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| ==Necrotizing Fasciitis (NF)== | | ==Necrotizing Fasciitis (NF)== |
| ===Risk Factors===
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| *DM
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| *Drug use
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| *Obesity
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| *Immunosuppression
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| *Recent surgery
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| *Traumatic wounds
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|
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| ===Clinical Features===
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| *Skin exam
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| **Erythema (without sharp margins)
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| **Exquisitely tender (pain out of proportion to exam)
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| **Skip lesions
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| **Hemorrhagic bullae (violaceous bullae)
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| ***May be preceded by skin anesthesia (destruction of superficial nerves)
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| **Crepitus (in type I infections)
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| *Swelling/edema may produce compartment syndrome
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| *Constitutional
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| **Fever
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| **Tachycardia
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| **Systemic toxicity
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| ===Work-Up===
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| *CBC
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| *Chem
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| *PT/PTT/INR
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| *CK
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| *Lactate
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| ===Diagnosis===
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| *Surgical exploration is the ONLY way to definitively establish the diagnosis of necrotizing infection
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| *Imaging
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| **Should not delay surgical exploration
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| **CT is study of choice
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| ====HUCLA NF vs Non-NF Criteria (Wall et al)====
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| *Retrospective study discovered:
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| **'''WBC count''' '''>15.4'''(x10<sup>3</sup>/mm<sup>3</sup>) OR '''Na''' '''<135'''(mmol/L)
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| **Associated with NF and combo of both increased likelihood of NF
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| **PPV 26%/NPV 99%
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| *Good tool to R/O NF, not a good tool for confirming presence of NF
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| **Helps distinguish NF from non-NF infection, when classic 'hard' signs of NF are absent
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|
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| ====Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score (Wong et al)====
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| *May use to risk stratify patients p/w signs of cellulitis to determine likelihood of necrotizing fasciitis
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| *Useful in context of a diagnosed or strongly suspected severe soft-tissue infxn
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| *Score based on: '''CRP, WBC, Hb, Na, Cr, Glucose'''
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| *Score > 6 has PPV of 92% and NPV of 96% for necrotizing fasciitis
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| **Be aware LRINEC score has not been prospectively validated, index of suspicion is key
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| #CRP (mg/L) ≥150: 4 pts
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| #WBC count (x10<sup>3</sup>/mm<sup>3</sup>):
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| ##<15: 0 pts
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| ##15-25: 1 pt
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| ##>25: 2 pts
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| #Hb (g/dL):
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| ##>13.5: 0 pts
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| ##11-13.5: 1 pt
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| ##<11: 2 pts
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| #Na (mmol/L) <135: 2 pts
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| #Cr (mg/dL) >1.6: 2 pts
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| #glucose (mg/dL) >180: 1 pt
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| ===Treatment===
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| *Surgical exploration and debridement
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| **Indicated in setting of severe pain, toxicity, fever, elevated CK (w/ or w/o radiographic evidence)
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| *Abx
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| **Must cover Gram +/- and anaerobes (esp GAS and clostridium)
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| **[[Piperacillin-Tazobactam]] 3.375-4.5g q6hr AND [[clindamycin]] 600-900mg q8hr AND [[vancomycin]] 1gm IV q12hr
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| ==Necrotizing Myositis== | | ==Necrotizing Myositis== |
