necrotizing fasciitis

1. NECROTIZING FASCITIS
PRESENTED BY ABDURAHMAN MAASHI

2. BACKGROUND
IT IS SOFT TISSUE INFECTION OCCUR IN 500 TO 1500 TIMES A YEAR IN THE US
SOMETIMES ASSOCIATED WITH DIABETES , IV DRUG ABUSE , OBESITY , ALCOHOL
ABUSE , IMMUNE SUPPRESSION , MALNUTRITION
OCCASIONALLY AN INCITING EVENT CAN BE IDENTIFIED BUT IN 20 TO 50 % OF
CASES THE EXACT CAUSE IS UNKNOWN , THESE INFECTIONS ARE ASSOCIATED
WITH A HIGH MORTALITY RANGING FROM 25% TO 40 % WITH THE HIGHER RATES
IN THE TRUNCAL AND PERIANAL AREAS
ANY SITE IN THE BODY CAN BE AFFECTED BUT MOST COMMONLY SITES GENITALIA
, PERINEUM ( FOURNIER’S GANGRENE), ABDOMINAL WALL , LOWER EXTREMITIES

3. SUBCUTANEOUS TISSUE , FASCIA , MUSCLE ALL CAN BE AFFECTED , THE
INFECTION INVOLVES THE FASCIA AND QUICKLY TRAVEL ALONG THE EASILY
SEPARABLE AVASCULAR PLANES

4. TYPES
TYPE 1 POLYMICROBIAL SOURCE INCLUDING GRAM POSITIVE COCCI , GRAM
NEGATIVE RODS , AND ANAEROBIC BACTERIA
TYPE 2 MONOMICROBIAL B-HEMOLYTIC STREPTOCOCCUS OR STAPHYLOCOCCUS
WITH MRSA CONTRIBUTING TO INCREASING THE NUMBER OF COMMUNITY
ACQUIRED NSTI WITH HX OF TRAUMA IS OFTEN ELICITED AND CAN CAUSE TOXIC
SHOCK SYNDROME
TYPE 3 RARE BUT FULMINANT SUBSET RESULT FROM V VULNIFICUS INFECTION OF
TRAUMATIZED SKIN EXPOSED TO BODY OF SALT WATER

5. CLINICAL PRESENTATION
ERYTHEMA , BULLAE , NECROSIS , PAIN AND CREPITUS
THEY MAY EXHIBIT SIGNS OF HEMODYNAMIC INSTABILITY AND GAS WITHING THE
SOFT TISSUES ON IMAGES IS PATHGNOMIC
SYMPTOMS MINIMAL SKIN CHANGES TO FRANK NECROSIS

6. INVESITGATIONS
THERE ARE NO DIFFINTIVE DIAGNOSTIC TEST
C-REACTIVE PROTEIN OCCURES EARLY IN INFECTION
LABORATORY RISK INDICATOR OF NF LRINEC SCORE
BLOOD CULTURE FOR FURTHER ANTIBIOTIC TREATMENT
IMAGING TO DECTED SUBCUTENOUS GAS MRI , CT SCAN , ULTRASOUND
SURGICAL INTERVENTION “ FINGER TEST “

7. LRINEC SCORE

8. A SCORE OF 8 OR GREATER THAN SUGGEST HIGH PROBAILITY OF NSTI
6 TO 7 INTERMEDIATE PROBABILITY , LESS THAN 5 LOW PROBAILITY

9. MANAGEMENT
SOURCE CONTROL WITH WIDE SURGICAL DEBRIDMENT
BROAD SPECTRUM INTRAVNOUS ANTIBIOTICS
SUPPORTIVE CARE AND RESUSCITATION
INCISION MADE PARALLEL TO NEUROVASCULAR STRUCTURES AND THROUGH
FASCIAL PLANE REMOVING ANY PURLENT OR DEVITALIZED TISSUE UNTIL VIABLE
BLEEDING TISSUE
ON INSPECTION TISSUE APPEAR NECROTIC WITH DEAD MUSCLE , THROMBOSED
VESSLES THE CLASSIC “ DISH WATER “ FLUID AND POSITIVE FINGER TEST IN WHICH
TISSUE LAYERS EASILY SEPARATED FROM ONE ANOTHER

10. IN FOURNIER’S GANGRENE YOU SHOULD PRESERVE ANAL SPHINCTER , TESTICLES
RETURN TO OR SHOULD BE PLANNED FOR THE NEXT 24 HR TO 48 HR TO VERIFY
SOURCE CONTROL AND THE EXTENT OF DAMAGE
ANTIBIOTIC THERAPY SHOULD COVERS GRAM POSITIVES , INCULDING MRSA ,
GRAM NEGATIVES , ANAEROBIC
THE INFECIOUS DISEASES SOCIETY OF AMERICA RECOMMENDS INTIATING
VANCOMYCIN AND TAZOCIN UNLESS MONOMICROBIAL AGENT IS IDENTIFIED
ANTIBIOTIC THERAPY SHOULD CONTINUE UNTIL NO FURTHER DEBRIDMENT
NEEDED AND CLINICALLY IMPROVING AND HAS BEEN AFEBRILE FOR 48 TO 72 HR

11. OTHER STRATGIES INCULDE ANTIMICROBIAL CREAMS , SUBATMOSPHERIC
PRESSURE WOUND DRESSING , OPTIMIZATION OF NUTRITION , HYPERBARIC
OXYGEN HAS CONTROVERY
BY INHIBITING INFECTION BY CREATING OXYDATIVE BURST , AND CONTROVERSY
FOR IVIG BY MODULATE IMMUNE RESPONSE TO STREPTOCOCAL SUPERANTIGENS
WOUND CLOUSRE IS PERFORMED ONCE BACTERIOLOGIC , METABOLIC AND
NUTRITIONAL IS OBATIANED