Following caustic injury to the skin with an alkaline agent the effected area should initially be:
The treatment for both types of injuries is based on neutralization of the inciting solution and starts with running distilled water or saline over the affected skin for at least 30 minutes for acidic solutions and 2 hours for alkaline injuries. It should be noted that neutralizing agents do not offer a significant advantage over dilution with water, may delay treatment, and may worsen the injury due to the exothermic reaction that may occur. The clinician observes and treats based on the degree of presentation. Many cases are successfully managed conservatively with topical emollients and oral analgesics, and most cases result in edema, erythema, and induration. If signs of deep second-degree burns develop, local wound care may include debridement, Silvadene, and protective petroleum gauze. In severe cases, injury to the underlying vessels, bones, muscle, and tendon may occur, and these cases may be managed within 24 hours by liposuction through a small catheter and then saline injection. Surgery is indicated for tissue necrosis, uncontrolled pain, or deep-tissue damage. Antibiotics should not be administered unless signs of infection are present.
The treatment of a hydrofluoric acid skin burn is:
Injuries that have specific additional treatments include hydrofluoride burns. Hydrofluoride is found in air conditioning cleaners and petroleum refineries. Treatment of hydro fluoride burns should include topical or locally injected calcium gluconate to bind fluorine ions. Intra-arterial calcium gluconate can provide pain relief and preserves arteries from necrosis, whereas intravenous (IV) calcium repletes resorbed calcium stores. Topical calcium carbonate gel and quaternary ammonium compounds detoxify fluoride ions. This mitigates the leaching of calcium and magnesium ions by the hydrofluoric acid from the affected tissues and prevents potentially severe hypocalcemia and hypomagnesemia that predispose to cardiac arrhythmias.
The area most amenable to salvage by resuscitative and wound management techniques following thermal injury is called the:
Exposure of the skin to thermal extremes disrupts its primary function as a barrier to heat loss, evaporation, and microbial invasion. The depth and extent of injury are dependent on the duration and temperature of the exposure. The pathophysiology and management are discussed elsewhere in this book. Briefly, the epicenter of the injury undergoes a varying extent of necrosis (depending on the exposure), otherwise referred to as the zone of coagulation, which is surrounded by the zone of stasis, which has marginal perfusion and questionable viability. This is the area of tissue that is most amenable to salvage by appropriate resuscitative and wound management techniques, which would theoretically limit the extent of injury. The outermost area of skin shows characteristics similar to other inflamed tissues and has been designated the zone of hyperemia. The degree of burn corresponds to histologic layers of the affected dermis and correlates with management and prognosis pertaining to timeline of healing and magnitude of scarring.
Tissue ischemia resulting in wounds that are characterized as a partial-thickness injury with a blister is considered:
Tissue pressures that exceed the pressure of the microcirculation (30 mm Hg) result in tissue ischemia. Frequent or prolonged ischemic insults will ultimately result in tissue damage. Areas of bony prominence are particularly prone to ischemia, the most common areas being ischial tuberosity (28%), trochanter (19%), sacrum (17%), and heel (9%). Tissue pressures can measure up to 300 mm Hg in the ischial region during sitting and 1 50 mm Hg over the sacrum while lying supine. Muscle is more susceptible than skin to ischemic insult due to its relatively high metabolic demand. Wounds are staged as follows: stage 1, nonblanching erythema over intact skin; stage 2, partial-thickness injury (epidermis or dermis) blister or crater; stage 3, full-thickness injury extending down to, but not including, fascia and without undermining of adjacent tissue; and stage 4, full-thickness skin injury with destruction or necrosis of muscle, bone, tendon, or joint capsule.
The presence of sulfur granules in a draining wound should lead to the use of which of the following antibiotics?
Actinomycosis should be considered in the differential diagnosis of any acute, subacute, or chronic cutaneous swelling of the head and neck. The cervicofacial form of Actinomycetes infection is the most common presentation, typically as an acute pyogenic infection in the submandibular or paramandibular area, but infection could be elsewhere in the mandibular and maxillary regions. The primary skin infection may spread to adjacent structures such as the scalp, orbit, ears, and other areas. Oral infection may spread to the hypopharynx, larynx, trachea, salivary glands, and sinuses. Actinomycosis can spread beyond boundaries of tissue planes and may also mimic chronic osteomyelitis. Treatment consists of a combination of penicillin therapy and surgical debridement. Debulking and debriding infected tissue arising from sinus tracts and abscess cavities inhibit actinomycosis growth in most cases.
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