suddenly occur. Signs of impending airway compromise include stridor,
tachypnea, dyspnea, drooling, and agitation. The upper airway may be
distorted making endotracheal intubation difficult or impossible. Cricothy-
rotomy may also be difficult and increases the risk of spreading infection
into the mediastinum. Fiberoptic nasotracheal intubation is preferred.
(a)LA is usually a clinical diagnosis. Soft-tissue radiographs of the
neck may confirm the diagnosis by demonstrating edema of the affected
area, airway narrowing, and gas collections. However, radiographs should
not delay treatment or place the patient in an area where emergent airway
management is difficult. (b)Prior to antibiotics, incision and drainage was
the treatment of choice. Today, surgery is used only for those patients who
fail to respond to antibiotic therapy or those with purulent collections. In
these rare cases, surgery, including incision and drainage then excision of
facial planes, would best be performed in an operating room (OR), not at
the bedside. Patients with LA without respiratory compromise should be
maintained in a sitting position. (c)While steroids have been used for peri-
tonsillar abscesses to decrease inflammation, their value for LA is unclear.
(d)Antibiotics must be started immediately. Appropriate regimens include
high-dose penicillin with metronidazole, or cefoxitin used alone. Clin-
damycin, ticarcillin-clavulanate, piperacillin-tazobactam, or ampicillin sul-
bactam may also be used. Oral antibiotics are not adequate.
177.The answer is a.(Tintinalli, p 1523.)Erysipelas is an acute super-
ficial cellulitisof the dermis, lymphatics, and subcutaneous tissue. It is
characterized by a sharply demarcated bordersurrounding skin that is
raised, deeply erythematous, indurated, and painful, and is associated with
nephrotic syndrome, postoperative wounds, and small breaks in the skin.
Erysipelas is more superficial than cellulitis and is more likely to occur in the
young and in the elderly, but the distinction between the two is often subtle
and therapeutically irrelevant. Treatment of erysipelas and facial cellulitis
requires hospital admission and parenteral antibiotics. Treatment is aimed at
the predominant organism, group A Streptococcus,butStaphylococcusand
otherStreptococcusspecies are also found. An immediate ophthalmologic
consult should be obtained if there is any orbital or periorbital involvement.
(b)While cellulitis may often be treated with oral antibiotics, treatment
for erysipelas or facial cellulitis warrants parenteral antibiotics. A Tzanck
smear is a test that is done to diagnose infections caused by herpesviruses.
Cells are examined under a microscope for evidence of inclusion bodies.
(c)Erysipelas and facial cellulitis may be unilateral or bilateral. When
198 Emergency Medicine