Abscess, Skin/Soft Tissue

Abscess, Skin/Soft Tissue

Description

• A localized collection of pus surrounded and walled off by inflamed tissue
• The collection may be classified as bacterial or sterile:
• Bacterial: most abscesses are bacterial with the microbiology reflective of the microflora of the involved body part.
• Sterile: more associated with intravenous drug abuse and injection of chemical irritants

Pathophysiology

Microbiology is related to abscess type:

• Dog/cat bites:
• Pasteurella species/anaerobes
• Usually polymicrobial
• Capnocytophaga canimorsus:
• Gram-negative rod associated with severe sepsis from dog bites
• Immunocompromised patients
• 25% mortality
• Orbital:
• Associated with paranasal sinusitis, hematogenous spread, or local skin trauma
• Organisms include staphylococci, streptococci, Haemophilus influenza, Escherichia coli.
• May be polymicrobial
• Breast: dependent on type of abscess:
• Puerperal:
• Classically occurs during lactation
• Located in peripheral wedge
• Caused by staphylococci
• Duct ectasia:
• Caused by ectatic ducts
• Periareolar location
• Caused by several organisms (polymicrobial), with a mix of staphylococci, anaerobic streptococci, bacteroids, and enterococci
• Hidradenitis suppurativa:
• Chronic abscesses of apocrine sweat glands:
• Groin and axilla
• Staphylococcus aureus and Staphylococcus viridans common pathogens
• E. coli and Proteus species may be present in chronic disease.
• Pilonidal abscess:
• Caused by epithelial disruption of gluteal fold over coccyx
• Staphylococcal species most common
• May be polymicrobial with bacteroides and E. coli
• Bartholin abscess:
• Obstruction of Bartholin duct
• Mixed vaginal flora
• May include Neisseria gonorrhoeae, Chlamydia trachomatis, and E. coli
• Perirectal:
• Originates in anal crypts and extends through ischiorectal space
• Inflammatory bowel disease and diabetes are major predisposing factors.
• Bacteroides fragilis and E. coli most common pathogens
• Requires treatment in operating room
• Muscle (pyomyositis):
• Typically occurs in tropics
• Increasingly common in patients with human immunodeficiency virus or diabetes
• S. aureus most common
• Intravenous drug abuse:
• Most common pathogens staphylococcal species, Streptococcus milleri, and anaerobes
• Methicillin-resistant S. aureus (MRSA) common
• Isolates often oral origin
• May be sterile
• Furuncle:
• Arises from infected hair follicle
• Most common on back, axilla, and lower extremities
• Staphylococcal species most common
• Community-acquired MRSA increasingly common
• Carbuncle:
• Larger and more extensive than furuncle
• Often multiple in honeycomb pattern on back of neck
• More common in diabetics
• Usually caused by staphylococci
• Community-acquired MRSA increasingly common
• Paronychia:
• Infection surrounding the nail fold
• Usually caused by S. aureus
• Felon:
• Closed-space abscess in distal pulp of finger
• Usually caused by S. aureus

Etiology

Conditions associated with soft-tissue abscess formation include the following:

• Soft-tissue trauma
• Mammalian bites
• Bacteremia with hematogenous seeding
• Obstruction of normal drainage (i.e., sweat glands)
• Tissue ischemia
• Intravenous drug use
• Endocarditis
• Lactation disease
• Crohn disease

Diagnosis

Signs and Symptoms

• Local:
• Erythema, tenderness, pain, heat, swelling, fluctuance
• Systemic:
• Ranges from absent to fever, rigors, hypotension, and altered mentation
• Regional lymphadenopathy and lymphangitis may occur.
• May be associated with surrounding cellulitis

Essential Workup

• History and physical examination:
• Identify subcutaneous air and involvement of deeper structures.
• Gram stain unnecessary for simple abscesses in healthy patients
• Wound cultures:
• Not indicated in simple abscesses unless MRSA is a consideration
• May help differentiate aerobic from anaerobic infections
• May be useful in confirming community-acquired MRSA in patients with recurrent abscesses
• May guide specific therapy in a compromised host, abscesses of the central face or hand, and treatment failures

Tests

Lab

• Glucose determination is a useful screening test for diabetics.
• CK if myositis suspected
• Blood cultures indicated if endocarditis is suspected or patient is systemically ill

Imaging

• Plain films may reveal gas in tissue planes.
• Ultrasound, CT, or MRI helpful when diagnosis is in question

Differential Diagnosis

• Cellulitis
• Aneurysm (especially with intravenous drug abusers)
• Cysts
• Hematoma

Treatment

Pre Hospital

Caution: septic patients may require rapid transport with intravenous access and volume resuscitation.

Pediatric Considerations

Incision and drainage are painful procedures that often require procedural sedation and analgesia.

Initial Stabilization

Septic patient:

• Immediate intravenous access
• Oxygen
• Crystalloid volume resuscitation
• Central venous pressure monitoring
• Mixed venous sampling
• Blood cultures
• Early antibiotic therapy

ED Treatment

• Incision and drainage are the mainstays of treatment.
• Antibiotics are indicated for the following conditions:
• Sepsis
• Systemic illness
• Endocarditis
• Facial abscesses drained into the cavernous sinus
• Concurrent cellulitis (see Medication)
• Mammalian bites
• Immunocompromised hosts

Medication (Drugs)

• Augmentin (particularly mammalian bites): 250-500 mg PO q8h (pediatric dose: 40-80 mg/kg per day divided into three doses)
• Cephalexin: 250-500 mg PO q8h or 500 mg PO q12h (pediatric dose: 25-50 mg/kg per day PO in four doses)
• Clindamycin (MRSA): 150-450 mg PO q6h (pediatric dose: 10-20 mg/kg per day PO or IV in three-four divided doses)
• Dicloxacillin: 250-500 mg PO q6h (pediatric dose: 50-100 mg/kg per day in four divided doses)
• Erythromycin: 500 mg-1 g PO or IV q6h (pediatric dose: 40 mg/kg per day PO divided q6h)
• Gentamicin: 5 mg/kg per day IV q24h (pediatric dose: 7.5 mg/kg per day IV divided q8h)
• Levaquin: 500 mg IV q24h (contraindicated in children)
• Rifampin (MRSA): 300 mg PO q.i.d. (pediatric dose 10 mg/kg up to 300 mg)
• Septra DS (MRSA): one tab PO b.i.d. (pediatric 5 mL susp/10 kg up to 20 mL per dose)
• Unasyn: 1.5-3.0 g IV q6h (pediatric dose: <40>40 kg, adult dose)
• Vancomycin: 1 g IV q12h (pediatric dose: 40 mg/kg per day IV divided q6h)

Surgery

Perirectal abscess requires treatment in the operating room.

Follow-Up

Disposition

In accordance with abscess type and severity of infection

Admission Criteria

• Sepsis
• Endocarditis
• Systemic illness
• Perirectal involvement
• Any abscess requiring incision and debridement in the operating room

Discharge Criteria

Most patients with uncomplicated abscesses can be treated with incision and drainage and close follow-up.

References

1. Benson EA. Management of breast abscesses. World J Surg. 1989;13:753-756.
2. Buescher ES. Community-acquired methicillin-resistant Staphylococcus aureus in pediatrics. Curr Opin Pediatr. 2005;17(1):67-70.
3. Canales FL, Newmeyer WL, Kilgore ES. The treatment of felons and paronychias. Hand Clin. 1989;5:515-522.
4. Chiedozi LC. Pyomyositis: review of 205 cases in 112 patients. Am J Surg. 1979;137:255-259.
5. Loyer EM, DuBrow RA, David CL, et al. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR. 1995;166:149-152.
6. Summanen PH, Talan DA, Strong C, et al. Bacteriology of skin and soft-tissue infections in intravenous drug users and individuals with no history of intravenous drug use. Clin Infect Dis. 1995;20(Suppl 2):S279-282.
7. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. N Engl J Med. 1999;340:85-92.

Codes
ICD9-CM
682.9
ICD10
L02.9

Acute Coronary Syndrome: Drug Induced

Acute Coronary Syndrome: Drug Induced

Description
Imbalance in myocardial blood supply and oxygen requirement
Etiology
• Sympathomimetics are associated with myocardial oxygen mismatch due to induced vasoconstriction:
o Cocaine
o Cocaethylene is a toxic compound formed by hepatic transesterification of alcohol and cocaine further exacerbates the sympathomimetic effects of cocaine.
o Amphetamines (crank)
o Ephedrine (dietary supplement), pseudoephedrine (decongestant)
o Ma huang (herbal diet supplement)
o Dipivefrin (glaucoma eye drop)
o Phenylpropanolamine (nasal decongestant)
o Epinephrine
o Methylene 3,4 dioxymethamphetamine (ecstasy)
• Cocaine-induced chest pain also caused by:
o Increased myocardial workload
o Accelerated atherosclerosis
o Activation of platelets and promotion of thrombosis
• Antimigraine therapy—sumatriptan, methysergide, ergotamine, and isometheptene:
o Vasoconstrictors
o Particularly with cardiac risk factors or known coronary disease
• Calcium channel blockers—nifedipine:
o Reflex tachycardia and vasoconstriction
• Beta-blockers (metoprolol and propanolol):
o α-adrenergic mediated coronary vasospasm
• Carbon monoxide found with gas heaters, smoke inhalation, furniture stripping with methylene chloride:
o Decreasing oxygen-carrying capacity
o Shifting the oxyhemoglobin dissociation curve to the left
o Binding to myoglobin
• Bromocriptine:
o Vasoconstrictor
o Used for acromegaly, Parkinson disease, hyperprolactinemia, amenorrhea/galactorrhea, lactation cessation
o Risk increased by predisposing conditions:
 Pregnancy-induced hypertension
 Other vasospastic conditions (Raynaud disease or migraine headaches)
• Other dopaminergic agents (dopamine):
o Vasoconstriction and vasospasm
• Sildenafil:
o Vasodilatory properties
o Transient decreases in supine blood pressure
o Increase the risk of cardiac event during sexual activity
• Oral contraceptives:
o Prothrombotic
o Higher incidence of MI in young women with concomitant smoking
Diagnosis
Signs and Symptoms
• Chest pain
• Substernal pressure
• Heaviness
• Squeezing
• Burning sensation
• Tightness
• Sympathomimetic toxidrome symptoms:
o Agitation
o Tremulousness
o Tachypnea
o Tachycardia
o Hypertension
o Hyperthermia
o Moist skin
o No urine retention
History
• Recent ingestion of medication/drug that induces coronary vasospasm
• Cardiac risk factors or known cardiac disease
Physical Exam
• Physical exam is usually unrevealing
• Blood pressure (BP) is usually elevated during symptoms
Essential Workup
History is critical in diagnosing and differentiating drug-induced and unusual causes of acute coronary syndromes.
Tests
• ECG:
o Normal approximately 50% of the time
o Compare to prior tracings
o New ST segment changes or T-wave inversions
o 1-mm depression of the ST segment below the baseline
o 80 msec from the J point
o Helpful in diagnosing other etiologies
• ECG in carbon monoxide poisoning:
o Premature ventricular contractions:
o Dysrhythmias
o Tachycardia
o Nonspecific ST-T wave abnormalities
o Acute MI: ST elevation or depression
Lab
• Serial cardiac enzymes
• Troponin may be more helpful.
• Creatine kinase may be elevated in cocaine-induced rhabdomyolysis
• Carboxyhemoglobin level for suspected carbon monoxide (CO) toxicity
• Serum toxicology screening
Imaging
• Chest radiograph:
o Usually normal
o May show cardiomegaly
o Congestive heart failure
o May identify other etiologies of chest pain such as pneumonia
• Exercise stress testing: Identify underlying atherosclerosis.
• A technetium Tc-99m perfusion scan: myocardial damage/MI
• ECG: wall motion abnormalities
Diagnostic Procedures/Surgery
• Gold standard: cardiac catheterization
• Most patients will have angiographically normal coronary arteries.
Differential Diagnosis
• Anxiety
• Aortic dissection
• Biliary colic
• Costochondritis
• Esophageal reflux
• Esophageal spasm
• Herpes zoster
• Hiatal hernia
• Mitral valve prolapse
• Myocardial infarction
• Panic disorder
• Peptic ulcer disease
• Pneumonia
• Psychogenic
• Pulmonary embolus
• Unstable angina
Treatment
Pre Hospital
• Remove patient from contaminated environment if carbon monoxide toxicity is a consideration.
• IV access
• Oxygen
• Cardiac monitoring
• Sublingual nitroglycerin for symptom relief
Alert
• All chest pain should be treated and transported as a possible life-threatening emergency.
• Avoid β-adrenergic antagonists in cases of suspected cocaine use.
Initial Stabilization
• Place patient on a monitor
• IV access should be obtained
• O2: 100% oxygen
• Nitrates

ED Treatment
• Aspirin
• β-adrenergic blockers should be avoided in patients who are suspected to have used cocaine.
• Benzodiazepines: cocaine use
• Reduce BP and heart rate.
• Decreasing myocardial oxygen demand
• Heparin or enoxaparin
• Thrombolytics: Use with caution in suspected vasospasm induces acute coronary syndrome
• Cardiac catheterization: diagnostic and/or therapeutic
• Carbon monoxide toxicity:
o 100% O2
o Hyperbarics if
o Carboxyhemoglobin level is >25–40%.
o Any period of coma
o Neurologic deficits
o Persistent metabolic acidosis
o Pregnant and carboxyhemoglobin level is >15%.
o Cardiac instability
o Acute MI, unless hemodynamically unstable
• Half-life of carboxyhemoglobin:
o Room air: 300 minutes
o 100% O2: 90 minutes
o Hyperbaric chamber at 3 ATM: 20 minutes
Medication (Drugs)
• Aspirin: 160-325 mg PO
• Enoxaparin (Lovenox): 1 mg/kg SC q12h
• Heparin: 80 units/kg IV bolus, then 18 units/kg/hr
• Labetalol: 20 mg IV or 100 mg PO
• Lorazepam: 1-2 mg IV
• Metoprolol: 5 mg IV q5min-q15 min followed by 25-50 mg PO starting dose as tolerated (note: beta-blockers contraindicated in cocaine chest pain)
• Morphine: 2 mg IV, may titrate upward in 2-mg increments for relief of pain assuming no respiratory deterioration and SBP >90 mm Hg
• Nitroglycerin: 0.4 mg sublingual
• Nitroglycerin: IV drip at 5-10 µg/min
• Nitropaste: 1-2 inches transdermal
• Tenecteplase: for 60-kg person, 30 mg; >60-69 kg, 35 mg; 70-79 kg, 40 mg; 80-89 kg, 45 mg, >90 kg, 50 mg given IV; or Reteplase, 10 units IV over 2 minutes, repeat in 30 minutes
Follow-Up
Disposition

Admission Criteria
• Similar to patients with acute coronary syndromes of atherosclerotic origin
• New-onset chest pain
• Rest chest pain
• Accelerated chest pain symptoms
Discharge Criteria
Chronic stable chest pain

References
1. Lai TI, Hwang JJ, Fang CC, Chen WJ. Methylene 3,4 dioxymethamphetamine-induced acute myocardial infarction. Ann of Emerg Med. 2003;42(6):759-762.
2. Lange RA, Hillis LD. Cardiovascular complications of cocaine use. N Engl J Med. 2001;345:351-358.
3. Manini AF, Kabrhel C, Thomsen. Acute Myocardial Infarction after over-the-counter use of Pseudoephedrine. Ann of Emerg Med. 2005;45(2):213-218.
4. Marius-Nunez AL. Myocardial infarction with normal coronary arteries after acute exposure to carbon monoxide. Chest. 1990;97:491-494.
5. Ottervanger JP, Wilson JH, Stricker BH. Drug-induced chest pain and MI. Reports to a national center and review of the literature. Eur J Clin Pharmacol. 1997;53:105-110.
6. Qasim A, Townend J, Davies MK. Esctasy induced myocardial infarction. Heart. 2001;85(6):E10
7. Tanis BC, van den Bosch MA, Kemmeren JM, et al. Oral contraceptives and the risk of myocardial infarction. N Engl J Med. 2001;345:1787-1793.
8. Wasson S, Jayam VK. Coronary vasospasm and myocardial infarction induced by oral sumatriptan. Clin Neuropharmocol. 2004;27(4):198-200.
Codes
ICD9-CM
411.1
ICD10
I20.9
T88.7

Acute Coronary Syndrome: Drug Induced

Acute Coronary Syndrome: Drug Induced

Description
Imbalance in myocardial blood supply and oxygen requirement
Etiology
• Sympathomimetics are associated with myocardial oxygen mismatch due to induced vasoconstriction:
o Cocaine
o Cocaethylene is a toxic compound formed by hepatic transesterification of alcohol and cocaine further exacerbates the sympathomimetic effects of cocaine.
o Amphetamines (crank)
o Ephedrine (dietary supplement), pseudoephedrine (decongestant)
o Ma huang (herbal diet supplement)
o Dipivefrin (glaucoma eye drop)
o Phenylpropanolamine (nasal decongestant)
o Epinephrine
o Methylene 3,4 dioxymethamphetamine (ecstasy)
• Cocaine-induced chest pain also caused by:
o Increased myocardial workload
o Accelerated atherosclerosis
o Activation of platelets and promotion of thrombosis
• Antimigraine therapy—sumatriptan, methysergide, ergotamine, and isometheptene:
o Vasoconstrictors
o Particularly with cardiac risk factors or known coronary disease
• Calcium channel blockers—nifedipine:
o Reflex tachycardia and vasoconstriction
• Beta-blockers (metoprolol and propanolol):
o α-adrenergic mediated coronary vasospasm
• Carbon monoxide found with gas heaters, smoke inhalation, furniture stripping with methylene chloride:
o Decreasing oxygen-carrying capacity
o Shifting the oxyhemoglobin dissociation curve to the left
o Binding to myoglobin
• Bromocriptine:
o Vasoconstrictor
o Used for acromegaly, Parkinson disease, hyperprolactinemia, amenorrhea/galactorrhea, lactation cessation
o Risk increased by predisposing conditions:
 Pregnancy-induced hypertension
 Other vasospastic conditions (Raynaud disease or migraine headaches)
• Other dopaminergic agents (dopamine):
o Vasoconstriction and vasospasm
• Sildenafil:
o Vasodilatory properties
o Transient decreases in supine blood pressure
o Increase the risk of cardiac event during sexual activity
• Oral contraceptives:
o Prothrombotic
o Higher incidence of MI in young women with concomitant smoking
Diagnosis
Signs and Symptoms
• Chest pain
• Substernal pressure
• Heaviness
• Squeezing
• Burning sensation
• Tightness
• Sympathomimetic toxidrome symptoms:
o Agitation
o Tremulousness
o Tachypnea
o Tachycardia
o Hypertension
o Hyperthermia
o Moist skin
o No urine retention
History
• Recent ingestion of medication/drug that induces coronary vasospasm
• Cardiac risk factors or known cardiac disease
Physical Exam
• Physical exam is usually unrevealing
• Blood pressure (BP) is usually elevated during symptoms
Essential Workup
History is critical in diagnosing and differentiating drug-induced and unusual causes of acute coronary syndromes.
Tests
• ECG:
o Normal approximately 50% of the time
o Compare to prior tracings
o New ST segment changes or T-wave inversions
o 1-mm depression of the ST segment below the baseline
o 80 msec from the J point
o Helpful in diagnosing other etiologies
• ECG in carbon monoxide poisoning:
o Premature ventricular contractions:
o Dysrhythmias
o Tachycardia
o Nonspecific ST-T wave abnormalities
o Acute MI: ST elevation or depression
Lab
• Serial cardiac enzymes
• Troponin may be more helpful.
• Creatine kinase may be elevated in cocaine-induced rhabdomyolysis
• Carboxyhemoglobin level for suspected carbon monoxide (CO) toxicity
• Serum toxicology screening
Imaging
• Chest radiograph:
o Usually normal
o May show cardiomegaly
o Congestive heart failure
o May identify other etiologies of chest pain such as pneumonia
• Exercise stress testing: Identify underlying atherosclerosis.
• A technetium Tc-99m perfusion scan: myocardial damage/MI
• ECG: wall motion abnormalities
Diagnostic Procedures/Surgery
• Gold standard: cardiac catheterization
• Most patients will have angiographically normal coronary arteries.
Differential Diagnosis
• Anxiety
• Aortic dissection
• Biliary colic
• Costochondritis
• Esophageal reflux
• Esophageal spasm
• Herpes zoster
• Hiatal hernia
• Mitral valve prolapse
• Myocardial infarction
• Panic disorder
• Peptic ulcer disease
• Pneumonia
• Psychogenic
• Pulmonary embolus
• Unstable angina
Treatment
Pre Hospital
• Remove patient from contaminated environment if carbon monoxide toxicity is a consideration.
• IV access
• Oxygen
• Cardiac monitoring
• Sublingual nitroglycerin for symptom relief
Alert
• All chest pain should be treated and transported as a possible life-threatening emergency.
• Avoid β-adrenergic antagonists in cases of suspected cocaine use.
Initial Stabilization
• Place patient on a monitor
• IV access should be obtained
• O2: 100% oxygen
• Nitrates

ED Treatment
• Aspirin
• β-adrenergic blockers should be avoided in patients who are suspected to have used cocaine.
• Benzodiazepines: cocaine use
• Reduce BP and heart rate.
• Decreasing myocardial oxygen demand
• Heparin or enoxaparin
• Thrombolytics: Use with caution in suspected vasospasm induces acute coronary syndrome
• Cardiac catheterization: diagnostic and/or therapeutic
• Carbon monoxide toxicity:
o 100% O2
o Hyperbarics if
o Carboxyhemoglobin level is >25–40%.
o Any period of coma
o Neurologic deficits
o Persistent metabolic acidosis
o Pregnant and carboxyhemoglobin level is >15%.
o Cardiac instability
o Acute MI, unless hemodynamically unstable
• Half-life of carboxyhemoglobin:
o Room air: 300 minutes
o 100% O2: 90 minutes
o Hyperbaric chamber at 3 ATM: 20 minutes
Medication (Drugs)
• Aspirin: 160-325 mg PO
• Enoxaparin (Lovenox): 1 mg/kg SC q12h
• Heparin: 80 units/kg IV bolus, then 18 units/kg/hr
• Labetalol: 20 mg IV or 100 mg PO
• Lorazepam: 1-2 mg IV
• Metoprolol: 5 mg IV q5min-q15 min followed by 25-50 mg PO starting dose as tolerated (note: beta-blockers contraindicated in cocaine chest pain)
• Morphine: 2 mg IV, may titrate upward in 2-mg increments for relief of pain assuming no respiratory deterioration and SBP >90 mm Hg
• Nitroglycerin: 0.4 mg sublingual
• Nitroglycerin: IV drip at 5-10 µg/min
• Nitropaste: 1-2 inches transdermal
• Tenecteplase: for 60-kg person, 30 mg; >60-69 kg, 35 mg; 70-79 kg, 40 mg; 80-89 kg, 45 mg, >90 kg, 50 mg given IV; or Reteplase, 10 units IV over 2 minutes, repeat in 30 minutes
Follow-Up
Disposition

Admission Criteria
• Similar to patients with acute coronary syndromes of atherosclerotic origin
• New-onset chest pain
• Rest chest pain
• Accelerated chest pain symptoms
Discharge Criteria
Chronic stable chest pain

References
1. Lai TI, Hwang JJ, Fang CC, Chen WJ. Methylene 3,4 dioxymethamphetamine-induced acute myocardial infarction. Ann of Emerg Med. 2003;42(6):759-762.
2. Lange RA, Hillis LD. Cardiovascular complications of cocaine use. N Engl J Med. 2001;345:351-358.
3. Manini AF, Kabrhel C, Thomsen. Acute Myocardial Infarction after over-the-counter use of Pseudoephedrine. Ann of Emerg Med. 2005;45(2):213-218.
4. Marius-Nunez AL. Myocardial infarction with normal coronary arteries after acute exposure to carbon monoxide. Chest. 1990;97:491-494.
5. Ottervanger JP, Wilson JH, Stricker BH. Drug-induced chest pain and MI. Reports to a national center and review of the literature. Eur J Clin Pharmacol. 1997;53:105-110.
6. Qasim A, Townend J, Davies MK. Esctasy induced myocardial infarction. Heart. 2001;85(6):E10
7. Tanis BC, van den Bosch MA, Kemmeren JM, et al. Oral contraceptives and the risk of myocardial infarction. N Engl J Med. 2001;345:1787-1793.
8. Wasson S, Jayam VK. Coronary vasospasm and myocardial infarction induced by oral sumatriptan. Clin Neuropharmocol. 2004;27(4):198-200.
Codes
ICD9-CM
411.1
ICD10
I20.9
T88.7

Acute Coronary Syndrome: Coronary Vasospasm

Acute Coronary Syndrome: Coronary Vasospasm

Description

Ø Spontaneous episodes of chest pain due to coronary artery vasospasm in absence of increase in myocardial oxygen demand in either normal or diseased coronary vessels

Ø Also known as Prinzmetal angina or variant angina

Ø Most common in younger patients and men

Ø Occurs in patients without other cardiac risk factors

Ø Risk factors:

o Smoking

o Hyperinsulinemia

o Insulin resistance

Ø Associated with minimal coronary artery disease:

o Usually has normal coronary angiogram

Etiology

• Abnormal vasodilator function in coronary arteries
• Focal coronary artery vasospasm
• Often adjacent to or at the site of fixed stenoses
• Unopposed alpha sympathetic stimulation
• Sympathetic stimulation by endogenous hormones may cause vasoconstriction
• Hypersensitivity of coronary arteries due to mediators of vasoconstriction
• May or may not be associated with a fixed coronary lesion

Diagnosis

Signs and Symptoms

• Chest pain:
• Retrosternal
• Radiates to neck, jaw, left shoulder, or arm
• Occurs at rest
• Palpitations
• Presyncope or syncope
• Associated with migraine headaches and Raynaud disease in a minority of patients
• May occur during cold weather or stress
• May be prolonged in duration compared to typical angina
• May be elicited by hyperventilation
• May be relieved by exercise
• Circadian pattern, most commonly in early morning

Tests

ECG:

• Transient ST-segment elevation is characteristic
• May be followed by ST depression or T-wave inversion
• May have associated arrhythmia during coronary spasm
• Heart block with right coronary artery spasm
• Ventricular tachycardia with LAD spasm

Lab

• CK-MB and troponin I or T
• Toxicologic screen:
• Helpful if cocaine is suspected as etiology of chest pain

Imaging

• Chest radiograph:
• May be helpful to rule out other etiologies such as pneumonia, pneumothorax, or aortic dissection
• Thallium scintigraphy may be useful to localize area of spasm

Diagnostic Procedures/Surgery

• Exercise stress testing:
• Helpful only if there are underlying fixed stenoses
• Coronary angiography:
• Mild atherosclerosis is often the norm
• Provocative test with ergonovine, acetylcholine, or hyperventilation will induce coronary spasm

Differential Diagnosis

• Angina pectoris
• Anxiety and panic disorders
• Aortic dissection
• Esophageal rupture
• Esophageal spasm
• Esophagitis
• Gastroesophageal reflux
• Mitral valve prolapse
• Musculoskeletal chest pain
• Myocardial infarction
• Peptic ulcer disease
• Pericarditis
• Pneumothorax
• Pulmonary embolism

Treatment

Pre Hospital

Treat as any other acute coronary syndrome

Initial Stabilization

• IV access
• Oxygen
• Cardiac monitoring
• Vital signs and oxygen saturation

ED Treatment

• All patients with chest pain in which cardiac ischemia is a consideration should receive an aspirin upon arrival to the ED:
• Possibility of actually increasing severity of episodes in Prinzmetal angina due to inhibiting biosynthesis of naturally-occurring coronary vasodilator prostacyclin
• Nitroglycerin should then be administered and is appropriate to help relieve both ischemic and vasospastic chest pain.
• A trial of calcium-channel blockers is indicated if clinical history is consistent with coronary vasospasm
• Heparin and beta-blockers are not helpful:
• Beta-blockers may actually be detrimental due to unopposed alpha-mediated vasoconstriction.

Medication (Drugs)

• Aspirin: 325 mg PO
• Diltiazem: 30-60 mg PO
• Nitroglycerin, either:
• 0.4 mg sublingual
• 10-20 mcg/min IV, titrating to effect
• 1-2 inches of nitropaste
• Verapamil: 40-80 mg PO

Follow-Up

Disposition

Admission Criteria

• New-onset chest pain
• Rest chest pain (by definition most patients with coronary vasospasm)
• Accelerated chest symptoms

Discharge Criteria

Stable (chronic chest pain)

References

1. Braunwald E. Unstable angina: an etiologic approach to management [editorial]. Circulation. 1998;98:2219-2222.
2. Crea F, Kaski JC, Maseri A. Key references on coronary artery spasm. Circulation. 1994;89:2442-2446.
3. Gersh BJ, Braunwald E, Bonow RO. Chronic coronary artery disease. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular disease. 6th ed. Philadelphia: WB Saunders, 2001;1324-1328.
4. Mayer S, Hillis LD. Prinzmetal's variant angina. Clin Cardiol. 1998;21:243-246.
5. Orford JL. Coronary artery vasospasm. Med J. 2001;2:111.
6. Prinzmetal M, Kennamer R, Merliss R. A variant form of angina pectoris. Am J Med. 1959;27:375-388.
Codes
ICD9-CM

413.1

Abdominal Trauma, Imaging

Abdominal Trauma, Imaging

Description

This is a diagnostic procedure; basis for its use will vary with results of examination.

Diagnosis
Signs and Symptoms

• Abdominal trauma may present in an unstable patient with multiple associated injuries or as an isolated injury in a stable patient with no physical findings.
• Assessment of the abdomen focuses on the need for early surgical management; the diagnosis of specific organ injuries should be handled later.

History

• History should include mechanism of injury, restraint use and type, airbag or helmet use, prehospital vital signs, initial mental status and change in mental status, and any prehospital treatments performed and their effect on patient status.
• AMPLE history (allergies, especially to radiographic contrast agents, medications, past medical history, last meal, events leading up to the injury)

Physical Exam

• Comprehensive physical exam should include complete bodily exposure and perineal and digital rectal exams.
• Abdominal stab wounds should be locally explored after local anesthesia; penetration of the abdominal wall fascia requires further evaluation.
• Caution should be taken because the physical exam is accurate in determining serious abdominal injury in only 45–50% of cases.

Essential Workup

• See Abdominal Trauma (Blunt) and Abdominal Trauma (Penetrating)

Tests

General approach to imaging in blunt abdominal trauma:

• The ideal abdominal imaging study is rapid, inexpensive, sensitive for operative injury; identifies many nonoperative injuries requiring close observation and follow-up; requires minimal training to perform and interpret; and does not exist yet.
• Ultrasound has become the initial screening test of choice for hemodynamically stable patients; it has replaced diagnostic peritoneal lavage in many clinical settings.
• CT scan is the definitive test for most patients, especially children, but requires intravenous contrast material:
• Unstable patients should not be transported for a CT scan.
• Most patients require serial physical examinations and a period of observation even after negative imaging studies.

Imaging

Ultrasound

• Advantages:
• Rapid
• Noninvasive
• Can be performed at patient's bedside
• Does not require contrast agents or ionizing radiation
• Disadvantages:
• Operator dependent
• Does not reliably identify specific organ injury
• Not sensitive enough to exclude all injuries. Serial examination and observation are required if ultrasound is the sole imaging study.
• Is not well suited for penetrating injuries; may miss significant bowel injuries not accompanied by hemoperitoneum
• Does not evaluate spinal or retroperitoneal injuries
• Indications:
• Blunt trauma in either stable or unstable patients
• Contraindications:
• Absolute:
• Pre-existing indication for exploratory laparotomy
• Relative:
• Obesity
• Subcutaneous emphysema
• Positive test:
• Demonstration of free fluid or obvious solid organ injury (approximately 250 mL free fluid required in adults)
• Adequate exam includes visualization of Morrison pouch, pericardium, both paracolic gutters, and the pelvic rectouterine pouch (pouch of Douglas), and exam of the liver and spleen for parenchymal injuries.
• Considerations:
• Positive test result should be followed by CT in a stable patient or by laparotomy in an unstable patient.
• Institutional factors determine which clinical department performs the study.

CT scan:

• Advantages:
• Sensitivity of 85–98%
• Provides specific organ injury information
• Allows for simultaneous reformatting and reconstruction of spinal structures
• Fosters nonoperative approach to solid organ injuries
• Diagnoses retroperitoneal and bony injuries missed by other modalities.
• Disadvantages:
• Requires intravenous contrast (acute contrast reactions and renal failure)
• Isolated diaphragmatic, pancreatic, bowel injuries may be missed, especially if performed immediately after injury.
• Indications:
• Hemodynamically stable patients
• Contraindications:
• Absolute:
• Pre-existing indication for exploratory laparotomy
• Hemodynamic instability
• Previous contrast reaction
• Relative:
• Multiple allergies
• Considerations:
• Modality of choice in children
• Many multiple-injury patients require CT imaging of the head, spine, chest, or pelvis; modern equipment provides for rapid scanning of multiple anatomic regions in one session.
• Monitoring must be continued in the CT suite; patients should be accompanied by appropriate medical personnel.
• Water may be substituted for oral contrast, but optimal detection of intestinal injury requires oral contrast and a 2- to 4-hour delay for intestinal opacification.

Diagnostic Procedures/Surgery

• Gunshot wounds to the abdomen require evaluation by a surgeon and will require laparotomy:
• Selective laparotomy is an option for experienced centers.
• Diagnostic peritoneal lavage:
• Advantages:
• Rapid
• Relatively simple to perform
• 97.8% accurate in diagnosing injury
• Disadvantages:
• Invasive
• Does not identify specific organ injury
• 1–2% complication rate
• May miss retroperitoneal injuries and intraperitoneal bladder rupture
• Indications:
• Hemodynamically unstable patients
• Patients requiring emergent surgery for other conditions (e.g., craniotomy for epidural hematoma)
• Stab wounds that penetrate the abdominal fascia
• Contraindications:
• Absolute: pre-existing indication for exploratory laparotomy
• Relative: previous abdominal surgery, severe abdominal distention, pregnancy, pediatric patients
• Nasogastric tube and Foley catheter placement mandatory before beginning procedure
• Positive test:
• Aspiration of >10 mL of blood, bile, bowel contents, or urine
• Diagnostic peritoneal lavage fluid in the urine or chest tube
• Blunt trauma with >100,000 erythrocytes/mm³
• Penetrating trauma >1,000 erythrocytes/mm³
• Considerations:
• Favored in stab wound patients when local wound exploration is confirmatory
• Favored in unstable blunt trauma patients because it may be performed simultaneously with other emergency-basis surgical interventions (e.g., craniotomy for epidural hematoma)
• Must always be accompanied by serial abdominal exams after procedure
• In the presence of pelvic fractures, use supraumbilical location.
• In pregnancy, consider supraumbilical or open technique.
• False-positive results may be obtained if performed >8 hours after injury.

Differential Diagnosis

See Abdominal Trauma (Blunt) and Abdominal Trauma (Penetrating).

Treatment

Pre Hospital

All patients with a significant mechanism of injury or suspicion of major trauma should be triaged to a facility equipped to manage such injury.

Pediatric Considerations

• Pediatric patients should be triaged to a pediatric trauma center or to an adult trauma center equipped to manage children.
• CT scan should be considered the diagnostic test of choice in children as a greater percentage of injuries in children will be managed nonoperatively.
• Diagnostic peritoneal lavage (DPL) is relatively contraindicated.

Initial Stabilization

• In unstable patients, management of the airway, breathing, and circulation; treatment of hypovolemic shock; and control of major hemorrhage must take precedence.
• See Abdominal Trauma (Blunt) and Abdominal Trauma (Penetrating).

ED Treatment

See Abdominal Trauma (Blunt) and Abdominal Trauma (Penetrating).

Follow-Up

Disposition

Admission Criteria

See Abdominal Trauma (Blunt) and Abdominal Trauma (Penetrating).

Discharge Criteria

See Abdominal Trauma (Blunt) and Abdominal Trauma (Penetrating).

References
1. Amoroso TA. Evaluation of the patient with blunt abdominal trauma: an evidence based approach. Emerg Med Clin North Am. 1999;17-75.
2. Chiquito PE. Blunt abdominal injuries. Diagnostic peritoneal lavage, ultrasonography and computed tomography scanning. Injury. 1996;27:117-124.
3. Pryor JP, Reilly PM, Dabrowski GP, et al. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med. 2004;43(3):344-353.
4. Rose JS. Ultrasound in abdominal trauma. Emerg Med Clin North Am. 2004;22(3):581-599.
5. Stengel D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev. 2005;18(2):cd004446.

Miscellaneous
SEE ALSO: Abdominal Trauma, Blunt; Abdominal Trauma, Penetrating
Codes
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