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***Must inform registrar and/or consultant on-call***
introduction (1,2)
introduction (1,2)
- Life-threatening infection that spreads rapidly along fascial planes and subcutaneous tissue with mortality of around 53%.
- Classification:
- Type I. Mixed/polymicrobial (80%) – anaerobes (e.g. E. coli) and aerobes (e.g. S. aureus). More common with elderly or patients with co-morbidities such as diabetes
- Type II. Monomicrobial – classic ‘flesh-eating bacteria’ that is usually caused by b-haemolytic streptococci.
- Type III. Clostridial – ‘gas gangrene’ with myonecrosis usually due to C. perfringens. Often follows trauma/surgery, or Vibrio species
- Type IV. Fungal
- Mechanism or injury and demographics
- Could be due to trauma, bite, scratch, sting, recent surgery, or haematogenous spread with no known focus of infection
- Can be young fit individuals, however immunocompromise predisposes individuals (history of diabetes, elderly, steroids, HIV)
- Fournier's Gangrene - Necrotizing Fasciitis of the scrotum and perineum. Requires management jointly with urology and/or general surgery
Image reference: Necrotising Fasciitis. Licensed with CC BY 2.0, via Wikimedia Commons
assessment
assessment
- Symptoms:
- Intense pain out of proportion to visible injury (if any).
- Systemic toxicity - visibly unwell patient
- Obtunded or unresponsive
- Signs:
- Signs of septic shock: pyrexia, tachycardia, hypotension, impaired consciousness.
- Rapidly progressing erythema.
- Vesiculation +/- bullae +/- crepitus may be present in the area of concern.
- N.B. - May not present with any obvious skin changes
- Investigations:
- Obtain LRINEC score: FBC, U&E, CRP, Glucose
- ABG – High lactate represents decompensation! acidosis, hypoxia, respiratory failure.
- Other Bloods: Clotting, LFTs, blood culture (before Antibiotics therapy)
- Wound swabs (if applicable)
- XR of soft tissue if crepitus is present – subcutaneous gas may be visible.
Management (1,3)
Management (1,3)
- Keep NBM
- 2x large bore IV access
- Urinary Catheter
- Start IV fluids
- Start on antibiotics as per local protocol
- Contact registrar/consultant on-call.
- Seek urgent microbiology advice.
- Seek early intensive care opinion.
- Inform theatres after patient discussed with senior
- Mark any areas of redness and reassess for rapid spread
- Patients require early and radical surgical debridement.
references
references
1. Chiu TW. Stone’s Plastic Surgery Facts: A Revision Guide, Fourth Edition. CRC Press; 2018. 2. Sultan HY, Boyle AA, Sheppard N. Necrotising fasciitis. BMJ. 2012 Jul 27;345(jul20 1):e4274–e4274. 3. Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug;51(8):344–62.
Useful resource:Tidy C. Necrotising Fasciitis. patient.co.uk. 2015 Jul 29. 2495 (v23)
Image References:Header Image Reference: Licensed by Adobe Stock (2019)Necrotising Fasciitis Reference: By Piotr Smuszkiewicz, Iwona Trojanowska and Hanna Tomczak [CC BY 2.0, via Wikimedia Commons]
Useful resource:Tidy C. Necrotising Fasciitis. patient.co.uk. 2015 Jul 29. 2495 (v23)
Image References:Header Image Reference: Licensed by Adobe Stock (2019)Necrotising Fasciitis Reference: By Piotr Smuszkiewicz, Iwona Trojanowska and Hanna Tomczak [CC BY 2.0, via Wikimedia Commons]
This subpage has been reviewed by:
1) Mr. Martin Shapev - Plastic Surgery Registrar, RD&E (06/02/2020)
1) Mr. Martin Shapev - Plastic Surgery Registrar, RD&E (06/02/2020)
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