18 yo F with Neck Pain SACGR May 18, 2006

18 yo F with Neck Pain Tongue pierced 2 weeks ago Tongue pierced 2 weeks ago Tooth extracted and abscess drained 3 days ago, continuing on PCN Tooth extracted and abscess drained 3 days ago, continuing on PCN Presents to ED with pain in throat and neck Presents to ED with pain in throat and neck En route to Neck CT she has a respiratory arrest and is intubated En route to Neck CT she has a respiratory arrest and is intubated

18 yo F with Neck Pain Surgical I & D reveals necrotic tissue on the right hypopharynx Surgical I & D reveals necrotic tissue on the right hypopharynx Repeat I & D finds necrotic tissue on left as well Repeat I & D finds necrotic tissue on left as well After 5 surgeries she’s now developed mediastinal air and fluid accumulation, has a tracheostomy, chest tubes and numerous neck drains After 5 surgeries she’s now developed mediastinal air and fluid accumulation, has a tracheostomy, chest tubes and numerous neck drains

18 yo F with Neck Pain Cultures show Provotella bucca and Peptostreptococcus tetradius Cultures show Provotella bucca and Peptostreptococcus tetradius Blood Cultures are all negative Blood Cultures are all negative Antibiotics started with empiric Zosyn and Clindamycin, then switched to Ciprofloxacin, PNC-G, Metronidazole, and Imipenam Antibiotics started with empiric Zosyn and Clindamycin, then switched to Ciprofloxacin, PNC-G, Metronidazole, and Imipenam

Necrotizing Soft Tissue Infections Includes Progressive Crepitant Anaerobic Cellulitis, Bacterial Synergistic Gangrene, Necrotizing Fasciitis including Fournier’s Gangrene, and Non-clostridial Myonecrosis Includes Progressive Crepitant Anaerobic Cellulitis, Bacterial Synergistic Gangrene, Necrotizing Fasciitis including Fournier’s Gangrene, and Non-clostridial Myonecrosis Infections typically cause local tissue hypoxia exacerbated by an infection-induced occlusive endarteritis Infections typically cause local tissue hypoxia exacerbated by an infection-induced occlusive endarteritis Additionally, toxin effects and intravascular sequestration result in a paucity of PMNs at the site of infection Additionally, toxin effects and intravascular sequestration result in a paucity of PMNs at the site of infection

Necrotizing Soft Tissue Infection Outcomes with HBO 2 Mortality (classically 30-40%): Mortality (classically 30-40%): –Bakker (1984) – 18% –Gozal (1986) – 12.5% –Mader (1988) – 25% in HBO 2 cases vs. 67% in non-HBO 2 cases –Riseman (1990) – 23% vs. 66% –Hollabaugh (1998) - 7% vs. 42%

HBO2 in Necrotizing Fasciitis Riseman JA. Surgery patients with necrotizing fasciitis retrospectively reviewed 29 patients with necrotizing fasciitis retrospectively reviewed Group 1 (n=12) received surgery and antibiotics only Group 1 (n=12) received surgery and antibiotics only Group 2 (n=17) also received HBO2 Group 2 (n=17) also received HBO2 Group 2 had higher incidence of diabetes and shock Group 2 had higher incidence of diabetes and shock

HBO2 in Necrotizing Fasciitis Riseman JA. Surgery 1990 Control HBO2 Control HBO2 Mortality rate 67% 23% * Mortality rate 67% 23% * Debridements/pt * Debridements/pt * * p<0.03 * p<0.03

HBO 2 for Necrotizing Soft Tissue Infections Antibiotic and surgical treatment are generally effective Antibiotic and surgical treatment are generally effective When morbidity and mortality are high, then HBO 2 may be a useful adjunct When morbidity and mortality are high, then HBO 2 may be a useful adjunct –Immunocompromised –Diabetes, Vasculopathy –Older Age –Poor nutritional status –Poor prognosis, poor response to standard treatments