Interesting case presentation Nadia Rahati EM resident PGY1 Iran University of Medical sciences July 2014 20:11:08

Present Illness A 30 years old man arrived to emergency department with chief compliment from abdominal pain that had accrued after Blunt trauma from 2 days ago his pain was localized in left lower abdominal Area 20:11:08

Past Medical History NO ILLNESS AND NO DRUG USE 20:11:08

Physical Examination GA: .an ill young man VS: .Bp:120/80 PR:100 /min RR:18 T:38: Chest phE: No remarkable finding Abdominal phE: Scar(linear laceration) ecchymosis(-)Bs(NL) mass(-) guarding (-) tenderness(+) Neurological phE: NORMAL 20:11:08

PROBLEM LIST An young man Decrease abdominal pain after blunt trauma Temperature :38 Ill and toxic Small, red, painful lump on the skin Chills Nausea Dizziness Weakness 20:11:08

Laboratory tests CBC: Biochemistry: WBC:16.8 Na:130 k: 3.8 Bs:100 Bun:21 Hg:15.8 Cr:1/2 Ca:9 PLT:17 MCV:87.88 20:11:08

ED ORDERS IV line fixed CBC,BUN,CR,Na,k,Bs,amylase,ALT,AST IV fluid N/S 500cc infusion /4 hours Acetaminophen 1 gr iv infusion /20 min ECG CXR Bed side abdominal ultrasonography Spiral abdominal pelvic ct scan Transfer to acute 1 20:11:08

CHEST X RAY 20:11:08

Pelvic x ray 20:11:08

Cervical x ray 20:11:08

FASCIITIS NECROTIZING Necrotizing fasciitis is an infection of striker fascia, usually caused by multiple pathogens develops. Thrombosis, cardiovascular disease, infectious character of the interface skin and blood circulation deep ones. As a result, skin necrosis, ischemia or gangrene develops 20:11:08

RADIOGRAPHIC FEATURES Plain film The common plain radiographic findings non specific an often similar to those of cellulitis, with increased soft-tissue thickness and opacity. Radiographs can be normal until the advanced stages of infection and necrosis. The characteristic finding of gas in the soft tissues is seen in only a minority of cases. CT CT classically tends to show soft-tissue gas associated with fluid collections within the deep fascia, although this finding is inconstant. Other non specific findings include asymmetrical fascial thickening associated with fat stranding edema extending into the inter-muscular septa and the muscle thickening of one or both of the superficial and deep fascial layers Although fascial fluid collections are typically non-focal, abscesses may be seen. 20:11:08

Soft tissue necrotizing ct 20:11:08

SOFT TISSUE NECOTIZING 20:11:08

Late diagnosLATE DIAGNOSED NECROTIZING fasciitis as a cause of multiorgan dysfunction syndrome 20:11:08

TREATMENT The treatment for NSTI involves the principles of treatment for any kind of surgical infection: source control, antimicrobial therapy, support, and monitoring. It is clear that early and complete debridement is essential for the treatment of NSTI. Broad-spectrum antimicrobial therapy should be started early to include coverage for gram-positive, gram-negative, and anaerobic organisms. Special consideration for group A Streptococcus and Clostridium species should be taken. . Acceptable regimens include monotherapy agents, such as imipenem, meropenem, ertapenem, piperacillin/tazobactam, and tigecycline. Multidrug regimens have also been described, including triple-drug therapy regimens, such as high-dose penicillin, high-dose clindamycin, and a fluoroquinolone or an aminoglycoside for coverage of gram-negative organisms Amputation if the disease spreads through an arm or leg 100% oxygen at high pressure (hyperbaric oxygen therapy) for certain types of bacterial infections 20:11:08