Necrotizing fasciitis: Difference between revisions
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**CT is study of choice | **CT is study of choice | ||
{{LRINEC SCORE}} | |||
===HUCLA NF vs Non-NF Criteria (Wall et al)=== | ===HUCLA NF vs Non-NF Criteria (Wall et al)=== | ||
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*Useful tool to rule out NF, not a good tool for confirming presence of NF | *Useful tool to rule out NF, not a good tool for confirming presence of NF | ||
**Helps distinguish NF from non-NF infection, when classic 'hard' signs of NF are absent however clinical judgment should still be used in patient with high suspicion of the disease | **Helps distinguish NF from non-NF infection, when classic 'hard' signs of NF are absent however clinical judgment should still be used in patient with high suspicion of the disease | ||
==Management== | ==Management== | ||
Revision as of 14:35, 19 December 2015
Background
- A rare, rapidly progressive infection primarily involving the fascia and subcutaneous tissue
- Most severe form of soft tissue infection and potentially limb and life threatening
- Early recognition and aggressive debridement are major prognostic determinants and delay increases mortality[1]
Risk Factors
- DM
- Drug use
- Obesity
- Immunosuppression
- Recent surgery
- Traumatic wounds
Clinical Features
- Skin exam
- Erythema (without sharp margins)
- Exquisitely tender (pain out of proportion to exam)
- Skip lesions
- Hemorrhagic bullae (violaceous bullae)
- May be preceded by skin anesthesia (destruction of superficial nerves)
- Crepitus (in type I infections)
- Swelling/edema may produce compartment syndrome
- Constitutional
- Fever
- Tachycardia
- Systemic toxicity
Differential Diagnosis
Skin and Soft Tissue Infection
- Cellulitis
- Erysipelas
- Lymphangitis
- Folliculitis
- Hidradenitis suppurativa
- Skin abscess
- Necrotizing soft tissue infections
- Mycobacterium marinum
Look-A-Likes
- Sporotrichosis
- Osteomyelitis
- Deep venous thrombosis
- Pyomyositis
- Purple glove syndrome
- Tuberculosis (tuberculous inflammation of the skin)
Diagnostic Evaluation
Work-Up
- CBC
- Chem
- PT/PTT/INR
- CK
- Lactate
Evaluation
- Surgical exploration is the ONLY way to definitively establish the diagnosis of necrotizing infection
- Imaging
- Should not delay surgical exploration
- CT is study of choice
Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score[2]
Has not been prospectively validated, index of suspicion is key and 10% of the patients with a score < 6 had Necrotizing Fasciitis. A score > 6 has PPV of 92% and NPV of 96% for 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 >180 mg/dL (10 mmol/L): 1 point
Grouping by Scores
- Low Risk: score 5 (10% of pts with score < 6 still had nec fasc)
- Moderate Risk: score 6– 7
- High Risk: score >8
HUCLA NF vs Non-NF Criteria (Wall et al)
- Retrospective study discovered:[3]
- WBC count >15.4(x103/mm3) OR Na <135(mmol/L)
- Associated with NF and combo of both increased likelihood of NF
- PPV 26%/NPV 99%
- Useful tool to rule out NF, not a good tool for confirming presence of NF
- Helps distinguish NF from non-NF infection, when classic 'hard' signs of NF are absent however clinical judgment should still be used in patient with high suspicion of the disease
Management
- Surgical exploration and debridement is both the definitive diagnostic modality and the definitive treatment
- Indicated in setting of severe pain, toxicity, fever, elevated CK (with or without radiographic evidence)
- Antibiotics
- Must cover gram positives, gram negatives, and anaerobes (especially GAS and clostridium)
- Piperacillin-Tazobactam 3.375-4.5g q6hr AND clindamycin 600-900mg q8hr AND vancomycin 1gm IV q12hr
- In diabetics, maintain strict glycemic control (with IVFs and IV insulin if necessary)
Disposition
- Admit to ICU
See Also
- Necrotizing soft tissue infections
- Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score
- EBQ:LRINEC Score
References
- ↑ Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004). "The LRINEC Laboratory Rother soft tissue infections". Critical Care Medicine 32 (7): 1535–1541. doi:10.1097/01.CCM.0000129486.35458.7D. PMID 15241098
- ↑ Wong C. "The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections". Crit Care Med. 2004. 32(7):1535-41.
- ↑ Wall DB et al. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Surg. 2000 Sep;191(3):227-31.