POTD: High-Pressure Injection Injury

High-Pressure Injection Injury

·      Patients present with seemingly innocuous findings after high-pressure injection injury

·      Their condition often rapidly deteriorate

·      Substances can be paint, paint stripper, grease, oil, water or air.

·      This is a surgical emergency and early consultation is critical for surgical decompression and debridement

·      Less viscous substances can penetrate deeper with less pressure, leading to worsened outcomes, even if initially the wound may appear benign on the exterior, and even if the patient’s pain is initially minimal

·      Paint and paint thinners produce a large and early inflammatory response leading to ischemia and tissue death and the rate of associated amputation is high.

·      Initial emergency department management:

o   pain control, radiographs (look for free air), elevation, splinting, IV antibiotics, tdap, emergent hand specialist consultation

o   These injuries are not high-risk injuries for tetanus, and prophylaxis, even if indicated, therefore tdap should not delay other steps in management.

o   In fact, none of the emergency department interventions, (besides pain control), is as important as recognition of the potential severity of the injury and early consultation with a hand specialist

o   There is no amount of cleansing this wound in the ED that is recommended because the penetration is deep and this patient needs to go to the OR.

·      It is interesting to note that although digital blocks are excellent tools to relieve pain and provide anesthesia, they are not recommended in high-pressure injection injury as one of our major concerns is compartment syndrome.

o   Digital blocks can lead to an increase in compartment pressure and worsen injury/tissue ischemia. Systemic pain control is recommended.

The below picture is of a hand in the OR, you can see the initial presentation appears someone benign and once the hand is opened up, you see a lot of tissue necrosis.

Below pictures show benign physical exam findings and some free air on xray

Sources: Tintinalli, Rosen's Emergency Medicine, uptodate, Peer IX, ortho blog for photos: http://www.cmcedmasters.com/ortho-blog/high-pressure-injection-injuries

POTD: Varicella-zoster virus (VZV)

Noticing the trend in decreased vaccination, let’s review varicella.

• Varicella-zoster virus (VZV): one of eight herpesviruses known to cause human infection

• full-body rash that starts on the trunk and is characterized by lesions in various stages of development.

  • Buzz words: asynchronous vesicular lesions

·      Requires airborne precautions

·      Chickenpox used to be very common in the United States.

o    Each year, chickenpox caused about 4 million cases, about 10,600 hospitalizations and 100 to 150 deaths.

·      Two doses of the vaccine are about 90% effective at preventing chickenpox.

·      Although varicella is usually a self-limited disease and usually management is supportive

o   Exception to this is if you are at risk for complication or develop complications. 

·      Who is most at risk for complications from varicella?

o   Older patients, pregnant patients, and anyone who is immunocompromised (think on chronic steroids or immunosuppressants who are not vaccinated).

·      Complications: hepatitis, pneumonia, superimposed cellulitis, meningitis and encephalitis

·      Pneumonia is more frequent complication in these at risk populations (especially pregnant patients) who develop varicella.

·      Severe complications of varicella pneumonia in pregnant patients: development of congenital varicella syndrome in the baby and, if the mother develops varicella rash right before or after delivery, risk for neonatal varicella.

·      When associated with pregnancy, varicella pneumonia is the leading cause of varicella-related illness and death in adults, with a reported maternal mortality rate of up to 44%.

·      Patients with severe varicella disease should be admitted and treated with intravenous acyclovir.

o   Special attention to airway monitoring

·      When do we give Varicella-zoster immune globulin (VZIG)?

o   VZIG is indicated for prophylaxis in susceptible pregnant women who have been exposed to the varicella-zoster virus.

o   The primary purpose of VZIG prophylaxis is to prevent or attenuate maternal disease.

·      PO acyclovir for those cases that are not severe and can be managed with close outpatient follow up

Sources:

https://www.cdc.gov/vaccines/vpd/varicella/index.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155623/

Peer IX

Uptodate: varicella: https://www.uptodate.com/contents/treatment-of-varicella-chickenpox-infection

POTD: Trauma Tuesday. Blunt Abdominal Trauma: What's the injury?

Let’s start with a case:

19 year-old Male presents after MVC as unrestrained driver in head on collision. He appears tachypneic and is noted to have decreased breath sounds on his left side. Just as the Trauma Team is prepping for a chest tube, POCUS shows +lung sliding at the apex and something that looks strange at the bases…

What does this patient have?

·      Diaphragmatic rupture with herniation of the abdominal contents into the thoracic cavity

·      Pathophysiology? Blunt trauma causes compression of the abdominal cavity and the pressure gradient between the thoracic and abdominal cavities

o   Previously thought to be more common on left side due to absence of liver

• No longer true! more or less the same frequency

• Right sided injury with greater mortality

  • d/t force required for injury is higher

  • more delay in diagnosis

o   Proceed cautiously if considering chest tube placement in these patients to avoid visceral injury from the chest tube

• Keep in mind that ptx is more common

·      Can lead to respiratory distress and the degree of his respiratory distress is related:

• o    size of the diaphragmatic tear

• o   amount of abdominal viscera that is herniated

·      The mortality rate higher with blunt trauma than penetrating trauma because blunt diaphragmatic injury tends to lead to larger defects.

·      If the injury is large enough, it can be detected on cxr

·      CT scan can help identify these injuries when they are not visible on chest xray

·      Small injuries are notoriously very difficulty to detect

• Patients can even present from weeks to months to years later with symptoms from a previously undiagnosed injury

·      Complications

o   tension gastrothorax, visceral ischemia, perforated viscus

Sources:

ACEP Clinical Policy on acute blunt abdominal trauma

Tintinellis

Peer IX

Cxr from: https://www.semanticscholar.org/paper/Blunt-diaphragmatic-rupture%3A-four-year%E2%80%99s-experience-Matsevych/35f84bfd12f4633dcb29539464a67e9cca51bd29/figure/3