54 year old male with left leg pain and sob ninad a. shroff, md

54 Year Old Male with Left Leg Pain and 54 Year Old Male with Left Leg Pain and SOBSOB

Ninad A. Shroff, MDNinad A. Shroff, MD


09:25: Arrival via BLS unit09:25: Arrival via BLS unit Seen previous day in the ED for left Seen previous day in the ED for left

thigh pain after exercise and diagnosed thigh pain after exercise and diagnosed with a musculoskeletal injurywith a musculoskeletal injury

Shortness of breath began few hours Shortness of breath began few hours prior to arrivalprior to arrival

No chest painNo chest pain


Past Medical HistoryPast Medical History HypertensionHypertension Peptic Ulcer DiseasePeptic Ulcer Disease Unclear liver diseaseUnclear liver disease

MedicationsMedications PropranololPropranolol FurosemideFurosemide AmilorideAmiloride AcetaminophenAcetaminophen PercocetPercocet


Initial Physical ExamInitial Physical Exam T: 97.0 BP: 122/82 P: 116 R: 33 Pox: T: 97.0 BP: 122/82 P: 116 R: 33 Pox:

89%89% Patient in mild respiratory distressPatient in mild respiratory distress Lungs: ClearLungs: Clear Heart: Regular, tachycardiaHeart: Regular, tachycardia MSK: Left thigh swollen with some MSK: Left thigh swollen with some

ecchymosis and a 4cm x 4cm area of ecchymosis and a 4cm x 4cm area of erythema with some bullae. erythema with some bullae. Neurovascularly intactNeurovascularly intact


Initial Differential Initial Differential DiagnosisDiagnosis DVT/PEDVT/PE CHF/CardiacCHF/Cardiac InfectiousInfectious SepsisSepsis


Initial OrdersInitial Orders EKGEKG LabsLabs Chest x-rayChest x-ray Left lower extremity doppler Left lower extremity doppler

USUS

54 Year Old Male with Left Leg Pain and 54 Year Old Male with Left Leg Pain and SOBSOBEKGEKG


CXR: NADCXR: NAD Initial bedside doppler US Initial bedside doppler US

done by ED resident showed done by ED resident showed (+) DVT(+) DVT 9:50 AM: Subcutaneous 9:50 AM: Subcutaneous

enoxaparin and Ct angiogram enoxaparin and Ct angiogram of the chest orderedof the chest ordered


10:1810:18 BP: 106/67 P: 116 R: 34 Pox: BP: 106/67 P: 116 R: 34 Pox:

90% on 100% 90% on 100% 11:1011:10

Ct angiogram chest (-) for PECt angiogram chest (-) for PE Vital signs remained the sameVital signs remained the same Leg wound larger in sizeLeg wound larger in size Surgery calledSurgery called


Lab ResultsLab Results CBCCBC

Wbc:Wbc: 10.710.7 Hgb:Hgb: 17.817.8 Platelets:Platelets: 156156 Diff:Diff: 22 segs, 66 bands, 8 22 segs, 66 bands, 8

lymphslymphs CoagsCoags

PT:PT: 23.023.0 INR:INR: 1.91.9 PTT:PTT: 31.031.0


Lab ResultsLab Results ElectrolytesElectrolytes

Na:Na: 139139 K+:K+: 5.45.4 Cl:Cl: 111111 Co2:Co2: 1111 BUN:BUN: 3838 CR:CR: 2.12.1 Ca:Ca: 7.2 (nl range 8.4-10.2)7.2 (nl range 8.4-10.2)


11:1411:14 Left femur x-ray orderedLeft femur x-ray ordered

11:3011:30 Patient respiratory distress Patient respiratory distress

worsened requiring worsened requiring endotracheal intubationendotracheal intubation

Ceftriaxone, vancomycin, and Ceftriaxone, vancomycin, and clindamycin orderedclindamycin ordered


12:1512:15 Official bedside US confirmed DVTOfficial bedside US confirmed DVT Surgery at bedsideSurgery at bedside Patient dropped BP to 59/27Patient dropped BP to 59/27 Central line placed and Central line placed and

norepinephrine begun in addition norepinephrine begun in addition to ongoing fluid resusucitationto ongoing fluid resusucitation

Left leg wound continues to Left leg wound continues to enlargeenlarge

OR preparations being madeOR preparations being made


13:1513:15 Attending surgeon performs bedside Attending surgeon performs bedside

debridement of leg wound revealing debridement of leg wound revealing significant necrotic tissuesignificant necrotic tissue

Hypotension persists. Dopamine Hypotension persists. Dopamine startedstarted

14:0014:00 Patient into temporary junctional Patient into temporary junctional

rhythm and hypoglycemiarhythm and hypoglycemia


14:1014:10 Cardiopulmonary arrest with successful Cardiopulmonary arrest with successful

resuscitationresuscitation 14:2514:25

Transferred to the ORTransferred to the OR Shortly thereafter, patient went into Shortly thereafter, patient went into

arrest again and passed awayarrest again and passed away


TimelineTimeline PTA: PTA: Previous day ED visit for left leg painPrevious day ED visit for left leg pain 09:25: 09:25: ArrivalArrival 11:10: 11:10: Surgery consultationSurgery consultation 11:30: 11:30: Endotracheal intubationEndotracheal intubation 12:15:12:15: Pressors begunPressors begun 13:15:13:15: Bedside debridementBedside debridement 14:10:14:10: Cardiopulmonary arrestCardiopulmonary arrest 14:25: 14:25: Transfer to OR; DeathTransfer to OR; Death


PostmortemPostmortem Culture resultsCulture results

Wound and blood culturesWound and blood cultures All positive for Strep All positive for Strep pyogenespyogenes

Group AGroup A Additional historyAdditional history

Patient had visited his pmd prior Patient had visited his pmd prior to his initial ER visit and had to his initial ER visit and had received an “injection” into his received an “injection” into his left hip/thigh area for painleft hip/thigh area for pain

Necrotizing FasciitisNecrotizing Fasciitis Progressive, rapidly spreading, Progressive, rapidly spreading,

inflammatory infection within the inflammatory infection within the deep fascia, with secondary necrosis deep fascia, with secondary necrosis of the subcutaneous tissueof the subcutaneous tissue

Necrotizing FasciitisNecrotizing Fasciitis Descriptions of the disease date back Descriptions of the disease date back

to the days of Hippocrates (400 BC)to the days of Hippocrates (400 BC) First described in medical literature First described in medical literature

by Dr. Frank Meleny in 1924by Dr. Frank Meleny in 1924

Necrotizing FasciitisNecrotizing Fasciitis Previously known as strep gangrene, Previously known as strep gangrene,

phagedena, phagedenic phagedena, phagedenic gangraenosa, necrotizing gangraenosa, necrotizing subcutaneous infection, suppurative subcutaneous infection, suppurative fasciitisfasciitis

In 1952, the term In 1952, the term necrotizing necrotizing fasciitisfasciitis 1 1stst published in literature published in literature

Necrotizing FasciitisNecrotizing Fasciitis Mortality extremely highMortality extremely high

Up to 25%Up to 25% 70% in cases presenting with sepsis or 70% in cases presenting with sepsis or

renal failurerenal failure

Necrotizing FasciitisNecrotizing Fasciitis Risk FactorsRisk Factors

Local tissue trauma with subsequent Local tissue trauma with subsequent bacterial invasionbacterial invasion

Local ischemiaLocal ischemia Reduced host defensesReduced host defenses

Necrotizing FasciitisNecrotizing Fasciitis Other Predisposing FactorsOther Predisposing Factors

Skin biopsySkin biopsy Needle puncture sitesNeedle puncture sites FrostbiteFrostbite Chronic venous leg ulcersChronic venous leg ulcers Open bone fracturesOpen bone fractures Insect bitesInsect bites Surgical woundsSurgical wounds AbscessesAbscesses


Systemic illnessSystemic illness Predisposes to local tissue ischemia and Predisposes to local tissue ischemia and

hypoxiahypoxia Diabetes, cancerDiabetes, cancer

AlcoholismAlcoholism ImmunosuppressionImmunosuppression Idiopathic/SpontaneousIdiopathic/Spontaneous

50% of cases?50% of cases?


Pediatric considerationsPediatric considerations Omphalitis and circumcisionOmphalitis and circumcision Surgery or traumaSurgery or trauma VaricellaVaricella Congenital or acquired immunodeficienciesCongenital or acquired immunodeficiencies

Necrotizing FasciitisNecrotizing FasciitisClinical CourseClinical Course

Tends to begin with constitutional Tends to begin with constitutional symptoms such as fever and chills symptoms such as fever and chills and is often mistaken as viral in and is often mistaken as viral in etiologyetiology

Soreness in the affected part of the Soreness in the affected part of the body may be present earlybody may be present early


24-48 hours later, erythema followed 24-48 hours later, erythema followed by vesicles and/or bullae over by vesicles and/or bullae over affected areaaffected area

Pain may be out of proportion to Pain may be out of proportion to clinical findingsclinical findings

Anesthesia in affected area may be a Anesthesia in affected area may be a sign of thrombosis of local sign of thrombosis of local subcutaneous blood vesselssubcutaneous blood vessels


Without treatment, deeper muscular Without treatment, deeper muscular layers become involved with layers become involved with resultant myositis or myonecrosisresultant myositis or myonecrosis

Rapid progression to systemic Rapid progression to systemic infection, sepsis and deathinfection, sepsis and death

Necrotizing FasciitisNecrotizing FasciitisClassificationClassification

Type 1Type 1 PolymicrobialPolymicrobial Usually after trauma or surgeryUsually after trauma or surgery Anaerobic and facultative bacteria in Anaerobic and facultative bacteria in

synergysynergy May be mistaken for simple cellulitis May be mistaken for simple cellulitis

externally, but with significant externally, but with significant underlying necrosisunderlying necrosis


Type 1Type 1 Example of bacteria involved include Example of bacteria involved include S. S.

aureusaureus, , BacteriodesBacteriodes Prevotella Prevotella species usually found in NF of species usually found in NF of

the mouth, jaw, neck, and/or facethe mouth, jaw, neck, and/or face PseudomonasPseudomonas species in extremely species in extremely

immune-compromised patientsimmune-compromised patients


Type 1Type 1 Type 1 variant caused by a minor skin Type 1 variant caused by a minor skin

wound contaminated by saltwater wound contaminated by saltwater containing containing Vibrio vulnificusVibrio vulnificus

Soft tissue necrotizing infection at location Soft tissue necrotizing infection at location of the woundof the wound

Those with liver and/or blood disease at Those with liver and/or blood disease at higher risk of this infectionhigher risk of this infection


Type 1Type 1 Fournier’s gangreneFournier’s gangrene

Necrotizing FasciitisNecrotizing FasciitisFournier’s GangreneFournier’s Gangrene

Rapidly progressing polymicrobial Rapidly progressing polymicrobial necrotizing fasciitis of the perineumnecrotizing fasciitis of the perineum

Usually genitourinary, rectal or Usually genitourinary, rectal or penile/scrotal sourcepenile/scrotal source

Necrotizing FasciitisNecrotizing FasciitisForunier’s Gangrene- Risk FactorsForunier’s Gangrene- Risk Factors

Immune CompromiseImmune Compromise DiabetesDiabetes AlcoholismAlcoholism HIVHIV CancerCancer

Necrotizing FasciitisNecrotizing FasciitisFournier’s Gangrene- Risk FactorsFournier’s Gangrene- Risk Factors

HygieneHygiene HomelessnessHomelessness ParaplegiaParaplegia CathetersCatheters Nursing HomeNursing Home Tinea crurisTinea cruris

Necrotizing FasciitisNecrotizing FasciitisFournier’s Gangrene- Risk FactorsFournier’s Gangrene- Risk Factors

SurgicalSurgical CircumcisionCircumcision VasectomyVasectomy OrchiectomyOrchiectomy Hernia repairHernia repair HemorrhoidectomyHemorrhoidectomy


Once bacteria break through skin Once bacteria break through skin barrier, rapid spread along the barrier, rapid spread along the perineal fascial planesperineal fascial planes

Posteriorly and laterally, Colles’ Posteriorly and laterally, Colles’ fascia fuses with urogenital fascia fuses with urogenital diaphragmdiaphragm

Anteriorly, Buck’s and Scarpa’s fascia Anteriorly, Buck’s and Scarpa’s fascia allowing lateral extension and allowing lateral extension and extension to the abdominal wallextension to the abdominal wall

Necrotizing FasciitisNecrotizing Fasciitis


Testicles usually sparedTesticles usually spared Toxic appearingToxic appearing INAPPROPRIATE INDIFFERENCEINAPPROPRIATE INDIFFERENCE Mortality 10%- 50%Mortality 10%- 50%


Type 2Type 2 Group A streptococcusGroup A streptococcus ““Flesh-eating bacteria”Flesh-eating bacteria” Gas usually not evidentGas usually not evident 50% of cases in previously young and 50% of cases in previously young and

healthy patientshealthy patients Varicella infection and use of NSAIDS Varicella infection and use of NSAIDS

are predisposing factorsare predisposing factors


Type 3Type 3 Clostridial myonecrosisClostridial myonecrosis

Usually Usually Clostridium perfringensClostridium perfringens If spontaneous, the If spontaneous, the C. septicumC. septicum more likely, more likely,

especially in association with leukemia or especially in association with leukemia or colon cancercolon cancer

Gas gangreneGas gangrene

Necrotizing FasciitisNecrotizing FasciitisDiagnosisDiagnosis

Diagnosis may be extremely difficult Diagnosis may be extremely difficult and may not be evident until lateand may not be evident until late

CLINICAL SUSPICIONCLINICAL SUSPICION the key the key Pain out of proportion to examPain out of proportion to exam Toxic appearingToxic appearing


CBC with differentialCBC with differential ElectrolytesElectrolytes Calcium levelCalcium level

Extensive fat necrosis may cause Extensive fat necrosis may cause hypocalcemiahypocalcemia


Coagulation profileCoagulation profile DICDIC

Blood culturesBlood cultures Wound culturesWound cultures Plain x-raysPlain x-rays

GasGas CT/MRICT/MRI

Necrotizing FasciitisNecrotizing FasciitisTreatmentTreatment

AirwayAirway BreathingBreathing

Supplemental oxygenSupplemental oxygen Pulse oximetryPulse oximetry

CirculationCirculation Cardiac monitorCardiac monitor Aggressive fluid resuscitationAggressive fluid resuscitation Central venous accessCentral venous access


Broad-spectrum antibioticsBroad-spectrum antibiotics Penicillin or cephalosporin plus an Penicillin or cephalosporin plus an

aminoglycoside plus anaerobic coverageaminoglycoside plus anaerobic coverage


SurgerySurgery Surgical emergencySurgical emergency Early debridementEarly debridement


Hyperbaric therapyHyperbaric therapy Use once antibiotics initiated and surgical Use once antibiotics initiated and surgical

debridement completeddebridement completed Increases normal oxygen saturation in Increases normal oxygen saturation in

infected wounds by a thousand foldinfected wounds by a thousand fold BacteriocidalBacteriocidal Improved neutrophil functionImproved neutrophil function Enhanced wound healingEnhanced wound healing

Retrospective studies show that HBO used Retrospective studies show that HBO used as an adjunct to surgery and antibiotics as an adjunct to surgery and antibiotics may significantly reduce mortalitymay significantly reduce mortality


IV immunoglobulinIV immunoglobulin Anecdotal evidence suggests use as an Anecdotal evidence suggests use as an

adjunct to therapy in severe adjunct to therapy in severe streptococcal infectionsstreptococcal infections

Necrotizing FasciitisNecrotizing FasciitisDispositionDisposition

All require admission to an ICU All require admission to an ICU setting for surgical debridement and setting for surgical debridement and IV antibiotics and aggressive IV antibiotics and aggressive resuscitationresuscitation

Necrotizing FasciitisNecrotizing Fasciitis Conditions Similar to NFConditions Similar to NF

MucormycosisMucormycosis Highly fatal rare infection caused by Highly fatal rare infection caused by

airborne fungi of the order airborne fungi of the order MucoralesMucorales Commonly found in bread and fruit moldCommonly found in bread and fruit mold Affects severely immune-compromisedAffects severely immune-compromised Rapid soft tissue necrosis and bullaeRapid soft tissue necrosis and bullae Known to affect sinuses and can rapidly Known to affect sinuses and can rapidly

extend into brainextend into brain Needs rapid surgical debridement and Needs rapid surgical debridement and

systemic antifungalssystemic antifungals

Necrotizing FasciitisNecrotizing Fasciitis Conditions Similar to NFConditions Similar to NF

Brown Recluse Spider BiteBrown Recluse Spider Bite Localized skin and soft tissue necrosisLocalized skin and soft tissue necrosis May take several weeks to months to heal by May take several weeks to months to heal by

secondary intentionsecondary intention Systemic symptoms possible but rareSystemic symptoms possible but rare Local wound careLocal wound care Antibiotics if appears infectedAntibiotics if appears infected Consider topical and/or systemic steroidsConsider topical and/or systemic steroids Dapsone and hyperbaric chamber also a Dapsone and hyperbaric chamber also a

considerationconsideration

SourcesSources Armed Forces Infectious Disease Society. Armed Forces Infectious Disease Society. www.afids.comwww.afids.com Hardin, MD. Www.lib.uiowa.eduHardin, MD. Www.lib.uiowa.edu Hulev, Dubravko. “Hulev, Dubravko. “Necrotizing Fasciitis of the Abdominal Wall With Lethal Necrotizing Fasciitis of the Abdominal Wall With Lethal

Outcome: A Case ReportOutcome: A Case Report”. The Internet Journal of Plastic Surgery. Vol. 2, ”. The Internet Journal of Plastic Surgery. Vol. 2, Number 2. Number 2. www.ispub.comwww.ispub.com

Maynor, M. “Maynor, M. “Necrotizing FasciitisNecrotizing Fasciitis”. Emedicine.com. Dec 11, 2006”. Emedicine.com. Dec 11, 2006 Mohite, Prashant and Bhatnagar, Ashok. “A Case Of Fournier's Gangrene Mohite, Prashant and Bhatnagar, Ashok. “A Case Of Fournier's Gangrene

Reconstructed By Pedicle Thigh FlapReconstructed By Pedicle Thigh Flap””.. The Internet Journal of Plastic The Internet Journal of Plastic Surgery.Surgery. Vol. 3, Number 1. www.ispub.comVol. 3, Number 1. www.ispub.com

National Necrotizing Fasciitis Foundation. National Necrotizing Fasciitis Foundation. www.nnff.orgwww.nnff.org Netter, F.H. Netter, F.H. Atlas of Human AnatomyAtlas of Human Anatomy. Ciba-Geigy 7. Ciba-Geigy 7thth printing, 1994 printing, 1994 Roemmele, J.A. and D. Batdorff. “Surviving The “Flesh-Eating Bacteria” Roemmele, J.A. and D. Batdorff. “Surviving The “Flesh-Eating Bacteria”

Understanding, Preventing, Treating, and Living With The Effects of Understanding, Preventing, Treating, and Living With The Effects of Necrotizing Fasciitis”. Avery. 2000Necrotizing Fasciitis”. Avery. 2000

Rosen, P. et al. Rosen, P. et al. The 5 Minute Emergency Medicine ConsultThe 5 Minute Emergency Medicine Consult. 1999. 1999 Schwartz, R.A. “Schwartz, R.A. “Necrotizing FasciitisNecrotizing Fasciitis”. Emedicine.com. May 14, 2008”. Emedicine.com. May 14, 2008 Www.dermatalas.med.jhmi.eduWww.dermatalas.med.jhmi.edu

http://www.afids.com/

http://www.ispub.com/

http://www.nnff.org/

http://www.dermatalas.med.jhmi.edu/

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