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Subcutaneous Fat Necrosis

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881. Intestinal and Multivisceral Transplantation (Follow-up)

perforation is warranted in any intestinal transplant recipient with unexplained fever, diarrhea, or gastrointestinal bleeding. Enteral nutrition is provided as soon as intestinal function returns. In the absence of other clinical complications, enteral feedings are started on the third-to-fifth postoperative day. The concentration and type of enteral nourishment are tailored to the patient's clinical response. A low-fat diet is used in the early posttransplant period. On average, recipients of ISB (...) supplements (gluconate forms) Rice starch products Medium chain triglycerides Fat restriction Restrict fat to around 30% of daily intake if colon is in continuity (combined with soluble fibers and complex starches). If the patient has no colon, fat restriction may not be necessary, as fat is felt to be a good energy source in these patients. Glutamine Lactose avoidance Oxalate avoidance Jejunostomies isotonic high sodium (encouraged target is 90 mmol/L) Fiber Clinical trial data suggest that fiber assists

2014 eMedicine Surgery

882. Hidradenitis Suppurativa (Follow-up)

recurrence. The block of tissue excised should be adequately wide and sufficiently deep. To ensure that the deep coils of the apocrine gland are removed, the subcutaneous tissue down to the deep fascia, or at least 5 mm of subcutaneous fat, should be excised. The extent of the sinus tracts is intraoperatively marked by injecting 3-5 mL of a methyl-violet solution. Complete surgical excision is achieved when all color-coded areas are fully removed. In cases where blue-stained areas occurred (...) was developed. Wide excisions reach into the healthy deep subcutaneous fat, but the STEEP procedure with its successive tangential transsections leaves the epithelialized bottoms of the sinus tracts and a large extent of the subcutaneous fat intact, leading to more superficial and smaller defects. STEEP is done with the patient under general anesthesia. For the performance of the multiple transversal sections, electrosurgery has some important advantages over the carbon dioxide laser, since transversal

2014 eMedicine Surgery

883. Cellulitis (Follow-up)

-shift polymorphonuclear neutrophils Previous Next: Surgical Examination and Drainage Urgent consultation with a surgeon should be sought in the setting of crepitus, circumferential cellulitis, necrotic-appearing skin (bronzing), evolving bullae, rapidly evolving cellulitis, pain disproportional to physical examination findings, severe pain on passive movement, or other clinical concern for necrotizing fasciitis. Wong et al have developed a scoring tool to assist in the diagnosis of necrotizing (...) fasciitis. [ ] Cellulitis associated with an abscess requires surgical drainage of the source of infection for adequate treatment. Serious concern for necrotizing fasciitis and/or the presence of necrotic skin should prompt examination of the fascial planes by immediate computed tomographic imaging or surgical direct observation, which, in most cases, can be performed at the bedside by an experienced surgeon. Circumferential cellulitis may result in compartment syndrome, which may require surgical

2014 eMedicine Emergency Medicine

884. Burns, Thermal (Follow-up)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) be debrided (see the image below); the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided. The World Health Organization (WHO) recommends debridement of all bullae and excision of all adherent necrotic tissue

2014 eMedicine Emergency Medicine

885. Toxicity, Cocaine (Diagnosis)

aspiration pneumonitis or after an intravenous injection of bacteria or toxic organic or inorganic materials Aneurysm or pseudoaneurysm: May be noted with mainlining (ie, directly injecting into a central artery or vein); this finding is an indication for further imaging studies In addition, radiography may be useful for evaluating cellulitis, an abscess, or a nonhealing wound in an intravenous drug user; it may reveal a foreign body or subcutaneous emphysema produced by gas-forming organisms (...) is fat soluble and freely crosses the blood-brain barrier. Cocaine appears to stimulate the CNS, with particular activity in the limbic system. There, it potentiates dopaminergic transmission in the ventral basal nuclei, producing the pleasurable behavioral effects that result in its widespread use. Cocaine enters the United States in the form of a hydrochloride salt, having undergone numerous steps in refinement from the original coca leaf. In its hydrochloride form, cocaine may be absorbed

2014 eMedicine Emergency Medicine

886. Systemic Lupus Erythematosus (Follow-up)

and steroid use in patients with SLE when used in combination with standard therapy. [ ] In March, 2011, the US Food and Drug Administration (FDA) approved the use of belimumab in combination with standard therapies (including steroids, nonbiologic DMARDS [eg, hydroxychloroquine, azathioprine, methotrexate]) to treat active autoantibody-positive SLE. [ ] In July 2017, a subcutaneous (SC) formulation was approved that allows patients to self-administer a once-weekly dose. [ ] Patients of African-American (...) on a low-fat diet. Many patients with SLE have low levels of vitamin D because of less sun exposure; therefore, these patients should take vitamin D supplements. Exercise is important in SLE patients to avoid rapid muscle loss, bone demineralization, and fatigue. Smoking should also be avoided. Antimalarial therapy (hydroxychloroquine) has been shown to prevent disease flares and to decrease mortality. [ ] In contrast, high rates of sulfa allergy and anecdotal reports of disease flares have led

2014 eMedicine Emergency Medicine

887. Cellulitis (Treatment)

-shift polymorphonuclear neutrophils Previous Next: Surgical Examination and Drainage Urgent consultation with a surgeon should be sought in the setting of crepitus, circumferential cellulitis, necrotic-appearing skin (bronzing), evolving bullae, rapidly evolving cellulitis, pain disproportional to physical examination findings, severe pain on passive movement, or other clinical concern for necrotizing fasciitis. Wong et al have developed a scoring tool to assist in the diagnosis of necrotizing (...) fasciitis. [ ] Cellulitis associated with an abscess requires surgical drainage of the source of infection for adequate treatment. Serious concern for necrotizing fasciitis and/or the presence of necrotic skin should prompt examination of the fascial planes by immediate computed tomographic imaging or surgical direct observation, which, in most cases, can be performed at the bedside by an experienced surgeon. Circumferential cellulitis may result in compartment syndrome, which may require surgical

2014 eMedicine Emergency Medicine

888. Burns, Thermal (Treatment)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) be debrided (see the image below); the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided. The World Health Organization (WHO) recommends debridement of all bullae and excision of all adherent necrotic tissue

2014 eMedicine Emergency Medicine

889. Toxicity, Cocaine (Overview)

aspiration pneumonitis or after an intravenous injection of bacteria or toxic organic or inorganic materials Aneurysm or pseudoaneurysm: May be noted with mainlining (ie, directly injecting into a central artery or vein); this finding is an indication for further imaging studies In addition, radiography may be useful for evaluating cellulitis, an abscess, or a nonhealing wound in an intravenous drug user; it may reveal a foreign body or subcutaneous emphysema produced by gas-forming organisms (...) is fat soluble and freely crosses the blood-brain barrier. Cocaine appears to stimulate the CNS, with particular activity in the limbic system. There, it potentiates dopaminergic transmission in the ventral basal nuclei, producing the pleasurable behavioral effects that result in its widespread use. Cocaine enters the United States in the form of a hydrochloride salt, having undergone numerous steps in refinement from the original coca leaf. In its hydrochloride form, cocaine may be absorbed

2014 eMedicine Emergency Medicine

890. Pediatrics, Respiratory Distress Syndrome (Overview)

permeability, influx of protein rich edema fluid into the alveolar sacs, dysfunction of surfactant production, and defective ion transport leading to impaired fluid clearance from alveolar cells. These changes are the hallmark of ARDS pathophysiology and are accompanied by dysregulated inflammation from dysfunctional leukocytes and influx of pro-inflammatory cytokines like interleukins and tumor-necrosis factor. The role of neutrophils in this mechanism is controversial. Animal models have favored both (...) , if they are associated with shock and thrombocytopenia. [ ] Other more common etiologies include bronchiolitis, aspiration pneumonia, aspiration of gastric contents, major trauma, pulmonary contusion, burns, inhalational injury, massive transfusions or transfusion-related acute lung injury (TRALI). [ , , , , , ] Transfusion of all type of blood products including packed red blood cells, fresh frozen plasma and platelets has been associated with development of ARDS. [ , ] Other causes include acute pancreatitis, fat

2014 eMedicine Emergency Medicine

891. Gout and Pseudogout (Overview)

are as follows: Avoidance or restricted consumption of high-purine foods Avoidance of excess ingestion of alcoholic drinks, particularly beer Avoidance of sodas and other beverages or foods sweetened with high-fructose corn syrup Limited use of naturally sweet fruit juices, table sugar, and sweetened beverages and desserts, as well as table salt Maintenance of a high level of hydration with water (≥8 glasses of liquids daily) A low-cholesterol, low-fat diet, if such a diet is otherwise appropriate (...) chemotactic factors, and tumor necrosis factor (TNF)-α. [ , ] Neutrophil phagocytosis leads to another burst of inflammatory mediator production. Chatfield et al reported that the interaction of urate crystals with lysosomes results in the formation of web-like chromatin structures known as neutrophil extracellular traps (NETs) and subsequent cell death (NETosis), via a mechanism independent of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase. The urate crystal–induced NETs are enriched

2014 eMedicine Emergency Medicine

892. Hernias (Overview)

, or extension at the hip Sciatic hernia - Tender mass in the gluteal area that is increasing in size; sciatic neuropathy and symptoms of intestinal or ureteral obstruction can also occur Perineal hernias - Perineal mass with discomfort on sitting and occasionally obstructive symptoms with incarceration Umbilical hernia - Central, midabdominal bulge Epigastric hernia - Small lumps along the linea alba reflecting openings through which preperitoneal fat can protrude; may be adjacent to the umbilicus (...) to other hernia types may vary, as follows: Umbilical hernia - After exposure of the umbilical sac, a plane is created to encircle the sac at the level of the fascial ring, and the defect is closed transversely with interrupted sutures; if the defect is very large (>2 cm), mesh may be required Epigastric hernia - A small vertical incision directly over the defect is carried to the linea alba, and incarcerated preperitoneal fat is either excised or returned to the properitoneum; the defect is closed

2014 eMedicine Emergency Medicine

893. Fournier Gangrene (Overview)

and superficial fascia Because Fournier gangrene is predominately an infectious process of the superficial and deep fascial planes, understanding the anatomic relationship of the skin and subcutaneous structures of the perineum and abdominal wall is important. The skin cephalad to the inguinal ligament is backed by Camper fascia, which is a layer of fat-containing tissue of varying thickness and the superficial vessels to the skin that run through it. Scarpa fascia forms another distinct layer deep to Camper (...) , an obliterative endarteritis develops, and the ensuing cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. Rates of fascial destruction as high as 2-3 cm/h have been described. Infection of superficial perineal fascia (Colles fascia) may spread to the penis and scrotum via Buck and Dartos fascia, or to the anterior abdominal wall via Scarpa fascia, or vice versa. Colles fascia is attached to the perineal body and urogenital diaphragm posteriorly

2014 eMedicine Emergency Medicine

894. Cellulitis (Overview)

, the tissue is hemorrhagic and necrotic. Hematoxylin and eosin (H&E) stain, high power. This image shows deeper subcutaneous tissue involved in a case of cellulitis, with acute inflammatory cells and fat necrosis. Hematoxylin and eosin (H&E) stain, high power. This image shows cellulitis caused by herpes simplex virus, with the multinucleated organism in the center of the picture. of 14 Tables Table 1. Empiric Antibiotic Therapy for Cellulitis by Etiology and Anatomic Location Location Likely Organisms (...) Herchline, MD; Chief Editor: Michael Stuart Bronze, MD Share Email Print Feedback Close Sections Sections Cellulitis Overview Practice Essentials The term cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and subcutaneous tissues, usually from acute infection (see the image below). Cellulitis usually follows a breach in the skin, although a portal of entry may not be obvious; the breach may involve microscopic skin changes or invasive qualities of certain bacteria

2014 eMedicine Emergency Medicine

895. Burns, Chemical (Overview)

as liquefaction necrosis. This involves denaturing of proteins as well as saponification of fats, which does not limit tissue penetration. Hydrofluoric acid is somewhat different from other acids in that it produces a liquefaction necrosis. The severity of the burn is related to a number of factors, including the pH of the agent, the concentration of the agent, the length of the contact time, the volume of the offending agent, and the physical form of the agent. The ingestion of solid pellets of alkaline (...) it gives up the proton; the strength of a base is determined by how avidly it binds the proton. The strength of acids and bases is defined by using the pH scale, which ranges from 1-14 and is logarithmic. A strong acid has a pH of 1, and a strong base has a pH of 14. A pH of 7 is neutral. Next: Pathophysiology Most acids produce a coagulation necrosis by denaturing proteins, forming a coagulum (eg, eschar) that limits the penetration of the acid. Bases typically produce a more severe injury known

2014 eMedicine Emergency Medicine

896. Burns, Thermal (Overview)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) be debrided (see the image below); the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided. The World Health Organization (WHO) recommends debridement of all bullae and excision of all adherent necrotic tissue

2014 eMedicine Emergency Medicine

897. Anemia, Sickle Cell (Follow-up)

for the treatment of severe pain associated with a vasoocclusive crisis Use of analgesics and physical therapy for the treatment of avascular necrosis In July 2017, the US Food & Drug Administration (FDA) approved L-glutamine oral powder (Endari) for patients age 5 years and older to reduce severe complications of SCD. [ , ] L-glutamine increases the proportion of the reduced form of nicotinamide adenine dinucleotides in sickle cell erythrocytes; this probably reduces oxidative stress, which contributes (...) is an efficient iron chelator. It is administered as a prolonged infusion intravenously or subcutaneously for 5-7 days a week. Although effective, there are significant challenges associated with its use that can result in non-compliance. [ ] Deferiprone and deferasirox, oral iron chelators, are effective for iron overload treatment and have differences (eg, different pharmacokinetics and adverse effect profiles). Deferasirox has a capacity similar to deferoxamine in chelating iron, but it is administered

2014 eMedicine Emergency Medicine

898. Toxicity, Warfarin and Superwarfarins (Diagnosis)

and in patients with preexisting protein C deficiency and is found, less commonly, in men and in patients with protein S deficiency. Patients initially become hypercoagulable because warfarin depresses levels of the anticoagulant proteins C and S more quickly than it does coagulant proteins II, VII, IX, and X. Extensive thrombosis of the venules and capillaries occurs within the subcutaneous fat. Women note an intense, painful burning in areas such as the thigh, buttocks, waist, and/or breast several days (...) ) who underwent dialysis, warfarin was found to be associated with a 44% higher risk of bleeding and did not reduce the risk of stroke. [ ] Skin necrosis Skin necrosis, usually observed between the third and eighth days of therapy, is a relatively uncommon, adverse reaction to warfarin. When skin necrosis occurs, it can be extremely severe and disfiguring and may require treatment through debridement or amputation of the affected tissue, limb, breast, or penis. It occurs more frequently in women

2014 eMedicine Emergency Medicine

899. Myocardial Infarction (Treatment)

variability and narrow therapeutic window. Low molecular weight heparin (LMWH) Enoxaparin is given at a dose of 1 mg/kg subcutaneously (SC) every 12 hours. It should be continued for the duration of hospitalization or until PCI is performed. A dose reduction is required for patients with impaired kidney function. Enoxaparin results in a more predictable and efficient anticoagulation compared to unfractionated heparin, leading to reduction in recurrent MI events [ , ] ; however, there is possibly a higher (...) bleeding risk in patients undergoing PCI. [ ] These findings were demonstrated in the Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q wave Coronary Events (ESSENCE) trial. [ , , ] Bivalirudin Bivalirudin is direct thrombin inhibitor that is given as 0.1 mg/kg loading dose, followed by 0.25 mg/kg per hour only in patients managed with an early invasive strategy. This regimen is continued until diagnostic angiography or PCI. [ ] In the Acute Catheterization and Urgent Intervention Triage Strategy

2014 eMedicine Emergency Medicine

900. Anemia, Sickle Cell (Treatment)

for the treatment of severe pain associated with a vasoocclusive crisis Use of analgesics and physical therapy for the treatment of avascular necrosis In July 2017, the US Food & Drug Administration (FDA) approved L-glutamine oral powder (Endari) for patients age 5 years and older to reduce severe complications of SCD. [ , ] L-glutamine increases the proportion of the reduced form of nicotinamide adenine dinucleotides in sickle cell erythrocytes; this probably reduces oxidative stress, which contributes (...) is an efficient iron chelator. It is administered as a prolonged infusion intravenously or subcutaneously for 5-7 days a week. Although effective, there are significant challenges associated with its use that can result in non-compliance. [ ] Deferiprone and deferasirox, oral iron chelators, are effective for iron overload treatment and have differences (eg, different pharmacokinetics and adverse effect profiles). Deferasirox has a capacity similar to deferoxamine in chelating iron, but it is administered

2014 eMedicine Emergency Medicine

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