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Initiate broad-spectrum IV antibiotics, mark the margins of erythema, and admit for observation and resolution of erythematous lesion
2%
36/1572
Vascular surgery consultation
34/1572
Discharge with oral antibiotics and outpatient follow-up
1%
8/1572
Emergent surgical debridement
94%
1481/1572
Admission with surgical debridement the next operating day
0%
4/1572
Select Answer to see Preferred Response
The patient is presenting with necrotizing fasciitis of the left hand which requires emergent surgical debridement. Necrotizing fasciitis is a rapidly-progressing and potentially lethal soft tissue infection involving the fascial planes. Most infections are polymicrobial and associated with HIV, IV drug abuse, skin abrasions, and insect bites. Due to the speed of progression, emergent surgical debridement, or amputation is the standard of treatment to minimize soft tissue involvement and reduce mortality. Wong et al. performed a retrospective observational study validating the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for distinguishing necrotizing fasciitis from other infections. They reported the cutoff value of 6 points from the multiple logistic regression model yielded a 92% positive predictive value and 96% negative predictive value. They concluded the LRINEC score is a powerful scoring system that can aid in the early diagnosis of necrotizing fasciitis and patients with score >/= 6 should be carefully evaluated. Gonzalez et al. performed a case series of 12 patients with necrotizing fasciitis of the upper extremity. The authors reported 11/12 cases involved beta-hemolytic streptococcus or polymicrobial infections and were commonly associated with IV drug abuse, diabetes mellitus, and HIV. They concluded early disease recognition is paramount to treatment success due to the rapid and destructive nature of the infection and to minimize morbidity. Figure A is a photograph of the left hand demonstrating bullae, erythema, and swelling indicative of necrotizing fasciitis. Illustration A is a table depicting the LRINEC scoring system. Incorrect Answers: Answer 1: Initiating IV antibiotics is a critical portion of treating necrotizing fasciitis, but should be in conjunction with emergent surgical debridement. Simple observation would lead to increased morbidity or mortality. Answer 2: Vascular surgery consultation would delay the appropriate surgical treatment. Answer 3: Discharging the patient on oral antibiotics would result in the rapid spread of the infection and high mortality rates. Answer 5: Surgical debridement is necessary for effective treatment, but should be performed on an emergent basis.
5.0
(2)
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