An ER Night Shift Part 1: Cellulitis
I work in a regional ER serving a community of 200,000 people and I thought it might be interesting to look at the patients I saw, from an austere/survival medicine perspective, on a recent night shift. On this night, I saw or supervised the care of the following 26 patients with these ultimate diagnoses: (problem, age, sex)
Cellulitis after a catfish bite 38 M
Dislocated jaw 20 M
Infected scabies 14 F
Stab wound chest 33 F
CORD 51 M
Hip Dislocation 74 M
Aggressive mental health patient 30 F
Tonsillitis 22 M
Fractured tibia 33 F
Lacerated hand 36 M
Appendix 17 F
Infection 36 M
Constipation 64 M
Asthma 15 M
Miscarriage 27 F
Croup 4 M
Hanging 17 M
UTI 48 M
Trauma – pushbike. Chest pain 8 M
D’s & V’s 32 M
FB eye 16 M
Fell from car – abrasions 20 M
Supracondylar fracture 7 M
Subdural 20 M
Fractured ulna 38 M
Snake bite 21 M
What I plan to do over the next little while (and it might take a while to get through them!) is look at each patient in turn – how they presented, how easy it was to diagnose the problem and what are the options for diagnosis and treatment in an SHTF type scenario.
So, to begin……
Patient 1: Cellulitis after a catfish spine jab 38 yr. old Man
This patient was a 38-year-old man who had been fishing with friends three days before he came to the hospital. While landing a fish he grabbed hold of it with his hand and got several spines impaled in it. He said that he easily pulled them out and washed his hand with clean fresh water and got on with his fishing. After 36 hours, his hand started to hurt around the area of the wounds. He noticed it was becoming red. Over 12 hours the redness spread from the palm of his hand up onto the inner aspect of his wrist. The pain increased and he was unable to move his wrist much due to pain or make a fist because of swelling in his fingers and palm.
What is cellulitis?
Cellulitis is an infection in the layers of the skin – the dermis and the epidermis. Classically it presents as it did in this man – an injury which damages the skin (although we do see it in apparently intact skin sometimes), after a day or so the area becomes hot, red, swollen and painful – over time (hours to days) it gets worse – more pain and worsening of the other symptoms. Usually, it is obvious what is going on. It can be confused sometimes with a severe skin allergy, but the history of what happened usually gives it away.
Sometimes the patient also has signs and symptoms of the infection moving more widely in the body – they may feel hot, have chills or shakes, be off their food and experience nausea or vomiting. The presence of these suggests the infection is more established and more aggressive treatment is required.
Is cellulitis the same as gangrene?
No, it isn’t – although there are some similarities. Gangrene can involve the skin – it is often perceived as a black/purple congested looking limb, with a boundary on the skin slowly up moving up the limb. But with gangrene, the infection is deeper into the muscles as well. Treatment is surgical, with the removal of infectious tissue by cutting it away. It usually requires multiple operations. In an austere situation, the only option is amputation before it spreads into the trunk. It is caused by the bug Clostridium perfringes, from the same family of bugs that causes tetanus and botulism.
In terms of general treatment, the patient should rest and stay hydrated – eating normal meals isn’t vital, but staying hydrated is and the patient should be encouraged to take a small amount of high energy food. If available simple pain relief like acetaminophen/paracetamol (+/- codeine) can be administered.
The specific treatment for cellulitis has two parts.
Firstly, elevation to improve drainage of the area: Elevate the area, ideally above the level of the heart. The body is good at dealing with an infection on a limb, but part of the infectious process is local swelling and the swelling can make it harder to treat. In an austere environment, the elevation is the bit that you can do relatively easily – please don’t under-estimate how useful simple elevation can be. The benefit is rapidly undone if the patient starts using the limb again – so if it is leg cellulitis apart of going to the toilet, stay off it until you start to see an improvement. In the case of arm cellulitis, avoid using them for much at all and focus on the elevation.
The second part is antibiotics: There are several agents which are appropriate for most cellulitis:
- Flucloxacillin 500mg tablets three times a day for 5-7 days (or Dicloxacillin)
- Cephalexan 500mg tablets three times a day for 5-7 days
Cellulitis is most commonly caused by two bacteria – either Staphylococcus aureus or Streptococcus pyogenes and both these antibiotics give good coverage. Since this case is from a freshwater fish then it is possible some other organisms are involved, as bacteria in salt or fresh water or where fish are involved are potentially more unusual.
Given that, there are two additional antibiotic options providing better coverage:
- Amoxycillin and clavulanic acid 625 tablets three times a day for 5-7 days
- Clindamycin 450mg tablet three times a day for 5-7 days
In this case, we used Clindamycin, which covers most of the freshwater bugs as well as the common two.
It is possible that bits of the spine of the fish have broken off in the wound. Without access to ultrasound or x-ray, it is difficult to tell. Currently, we will often go looking for foreign bodies using USS and dissection of the tissues where it is located. This is a significant challenge in an austere situation. If foreign bodies are present they will usually act a focus for a collection of pus – drain the pus and hopefully, the foreign body will float out with the pus. It is not perfect, but most of the time it will clear small foreign bodies.
The last resort for cellulitis is amputation.
With a deep-seated, expanding infection in the absence of antibiotics, the only option is to amputate the limb before the infection gets from the limbs onto the trunk. I am not going to describe in detail the technique for that here, but there are plenty of reference books providing the details for how to do this if required.
The indications for an austere amputation are:
- Massive gangrene.
- Overwhelming local infection that endangers life despite antibiotic therapy and surgical measures if the infection continues to move up the limb.
- Rapidly spreading cellulitis in the absence of antibiotic therapy
- Established death of a limb – the limb is black and pulseless.
Coming soon: The case of a man with a dislocated jaw…
Note: Details and stories have been changed enough to ensure patient privacy.
BCE is a Critical Care doctor who has 25 years’ experience in pre-hospital, remote and austere medicine. He has been a prepper/survivalist for even longer and pessimistically thinks a grid-down long-term collapse is not far away. He is passionate about improving medical knowledge within the prepper community and he is currently working on a book about truly primitive medicine and improvisation. He lives somewhere south of the equator on a Doomstead in a (hopefully) quiet isolated part of the world.
He helped write and edit the book “Survival and Austere Medicine” which is available for free download at https://www.ausprep.org/manuals and from a number of other sites and for purchase (at cost) from Lulu at http://www.lulu.com/shop/search.ep?contributorId=1550817
Questions, comments, and criticisms are welcome – post here and he will respond.