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					Necrotizing Fasciitis



                                Cindy A. Fehr
                  Malaspina University-College
                                BSN Program
                                   NRSG 335
                                     Fall 2005
               What Is It?
• Soft tissue infection that unleashes
  damaging toxins & enzymes that can
  consume flesh
• Progressively destroys connective tissue
  causing disabling injuries and death
• Life threatening infection
• 30% mortality rate
                        Cause
• Any toxin-causing bacterium, usually anaerobic
• Type I
      • Polymicrobial
      • Usually affects older adults with pre-existing
        conditions such as diabetes mellitus
• Type II
      • Most common is Group A beta hemolytic
        streptococci in previously healthy individuals
• Other Causative Organisms
      • Clostridium, peptococcus, E. coli, Streptococcus
        pyrogenes, S. aureus, S. marcescens
              Bacterial Action
• Injury point (minor trauma to skin) but no
  skin damage or opening necessary
     • Insect bite, contusion, frost bite, chronic leg
       ulcer, surgical incision

• Bacteria begin to multiply & travel along
  fascial plane, release exotoxins that
  destroy superficial & deep fascia and SQ
  fat
                 Common Sites
– Extremities
                      Left upper extremity shows necrotizing fascitis in an individual who used illicit drugs. eMedicine Images

– Abdominal wall

– Perineum

– Post-op wounds


        Necrotizing fasciitis. Sixty-year-old woman who had undergone postvaginal hysterectomy eMedicine Images
                    Signs & Symptoms
• Early S&S:
   –   Mimic common, less serious conditions
   –   Acute illness, low grade fever
   –   Tachycardia
   –    WBC > 11,000
   –   HCT < 36%
   –   Metabolic acidosis
   –   Erythematous, edema, very tender area of cellulitis at
       infection site

• As Infection Continues:
   – Severe pressure-like pain greater than visible signs

• If Continues Further  deeper tissue damage,
  progressing to less pain and numbness
                  PATHOPHYSIOLOGY OF NECROTIZING FASCIITIS

                                                Entry of Pathogenic Organism



                                           Pathogen secretes pyrogenic exotoxin A



                Stimulates production of cytokines which damage endothelial lining - redness of inflamed tissue




  vasculitis & thrombosis of
adjacent tissue (dusky blue skin
                                                                          leakage of fluid into extravascular space



  Further necrosis involving
  SQ nerves (decreased pain
    leading to numbness)
                                                                    decreased blood flow, tissue hypoxemia, tissue death
    Muscle often spared &
      sometimes skin




                                                      If left untreated
Other
Associated
Conditions
                                                 Gangrene within 4-5 days
 DIC
 Respiratory
 Failure leading
 to ARDS                    Tissue sloughing by second week & releasing toxins into bloodstream
 MODS


           Can occur within days                                                              grim prognosis at this
                                                           Sepsis
             of initial infection                                                                     point



                                                    death within 24-96
                                                          hours
               Stages of Skin Damage

• Early
  – Skin pink, painful, edema beyond area of erythema
  – Skin smooth, shiny
  – Quickly spreading erythema & ecchymosis


• Middle
  – As endotoxins destroy flesh, gas produced from this process
    accumulates
  – Skin turns more bluish-grey to purple
  – Wound leading edge can advance > 2 inches (5 cm) per hour
               Stages of Skin Damage

• Late
  – Bullae/vesicles (often purple) appear with yellow serous progressing
    to sanguinous (hemorrhagic)  blood loss & anemia
  – As SQ fat necroses, watery thin foul-smelling fluid oozes from
    wounds
  – Purple-blue spot progressing to graying-green slough & deep blue
    and purple (almost black) areola which spreads rapidly


                                  This is an example of the large black, liquid filled blisters
                                  that are sometimes associated with NF.
                                  Source: National Necrotizing Fasciitis Foundation
                              Diagnosis
• Early
   – CT, MRI (detecting signs of gas in soft tissues)
   – U/S, bedside biopsy
   – Surgical diagnosis  fascia normally adheres to bone but on
     dissection, no resistance with NF
• Labs
   –    antistreptolysin O antibody titre
   –    sedimentation rate
   –    WBC count with shift to left
   –    HCT
   –    creatinine phosphokinase (if muscle involvement)
   –   Hypoalbuminemia
   –   Anemia                              typify presentation
   –   Hyperbilirubinemia
              Treatment & Nursing Interventions
•   Early recognition and treatment crucial to positive outcomes
• Surgery
     – remove diseased tissue (cut larger than area involved)
     – Frequent & numerous  risks associated with multiple anesthetics,
       hypothermia, mentation changes (esp. with older adults), fluid shifts, blood loss


•   A 30 y.o. man developed rapidly progressive
    Painful erythema and edema to right foot
    Following a bee sting. NF developed within
    2 days and upon diagnosis area was
    Aggressively debrided in OR



• Antibiotics
     – halt infection
     – Penicillin 1st choice with strep infections; combined with clindamycin,
       erythromycin, ceftriaxone
     – Vasc damage s blood flow to SQ tissue & prevents abx from reaching
       intended site
     – Clotting around sx excision s abx to tissues
  Treatment & Nursing Interventions cont.
• IV immunoglobulin Therapy
   – to support natural immune system

• Heparin
   –  risk of vasculitis, thrombosis & DIC

• Hyperbaric Chamber
   – Controversial
   –  O2 to tissue  slow anaerobic multiplication (change growth
     environment) while also support healthy, healing tissue & cells

• Strict Isolation
   – Mask, gloves, gown, goggles if splashing possible
   – Thought to be very contagious
  Treatment & Nursing Interventions cont.
• Nursing
  –   Assess & recognize & early interventions
  –   VS hourly; chest assess, ABG, oxygen saturations
  –   Frequent lab values
  –   wound & blood cultures before abx begin
  –   Frequent dressing changes & wound measurements
       • date & time erythema q 1-4 hrs – watch wound parametersfor signs of
         progression
       • Remember: extent of fascial necrosis more extensive than what seen on
         surface of skin
       • Wet to dry dressings with topical antimicrobials at least q4h
  – Medications – hemodynamic support, abx, analgesics
  – Strict monitoring of in/out – hourly monitoring
  – Keep family & patient informed
  Treatment & Nursing Interventions cont.

• Nursing cont.
   – Plenty emotional support  uncertainty, vulnerability
   – Pain relief
   – Immobilize & elevate affected area to  swelling which can further
     compromise blood flow to tissues
   – IV hydration d/t losses through excised area & fluid shifts
   – S&S sepsis & shock
       •  temp,  HR,  mentation, weak PP,  u/o, cap refill >3sec, low syst
         BP
   – Aggressive enteral/parenteral nutrition to support wound healing
       • > 2X normal basal metabolic needs
   – Risk for acid/base imbalances
   Treatment & Nursing Interventions cont.
• After Controlling Infection
      – Skin grafts
      – Emotional & psychological support – body image, life changing
        stressor, pain, depression, anxiety, fear, anger, hopelessness, role
        changes during rehabilitation/convolescence




          During Acute Treatment

 Original injury was minimal to her ring finger




                                                                     This photo shows an amazing lifelike
                                                  Side view of arm
                                                                     armcover that completely covers the scars