NECROTIZING FASCITIS

Question 1

(1) rare and rapidly progressing infections involving any layer of soft tissue including skin, subcutaneous fat,
fascia, and/or muscle.
(2) associated with extensive tissue destruction, systemic toxicity, limb loss and are potentially fatal.
(3) represent a medical emergency. Early diagnosis, prompt surgical consultation, and initiation of broad-spectrum antibiotics are essential in improving outcomes.

Answer 1

Necrotizing Fasciitis

Question 2

Necrotizing Fasciitis Risk Factors

Answer 2

(a) Major penetrating trauma
(b) Minor laceration or blunt trauma (muscle strain, sprain, or contusion)
(c) Skin breach (varicella lesion, insect bite, injection drug use)
(d) Recent surgery
(e) Mucosal breach (hemorrhoids, rectal fissures, episiotomy)
(f) Immunosuppression
(g) Malignancy
(h) Obesity
(i) Alcoholism

Question 3

Necrotizing Fasciitis Presentation

Answer 3

(1) Most frequently occurs in the extremities (Predilection for the lower leg) and may mimic DVT.
(2) Initially there is pain, erythema, edema, cellulitis and high fever.
(3) pain is progressive, relentless, and severe and is often out of proportion to the severity of the physical findings.***
(4) Skin exam may be unrevealing early on, or may be confused with cellulitis or abscess; may see blistering, crepitus, soft tissue edema, erythema, discoloration,
necrosis, bullae, vesicles, or ulceration

Question 4

Differential Diagnosis

Answer 4

(1) Deep Vein Thrombosis

(2) Cellulitis

Question 5

Labs/Studies/Imaging

Answer 5

(1) MRI
(2) X-ray, CT or US-air bubble in the soft tissues.
(3) Cultures: Group A Strep and mixed aerobic and anaerobic bacteria.
(4) Direct inspection at surgery shows the fascia is swollen and dull gray with areas of necrotic tissue.

Question 6

Necrotizing Fasciitis Treatment

Answer 6

(1) Prompt and wide surgical debridement is the cornerstone of treatment.
(a) Extensive, definitive debridement should be the goal with the first surgery. This may require amputation of an extremity to control the disease. Surgical debridement is repeated until all infected devitalized tissue is removed.
(2) Broad-spectrum antibiotics once diagnosis of NSTI is suspected.
(a) Antibiotics are the main adjunctive therapy to surgery. Broad-spectrum empiric antibiotics should be started immediately when NF is suspected and should include coverage of Gram positive, Gram-negative, and
anaerobic organisms.

Question 7

Disposition

Answer 7

(1) Immediate medevac is required for this patient.
(2) Close contacts of patients and health care workers do not require chemoprophylaxis with antibiotics (good to brief the CoC on)

Question 8

Complications

Answer 8

(1) Toxic shock syndrome (acute toxin-mediated febrile illness caused by the production and release of exotoxins by S. aureus.)
(2) Amputation
(a) Septic shock
(3) Death