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55770_Necrotizing Fasciitis

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					Necrotizing Fasciitis
          By
  Dr.Hana’a Tashkandi
Necrotizing Fascitiis
Definition •
Risk factors •
Etiology •
Pathophysiology •
Epidemiology •
Clinical Features •
Investigations •
Management •
Diffuse Necrotizing Infection
(flesh-eating)




     Dangerous………………Why? •
Difficult to diagnose •
Extremely toxic •
Spread rapidly •
May lead to limb amputation •
Classification
@ Colistridial :

         # Necrotizing cellulitis
         # Myositis

@ Non-colistridial :

         # NECROTIZING FASCIITIS
         # Streptococcal gangrene
Necrotizing Fasciitis


It is a progressive, rapidly spreading,
inflammatory infection located in the deep
fascia with 2ry necrosis of the
subcutaneous tissue.
Risk Factors
Immunocompression illnesses •
      e.g.: DM, Cancer, alcoholism, vascular
  insufficiency, organ transplant, HIV or
neutropenia.

Trauma or foreign bodies in surgical wound.       •

Idiopathic as scrotal or penile necrotizing   •
fasciitis.
Causative Agents

It is a mixed microbial flora:

         #   microaerophilic streptococci.
         #   staphylococci.
         #   aerobic gram –ve
         #   anaerobes ( peptostreptococi –
                            bacteroids)
Pathophysiology
Mortality & Morbidity

The overall morbidity & mortality is 70 –
80%

Fournier’s gangrene has a reported mortality
as high as 75%
Sex:     Male : Female    3:1


Age:
           * the mean age is 38 to 44
years.
           * pediatric cases are rare but
            reported from countries where
            poor hygiene in.
Clinical Features

Symptoms:
       *sudden onset of pain and swelling at
the site of trauma or recent surgery.
       *in some cases, the symptoms may
begin at the site distant from the initial
traumatic insult.
        *Fournier's gangrene begin with pain
and itching of the scrotal skin.
Clinical Features (cont.)
Sings:
        * pt. appears moderately to severely toxic (but sometimes
might looks well)
        * typically, erythema that quickly spread over a course of hours
to days.
        * the redness quickly spread & the margin of infection move
out into normal skin without being raised nor sharply demarcated.
        * anesthesia

# Note:
  *I.M. injections & I.V. infusions may lead to necrotizing fasciitis.
  *minors insect bites may set the stage for necrotizing infections.
Investigations


Lab: CBC, U&E, Glu, Creatinine, Blood &
       tissue cultures, Urine analysis, &
       ABG.
Investigations (cont.)
Imaging Studies:

  # X-ray  gas in the subcutaneous
              fascia planes.
  ?? D.D. of subcutaneous gas in a
      radiograph.

  # C.T.  demonstrating necrosis with
            asymmetric fascial thickening
            & gas in the tissues.

  # MRI.
Investigations (cont.)
Microbiology:

  Gram stain & wound culture


Procedures:

  Biopsy is the best method to use to obtain
  proper cultures for micro-organisms.
Emergency Department care

                            A•

                            B•

                            C•

                            D•
Management
If streptococci are the identified major pathogens,
the D.O.C is Penicillin-G with clindamycin as an
alternative.

To ensure adequate treatment, we have to cover
aerobic & anaerobic bacteria.

The anaerobic coverage can be provided by
Metronidazole or 3rd generation cephalosporin's.
Management (cont.)

Gentamicine combined with clindamycine or
chloramphenicol has been reported as a
standard coverage.

Ampicilline may be added to the basic
regimen to treat enterococci if suspected
by gram stain.
Further In-Patient Care


                Surgical debridment. •

                        Fasciotomy. •

                             H.B.O. •
Complications


                            Renal Failure. •

Septic Shock with cardiovascular collapse. •

        Scarring with cosmetic deformity. •
Medico-legal Pitfalls


Early in the course of the disease,
necrotizing fasciitis may appear quiet
benign.

Be wary of the patient with pain out of the
proportion to physical finding.
THANK YOU




     Hana’a Tashkandi

				
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posted:10/30/2011
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