Necrotising fasciitis is a surgical emergency having mortality 30–50% even with the best care. Therefore immediate diagnosis & management is a must.

1. by Yapa Wijeratne
Faculty of Medicine
University of Peradeniya
Sri Lanka

2.  Infection of subcutaneous tissue->
destruction of fascia and fat
 Rapidly progressive bacterial infection
 Pain, erythema edema, fever->severe pain
with limb swelling->high fever, bluish
discoloration & blisters Gangrene and &
muscle necrosis

3. 1. Oedema beyond area of erythema
2. Crepitus
3. Skin blistering
4. Fever (often absent)
5. Greyish drainage (‘dishwater pus’)
6. Pink/orange skin staining
7. Focal skin gangrene (late sign)
8. Final shock, coagulopathy and multiorgan failure

5.  Polymicrobial, synergistic infection –
 Most commonly a streptococcal species (group aβ
haemolytic) in combination with
 Staphylococcus,
 Escherichia coli,
 Pseudomonas,
 Proteus,
 Bacteroides or
 Clostridium;
 80% have a history of previous trauma/infection
 over 60% commence in the lower extremities.

6. 1. Diabetes
2. Smoking
3. Penetrating trauma
4. Pressure sores
5. Immunocompromised states
6. Intravenous drug abuse
7. Skin damage/infection (abrasions, bites & boils)

7.  Febrile and tachycardic (early stages)
 Very rapid progression to septic shock.
 Oedema stretching beyond visible skin erythema,
 Disproportionate pain in relation to the affected area
 Skin vesicles
 Palpation
◦ A woody hard texture to the subcutaneous tissues,
◦ An inability to distinguish fascial planes & muscle groups
◦ Soft-tissue crepitus.
 Lymphangitis tends to be absent.

8.  Radiographs : air in the tissues
 Diagnosis: on the basis of symptoms and signs
without recourse to ‘screening radiography’
 unnecessary delay may be lethal.

9. 1. Urgent fluid resuscitation,
2. Monitoring of haemodynamic status
3. High-dose broad-spectrum IV antibiotics.
4. Surgical debridement- diseased area should be
debrided ASAP until viable, healthy, bleeding
tissue is reached.

10.  Advisable,
◦ Early review in the operating theatre
◦ Further debridement
◦ Use vacuum-assisted dressings.
 Early skin grafting - may minimise protein and fluid
losses.
 Mortality 30–50%

11.  Case
 76 yr old H/w from Kandy presented with swelling of the left LL
for 5days. She was apparently well before & developed mild
fever with left leg pain. Leg pain was severe, resting type, not
radiating, persistent throughout the day, & not responding to
the PCM. Swelling was developed with redness & accidental
trauma has ulcerated the causing discharge. She was admitted
to the local hospital on 3rd day but no surgical intervention was
made. 5th day after onset of symptoms she was transferred to
THK.
 She has had STEMI 1yr ago. No Diabetes mellitus.
 On admission she was afebrile, haemodynamically stable.
Examination of CVS, RS, abdomen & NS clinically normal.
 WBC 29k/ul ↑↑
 Urea 125 mg/dl (10-50) ↑↑
 SE, RBC, Hb, PLT, RBS normal.
 ECG: sinus arrythmia, p mitrale
 ECHO revealed EF 45% impaired LV function with diastolic
dysfunction. G II MR+ AR+

12.  Spinal anesthesia given.
 Indurated upto mid thigh. Able to move toes. Skin
necrosis +. Pulse – difficult to feel.
 Necrotized tissue excised. Underlying fascia split.
Underlying muscle viable.
 Necrotising fasciitis

13. 1. NBM
2. QHT
3. Input/ output chart
4. Elevate footend
5. > 3 ʘ N/s IV
6. 2 ʘ Hartmann
7. IV meropenem 500mg bd
8. Tramadol 50 mg tds
9. Domperidone 10mg bd
10. IM Pethidine 75 mg SOS
11. IM Phenagan 25 mg SOS
12. Monitor PR/ RR/ BP 1 hrly