E M S H O RT S
By Stephanie Taft, MD
N e c r o t i z i n g S o f t Ti s s u e I n f e c t i o n s
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Rare
Early diagnosis is key to survival
Must have high suspicion because early infection may not have many external signs
Risk Factors: Diabetes Mellitus, Alcoholism, Malnutrition, Chronic medical disease, Postoperative patients, IV drug use
PATIENTS DO NOT HAVE TO HAVE ANY OF THE RISK FACTORS.
Early signs: cellulitis or small ulcer; erythema, warmth, edema in overlying skin; skin anesthesia, localized pain, hyperthermia, tachycardia, diffuse swelling of area
Late signs: tense edema, bronze or purple discoloration of skin, hemorrhagic bullae, crepitus,
hypotension, seropurulent drainage (“dishwater pus”), foul odor, severe pain and systemic
symptoms out of proportion to local infection (think clostridial infection or streptococcal gangrene), failure to respond to antibiotics, rapid progression
Wound is easily instrumented/lifted — eschar is easily removed
No bleeding if incised
May also see “la belle indifference” related to skin anesthesia — inappropriate lack of concern
MRSA necrotizing soft tissue infection may have much more indolent course than other bacteria
Infections on the torso or closer to the torso require more vigilance because associated with
higher morbidity and mortality
Lab abnormalities: elevated WBC, hyponatremia, elevated lactate
Imaging: plain films insensitive but helpful if they show gas in the soft tissues; CT more sensitive
and more feasible due to availability and rapidity; MRI technically the best modality but may not
be the best test in a given clinical circumstance (e.g. hard to get or pt too sick to go to MRI).
Management: SURGERY (Medical disease that is managed surgically.)
Broad spectrum antibiotics +/- MRSA coverage (commonly piperacillin/tazobactam + clindamycin (inhibits toxin production) +/- vancomycin
IVF, early goal directed therapy, IVIG works for strep A but pt needs a surgeon above all
If patient presents with multiple features, consult the surgeon early.
If you have a suspicion but few features are present, document well, re-assess frequently, request
routine consultation (i.e. does not need to be emergent consultation).
ECG Pearls
July 2010
Question of the Month
In the 1949 film “Prince of
Foxes,” Orson Wells portrayed
what infamous renaissance
poisoner?
Answer to last month
In 1720, troops of Czar Peter
the Great were defeated, not by
the Turkish empire, but by
what toxic substance growing
in the Volga Valley, which
poisoned both man and beast?
Ergot*
Robert Kn opp, MD at Region s EM Conferen ce, April 10, 2010
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3 causes of irregular narrow complex tachycardia
− MAT: 3 or more different p-wave morphologies
− Atrial flutter with variable block; see p-waves, rate 300 beats per minute; most common atrial
flutter is 2:1 block (regular, approx 150 bpm)
− Atrial fibrillation
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3 causes of irregular wide complex tachycardia
− Irregular narrow complex (see above) with aberrancy or bundle branch block
− Atrial fibrillation with WPW
− Polymorphic ventricular tachycardia (torsades)
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PSVT — some medication interactions require higher dose of adenosine (caffeine, theophylline) or lower
dose of adenosine (dipyridamole). Use adenosine cautiously if h/o COPD. Avoid use if active bronchoconstriction.
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Group beating means Wenckebach until proven otherwise
4 causes of R wave in V1: RBBB, posterior MI, RVH, WPW
Herbert, M and Swadron, S. Necrotizing Fasciitis. Emergency Medicine: Reviews and Perspectives. January 2009.
Majeski, J and John, J. Necrotizing Infections. Southern Medical Journal, Volume 96, Number 9, September 2003, pp 900-905 .
McGee, E. Necrotizing Fasciitis: Review of Pathophysiology, Diagnosis, and Treatment. Crit Care Nurs Q, Dec 30, 2004 ,Vol. 28, No. 1, pp. 80–84.
*From The Poison Quiz Book, 1st Edition by John Trestrail III, Boston Medical Publishing Corporation, 2001, p 98.