Refer to: Goodman SJ, Cahan L, Chow AW: Subgaleal abscessA preventable complication of scalp trauma (Medical Information). West J Med 127:169-172, Aug 1977

Medical Information

Subgaleal Abscess A Preventable Complication of Scalp Trauma STANLEY J. GOODMAN, MD LES CAHAN, MD ANTHONY W. CHOW, MD Torrance, California THE DIAGNOSIS AND 'TREATMENT of subgaleal abscess is most often self-evident and straightforward. However, these lesions frequently are associated with extended morbidity, and the diagnosis may not be initially obvious. Furthermore, such abscesses are often related to physician errors of omission or commission, and are frequently preventable. Our recent experience with five such cases within a short interval suggests that this complication is not at all uncommon. Our inability to uncover published information regarding clinical, bacteriological and therapeutic aspects of this entity in the English language literature prompted the present communication.

Reports of Cases CASE 1. A 32-year-old woman was involved in a motorcycle accident and was brought to the emergency room with several parietal and occipital scalp lacerations penetrating to the periosteum. She was lethargic; the neurologic examination gave findings consistent with left frontoparietal contusion. The scalp lacerations were closed in singlelayer fashion with 3-0 nylon, and the patient was admitted on the neurosurgery service. The patient became more alert and lateralizing signs disappeared over five days. On the sixth hospital day a subgaleal abscess was noted beneath one of the repaired scalp lacerations. The patient was afebrile. The abscess was opened, draining foulsmelling purulent pus. Staphylococcus aureus, Peptococcus asaccharolyticus and Peptostreptococcus anaerobius were isolated. The patient was From the Division of Neurosurgery, Department of Surgery (Drs. Goodman and Cahan), and the Infectious Disease Division, Department of Medicine (Dr. Chow), Harbor General Hospital, Torrance, and University of California, Los Angeles, School of Medicine. Reprint requests to: Anthony W. Chow, MD, Division of Infectious Disease, Harbor General Hospital, 1000 West Carson Street, Torrance, CA 90509.

treated with local wound care, methicillin and metronidazole. One month of continuous wound care elapsed before epithelialization and complete healing of the 4 by 5 cm defect occurred. Comment This patient had multiple superficial lacerations and appeared to have been casual in her personal hygiene. In the emergency room, her scalp was not adequately prepared. Too small an area was shaved and too little time was spent in wound irrigation. The resulting prolonged wound morbidity may have been prevented by initial proper scalp care. CASE 2. A 31-year-old man was involved in an auto accident and sustained a 4 cm stellate right frontal scalp laceration, several abrasions and lacerations over the chest and hands, and an Li compression fracture. Neurological examination showed no abnormalities. The scalp laceration was closed in the emergency room in* single-layer fashion. On the fourth hospital day, fluctuance and tenderness developed beneath the scalp laceration and rapidly spread circumferentially involving the eyelid. His temperature, taken rectally, rose to 39.2°C (102.6°F). The subgaleal abscess was opened and nonodorous seropurulent fluid drained. Two drains were placed into the subgaleal space through stab wounds. The incision wound was loosely closed with wire. Beta-hemolytic Group A Streptococcus and S. aureus were isolated. Treatment consisted of parenterally given penicillin and methicillin, and local subgaleal irrigation with bacitracin (50,000 units per liter of saline). The drains were pulled on the sixth day, the sutures removed on the eighth day and the wound healed

uneventfully. Comment When the subgaleal abscess was opened and drained, several in-driven hairs were seen on the periosteum. This abscess may have been prevented by adequate initial wound cleansing. CASE 3. A 5-day-old infant was admitted after pus drained spontaneously from a large, tense subgaleal abscess. Before vaginal delivery, maternal membranes had been artificially ruptured because of prolonged labor. A fetal electrocardiographic monitor consisting of an insulated electrode with a bared corkscrew end hooked into the scalp of the presenting fetal head had been used for one hour during the final stages of labor. A hexachloroTHE WESTERN JOURNAL OF MEDICINE

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phene bath followed by a providone-iodine shampoo (the routine scalp care applied after such fetal monitoring) was administered. The baby was discharged on the third day with a soft right occipital fluctuance thought to be edema. The mother observed a rapid increase in local heat and swelling, and finally pus spontaneously drained through a thinned out portion of the involved scalp. On examination the child was afebrile and normal except for a large 8 by 6 cm inflamed, right occipital-parietal fluctuant mass with purulent drainage through a more anterior scalp defect. X-ray studies of the skull showed no abnormalities. Blood, wound and cerebrospinal fluid (CSF) was cultured. In the operating room, the subgaleal abscess was treated by incision, drainage and the placement of subgaleal catheters. Wound culture yielded alpha-hemolytic Streptococcus, not group A or D, and Veillonella parvula. Cultures of blood and cerebrospinal fluid were sterile. Methicillin was administered parenterally, followed by orally given penicillin, and the subgaleal space was irrigated with bacitracin solution. The wound healed uneventfully.

Comment The subgaleal abscess in contrast to scalp infection is an unusual complication of fetal monitoring. In this patient, the subgaleal space was inoculated by the electrocardiographic corkscrew lead, which was inadvertently inserted too deeply into the scalp. CASE 4. A 70-year-old man sustained a left posterior parietal scalp laceration in a fall. The wound was cleansed, irrigated and closed in a single-layer with nylon. He returned three days later with purulent drainage from the scalp wound which was cleansed and left open. Orally taken penicillin was prescribed and the patient was discharged. He returned seven days later with an extensive 10 by 12 cm necrotizing subgaleal infection. In the center of the wound, there was exposed shiny white bone over a 2 by 3 cm area. Culture showed S. aureus and beta-hemolytic Streptococcus. The scalp was undermined to gain mobility, thoroughly cleansed and irrigated, and the wound edges were approximated after placing four subgaleal drains. Methicillin was given intravenously and subgaleal irrigation with bacitracin carried out. The purulent process subsided but the central portion of the scalp closure became devitalized, exposing a 6 by 6 cm area of white shiny bone. Vigor-

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ous local wound care failed to encourage granulation tissue formation to cover the exposed cranium. Two weeks later, a grid of twist drill holes approximately 5 mm apart was placed through the exposed bone down to dura, and over the following three weeks, granulation tissue grew up through the twist drill holes and gradually covered the denuded bone. One more scalp revision was done, and the scalp wound healed approximately three months after the initial laceration. Comment A necrotizing subgaleal abscess left the calvarium denuded of periosteum. Frequent interval x-ray studies of the skull failed to show frank osteomyelitis, and eventually the bone was covered by granulation tissue and scalp. The intensity of this closed space infection would undoubtedly have been minimized if the wound had been adequately treated when the patient first returned with purulent drainage three days after the laceration repair. CASE 5. A 17-year-old man was found uncon-

scious, apparently having fallen backwards. There was an occipital scalp laceration overlying a simple linear fracture. The patient was lethargic and had mild retrograde and antegrade amnesia; there were no other abnormalities noted. The scalp laceration was cleansed, closed in a single layer, and the patient was transferred to Harbor General Hospital because of suspicion of a seizure disorder. The lethargy and amnesia rapidly cleared. Electroencephalogram, brain scan and carotid angiography all gave normal findings. The patient complained of a stiff neck which was attributed to his fall. A lumbar puncture, however, showed an opening pressure of 265 mm of water, 8,250 red blood cells per ml and 10 leukocytes per ml (six lymphocytes and four polymorphonuclear cells), protein level of 30 mg per 100 ml and glucose value of 80 mg per 100 ml. Cultures of cerebrospinal fluid were sterile. These findings were interpreted as being consistent with posttraumatic subarachnoid hemorrhage, and the patient was discharged eight days after the fall. The patient was readmitted to the hospital two days later. His mother had witnessed several episodes of seizure-like activity. He was febrile (38.60C [101 .60F] rectally) and had definite neck stiffness. The remainder of the neurologic examination was entirely normal. Meningitis was suspected. Cerebrospinal fluid examination showed normal pressure with crystal clear fluid, four leukocytes per

MEDICAL INFORMATION

Although subgaleal abscess may result from hematogenous infection or contiguous spread from calvarial osteomyelitis, the most common cause is direct inoculation of microbes into the subgaleal space following scalp trauma (laceration, or puncture wounds). Once the subgaleal area is infected, inflammation spreads rapidly within the large closed space, threatening the viability of scalp and bone. Intracranial suppuration may result from secondary infection through emissary veins, calvarial foramina, fracture lines or surgical openings in the bone. Scalp lacerations are frequently repaired in emergency rooms by physicians with varied backgrounds and training. The most basic principles of management are often ignored. The scalp must be examinied, retracting hair sufficiently under a bright light to insure thorough inspection. Generous amounts of hair must be shaved when a scalp laceration is identified as extending through galea. Copious irrigation and meticulous cleansing of the wound and adjacent subgaleal space should be done. Wound closure should be done under sterile conditions with particular attention paid to galeal approximation. A sterile occlusive dressing should be applied for at least 72 hours to prevent contamination of the subgaleal space after wound closure is completed. The significance of purulent drainage from a repaired laceration must be stressed in order that extensive subgaleal spread of infection may be prevented by early treatment. Our preferred treatment of subgaleal abscess is surgical incision with meticulous debridement and vigorous cleansing of the subgaleal space. We leave in several subgaleal drains for twice daily irrigation over four to six days. The wound is loosely closed, permitting much quicker healing per primum compared with the delayed healing by secondary closure. Appropriate antibiotic therapy is administered systemically for one week and

ml (three polymorphs and one lymphocyte), 60 red blood cells per ml, protein level of 80 mg per 100 ml, glucose value of 73 mg per 100 ml (serum glucose, 102 mg per 100 ml). Gram stain, india ink preparation aind cultures of the cerebrospinal fluid were all negative. Re-exploration of the occipital laceration site showed there to be a small subgaleal abscess approximately 4 cm in diameter, spontaneously exuding scanty purulent material. The wound was opened and drained. Culture revealed S. aureus. The patient was vigorously treated with local wound care and intravenous cephalothin. The fever and stiff neck rapidly resolved and the wound healed by secondary intention.

Comnment This patient had a parameningeal reaction manifested by fever aind a stiff neck. The source of this reaction was a small subgaleal abscess not initially recognized because of the patient's long hair and an associated incomplete physical examination. This subgaleal abscess collected beneath a scalp laceration, and because of an underlying linear fracture produced inflammatory meningeal signs and symptoms. Consequently, there was a direct route for the potential development of an epidural or intradural suppurative complication.

Discussion A cursory treatment of scalp trauma invites complications. Reviewing his World War I experiences, Cushing cautioned ". . . even among the walking wounded every scalp wound must be regarded as a potential penetrating lesion of the .'" Botterell and Jefferson warned, "We brain have come to learn that many of the more virulent organisms do not enter with the missile but are introduced into the wound when it is being dressed .... The reassuring words of the doctor or nurse bending over the open wound may carry in the

streptococcus."2

TABLE 1.-Bacteriology of Subgaleal Abscess Following Scalp Laceration Isolates Case No.

Aerobes

. Staphylococcus

aureus

2 .Staphylococcus aureus

Anaerobes

Antibiotic(s) of Choice

Peptococcus asaccharolyticus Peptostreptococcus anerobius

Methicillin and

V

Methicillin and penicillin

.

.

.

penicillin

Streptococcus, Group A not Group A 3 .Streptococcus, 4 .Staphylococcus aureus Streptococcus, B hemolytic 5 .Staphylococcus aureus

or D

Veillonella parvula

Pcnicillin Methicillin and penicillin Methicillin

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orally for an additional week. Complicated wounds involving devitalized scalp or bone will obviously require extraordinary treatment regimens. The bacteriology of subgaleal abscess has not been previously reported, and our experience has included recently developed anaerobic culture techniques. We observed that four of five cases involved polymicrobial pathogens (Table 1). S. aureus was isolated in four cases, Streptococcus in three and anaerobic cocci in two cases. Therefore, combined therapy of methicillin and penicillin appears to be the treatment of choice. In patients allergic to penicillin, clindamycin or cephalothin is an excellent alternative since they are effective against S. aureus and Streptococcus, as well as anaerobic cocci.3-5 The polymicrobial cause of subgaleal abscess supports the notion that bacterial synergism may be an important factor in the pathogenesis of serious soft tissue infections, and reaffirms the importance of early surgical intervention in these cases.6-9 Infection restricted to the scalp has been reported as a rare complication of fetal scalp monitoring (electrocardiographic) and blood sampling.'0"'1 Such infections have usually been diagnosed at 4 or 5 days of age, and many of the cases were reportedly "sterile" on routine culture. Sophisticated anaerobic culture techniques were not employed in these studies. We do not know of a previous report of a subgaleal abscess complicating fetal scalp monitoring. Meticulous attention to fundamental principles of surgical management remains the single most important factor in reducing the incidence and morbidity of subgaleal abscess complicating scalp wounds. REFERENCES 1. Cushing H: A study of a series of wounds involving the brain and its enveloping structures. Br J Surg 5:558-684. 1918 2. Botterell EH, Jefferson G: Treatment of scalp wounds in airraids and other casualties. Br Med J 1:781-783, Jun 27, 1942 3. Chow AW, Montgomerie JZ, Guze LB: Parenteral clindamycin therapy for severe anaerobic infection. Arch Intern Med 134:78-82, Jul 1974 4. Fass RJ, Saslaw S: Clindamycin-Clinical and laboratory evaluation of parenteral therapy. Am J Med Sci 263:369-382, May 1972 5. Tally FP, Jacobus NV, Bartlett JC, et al: Susceptibility of anaerobes to cefoxitin and other cephalosporins. Antimicrob Ag Chemother 7:128-132, Feb 1975 6. Baxter CR: Surgical management of soft tissue infections. Surg Clin North Am 52:1483-1499, Dec 1972 7. Brewer GE, Meleney FL: Progressive gangrenous infection of the skin and subcutaneous tissue following operation for acute perforated appendicitis-A study in symbiosis. Ann Surg 84:438450, Sep 1926 8. Finegold SM, Bartlett JG, Chow AW, et al: Management of anaerobic infections. Ann Intern Med 83:375-389, Sep 1975 9. Meleney FL: Clinical Aspects and Treatment of Surgical Infections. Philadelphia, W. B. Saunders Co., 1949 10. Balfour HH, Block SH, Bowe ET, et al: Complications of fetal blood sampling. Am J Obst Gynecol 107:288-294, May 1970 11. Cordero L Jr, Hon EH: Scalp abscess: A rare complication of fetal monitoring. J Ped 78:533-536, Mar 1971

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Refer to: Sung JP, O'Hara VS, Lee C-Y: Barium peritonitis (Medical Information). West J Med 127:172-176, Aug 1977

Medical Information

Barium Peritonitis JAMES P. SUNG, MD VINCENT S. O'HARA, MD CHI-YAN LEE, MD Fresno, California BARIUM MEAL (upper gastrointestinal) and barium enema studies have long been considered essential procedures for evaluating diseases of the gastrointestinal tract. While it is generally accepted that these procedures are safe and morbidity is low, unfortunately such procedures are not entirely innocuous and serious complications have been reported, including necrotizing proctitis,' peritonitis,2 barium granuloma of the rectum,3 septicemia,4 embolization5 and fatal intravasation.6 Between March 1974 and October 1975 three cases of barium peritonitis occurred in our hospital from perforation of the gastrointestinal tract during routine barium meal or barium enema examinations. In one patient there was extravasation through a normal cecum and hypovolemic shock developed while he was still on' the x-ray table. In another patient, who had a gastric pytlet obstruction, an anterior gastric ulcer perforated 72 hours after an upper gastrointestinal study. In a third patient, a normal rectum perforated and symptoms of peritonitis developed six hours after a barium enema procedure. The patients with the cecal and the gastric perforations were treated with aggressive fluid resuscitation; immediate surgical resection of the site of perforation; removal of the barium, feces or other foreign bodies, and peritoneal lavage with large volumes of physiological saline. The patient with the rectal perforation was treated medically with nasogastric suction, fluid therapy and antibiotics. All three patients survived the described treatment.

Rectal Laceration Most rectal lacerations occur between 3 and 8 cm from the anal verge on either the anterior or From the Departments of Surgery (Drs. Sung and O'Hara), and Internal Medicine (Dr. Lee), Veterans Administration Hospital, Fresno. Reprint requests to: James P. Sung, MD, Veterans Administration Hospital, 2615 E. Clinton Ave., Fresno, CA 93703.

Subgaleal abscess: a preventable complication of scalp trauma.

Refer to: Goodman SJ, Cahan L, Chow AW: Subgaleal abscessA preventable complication of scalp trauma (Medical Information). West J Med 127:169-172, Aug...
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