agent Dose
Group A Streptococcus
Penicillin V ( phenoxymethylpenicillin) 250 -500 mg qid
First generation cephalosporin 250 -500 mg qid
Erythromycin 250 -500 mg qid
Azithromycin 500 mg x 1 dose
Then 250 mg qd x 4
Clarithromycin 500 mg bid
Staphylococcus aureus ( not MRSA )
Dicloxacillin 125 -500 mg qid
generation cephalosporin 250 - 500 mg qid
First 250 – 500 mg qid
Cloxacillin 250 – 500 mg qid
Erythromycin ( variable effectiveness ) Then 250 mg qd x4
Azithromycin 500 mg x 1 dose

15. Agent Dose
Clarithromycin 500 mg bid
Clindamycin 150 -450 mg qid
Amoxicillin / clavulanate 875/125 mg bid
Or 500/125 mg tid
Ciprofloxacin 500 mg bid
Haemophilus influenzae
250-500 mg tid
Amoxicillin / clavulanate 250-500 mg tid
Cefactor 160 mg TMP/800 mg
Trimethoprin (TMP)/sulfamethazone smx bid
(SMX) 500 mg x 1 dose
Azithromycin Then 250 mg qdx4
500 mg bid
Clarithromycin

16. Emergency Department Protocol for
the Management of Cellulitis , Nova
Scotia, Canad
Cellulitis :
Acute spreading inflammation
involving the soft tissue,
excluding muscle, characterized
by recent onset soft-tissue
erythema, warmth, swelling &
tenderness, considered to be of
infective origin, and acquired in
the community.
Department of Emergncy Medcine * and Pharmacy ^ Dalhousie University Halifax,
Nova Scotia, Canad
Journal of Emergency Primary Health Care (JEPHC)

17. • Excluded infected surgical wounds
or previously treated (< 3 months)
deep diabetic infections.

18. Cellulitis Grading scale :
Grade Clinical features
I  Symptoms/signs restricted to superficial swelling, erythema, warmth, mild
lymphadenopathy, & mild pain; absence of systemic symptoms in patients
without risk factors for poor outcome .
II  dominant systemic signs – fever, chills lymphangitis &/or rapidly advancing
edge.
 mild cellulitis (as defined in grade I) in high-risk, non-neutropenic, splenic
patients.
III  severe facial, perineal or extensive skin involvement (i.e. if any dimension of
the area of skin involved is greater than the distance between the patient’s
median wrist and the point of the elbow).
 failure to respond to >48 hrs of adequate oral Rx,
 a history of episodes of cellulitis requiring prolonged intravenous therapy.
IV  deep perineal, orbital, joint, or deep hand involvement.
 cellulitis in neutropenic or asplenic patients.
 suspicion of necrotizing, deep-seated infection or severe sepsis .

19. Cellulitis algorithm
Suspicion of Appropriate
Diagnosis Abscess ? surgical
Infected bite of management.
Cellulitis1 Avoid antibiotics
unless surrounding
area of cellulitis.
Use the same grading
system for disposition, but
use Table I for antibiotic Consider the possibility of
Yes
choice. necrotizing infection ?
NO
Grade I Grade II Grade III Grade IV

20. Yes
NO
Grade I Grade II Grade III Grade IV
Cephalexin 500 Initial dose of Probenecid Candidate for Immediately give
mg QID po x 7 2g po & Cefazolin 1-2g 2,3 home IV therapy4 Clindamycin 900mg IV
days or, and Ceftriaxone 2g IV
Cloxacillin 500mg Cephalexin 500 mg and IMMEDIATE
QID po x 7 days QID po x 7 days. Yes NO REFERRAL
or, Azithromycin or, Cloxacillin 500mg
500 mg po QID po x 7 days
followed by 250 or, Azithromycin
Probenecid 2g IMMEDIATE
mg/day x 4 days. 500 mg po followed by Cefazolin or
po & Cefazolin CONSULTS:
250 mg/day x 4 days. Cloxacillin I.D. for all patients
1-2g IV2,3 1-2g IV2,3
Family doctor plus:
and reliable Family doctor Necrotizing
patient/family and reliable infection– surgery,
Closely supervised Refer for Deep hand
patient/family
home therapy. infection– Plastic
admission
Yes NO Probenecid 2g po & Surg.
Yes NO Cefazolin 1g IV q24 Orbital cellulitis–
hrs. Change to P.O. Opthalmology.5
Follo Return regimen as for Grade I,
w-up to ED in
with Follow- Return to ED if Grade I features
36-48h if
FP in no up with in 24-36h if obtained for > 24 hrs.
48- improve FP in no Reassessment by FP
72h ment 24-36h improvement in 5 days.

21. probenecid
• Inhibit renal tubular
reabsorption of uric acid which
lower serum uric acid levels.
• It is recommended for patients
with gout.
• Increase & prolong the serum
level of the antibiotic.

22. Studies suggest that intravenous cefazolin 2
g and oral probenecid 2 g daily is an
effective regimen in the treatment of SSTI.
The Annals of Pharmacotherapy , 23 January 2004

23. Toxic shock syndrome
(TSS)
A shock syndrome caused by the
inflammatory response to toxins produced
by various bacteria .

24. Types of Toxic Shock
Syndrome
• Staphylococcus bacteria
(TSS).
• Group A Streptococcus bacteria
(STSS)

25. Epidemiology :
• Discovered in 1978 in 7 children aged 8-17 years who had
shock from Staphylococcus aureus .
• The peak incidence of TSS occurred in 1980 associated with
increased vaginal tampons use in menstruating women
~ 2.4 – 16 cases / 100,000 population .
• CDC reported 200 cases / year from 1994 – 2001 with a steady
increase in strep TSS & decrease in incidence of staph TSS
since highly absorbent tampons were withdrawn from the
market .
• Strept TSS was 1st described in 1987 when reported 2 cases of
shock due to isolated Step.Pyogenes .
• TSS remains as highly fatal disease with mortality rate 30%-
70%.

26. Principles of disease
Staph . aureus Strep . pyrogenic
exotoxin
toxin entertoxine SPEA SPEB
( TSST-1) B
Mononuclear Blood
cells
IL TNF
cytokines
System

27. PATHOPHYSIOLOGY TSS:
 3 phases:
1. Growth and multiplication of the
bacteria.
2. Production of the toxin.
3. Activation of the immune system.

28. PHASE 1
Menstrual blood enhances
the growth of S.aureus
by providing a growth
medium for the micro-
organism.
The tampons contain
fibres that inhibit the
lactobacilli & diminish
their ability to limit the
growth of S.aureus.

29. PHASE 2 ; TOXIN PRODUCTION
1. High protein levels
2. Neutral pH
3. High oxygen levels
• Menstrual blood increases the protein levels and provides a neutral
pH which provides excellent conditions for toxin production.
• Tampons helps in introducing oxygen into the vagina also increasing
toxin production.
• Tampons cause microtrauma and increase the risk of the exposure
of the toxins to the blood..

30. Phase 3
superantigen toxin
MHC II + T cell
polyclonal T cell activation.
• cytokine storm
• TNF, (IL)
www.AMDTelemedicine.com

31. TSS Criteria for diagnosis
Fever of 38.9 c ( 102 F) or higher .
Rash ( diffuse macular erythema )that resembles the rash of scarlet fever
Desquamation of skin 1-2 weeks after onset of disease .
Hypotension ( syst BP less than 90 mm Hg , orthostatic drop of 15 mm Hg
or more or orthostatic dysness or syncope ) .
Clinical or lab abnormalities in at least 3 organ system :
GI : Nausea , vomiting , diarrhea .
Muscular : myalgia , creatine phosphokinase x 2 times normal .
Mucous membrane : vaginal oropharyngeal , conjunctival hyperemia .
Renal : Blood urea , creat X 2 times normal level , pyuria greater than 5
cells / high power field .
Hepatic : bilirubin , serum transaminases x 2 normal level .
Hematologic : thrombocytopenia , less than 100,000/mm3 .
Neurologic : disorientation or altered consciousness without focal
findings
Reasonable evidance for the absence of other cause of illness .

32. Definition of Streptococcal Toxic
Shock Syndrom
Must meet criteria from both 1 & 2 below :
1. Isolation of group A Streptococcus from :
a. A normally sterile site such as blood or CSF is a definite cases.
b. A normally nonsteriel site such as sputum or skin lesion is a
probable case .
2. Hypotension & at least 2 of the following :
a. Renal impairment .
b. Coagulopathy .
c. Liver involvement .
d. Adult respitarory distress syndrome .
e. Generallized erythematous macular rash that may desquamate
f. Soft tissue necrosis .

33. Comparison of Staphylococcal &
Strptococcal TSS:
Feature Staphylococcal Streptococcal
Age Primarily 15-35 yr 20-50 yr
Sex Greatest in woman Either
Sever pain Rare Common
Hypotension 100% 100%
Erythroderma rash Very common Less common
Renal failure Common Common
Bacteremia Low 60%
Tissue necrosis Rare Common
Predisposing facto Tampons ,paking , Cut , burns
,Bruises ,
Varicella ,
NSAID use ?
Thrombocytopenia Common Common
Mortality rate less 3% 30%-70%

34. Risk Factors for Toxic Shock
Syndrome
Use of superabsorbent tampons .
Post operative wound infections .
Post partum period .
Nasal paking .
Common bacterial infection .
Infection with influanza A .
Infection with varicella .
Diabetes mellitus .
Human immunodeficiency virus infection .
Chronic cardiac disease .
Chronic pulmonary disease .
Nonsteroidal anti inflammatory use ( may mask symptoms rather than
be a risk factor )

35. Complication :
• ARDS .
• SHOCK .
• Gangrene .
• Disseminated
intravascular
coagulation
(DIC ).
• Renal failure

36. DXD :
• Rocky mountain spoted fever .
• Streptococcal scarlet fever .
• Staphylococcal scalded-skin syndrome .
• Kawasaki syndrome .
• Leptospirosis .
• Viral illnesses

37. Managment :
• Aggressive IV fluid resuscitation .
• O2
• Removal of source of bacteria .
• Early antibiotic :
Recommended in strept TSS
Clindamycine : 600-900 mg IV x8h
• Wound debridement .
• Hyperbaric oxygen therapy .
• Vasopressor .
• Immunoglobulin IV 400 mg/ Kg .
• Corticosteroids if pt suspected of having Adrenal insufficiency
related to underlying disease or chronic steroid use .

38. Necrotizing fasciitis
Progressive, rapidly spreading,
inflammatory infection located in
the deep fascia, with secondary
necrosis of the s/c .

40. • 1989 toxic shock syndrome and strep A
necrotizing fasciitis reported.
• The overall morbidity and mortality is 70-
80%.
• Strep NF is frequently associated with
STSS .

41. • A retrospective study showed that upper
extremity necrotizing fasciitis has a high
mortality rate.
• In their review, about 35% of patients died.
• A state of altered consciousness and respiratory
distress at initial presentation were found to
be statistically significant factors for eventual
mortality
emedicine.medscape.com Mar 25, 2009
Michael Maynor, MD, Clinical Assistant Professor, Department of
Hyperbaric/Emergency Medicine, Louisiana State University School
of Medicine

42. Types :
• Type I NF
Polymicrobial infection :
anaerobes , non-group A Strep.
• Type II NF
Monomicrobial infection :
group A beta hemolytic Strep

43. Clinical Features :
Stages of NF progression
• I (Early)
Erythematus /warmth
Tenderness
Edema
Fever

44. • II (Intermediate)
• Bullae formation
• Necrotic patches
• Oozing

45. • III (Late)
Crepitus
Skin anesthesia
Sever systemic reaction .

46. Risk factor :
• Surgical procedures
• ( intraperitoneal infections and
drainage perianal abscesses ).
• IM injections and IV infusions .
• Insect bites .
• Local ischemia and hypoxia
(e.g., diabetes).
• Alcoholics.
• NSAIDs .

47. Diagnosis :
• CBC
• U&E
• Ca
• Blood c/s : +ve in GAS
• Deep sample biopsy
• Local XR : presence of
gas
• MRI differentiated
between acute cellulitis
from NF .

48. A risk score retrospectively devised in six
common laboratory parameters :
• CRP ≥150 mg/L (4 points) .
• WBC 15,000 to 25,000/microL (1 point) or
>25,000/microL (2 points) .
• HGB 11.0 to 13.5 g/dL (1 point) or ≤11 g/dL (2 points) .
• Na < 135 meq/L (2 points) .
• Creatinine > 1.6 mg/dL (141 mmol/L) (2 points).
• Serum glucose > 180 mg/dL (10mmol/L) (1point).
Uptodate 2009

49. • A total score ≥6 should raise the suspicion
for necrotizing fasciitis ( 7-10%).
• score ≥8 was highly predictive (>75 %).
• The score is only useful when severe soft
tissue infection is strongly suspected.

50. Mangmnat :
• Surgical debridement .
• fluid resuscitation .
• Antibiotic therapy :
Type I :
• ampicillin + clindamycin / metronidazole.
Type II :
• Clindamycin + penicillin .
Uptodate 2009

51. Conclusion:
Rapid identification and rapid
treatment is essential for
recovery from aggressive
disease.