Necrotizing Fasciitis
Mini Lecture
UCI 1/14/15
Objectives
- When to Suspect Nec Fasc
- 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
UCSD MedEd
Late Presentation
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!!
LRINEC Criteria
Our patient's
score =
9
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