FINGER TEST FOR NECROTIZING FASCIITIS

A patient presents with a deep muscle abscess. Is this necrotizing fasciitis? All too often I see the deliberation focus on things like the laboratory score or the imaging. The role of those things are being debated but what is beyond debate is to have the bedside skills for recognizing necrotizing infections.

 

Childers in 2001 and 2002 described the finger test as a diagnostic intervention at the bedside. It does not get enough attention. The instructions are to make a 2 cm incision down to fascia. “…if the tissues dissect with minimal resistance, the finger test is positive”

 

Other signs:

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

There is no reason ED physicians should not know this and perform it. We are already making incisions to check for abscess. Know the 4 surgical signs of necrotizing fasciitis.

 

TAKE HOME POINTS

The 4 surgical signs of necrotizing fasciitis are:

-lack of resistant to finger spread

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

Childers BJ Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68:109-16.

 

Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001;107:1025-35.

HERNIA TAXIS: DECOMPRESS BEFORE REDUCTION

I remember in residency calling general surgery for a hernia that could not be reduced. The surgeon was irritated and determined to prove it could be reduced. After about 30 minutes of sweat and tears the hernia was reduced and he instructed me to send the patient home. I later learned that his approach is generally frowned upon in the surgical literature, as forceful reduction can result in reduction en masse as well as perforation. In the days before emergency surgery was practiced, the technique of reduction was described as “taxis” which is a Greek word meaning “to draw up in rank and file.” One textbook disparages the notion, saying “vigorous taxis has no place in modern surgery, and it is only mentioned to be condemned.” That being said, There is an article challenging the notion that taxis was always wrong, and they found that it was safe and effective.(Harissis 2009)

The term “taxis” probably does not deserve its present obloquy. Reduction is safe if it is gentle and there is no bowel obstruction or strangulation. By using taxis (drawing the hernia up together, with slight traction and with lateral compression) the reduction is actually much more gentle.

First decompress the hernia. Grasp the hernia sac and gently squeeze. This evacuates some of the bowel contents, venous blood, and tissue fluid. The hernia shrinks and is more easily reduced. Less force is needed.

I have seen several umbilical hernias where other physicians struggled, and when I taught them this technique, the hernia was easily reduced.

Take home points:

Decompress hernias before reduction

STRANGULATED SMALL BOWEL OBSTRUCTION

STRANGULATED SMALL BOWEL OBSTRUCTION

A patient presents with nausea and vomiting, is found to have small bowel obstruction, and is to be admitted to the hospital. The hospitalist and general surgeon disagree over whether strangulation is present. Can we recognize strangulated small bowel obstruction at the bedside?

Strangulation means intestinal ischemia. Most of the time this is caused by a “closed loop obstruction,” meaning there is obstruction not only distally but also proximally, preventing the release of pressure. Small intestinal causes include hernia and torsion of a loop of bowel around an adhesive band. Any colon obstruction can cause a closed loop obstruction if the cecal valve is competent, for example, colon cancer. The most common colonic causes include sigmoid and cecal volvulus.

So how do we decide who might have strangulation? The consulting surgeon on this case says if there is no CT diagnosis of a closed loop, then the patient does not need surgery. But in well-designed studies, this finding is a low as 43% sensitive.(Sheedy Radiology 2006) CT sensitivity overall has been reported as high as 100% but that is when it is used as its own gold standard.(Frager Am J Roentgenol 1996)

Clinical indications of strangulation include the systemic inflammatory response syndrome (tachycardia, fever, leukocytosis), shock or acidosis, and guarding and rebound tenderness. These are all signs of advanced ischemia. Ideally we want to diagnose these patients earlier but in the early stages we do not have a proven approach. And yet, as with all things clinical, it starts with our risk stratification at the bedside.

Clinical gestalt is hard to study but is probably the most important diagnostic intervention we do. Did the patient get better after nasogastric decompression? Do they look well or ill? Is he or she looking worse than an hour ago? With an equivocal CT, these bedside considerations help us decide when to proceed with surgery.

Take home points:

Don’t completely trust the CT for diagnosing strangulated SBO

Shock, acidosis, and SIRS indicate strangulation has occurred

Bedside worsening suggests the need for surgery

CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation.

Sheedy SP, Earnest F 4th, Fletcher JG, Fidler JL, Hoskin TL.

Radiology. 2006 Dec;241(3):729-36.

PHYSICAL DIAGNOSIS OF SMALL BOWEL OBSTRUCTION

A middle aged man presented with worsening bloating, cramping abdominal pain, nausea, and vomiting. He had been in the ED the day before for similar symptoms, his x-rays were normal, and he had been diagnosed with gastroenteritis. With vomiting and cramping pain, you wonder about a bowel obstruction. Can physical diagnosis help?

LIMITATIONS OF RADIOGRAPHS

This is a very important topic because plain films have a sensitivity for small bowel obstruction approximately 50% and even noncontrast CT scan has limitations in sensitivity (Ros J Am Coll Radiol 2006).

DISTENSION IS HUGE!

The first thing is to recognize that intestinal obstruction is a heterogenous event, and presents differently according to the level of obstruction, whether proximal or distal. In general the more proximal obstructions present with dominant vomiting, and the distal obstructions present with prominent distension. This is huge (literally). When you see distension, pursue this finding, as it has high discriminatory value.(Eskelinen 1994)

SCARS OUTSIDE PREDICT SCARS INSIDE

The majority of patients (85%) with bowel obstruction have a history of previous abdominal surgery.(Eskelinen Scand J Gastroenterol 1994) In the poor historian, an abdominal scar is a useful proxy.

BOWEL SOUNDS

Diminished bowel sounds indicate ileus and increased bowel sounds indicate bowel obstruction, though there is overlap and these are neither sensitive nor specific.(Gu Dig Surg 2010) Listen for an increase in loudness, faster cycle times, and a higher pitch of sound. SBO can make everything higher: volume, frequency, pitch. If the radiologist says it is SBO vs ileus then the presence of bowel sounds is helpful in arguing against ileus. Gastroenteritis will cause increased bowel sounds.

OTHER FINDINGS

A history of constipation is present in only 37% but is 90% specific. Relief with vomiting is not common (19% sensitive) but very specific for bowel obstruction (93%) .

Take home points

-Note the history of abdominal surgeries or look for a scar

-Distension is huge! (sensitive and specific)

-Auscultation may have some value in ileus vs gastroenteritis vs SBO

INCARCERATED HERNIA

A patient presents with pain in his ventral hernia.  You wonder whether it could be strangulated. Does the bedside examination help?  Sure. Check for tenderness, localized peritoneal signs, assess appetite, ability to eat and drink, bowel habits.  Does this answer the question as to whether there is strangulation?  Probably not.

 

There is no question that strangulated hernias need immediate surgery.  And there is no question that reducible hernias, if there is no concern for infarction, do not need admission to the hospital.  But it seems that there is some debate over incarcerated hernias.  Many surgeons, at least in southern California, want to send patients with “incarcerated but non-strangulated hernias” home.  They will tell the emergency physician over the phone that there is no strangulation.

 

The problem is that there is no way to reliably identify this category of patient. The gold standard for diagnosis of strangulation is the surgeon’s eye and hands on the bowel.  This means looking at the bowel for color, signs of venous congestion, and peristalsis.  Some choose to do this laparoscopically through the hernia site (Ferzli Surg Endosc 2004). A study of 147 patients with incarcerated hernia found at operation that 61 were strangulated and 85 were merely incarcerated (Alvarez Hernia 2004). 41% of these patients experienced complications after surgery.  There are no studies I found that say physical diagnosis can reliably discriminate strangulation from mere incarceration.

 

Incarceration and acute pain suggests venous obstruction.  Even if one could be assured there is no strangulation, untreated venous congestion disrupts the health of the bowel and puts the patient at risk for local adhesions (Kingsnorth A Fundamentals of Surgical Practice 2011).  Surgeons, before telling emergency physicians to send patients home with incarcerated hernias, need to cite evidence for why this is safe.  A search today on pubmed for “outpatient incarcerated hernia” reveals that outpatient management of incarcerated hernias never been studied.

 

If you are the emergency physician what can you do?  Reduce the reducible hernias.  Give good analgesia, try to pull traction on the hernia and then compress it to evacuate the extra venous blood.  If it still doesn’t reduce, then this is a case where you call the surgeon and request surgery, or at least admission for observation.

 

Take home points:

Using physical diagnosis to decide strangulation is usually not possible

Using physical diagnosis to decide incarceration is easy

Patients with incarcerated hernias need surgical evaluation