Necrotizing Fasciitis Mini Lecture

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Necrotizing FasciitisMini Lecture

• UCI 1/14/15

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Objectives

• - When to Suspect Nec Fasc
• - Risk Factors
• - Signs Symptoms
• LRINEC Criteria
• - What to Do

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Actual Case from VA

• Overnight HPI Pt. is a 62 y/o M with poorly
  controlled IDDM and HTN who presents with L foot
  pain and redness x 2-3 days. The patient saw
  podiatry 3 weeks prior and had calluses removed
  from the affected foot, which was nicked in the
  process. He came in as the top of his foot was
  becoming increasingly red and painful making it
  harder to walk or stand. The pain was 7/10 at
  rest, localized to the foot, no radiation, worse
  with walking/standing.

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History Exam

• ROS was negative
• Soc Hx former smoker, no ETOH or drugs

• VS Hr 88, BP 175/90, Temp 98.4F, RR 20
• Exam benign except for 5x5cm erythematous patch
  on the dorsum of the L foot, tender to palpation,
  with 1cm ulceration with surrounding erythema on
  the ball of the foot with no drainage, L calf
  tenderness on palpation but no skin findings

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Abnormal Labs

• BMP Sodium 130, creatinine was 1.6 (baseline
  1.2), glucose 225
• A1C 10.8
• CBC WBC 15.5 with neutrophilic predominance, Hgb
  11.5, normal platelets
• BCX pending, UA clean
• CRP 180

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Is the Patient At Risk for Nec Fasc?
YES!

• What are the risk factors for nec fasc?

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Risk Factors

• Diabetes (particularly poorly-controlled)
• Injection drug use
• Alcoholism
• Obesity
• Immune suppression (cancer, transplant, on
  steroids, etc.)
• Chronic illness

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Signs/Symptoms of Nec Fasc

• Local
• Very early - pain out of proportion to findings
• Early - Swelling erythema
• Late - purpleish discoloration blistering
• /- Crepitus
• /- 'dishwater' colored fluid drainage
• /- tracking of erythema or tenderness
• Systemic
• SIRS , diarrhea and vomiting can occur

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Necrotizing Fasciitis
Early Presentation
Late Presentation
UCSD MedEd
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LRINEC Criteria

• Scoring system based on common lab results that
  asses the pretest probability for having
  necrotizing fasciitis. (CRP is important here.)
• Useful when the clinical presentation is
  uncertain.
• If clinical suspicion is high, treat and consult
  surgery regardless of the LRINEC score!!

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LRINEC Criteria
Our patient's score 9
He has HIGH (gt75) probability of Nec Fasc.
Yikes!!
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Who to Call Early Treatment

• 1. Vanc/Zosyn (cover staph/strep) and Clindamycin
  (stop toxin production)
• 2. Stat surgical consult
• 3. Supportive Care
• Control blood sugar, treat AKI, etc.
• Only Definitive Tx surgical intervention
• Nec Fasc is a surgical emergency!

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Back to the Case

• ER had put him on Vanc/Zosyn in ER, so we added
  Clindamycin and stat consulted Ortho.
• Ortho took him to the OR that day and saved his
  foot ) The patient was very grateful.
• We got his diabetes under control and his AKI
  resolved and he went for rehabilitation on IV
  antibiotics.

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Summary

• Recognize nec fasc and get surgery involved early
  
• Recognize Risk Factors
• Exam findings
• High suspicion ? treat and consult
  surgery
• Unsure ? calculate LRINEC score
• LRINEC score gt5 ? treat consult
  surgery!
• lt5 ?
  nec fasc unlikely
• Treatment
• Vanc, Zosyn, Clindamycin
• STAT SURGERY CONSULT
• Supportive

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Summary
Remember, nec fasc is a surgical emergency and
surgery is the only definitive treatment! Mortali
ty is very high, but the earlier you catch it,
the more life and limb you save )
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Summary

• Recognize nec fasc and get surgery involved early
  
• Recognize Risk Factors
• Exam findings
• High suspicion ? treat and consult
  surgery
• Unsure ? calculate LRINEC score
• LRINEC score gt5 ? treat consult
  surgery!
• lt5 ?
  nec fasc unlikely
• Treatment
• Vanc, Zosyn, Clindamycin
• STAT SURGERY CONSULT
• Supportive