Core EM - Emergency Medicine Podcast

Episode 204: Necrotizing Fasciitis

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We discuss the recognition and treatment of necrotizing fasciitis.

Hosts:

Aurnee Rahman, MD
Brian Gilberti, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Necrotizing_Fasciitis.mp3
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Tags: Critical Care, General Surgery
Show Notes
Table of Contents

0:00 – Introduction

0:41 – Overview

1:10 – Types of Necrotizing Fasciitis

2:21 – Pathophysiology & Risk Factors

3:16 – Clinical Presentation

4:06 – Diagnosis

5:37 – Treatment

7:09 – Prognosis and Recovery

7:37 – Take Home points

Introduction
  • Necrotizing soft tissue infections can be easily missed in routine cases of soft tissue infection.
  • High mortality and morbidity underscore the need for vigilance.
    • Definition
    • A rapidly progressive, life-threatening infection of the deep soft tissues.
    • Involves fascia and subcutaneous fat, causing fulminant tissue destruction.
    • High mortality often due to delayed recognition and treatment.
      • Types of Necrotizing Fasciitis
      • Type I (Polymicrobial)
        • Involves aerobic and anaerobic organisms (e.g., Bacteroides, Clostridium, Peptostreptococcus).
        • Common in immunocompromised patients or those with comorbidities (e.g., diabetes, peripheral vascular disease).
        • Type II (Monomicrobial)
          • Often caused by Group A Streptococcus (Strep pyogenes) or Staphylococcus aureus.
          • Can occur in otherwise healthy individuals.
          • Vibrio vulnificus (associated with water exposure) is another example.
          • Fournier’s Gangrene (Subset)
            • Specific to perineal, genital, and perianal regions.
            • Common in diabetic patients.
            • Higher mortality, especially in females.
              • Pathophysiology
              • Spread Along Fascia
                • Poor blood supply in fascial planes allows infection to advance rapidly.
                • Tissue ischemia worsened by vascular thrombosis → rapid necrosis.
                • High-Risk Patients
                  • Diabetes with vascular compromise.
                  • Recent surgeries or trauma (introducing bacteria into deep tissue).
                  • Immunosuppression (e.g., cirrhosis, malignancy, or immunosuppressive meds).
                  • NSAID use may mask symptoms, delaying diagnosis.
                    • Clinical Presentation

                    Early Signs & Symptoms

                    • Severe Pain out of proportion to exam findings.
                    • Erythema (often with indistinct borders).
                    • Fever, Malaise (systemic signs of infection).
                    • Rapid progression with possible color changes (red → purple).
                    • Bullae Formation (fluid-filled blisters) and skin necrosis/gangrene.
                    • Crepitus in polymicrobial cases (gas production in tissue).

                      • Late-Stage Signs

                      • Systemic toxicity: hypotension, multi-organ failure if untreated.
                        • Diagnosis
                        • Clinical Suspicion Is Key
                          • Pain out of proportion, rapid progression, systemic signs.
                          • The “finger test” (small incision to explore fascial planes).
                          • Surgical Consultation
                            • Early surgical exploration is often the definitive diagnostic step.
                            • Lab Tests
                              • LRINEC Score (CRP, WBC, Hemoglobin, Sodium, Creatinine, Glucose) to stratify risk.
                              • Not definitive but can guide suspicion.
                              • Imaging
                                • CT scan may reveal gas in tissues, fascial edema, or muscle involvement.
                                • Must not delay surgical intervention if clinical suspicion is high.
                                  • Treatment Principles
                                  • Immediate & Aggressive Surgical Debridement
                                    • Often multiple surgical procedures are required as necrosis progresses.
                                    • Debridement back to healthy tissue margins.
                                    • Empiric Broad-Spectrum Antibiotics
                                      • Cover gram-positive (including MRSA), gram-negative, and anaerobes.
                                      • Examples include:
                                        • Vancomycin or Linezolid (for MRSA).
                                        • Piperacillin-tazobactam or Carbapenems (for gram-negative & anaerobes).
                                        • Clindamycin (to inhibit bacterial toxin production).
                                        • Adjust based on culture results later.
                                        • Adjunct Therapies
                                          • Hyperbaric Oxygen Therapy (if available) for resistant cases.
                                          • Evidence is mixed; not universally accessible.
                                          • Supportive Care
                                            • Intensive monitoring, often in an ICU setting.
                                            • Fluid resuscitation & vasopressors for septic shock.
                                              • Prognosis & Disposition
                                              • High Mortality Rate
                                                • Influenced by infection site, patient’s baseline health, and speed of intervention.
                                                • Importance of Rapid Intervention
                                                  • Early recognition, aggressive surgery, and antibiotics improve survival.
                                                  • Long-Term Considerations
                                                    • Patients may require extensive rehabilitation.
                                                    • Reconstructive surgery often needed for tissue deficits.
                                                    • Disposition
                                                      • Operative management is mandatory; patients do not go home.
                                                      • Critical care admission is typical for hemodynamic monitoring and support.
                                                        • Five Key Take-Home Points
                                                        • High Suspicion Saves Lives: Recognize severe pain out of proportion as a critical red flag.
                                                        • Know Your NF Types & Risk Factors: Type I polymicrobial vs. Type II monomicrobial, plus subsets (Fournier’s).
                                                        • Clinical Diagnosis Above All: LRINEC and imaging help, but timely surgical exploration is paramount.
                                                        • Combined Surgical & Medical Therapy: Early debridement + broad-spectrum antibiotics (including toxin inhibition) is lifesaving.
                                                        • Extended Recovery & Mortality Risks: High mortality if missed or delayed. Expect prolonged rehab and possible multiple surgeries.
                                                          • Resources & Further Reading
                                                          • LRINEC Score Calculator 
                                                          • EMCrit – Necrotizing Fasciitis

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