Necrotizing fasciitis
This is a surgical emergency needing immediate resuscitation as per CCrISP protocol. While the majority are caused by GPC like staph and or strep, but many are polymicrobial. Therefore coverage with broad spectrum antibiotics:
- meropenem 1g TDS
- vancomycin 15-20mg/kg tds or bd
- clindamycin 600-900mg qid
Examination can differentiate NF from cellulitis by:
- Severity of sepsis
- Tissue crepitus
- Pain out of proportion to clinical findings
- Overlying tissue necrosis
Risk factors include obesity, immunosuppression and diabetes.
In the workup for suspected necrotizing fasciitis, bloods should be obtained (fbe, uec, crp, lfts, blood cultures). Imaging can be obtained with a CT scan - looking for gas in the soft tissues.
If there is diagnostic uncertainty, then fascial cutdown can be done (either in the ED under local or in theatre).
1. Necrotizing fasciitis clinical scenario
1.1. Front
You are reviewing a 31 year old type 1 diabetic male who recently had a haemorrhoidectomy. He has presented with severe perianal pain. On examination he has erythma extending into his perineum with crepitus.
How do you manage this patient?
1.2. Back
This scenario is extremely concerning for necrotizing fasciitis, which is a surgical emergency. As I am reviewing and examining this patient, I would follow CCrISP principles - ensuring the patient had a patent airway, his breathing was optimised with some oxygen, and would assess and access his circulation with 2 large bore IV cannulas and start immediate crystalloid resuscitation, and treatment with antibiotics.
I would also ensure adequate exposure and satisfy myself that there were no other causes for his sepsis.
Investigations I would send include an FBE, UEC, CRP, LFTs, BCs.
I would then discuss the case with my fellow and consultant informing them that this patient likely needs emergency debridement. If the patient was stable, or the diagnosis was less clear, we could further investigate with a CT scan looking for gas in the soft tissues.
I'd also discuss his case with infectious diseases and ICU as this patient will likely need intensive care support. As a type 1 diabetic, I'd be monitoring his sugars and ketones, ensuring he has his long acting insulin on board, and discussing his case with endocrinology for review.
Finally, assuming he is unstable and needs theatre, I'd be consenting him, or his next of kin if he is obtunded, and discussing with the SA and NIC for emergency theatre space. I'd be discussing with urology and
Operative management is to debride to healthy tissue. Bright fat, twitching muscles. Would bring back within 24 hours for relook. Plastics for flap/reconstruction.
2. Associated Notes