SSTI by POCUS
Transcript of SSTI by POCUS
![Page 1: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/1.jpg)
SSTI by POCUS
Miki Watanabe MD
![Page 2: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/2.jpg)
Case 1
58M with DM2 on insulin came to ER with L leg thigh erythema x 2 days. T 37.0, HR 90, BP 100/80.L thigh erythema 5x10cm, tender and warm. WBC 12000. Choose one correct answer. 1- Cellulitis can be detected by ultrasound as subcutaneous tissue cobble stone appearance 2- Cellulitis can be detected by air in the subcutaneous tissue 3- Cellulitis imaging by bedside ultrasound is not different from normal skin tissue 4- None of the above
![Page 3: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/3.jpg)
Case2
42 F with IVDU came to ER with rapidly worsening erythema of the L forearm. T39.0, BP110/80, HR120. L forearm showed 3x3 cm erythema, tender and warm. Choose one correct answer. 1- Skin abscess can be detected by ultrasound with STAFF appearance 2- Skin abscess by POCUS has high sensitivity>80% and specificity >80% 3- Skin abscess is difficult to differentiate by POCUS from cellulitis 4- None of the above
![Page 4: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/4.jpg)
Case3
50M with DM1 came to ER presenting R leg worsening erythema x 1 day. T 38.8. HR 120, BP 90/50. R leg tender with minor erythema but tender to touch. WBC 25000. CRP sky high. Na 129.
Choose one correct answer.
1- Necrotizing fasciitis still cannot be detected by POCUS
2- MRI is the best imaging choice for NF
3- Lab results are of no use to detect NF
4- None of the above
![Page 5: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/5.jpg)
SSTI US
• Fairly Easy Skills
• Great sensitivity
• Good specificity
• Differentiate Cellulitis vs Abscess
• Possible detection of Necrotizing Fasciitis
![Page 6: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/6.jpg)
Skin Pocus Basics
• Transducer
• Anatomy
• Pathology
![Page 7: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/7.jpg)
Transducer: Linear
![Page 8: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/8.jpg)
Skin Anatomy
![Page 9: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/9.jpg)
Skin Anatomy
![Page 10: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/10.jpg)
Skin infections
![Page 11: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/11.jpg)
SSTI by POCUS
![Page 12: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/12.jpg)
Skin infections: Cellulitis
![Page 13: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/13.jpg)
Cellulitis: subcutaneous edema(Cobblestoning)
![Page 14: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/14.jpg)
Skin infections:Abscess
![Page 15: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/15.jpg)
Abscess
![Page 16: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/16.jpg)
![Page 17: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/17.jpg)
Abscess - Sens 97% - Speci 83%
![Page 18: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/18.jpg)
Skin infections
![Page 19: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/19.jpg)
Necrotizing Fasciitis
![Page 20: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/20.jpg)
Necrotizing fasciitis
![Page 21: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/21.jpg)
![Page 22: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/22.jpg)
LRINEC SCORE
![Page 23: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/23.jpg)
![Page 24: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/24.jpg)
© 2004 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
2
Figure 3.
The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections *. Wong, Chin-Ho; MD, MRCS; Khin, Lay-Wai; MD, MSC; Heng, Kien-Seng; MD, FRCS; Tan, Kok-Chai; MD, FRCS; Low, Cheng-Ooi; MD, FRSC Critical Care Medicine. 32(7):1535-1541, July 2004. DOI: 10.1097/01.CCM.0000129486.35458.7D
Figure 3. Suggested clinical pathway in the management of soft tissue infections. LRINEC, Laboratory Risk Indicator for Necrotizing Fasciitis; IV, intravenous; CBC, complete blood count; CRP, C-reactive protein; MRI, magnetic resonance imaging.
![Page 25: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/25.jpg)
© 2004 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
2
Table 4.
![Page 26: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/26.jpg)
© 2004 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
2
Figure 2.
The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections *. Wong, Chin-Ho; MD, MRCS; Khin, Lay-Wai; MD, MSC; Heng, Kien-Seng; MD, FRCS; Tan, Kok-Chai; MD, FRCS; Low, Cheng-Ooi; MD, FRSC Critical Care Medicine. 32(7):1535-1541, July 2004. DOI: 10.1097/01.CCM.0000129486.35458.7D
Figure 2. Plot of probability of necrotizing fasciitis against the ascending categories of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. Cases of necrotizing fasciitis (n = 145) are represented by boxes and control patients are represented by crosses (n = 309). From the graph, a probability of necrotizing infections of 75% corresponds to a score of >=8.
![Page 27: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/27.jpg)
LRINEC score <=5, - NF development <50% LRI-NEC score 6–7 - NF development 50-75% LRINEC score >=8 - NF development >75% - positive predictive value, 93.4%; 95% CI, 85.5–97.2
![Page 28: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/28.jpg)
![Page 29: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/29.jpg)
• Magnetic resonance imaging has a sensitivity of 93% in detecting necrotizing fasciitis.
• Computed tomography has an estimated sensitivity of 80% in detecting necrotizing fasciitis.
• In one study, sonography revealed a sensitivity of 88.2%, specificity of 93.3%, positive predictive value of 83.3%, negative predictive value of 95.4%, and accuracy of 91.9% in the diagnosis of NF
![Page 30: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/30.jpg)
![Page 31: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/31.jpg)
- Prospective observational study in the National Taiwan University Hospital in 1996-1998
- 62 cases with suspected NF( fever/WBC, skin infection)
POCUS Dx:
Diffuse thickening of the subcutaneous tissue
+
Fluid accumulation along the fascia(4mm)
Compaired with
Inope diagnoses + Biopsy diagnoses
![Page 32: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/32.jpg)
![Page 33: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/33.jpg)
![Page 34: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/34.jpg)
STAFF
• Subcutaneous Thickening and Air
• Fascial Fluid
![Page 35: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/35.jpg)
- 32 cases - Subcutaneous change(87.5%) - Fascia change ( 56%)
![Page 36: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/36.jpg)
Case 1
58M with DM2 on insulin came to ER with L leg thigh erythema x 2 days. T 37.0, HR 90, BP 100/80.L thigh erythema 5x10cm, tender and warm. WBC 12000. Choose one correct answer. 1- Cellulitis can be detected by ultrasound as subcutaneous tissue cobble stone appearance 2- Cellulitis can be detected by air in the subcutaneous tissue 3- Cellulitis imaging by bedside ultrasound is not different from normal skin tissue 4- None of the above
![Page 37: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/37.jpg)
Case 1
58M with DM2 on insulin came to ER with L leg thigh erythema x 2 days. T 37.0, HR 90, BP 100/80.L thigh erythema 5x10cm, tender and warm. WBC 12000. Choose one correct answer. 1- Cellulitis can be detected by ultrasound as subcutaneous tissue cobble stone appearance 2- Cellulitis can be detected by air in the subcutaneous tissue 3- Cellulitis imaging by bedside ultrasound is not different from normal skin tissue 4- None of the above
![Page 38: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/38.jpg)
Case2
42 F with IVDU came to ER with rapidly worsening erythema of the L forearm. T39.0, BP110/80, HR120. L forearm showed 3x3 cm erythema, tender and warm. Choose one correct answer. 1- Skin abscess can be detected by ultrasound with STAFF appearance 2- Skin abscess by POCUS has high sensitivty>80% and specificity >80% 3- Skin abscess is difficult to differenciate by POCUS from cellulitis 4- None of the above
![Page 39: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/39.jpg)
Case2
42 F with IVDU came to ER with rapidly worsening erythema of the L forearm. T39.0, BP110/80, HR120. L forearm showed 3x3 cm erythema, tender and warm. Choose one correct answer. 1- Skin abscess can be detected by ultrasound with STAFF appearance 2- Skin abscess by POCUS has high sensitivty>80% and specificity >80% 3- Skin abscess is difficult to differenciate by POCUS from cellulitis 4- None of the above
![Page 40: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/40.jpg)
Case3
50M with DM1 came to ER presenting R leg worsening erythema x 1 day. T 38.8. HR 120, BP 90/50. R leg tender with minor erythema but tender to touch. WBC 25000. CRP sky high. Na 129. Choose one correct answer. 1- Necrotizing fasciitis still cannot be detected by POCUS 2- MRI is the best imaging choice for NF 3- Lab results are of no use to detect NF 4- None of the above
![Page 41: SSTI by POCUS](https://reader030.fdocuments.us/reader030/viewer/2022012707/61a82f80d3fa9d20174008de/html5/thumbnails/41.jpg)
Case3
50M with DM1 came to ER presenting R leg worsening erythema x 1 day. T 38.8. HR 120, BP 90/50. R leg tender with minor erythema but tender to touch. WBC 25000. CRP sky high. Na 129. Choose one correct answer. 1- Necrotizing fasciitis still cannot be detected by POCUS 2- MRI is the best imaging choice for NF 3- Lab results are of no use to detect NF 4- None of the above