Ep 109 Skin and Soft Tissue Infections – Cellulitis, Skin Abscesses and Necrotizing Fasciitis

This is EM Cases main episode podcast 109 Skin & Soft Tissue Infections - Cellulits, Skin Abscess & Necrotizing Fasciitis Myths and Misperceptions Why do EM physicians spend so little time talking about the things we see the most often? You may not be as energized for cellulitis as you are for an ED thoracotomy, but skin and soft tissue infections are encountered on nearly every shift - and you can do a lot more good for a lot more patients by recognizing and treating these common infections the right way. With a cellulitis misdiagnosis rate of up to 34%, there is definitely room for improvement. In this episode we ask Dr. Andrew Morris, ID specialist and Dr. Melanie Baimel EM specialist: How do you distinguish cellulitis from the myriad of cellulitis mimics? At what point do we consider treatment failure for cellulitis? What is the best antibiotic choice for patients who are allergic to cephalosporins? Which patients with cellulitis or skin abscess require IV antibiotics? Coverage for MRSA? What is the best and most resource wise method for analgesia before I&D of a skin abscess? What is the best method for drainage of a skin abscess? Which patients with skin abscess require a swab? Irrigation? Packing? Antibiotics? With the goal of sharpening your diagnostic skills when it comes to skin and soft tissue infections – there are lots of cellulitis mimics - and choosing wisely when it comes to treatment, we’ll be discussing best practices for management of cellulitis and skin abscesses, when to cover for MRSA, how to pick up nec fasc before it’s too late and a lot more… Podcast production, sound design & editing by Anton Helman EBM Bottom Line by Justin Morgenstern Written Summary and blog post by Alexander Hart & Shaun Mehta, edited by Anton Helman April, 2018 Cite this podcast as: Helman, A, Morris, A, Baimel, M. Skin and Soft Tissue Infections - Cellulitis, Skin Abscesses and Necrotizing Fasciitis. Emergency Medicine Cases. April, 2018. https://emergencymedicinecases.com/skin-soft-tissue-infections/. Accessed [date]. Cellulitis is a clinical diagnosis that is often misdiagnosed Cellulitis is a clinical diagnosis. There are no lab values or imaging studies that will confirm the diagnosis. The classic clinical findings of cellulitis that we learn in medical school - rubor, dolor, calor tumor - are non specific markers of inflammation which you’ll see in a variety of cellulitis mimics described below. Look for fever, streaking lymphangitis and regional lymphadenopathy which all make the diagnosis much more likely, but unfortunately are only found in a minority of patients with cellulitis. Beware of diagnostic momentum. We often see patients who have already been diagnosed with cellulitis and make the cognitive error of premature closure on alternative diagnoses. When to consider alternative diagnoses: * Very itchy rash * Bilateral rash * Not improving with antibiotics * In a risky location (inner thigh, over a joint, genitals) * Extreme pain or totally painless (think necrotizing fasciitis) * If its lasting for months on end How do you distinguish the mimics from cellulitis? Stasis dermatitis is probably the most commonly misdiagnosed, but it is usually bilateral as well as chronic, and the redness often diminshes on passive leg raise. Peripheral arterial disease can mimic cellulitis, but again, just do a passive leg raise and if the redness dimishes, it unlikely to be cellulitis. DVT and cellulitis rarely co-exist - observational studies suggest that only 1% of patients with cellulitis have a concurrent DVT. Monoarthritis such as septic arthritis/gout may have an accompanying overlying cellulitis. Examine the joint!