cellultis necrotizing Fasciitis Burn

1. Cellulitis/nec.fasc/burn
Mr.Mekki Hassan
Surgical Registrar
Universiy Hospital Waterford

2. Cellulitis
clinical presentation
• A 56-year-old diabetic on the ward presents with a
hot, swollen right lower leg, DD, plan of
management?
• Take a history and perform a full examination
(looking for signs of infection, demarcation,
abscesses, diabetic ulcers, skin trauma/IV access
and regional lymphadenopathy) and review the
charts.
• Take bloods for FBC, CRP, U+Es, Glc and blood
cultures if septic (high WCC and CRP will indicate
systemic upset; baseline creatinine will help guide
antibiotics if indicated).
• The differential is DVT and cellulitis

3. aetiology
• What bacteria typically cause cellulitis?
• Streptococcus pyogenes and Staphylococcus aureus
• Immunocompromised patients can become infected from
opportunistic organisms (Pseudomonas, Proteus) and anaerobes

4. classification
• How is cellulitis classified?
• I: no systemic toxicity
• II: significant comorbidity
• III: significant systemic upset
• IV: necrotising fasciitis

5. Medical treatment
• I would consult hospital antimicrobial guidelines:
• First line—PO flucloxacillin (narrow-spectrum active against staph and
strep); PO erythromycin or clarithromycin if allergic ,oral clindamycin
• Second line—IV flucloxacillin and benzylpenicillin. PO clarithromycin
or IV teicoplanin if allergic (if this is associated with a diabetic ulcer, I
would change to IV Co–Amoxiclav—broader spectrum cover)/iv
clindamycin
• Third line—IV benzylpenicllin and ciprofloxacin (discuss with
microbiology/linezolid?)

6. Surgical treatment
• When would you consider surgical intervention?
• Cellulitis associated with an abscess requires surgical drainage of the
source of infection for adequate treatment.
• Clinical concerns for necrotising fasciitis include crepitus,
circumferential cellulitis, necrotic-appearing skin, rapidly evolving
cellulitis, pain disproportional to physical examination findings, severe
pain on passive movement

7. necrotising fasciitis
clinical presentation:
• It is 1 a.m. A 65-year-old diabetic male presents with a painful red
swelling in his right thigh and groin. He is pyrexial, hypotensive and
dehydrated.DD, How will you treat him?
• Resuscitate the patient with oxygen and IV fluids and take baseline
bloods, BM, urinalysis and arterial gases.
• Take a history and examine the patient.
• Check for trauma, IV drug use, symptoms of bowel obstruction.
• Consider differential diagnosis—cellulitis/abscess/necrotising fasciitis/
strangulated hernia

8. Definition and aetiolgy
• What is necrotising fasciitis?
It is polymicrobial infection of skin and fascia with necrosis of
subcutaneous tissue, sparing the underlying muscle.
• It can progress rapidly to severe sepsis, multiorgan failure and death.
• Primary necrotising fasciitis is due to bacterial entry from mild skin
trauma.
• Secondary necrotising fasciitis is due to prior infection (e.g., deep
abscess/ visceral perforation).
• Risk factors are diabetes, immunosuppression, steroids, old age,
malnourishment and renal failure.

9. signs
• What are the clinical signs?
• Erythema, swelling, and pain
• Warning signs: dusky blue skin, crepitus
(indicating gas in the tissues), patchy
areas of necrosis, bullae and signs of
systemic sepsis

10. diagnosis
• How would you confirm the diagnosis?
• Blood tests: leucocytosis, acidosis, deranged
clotting, hypoalbuminaemia, abnormal
renal function
• Imaging: soft tissue gas on x-ray or CT (if
the patient is stable)
• Stab incision over crepitus releases murky
fluid from skin.

11. classification
• How do you classify necrotizing fasciitis?
• Type 1: polymicrobial.
• Type 2:strep pyogenes related (15%)
• Type 3:gas gangrene (clostridium perfrenges)

12. treatment
• How would you treat the patient?
• IV broad spectrum antibiotics are used against Streptococcus, Gram-
negative aerobes (E. coli and Pseudomonas), anaerobes (Bacteroides): •
Start with augmentin/metronidazole initially and consult with the
microbiologist on call.
• Take patient to theatre following initial resuscitation (may need HDU/ITU)
because this is a life-threatening emergency.
• Incise down to deep fascia; debride all nonviable tissue.vaC therapy
• Take back in 24 hr for a second look and further debridement.
• Some studies report the benefit of hyperbaric oxygen (controversial and
not widely use

13. Burn
• What are the causes of burn?
• Thermal
• Chemical
• Electrical
• Friction

14. assessment
• How to assess burn:
• History : mechanism ,duration, confined pace , associated
circumstances
• Exam:
• Depth
• percentage

15. classification
• Types of burn/depth
type level C/F blanching treatment
superfecial epidermis Red ,moist + conservative
Superfecial
partial
thickness
Part of
papillary
dermis
Pale ,dry + conservative
Deep partial
thickness
Full papillary
dermis
Red , mottled - surgical/burn
centre
Full thickness subcutaenous Lethary,hard - Burn centre

16. percentage
• Percentge:
• Lund and broader chart
• Wallace rule of 9
• Palmer surface 0,8 % burn
• > 15 % require fluid rescus

17. treatment
• How to manage(discuss with plastics?!)
• ATLS
• Fluids :parkland formula 4x%BSAx WT = ½ 8 hrs ½ 16 hrs
• Analgesia
• Emergency escharotomy
• Wound management
• Transfer to burn unit :
• Burn shock /face ,hand ,premium/deep/full thickness burn/electrical
,chemical burn