Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Feb 13 2024

Necrotizing Fasciitis

Images
https://upload.orthobullets.com/topic/1007/images/flesh_eaten[1]_moved.jpg
https://upload.orthobullets.com/topic/1007/images/screen_shot_2017-04-02_at_9.29.47_am.jpg
https://upload.orthobullets.com/topic/1007/images/screen_shot_2017-04-02_at_9.29.27_am.jpg
https://upload.orthobullets.com/topic/1007/images/screen_shot_2017-04-02_at_9.28.33_am.jpg
https://upload.orthobullets.com/topic/1007/images/screen_shot_2017-04-02_at_9.28.11_am.jpg
https://upload.orthobullets.com/topic/1007/images/screen_shot_2017-04-02_at_9.28.01_am.jpg
  • summary
    • Necrotizing Fasciitis is a life-threatening bacterial soft tissue infection that spreads along soft tissue planes rapidly.
    • Diagnosis is made clinically with the presence of skin discoloration, bullae, palpable crepitus and calculation of the LRINEC score. Emergent frozen section can help confirm diagnosis in early cases.
    • Treatment is emergent radical debridement of all devitalized tissues with broad-spectrum IV antibiotics.
  • Epidemiology
    • Risk factors
      • immune suppression
        • diabetes
        • AIDS
        • cancer
        • obesity
      • bacterial introduction
        • IV drug use
        • hypodermic therapeutic injections
        • insect bites
        • skin abrasions
        • abdominal and perineal surgery
  • Etiology
    • Associated conditions
      • cellulitis
        • overlying cellulitis may or may not be present
  • Classification
      • Necrotizing Fasciitis Classification
      • Type
      • Organism
      • Characteristics
      • Polymicrobial
      • Typically 4-5 aerobic and anaerobics pecies cultured:
      • Non-Group A Strep
      • Anaerobes including Clostridia
      • Facultative anaerobes
      • Enterobacteria
      • Synergistic virulence between organisms
      • Most common (80-90%)
      • Seen in immunosuppressed (diabetics and cancer patients)
      • Postop abdominal and perineal infections
      • Monomicrobial
      • Group A β-hemolytic Streptococci is most common organism isolated
      • 5% of cases
      • Seen in healthy patients
      • Extremities
      • Type 3
      • Marine Vibrio vulnificus
      • (gram negative rods)
      • Marine exposure
      • Type 4
      • Fungal
  • Presentation
    • Symptoms
      • early
        • localized abscess or cellulitis with rapid progression
        • minimal swelling
        • no trauma or discoloration
      • late findings
        • severe pain
        • high fever, chills and rigors
        • tachycardia
    • Physical exam
      • skin bullae
      • discoloration
        • ischemic patches
        • cutaneous gangrene
      • swelling, edema
      • dermal induration and erythema
      • subcutaneous emphysema (gas producing organisms)
  • Imaging
    • Radiographs
      • not required for diagnosis or treatment
  • Studies
    • Biopsy
      • indications
        • emergent frozen section can confirm diagnosis in early cases
      • technique
        • take 1x1x1cm tissue sample
        • can be performed at bedside or in operating room
        • surgical intervention should not be delayed to obtain
      • histological findings
        • necrosis of fascial layer
        • microorganisms within fascial layer
        • PMN infiltration
        • fibrinous thrombi in arteries and veins and necrosis of arterial and venous walls
    • LRINEC Scoring system
      • score > 6 has PPV of 92% of having necrotizing fasciitis
        • CRP (mg/L)
          • ≥150: 4 points
        • WBC count (×103/mm3)
          • <15: 0 points
          • 15–25: 1 point
          • >25: 2 points
        • Hemoglobin (g/dL)
          • >13.5: 0 points
          • 11–13.5: 1 point
          • <11: 2 points
        • Sodium (mmol/L)
          • <135: 2 points
        • Creatinine (umol/L)
          • >141: 2 points
        • Glucose (mmol/L)
          • >10: 1 point
  • Differentials
    • Gas gangrene
  • Treatment
    • Operative
      • emergent radical debridement and broad-spectrum IV antibiotics
        • indications
          • whenever suspicion for necrotizing fasciitis
        • antibiotics
          • initial antibiotics
            • start empirically with penicillin, clindamycin, metronidazole, and an aminoglycoside
          • definitive antibiotics
            • penicillin G
              • for strep or clostridium
            • imipenem or doripenem or meropenem
              • for polymicrobial
            • add vancomycin or daptomycin
              • if MRSA suspected
        • technique
          • hemodynamic monitoring with systemic resuscitation is critical
          • hyperbaric oxygen chamber if anaerobic organism identified
          • operative findings
            • liquefied subcutaneous fat
            • dishwater pus
            • muscle necrosis
            • venous thrombosis
      • amputation
        • indications
          • low threshold for amputation when life threatening
  • Prognosis
    • Life threatening infection
      • mortality rate of 32%
      • mortality correlates with time to surgical intervention
Card
1 of 26
Question
1 of 12
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options