1. Necrotizing Fasciitis Mini Lecture
UCI 1/14/15

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

3. 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.

4. 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

5. 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

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

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

8. 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

9. Necrotizing Fasciitis
Early Presentation
Late Presentation
UCSD MedEd

10. 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!!

11. 9 LRINEC Criteria Our patient's score =
He has HIGH (>75%) probability of Nec Fasc. Yikes!!

12. 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!

13. 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.

14. 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

15. 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 :)

16. 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