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18 yo F with Neck Pain

18 yo F with Neck Pain. SACGR May 18, 2006. 18 yo F with Neck Pain. Tongue pierced 2 weeks ago Tooth extracted and abscess drained 3 days ago, continuing on PCN Presents to ED with pain in throat and neck En route to Neck CT she has a respiratory arrest and is intubated.

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18 yo F with Neck Pain

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  1. 18 yo F with Neck Pain SACGR May 18, 2006

  2. 18 yo F with Neck Pain • Tongue pierced 2 weeks ago • Tooth extracted and abscess drained 3 days ago, continuing on PCN • Presents to ED with pain in throat and neck • En route to Neck CT she has a respiratory arrest and is intubated

  3. 18 yo F with Neck Pain • Surgical I & D reveals necrotic tissue on the right hypopharynx • Repeat I & D finds necrotic tissue on left as well • After 5 surgeries she’s now developed mediastinal air and fluid accumulation, has a tracheostomy, chest tubes and numerous neck drains

  4. 18 yo F with Neck Pain • Cultures show Provotella bucca and Peptostreptococcus tetradius • Blood Cultures are all negative • Antibiotics started with empiric Zosyn and Clindamycin, then switched to Ciprofloxacin, PNC-G, Metronidazole, and Imipenam

  5. Necrotizing Soft Tissue Infections • Includes Progressive Crepitant Anaerobic Cellulitis, Bacterial Synergistic Gangrene, Necrotizing Fasciitis including Fournier’s Gangrene, and Non-clostridial Myonecrosis • Infections typically cause local tissue hypoxia exacerbated by an infection-induced occlusive endarteritis • Additionally, toxin effects and intravascular sequestration result in a paucity of PMNs at the site of infection

  6. Necrotizing Soft Tissue InfectionOutcomes with HBO2 • Mortality (classically 30-40%): • Bakker (1984) – 18% • Gozal (1986) – 12.5% • Mader (1988) – 25% in HBO2 cases vs. 67% in non-HBO2 cases • Riseman (1990) – 23% vs. 66% • Hollabaugh (1998) - 7% vs. 42%

  7. HBO2 in Necrotizing FasciitisRiseman JA. Surgery 1990 • 29 patients with necrotizing fasciitis retrospectively reviewed • Group 1 (n=12) received surgery and antibiotics only • Group 2 (n=17) also received HBO2 • Group 2 had higher incidence of diabetes and shock

  8. HBO2 in Necrotizing FasciitisRiseman JA. Surgery 1990 • Control HBO2 • Mortality rate 67% 23% * • Debridements/pt 3.25 1.16 * • * p<0.03

  9. HBO2 for Necrotizing Soft Tissue Infections • Antibiotic and surgical treatment are generally effective • When morbidity and mortality are high, then HBO2 may be a useful adjunct • Immunocompromised • Diabetes, Vasculopathy • Older Age • Poor nutritional status • Poor prognosis, poor response to standard treatments

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