Thread: GSW to chest
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Old 01-30-2009, 12:11   #15
RichL025
Quiet Professional
 
Join Date: Oct 2007
Location: San Antonio, TX
Posts: 377
Quote:
Originally Posted by frostfire View Post
Doc Dutch, I understand the causative organism (staph and strep) and mechanism of cellulitis. Questions:

- Do you expect cellulitis to manifest in a short period of time (minutes, less than 12 hours, I assume the patient is not staying in for days)?
- Can the absence of cellulitis be mosly attributed to the prophylactic intervention?
Since DD is probably busy doing this for real, I'll presume by answering for her.

Cellulitis will not manifest in minutes - typical time frame is measured in days. The scary exception is a certain type of infection that can manifest within 12-24hours called Necrotizing Fasciitis (aka Necrotizing Soft Tissue Infection) - this is basically cellulitis on steroids and can kill rather rapidly. Luckily, 99% of the time, an otherwise healthy combat wound victim won't have to worry about this, but keep it in your mind if you see a cellulitis not responding to traditional Abx in an older diabetic patient (for example) who is getting SICK.

As far as the "abscence" of cellulitis attributed to anything, it's always hard to say. When we decide on providing many of these treatments, we don't do it because there's a slam-dunk cause and effect - we do them because studies show a benefit... in larger populations.

For example, if you line up 100 young otherwise healthy trauma victims with a GSW to the leg (for example), maybe 10 of them will get an infection. Take another group of 100 with identical wounds and give ALL of them prophy Abx. Then maybe 3 of them will get infections. Then we calculate up to cost of giving those 100 guys antibiotics, and compare it to the savings for the 7 guys who DIDN'T get infections because we prophylaxed them. If the costs of the antibiotics are lower, then we give them to our patients.

Note that when I say "costs", I don't mean just money. We also compare the risk of side effects from the antibiotics, and for the cost of the infection we try and figure in things like time lost from work, longer time in the hospital, and risks from the infection progressing to something more serious (like the Nec Fasc I mentioned above).

If all that sounds like very fuzzy science, IT IS! Now factor in the fact that we performed those studies in young healthy patients, then we try to apply the same findings to make treatment decisions in an 80 year old diabetic MVC victim... do the same rationales apply?

A LARGE amount of what we do in medicine is based on decision-making like above... generalizing the results of large studies to individual patients and trying to make rational treatment decisions.

So, in a very long winded way, I probably didn't answer your question as to whether the prophy abx saved the patient from cellulitis... but hopefully I showed you a little of the reason why it's not a straightfoward question...

RL
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