Necrotizing Fasciitis Mini Lecture UCI 1/14/15

Objectives - When to Suspect Nec Fasc - What to Do - Risk Factors - Signs & Symptoms LRINEC Criteria - What to Do

Actual Case from VA Overnight HPI: Pt. is a 62 y/o M with poorly controlled IDDM and HTN who presents with L foot pain and redness x 2-3 days. The patient saw podiatry 3 weeks prior and had calluses removed from the affected foot, which was nicked in the process. He came in as the top of his foot was becoming increasingly red and painful making it harder to walk or stand. The pain was 7/10 at rest, localized to the foot, no radiation, worse with walking/standing.

History & Exam ROS was negative Soc Hx: former smoker, no ETOH or drugs VS: Hr 88, BP 175/90, Temp 98.4F, RR 20 Exam: benign except for 5x5cm erythematous patch on the dorsum of the L foot, tender to palpation, with 1cm ulceration with surrounding erythema on the ball of the foot with no drainage, + L calf tenderness on palpation but no skin findings

Abnormal Labs BMP: Sodium 130, creatinine was 1.6 (baseline 1.2), glucose 225 A1C 10.8% CBC: WBC 15.5 with neutrophilic predominance, Hgb 11.5, normal platelets BCX pending, UA clean CRP 180

Is the Patient At Risk for Nec Fasc? YES! What are the risk factors for nec fasc?

Risk Factors Diabetes (particularly poorly-controlled) Injection drug use Alcoholism Obesity Immune suppression (cancer, transplant, on steroids, etc.) Chronic illness

Signs/Symptoms of Nec Fasc Local: Very early - pain out of proportion to findings Early - Swelling & erythema Late - purpleish discoloration & blistering +/- Crepitus +/- 'dishwater' colored fluid drainage +/- tracking of erythema or tenderness Systemic: SIRS +, diarrhea and vomiting can occur

Necrotizing Fasciitis Early Presentation Late Presentation UCSD MedEd

LRINEC Criteria Scoring system based on common lab results that asses the pretest probability for having necrotizing fasciitis. (CRP is important here.) Useful when the clinical presentation is uncertain. If clinical suspicion is high, treat and consult surgery regardless of the LRINEC score!!

9 LRINEC Criteria Our patient's score = He has HIGH (>75%) probability of Nec Fasc. Yikes!!

Who to Call & Early Treatment 1. Vanc/Zosyn (cover staph/strep) and Clindamycin (stop toxin production) 2. Stat surgical consult 3. Supportive Care Control blood sugar, treat AKI, etc. Only Definitive Tx: surgical intervention Nec Fasc is a surgical emergency!

Back to the Case ER had put him on Vanc/Zosyn in ER, so we added Clindamycin and stat consulted Ortho. Ortho took him to the OR that day and saved his foot :) The patient was very grateful. We got his diabetes under control and his AKI resolved and he went for rehabilitation on IV antibiotics.

Summary Recognize nec fasc and get surgery involved early : Recognize Risk Factors Exam findings High suspicion → treat and consult surgery Unsure → calculate LRINEC score LRINEC score >5 → treat & consult surgery! <5 → nec fasc unlikely Treatment Vanc, Zosyn, Clindamycin STAT SURGERY CONSULT Supportive

Summary Remember, nec fasc is a surgical emergency and surgery is the only definitive treatment! Mortality is very high, but the earlier you catch it, the more life and limb you save :)

Summary Recognize nec fasc and get surgery involved early : Recognize Risk Factors Exam findings High suspicion → treat and consult surgery Unsure → calculate LRINEC score LRINEC score >5 → treat & consult surgery! <5 → nec fasc unlikely Treatment Vanc, Zosyn, Clindamycin STAT SURGERY CONSULT Supportive