Painful scrotum and racing heart

[tniuqs]

Great... now you have screwed my chances to take a couple of hemocultures in the ER...

Seriously though... do you think this patients warrants aggressive antimicrobial therapy in the field or can he wait untill you get him in the ER and cultures are drawn? Does the transport time to the hospital play a role in deciding this? How so?

You are dispatched to a suburban residence for a complaint of a painful scrotum and weakness.

Depends on transport time as DartmouthDave is working in northern BC "suburban" is rather wide open to interpretation but seeing that this scenario presented and has drawn some positive attention. Transport time has to my knowledge not been addressed and quite possible that a medivac will be called for. Then transport to and "highly likely" to an Alberta hospital as the closest geographical ICU with surgical facilities is in Grande Prairie this could take up to 4 hours minimum.

If this patient is Gangrene and most highly likely now with the additional information. My initial suggestion of cipro po would be out of the question as was looking at this if in my "present" situation of quite remote post. Ok so I am just making excuses as my initial working dx was something venereal in nature, my bad ?

BUT smell of gangrene I too know well, quite unmistakable and one can smell it from the door (as the others I have had similar cases) now despite the "books" saying it is "sweet smelling" its nasty, nasty rancid (to my olfactory senses) HENCE it makes dx rather elementary, one of the very few occasions than the nose knows.

I would like to comment on the good doctors humour and it bring to light the clinical observation, as we do know what the identifiable pathogens with gangrene so just how would blood cultures be affected a loading dosage of a broad spectrum bug juice ? Most of us in ALS Kanukistan do carry blood taking equipment and standard practice IS to do blood sample, that prior to starting any anti biotic rx, just saying.

Another point is in the vast majority of cases in Northern BC there is no C+S lab ... a lot of blood work is sent out either with patient OR flown on scheduled flights to labs in the south.

Hence I would have a tendancy to think that the sooner the better for broad spectrum ?

(could one not just do swab of the site, and yes knowing that this is likely to be anaerobic)

<edit> argh always a day late and a dollar short !

Edited March 27, 2010 by tniuqs

[Kiwiology]

Great... now you have screwed my chances to take a couple of hemocultures in the ER...

Gosh if phlebotomy ws not a restricted profesion here requiring 4,000 hours of training in New Zealand (about that for Paramedic (ILS) too) I'd happily draw you some bloods for pre-abx cultures.

Seriously though... do you think this patients warrants aggressive antimicrobial therapy in the field or can he wait untill you get him in the ER and cultures are drawn? Does the transport time to the hospital play a role in deciding this? How so?

In an urban/suburban area doing abx on scene will slow things down. Get the abx in once in the ED...

One of our services takes the same view as Jack and does not carry prehospital abx (ironically they have some very isolated stations with long transport times) whereas one of the others (a predominantly urban service) does carry ceftriaxone.

When I questioned thier use of ceftriaxone given thier short transport times and what seems to be low use they swore by carrying it for suspected sepsis/meningococcial septicema.

If we can get ceft into this guy who is gonna get pretty crook, pretty soon 20 or 30 minutes earlier is that not a good thing?

[DartmouthDave]

Hello,

So, this guy went to the OR and everything was excised (penius,rectum, and surrounding tissues). A VAC dressing was inserted as well as a suprapubic cath. Plus, a colostomy as well.

He had a high APACE II score and did poorly. He was tx with lots of IV fluids, abx, Levophed, Dopamine for a low SvO2, and APC. He had a slow, painful and problematic recovery. Developed ARDS. Was placed on ARDSNET. The works....

A pile-o-problems. Took months to get out of the ICU to the Sx Ward. I wonder what happened after that.

I like this case for a few reasons. One, it was a BLS crew that responded and they actually 'exposed' and looked and knew things were going bad. Because they did a good physical assessment. Second, it shows how EMS can compliment ED care if done right. On arrival, the 1st 1000cc was in and the ball was rolling in the correct direction.

Cheers...

[chbare]

A couple of points:

1) A culture and sensitivity will take more than a day to complete and the gram stain will not help as Fournier's gangrene is polymicrobial.

2) Fournier's gangrene is a form of necrotizing fascitis and should be considered a true emergency requiring rapid transport.

3) Many providers like to have blood cultures drawn prior to antimicrobal therapy.

4) Empiric antimicrobal therapy will be given; however, agents such as Unasyn, Zosyn and others are good considerations.

Assuming we have identified the right condition?

Take care,

chbare.

[chbare]

Hello,

So, this guy went to the OR and everything was excised (penius,rectum, and surrounding tissues). A VAC dressing was inserted as well as a suprapubic cath. Plus, a colostomy as well.

He had a high APACE II score and did poorly. He was tx with lots of IV fluids, abx, Levophed, Dopamine for a low SvO2, and APC. He had a slow, painful and problematic recovery. Developed ARDS. Was placed on ARDSNET. The works....

A pile-o-problems. Took months to get out of the ICU to the Sx Ward. I wonder what happened after that.

I like this case for a few reasons. One, it was a BLS crew that responded and they actually 'exposed' and looked and knew things were going bad. Because they did a good physical assessment. Second, it shows how EMS can compliment ED care if done right. On arrival, the 1st 1000cc was in and the ball was rolling in the correct direction.

Cheers...

I take it you work in the hospital to know about the APACE II scoring system? Thanks for the scenarios.

Take care,

chbare.

[DartmouthDave]

Hello,

This case is based on a fellow that came through the hospital. I altered it to fit better as a case study. I picked a suburban/urban setting because I wanted to work with an environment that most poster would be familiar with. A major hospital 10-15 min away. Something like that.

Now, with longer transport times (ground or air) starting abx would be essential. Early abx improves outcome. I agree with this 100%. Now, how to make this happen...that is an other story.

Prehospital labs: I like this. It is a good idea. Makes for a smooth transition from EMS care to hospital care. Heck, if you are putting in a line pull a few tubes off as well. Toss in a few blood cultures as well, if needed Inexpensive. The skills are there.

Cheers....

[VentMedic]

Prehospital labs: I like this. It is a good idea. Makes for a smooth transition from EMS care to hospital care. Heck, if you are putting in a line pull a few tubes off as well. Toss in a few blood cultures as well, if needed Inexpensive. The skills are there.

In the U.S. that may be harder to regain the confidence of the agencies that govern quality control for labs. Too many foul ups with poorly trained individuals with improper specimen collection and handling techniques led to incorrect and sometimes fatal treatments from the lab results. Even labeling was an issue with some EMS providers failing to see that their specimen was correctly labeled in a timely manner to get the correct labs results on the right patient. The EMS agencies themselves could not provide evidence of any training or QA monitoring for this "skill". If they also fail to monitor intubation skills, lab draws probably won't be much of a priority either. Even for Specialty, Flight or CCT, we may have the lab at the sending hospital draw the specimens and fax or call the results to the MD at the base facility which can then be relayed to us during transit. If we have extra cartridges for the iSTAT to do different labs, then yes we may draw and run the specimens immediately for certain tests. However, if the transport is more than 30 minutes, we have to take into consideration the length of time, proper storage and exposure of certain specimens if we must transport them.

At one time EMS prehospital lab draws were not an issue but as with anything, when you let the lowest common denominator represent the rest of the flock, eagles can quickly be viewed as turkeys when it comes to soaring to new heights. Even the hospitals and clinics have raised their standard to where the phlebotomist that had once been OJT must now have at least 140 hours of education/training in just phlebotomy and they now have a national certification gaining popularity that reflects the national lab standards. That's longer than the EMT-B in the U.S. Any licensed hospital employee (RN, RRT) must now show initial and yearly competency in lab specimen collection. There are also agencies that do check and ensure this process is carried out. EMS still has not achieved that level of oversight in many areas and there probably would be some union that would say any additional education or competency expectation is unfair and someone is picking on them or treating them like criminals (to quote the LA FF article).

Edited March 27, 2010 by VentMedic

[DartmouthDave]

In the U.S. that may be harder to regain the confidence of the agencies that govern quality control for labs. Too many foul ups with poorly trained individuals with improper specimen collection and handling techniques led to incorrect and sometimes fatal treatments from the lab results. Even labeling was an issue with some EMS providers failing to see that their specimen was correctly labeled in a timely manner to get the correct labs results on the right patient. The EMS agencies themselves could not provide evidence of any training or QA monitoring for this "skill". If they also fail to monitor intubation skills, lab draws probably won't be much of a priority either. Even for Specialty, Flight or CCT, we may have the lab at the sending hospital draw the specimens and fax or call the results to the MD at the base facility which can then be relayed to us during transit. If we have extra cartridges for the iSTAT to do different labs, then yes we may draw and run the specimens immediately for certain tests. However, if the transport is more than 30 minutes, we have to take into consideration the length of time, proper storage and exposure of certain specimens if we must transport them.

At one time EMS prehospital lab draws were not an issue but as with anything, when you let the lowest common denominator represent the rest of the flock, eagles can quickly be viewed as turkeys when it comes to soaring to new heights. Even the hospitals and clinics have raised their standard to where the phlebotomist that had once been OJT must now have at least 140 hours of education/training in just phlebotomy and they now have a national certification gaining popularity that reflects the national lab standards. That's longer than the EMT-B in the U.S. Any licensed hospital employee (RN, RRT) must now show initial and yearly competency in lab specimen collection. There are also agencies that do check and ensure this process is carried out. EMS still has not achieved that level of oversight in many areas and there probably would be some union that would say any additional education or competency expectation is unfair and someone is picking on them or treating them like criminals (to quote the LA FF article).

[DartmouthDave]

Hello,

Sorry for the above post. I was AFK and when I came back it wouldn't let me edit. =(

I never considered the issue of quality control or errors. From my experience I haven't seen any EMS services draw labs in the field. Or, use iSTAT technology.

Cheers...

[JackMaga]

I would like to comment on the good doctors humour and it bring to light the clinical observation, as we do know what the identifiable pathogens with gangrene so just how would blood cultures be affected a loading dosage of a broad spectrum bug juice ?

2) Fournier's gangrene is a form of necrotizing fascitis and should be considered a true emergency requiring rapid transport.

Assuming we have identified the right condition?

I think chbare point is a very important one, which also respond to tniuqs poignant observation... from the looks of it it really seems like necrotizing fascitis, however one can never be too sure; getting cultures drawn before starting abx will ensure that, if in the following days things doesn't go as planned and the ICU physicians need to reasses their initialy diagnosis, they at least have coltures results that can help them.

So yes, the cultures won't change anything of the initial abx therapy this patients will get in the emergency setting (EMS/ER) and in the first days of his loooong ICU stay, however it may make a difference later, if the diagnosis needs to be reevaluated...

If we can get ceft into this guy who is gonna get pretty crook, pretty soon 20 or 30 minutes earlier is that not a good thing?

Yes, this patients really looks like he's rolling downhill... however there's no evidence that starting abx 20 minutes earlier does change patient mortality. The focus is on starting abx in the first hours, and surely before ICU admission, however it doesn't appear to be such a time-sensitive treatment so that minutes count.

What really need to be start asap is aggressive iv fluid administration, as that is one of the early interventions that really has been shown to be a life saver; this patients is only mildy hypotensive, but gives his story of hypertension in multiple treatment, I'll take a gamble and say tha his usual BP is way higher than 110/30 (besides that's quite a big differential BP!)...

All in all quite a challeging patient...

Edited March 28, 2010 by JackMaga