Necrotizing soft tissue infections: Difference between revisions

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FASCIITIS
==Background==
===FASCIITIS===
# does not involve muscle- but can spread to muscle
# syst toxicity
# skin c blebs, crepitus, necrosis
# risks- dm, pvd, trauma or recent surg
# pain varies since nerve endings damaged- cessation or absence of pain may indicate worsening sxs
# necrosis of fat can lead to soapanification and hypocalemia
# pcn/gent/clinda


- does not involve muscle- but can spread to muscle
===MYOSITIS===
# myonecrosis- deep soft- tissue infection with  death of muscle
# often with little skin changes but does have gas  formation
# result of trauma or surgical wounds
# exotoxin of clostridia damages and kills muscle,  setting up anaerobic environment that promotes further bacterial growth
# odor described as "sickly sweet:
# pt usually anuric
# muscle appears cooked or dead, does not bleed  when cut or retract when pinched


- syst toxicity
===NECROTIZTNG FASCIITIS===
 
# can occur p minor trauma
- skin c blebs, crepitus, necrosis
# mortality 20- 50%
 
- risks- dm, pvd, trauma or recent surg
 
- pain varies since nerve endings damaged- cessation or absence of pain may indicate worsening sxs
 
- necrosis of fat can lead to soapanification and hypocalemia
 
- pcn/gent/clinda
 
 
MYOSITIS
 
- myonecrosis- deep soft- tissue infection with  death of muscle
 
- often with little skin changes but does have gas  formation
 
- result of trauma or surgical wounds
 
-exotoxin of clostridia damages and kills muscle,  setting up anaerobic environment that promotes further bacterial growth
 
- odor described as "sickly sweet:
 
- pt usually anuric
 
- muscle appears cooked or dead, does not bleed  when cut or retract when pinched
 
 
 
NECROTIZTNG FASCIITIS
 
- can occur p minor trauma
 
- mortality 20- 50%
 


Microorganisms
Microorganisms
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- Grp A beta hemolytic strep pyogenes releases substance in cell wall that causes separation of the dermal connective tissue resulting in continued inflammation and necrosis
- Grp A beta hemolytic strep pyogenes releases substance in cell wall that causes separation of the dermal connective tissue resulting in continued inflammation and necrosis


==Diagnosis==
 
Signs/Symptoms


"Hard Signs"
"Hard Signs"
 
# Hypotension
- Hypotension
# Gas on XR
 
# Skin necrosis
- Gas on XR
# Bullae
 
# Crepitance
- Skin necrosis
 
- Bullae
 
- Crepitance


Other common signs/symptoms
Other common signs/symptoms
 
# Systemic toxicity
- Systemic toxicity
# Numbness or deep pain out of proportion to exam
 
# Violaceous or hemorrhagic appearance
- Numbness or deep pain out of proportion to exam
# Pain beyond margins of cellulitis
 
# Skip lesions
- Violaceous or hemorrhagic appearance
 
- Pain beyond margins of cellulitis
 
- Skip lesions
 


Other
Other
# Meleney's synergistic gangrene- (progressive bacterial synergistic gangrene) involves superficial and deep fascial planes with thrombosis of subQ vessels and gangrene of tissue
# Clostridial cellulitis- healthy muscle not invovled
# Fournier's syndrome- necrotizing subq infection of perineum- risk factors include infection or trauma to the perineal area,, anal intercourse, scratches, chemical or thermal burns or diabetes.  Obliteration of small branches of pudendal arteries results in dermal gangrene of perineal and scrotal skin.


- Meleney's synergistic gangrene- (progressive bacterial synergistic gangrene) involves superficial and deep fascial planes with thrombosis of subQ vessels and gangrene of tissue
===Labs===
 
#Hyponatremia, Na<135
- Clostridial cellulitis- healthy muscle not invovled
#Leukocytosis
 
_ Fournier's syndrome- necrotizing subq infection of perineum- risk factors include infection or trauma to the perineal area,, anal intercourse, scratches, chemical or thermal burns or diabetes.  Obliteration of small branches of pudendal arteries results in dermal gangrene of perineal and scrotal skin.
 
 
Labs
 
Hyponatremia, Na<135
 
Leukocytosis
 
 
Imaging
 
XR- gas
 
CT- most commonly used, up to 80% sensitive
 
UTZ- operator dependent
 
MRI- overly sensitive
 
 
Management
 
- wide surgical debridement and excision


- IV ABX
===Imaging===
#XR- gas
#CT- most commonly used, up to 80% sensitive
#UTZ- operator dependent
#MRI- overly sensitive


- Resuscitate as in sepsis
==Treatment==
# wide surgical debridement and excision
# IV ABX
# Resuscitate as in sepsis


Unclear benefit
Unclear benefit
# hyperbaric O2
# IVIG


- hyperbaric O2
===Antibiotic Regimens===
 
#Harbor:
- IVIG
## community-acquired- Ceftriaxone/vanc/clinda +/- gent
 
## hospital-acquired- Zosyn/vanc/clinda
## pcn allergic- Cipro/vanc/clinda/gent
 
#Other common regimens:
Antibiotic Regimens
## pen/ ox/ gent/ clinda- and also use vanco
 
Harbor:
 
- community-acquired- Ceftriaxone/vanc/clinda +/- gent
 
- hospital-acquired- Zosyn/vanc/clinda
 
- pcn allergic- Cipro/vanc/clinda/gent
 
Other common regimens:
 
- pen/ ox/ gent/ clinda- and also use vanco
 
 


==Source==
6/06 PANI
6/06 PANI


[[Category:ID]]
[[Category:ID]]

Revision as of 04:56, 28 March 2011

Background

FASCIITIS

  1. does not involve muscle- but can spread to muscle
  2. syst toxicity
  3. skin c blebs, crepitus, necrosis
  4. risks- dm, pvd, trauma or recent surg
  5. pain varies since nerve endings damaged- cessation or absence of pain may indicate worsening sxs
  6. necrosis of fat can lead to soapanification and hypocalemia
  7. pcn/gent/clinda

MYOSITIS

  1. myonecrosis- deep soft- tissue infection with death of muscle
  2. often with little skin changes but does have gas formation
  3. result of trauma or surgical wounds
  4. exotoxin of clostridia damages and kills muscle, setting up anaerobic environment that promotes further bacterial growth
  5. odor described as "sickly sweet:
  6. pt usually anuric
  7. muscle appears cooked or dead, does not bleed when cut or retract when pinched

NECROTIZTNG FASCIITIS

  1. can occur p minor trauma
  2. mortality 20- 50%

Microorganisms

- Type I Polymicrobrial- Anaerboic (mixed) staph, proteus, pseudomonas

- Type 2 Streptococcal (toxin-generating)

- Type 3 (?) Clostridium (gas gangrene)

- Grp A beta hemolytic strep pyogenes releases substance in cell wall that causes separation of the dermal connective tissue resulting in continued inflammation and necrosis

Diagnosis

"Hard Signs"

  1. Hypotension
  2. Gas on XR
  3. Skin necrosis
  4. Bullae
  5. Crepitance

Other common signs/symptoms

  1. Systemic toxicity
  2. Numbness or deep pain out of proportion to exam
  3. Violaceous or hemorrhagic appearance
  4. Pain beyond margins of cellulitis
  5. Skip lesions

Other

  1. Meleney's synergistic gangrene- (progressive bacterial synergistic gangrene) involves superficial and deep fascial planes with thrombosis of subQ vessels and gangrene of tissue
  2. Clostridial cellulitis- healthy muscle not invovled
  3. Fournier's syndrome- necrotizing subq infection of perineum- risk factors include infection or trauma to the perineal area,, anal intercourse, scratches, chemical or thermal burns or diabetes. Obliteration of small branches of pudendal arteries results in dermal gangrene of perineal and scrotal skin.

Labs

  1. Hyponatremia, Na<135
  2. Leukocytosis

Imaging

  1. XR- gas
  2. CT- most commonly used, up to 80% sensitive
  3. UTZ- operator dependent
  4. MRI- overly sensitive

Treatment

  1. wide surgical debridement and excision
  2. IV ABX
  3. Resuscitate as in sepsis

Unclear benefit

  1. hyperbaric O2
  2. IVIG

Antibiotic Regimens

  1. Harbor:
    1. community-acquired- Ceftriaxone/vanc/clinda +/- gent
    2. hospital-acquired- Zosyn/vanc/clinda
    3. pcn allergic- Cipro/vanc/clinda/gent
  2. Other common regimens:
    1. pen/ ox/ gent/ clinda- and also use vanco

Source

6/06 PANI

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