54 Year Old Male with Left Leg Pain and SOB Ninad A. Shroff, MD

1. 54 Year Old Male with Left Leg Pain and SOBNinad A. Shroff, MD

2. 54 Year Old Male with Left Leg Pain and SOB • 09:25: Arrival via BLS unit • Seen previous day in the ED for left thigh pain after exercise and diagnosed with a musculoskeletal injury • Shortness of breath began few hours prior to arrival • No chest pain

3. 54 Year Old Male with Left Leg Pain and SOB • Past Medical History • Hypertension • Peptic Ulcer Disease • Unclear liver disease • Medications • Propranolol • Furosemide • Amiloride • Acetaminophen • Percocet

4. 54 Year Old Male with Left Leg Pain and SOB • Initial Physical Exam • T: 97.0 BP: 122/82 P: 116 R: 33 Pox: 89% • Patient in mild respiratory distress • Lungs: Clear • Heart: Regular, tachycardia • MSK: Left thigh swollen with some ecchymosis and a 4cm x 4cm area of erythema with some bullae. Neurovascularly intact

5. 54 Year Old Male with Left Leg Pain and SOB • Initial Differential Diagnosis • DVT/PE • CHF/Cardiac • Infectious • Sepsis

6. 54 Year Old Male with Left Leg Pain and SOB • Initial Orders • EKG • Labs • Chest x-ray • Left lower extremity doppler US

7. 54 Year Old Male with Left Leg Pain and SOBEKG

8. 54 Year Old Male with Left Leg Pain and SOB • CXR: NAD • Initial bedside doppler US done by ED resident showed (+) DVT • 9:50 AM: Subcutaneous enoxaparin and Ct angiogram of the chest ordered

9. 54 Year Old Male with Left Leg Pain and SOB • 10:18 • BP: 106/67 P: 116 R: 34 Pox: 90% on 100% • 11:10 • Ct angiogram chest (-) for PE • Vital signs remained the same • Leg wound larger in size • Surgery called

10. 54 Year Old Male with Left Leg Pain and SOB • Lab Results • CBC • Wbc: 10.7 • Hgb: 17.8 • Platelets: 156 • Diff: 22 segs, 66 bands, 8 lymphs • Coags • PT: 23.0 • INR: 1.9 • PTT: 31.0

11. 54 Year Old Male with Left Leg Pain and SOB • Lab Results • Electrolytes • Na: 139 • K+: 5.4 • Cl: 111 • Co2: 11 • BUN: 38 • CR: 2.1 • Ca: 7.2 (nl range 8.4-10.2)

12. 54 Year Old Male with Left Leg Pain and SOB • 11:14 • Left femur x-ray ordered • 11:30 • Patient respiratory distress worsened requiring endotracheal intubation • Ceftriaxone, vancomycin, and clindamycin ordered

13. 54 Year Old Male with Left Leg Pain and SOB • 12:15 • Official bedside US confirmed DVT • Surgery at bedside • Patient dropped BP to 59/27 • Central line placed and norepinephrine begun in addition to ongoing fluid resusucitation • Left leg wound continues to enlarge • OR preparations being made

14. 54 Year Old Male with Left Leg Pain and SOB • 13:15 • Attending surgeon performs bedside debridement of leg wound revealing significant necrotic tissue • Hypotension persists. Dopamine started • 14:00 • Patient into temporary junctional rhythm and hypoglycemia

15. 54 Year Old Male with Left Leg Pain and SOB

16. 54 Year Old Male with Left Leg Pain and SOB • 14:10 • Cardiopulmonary arrest with successful resuscitation • 14:25 • Transferred to the OR • Shortly thereafter, patient went into arrest again and passed away

17. 54 Year Old Male with Left Leg Pain and SOBTimeline • PTA: Previous day ED visit for left leg pain • 09:25: Arrival • 11:10: Surgery consultation • 11:30: Endotracheal intubation • 12:15: Pressors begun • 13:15: Bedside debridement • 14:10: Cardiopulmonary arrest • 14:25: Transfer to OR; Death

18. 54 Year Old Male with Left Leg Pain and SOBPostmortem • Culture results • Wound and blood cultures • All positive for Strep pyogenes Group A • Additional history • Patient had visited his pmd prior to his initial ER visit and had received an “injection” into his left hip/thigh area for pain

19. Necrotizing Fasciitis • Progressive, rapidly spreading, inflammatory infection within the deep fascia, with secondary necrosis of the subcutaneous tissue

20. Necrotizing Fasciitis • Descriptions of the disease date back to the days of Hippocrates (400 BC) • First described in medical literature by Dr. Frank Meleny in 1924

21. Necrotizing Fasciitis • Previously known as strep gangrene, phagedena, phagedenic gangraenosa, necrotizing subcutaneous infection, suppurative fasciitis • In 1952, the term necrotizing fasciitis 1st published in literature

22. Necrotizing Fasciitis • Mortality extremely high • Up to 25% • 70% in cases presenting with sepsis or renal failure

23. Necrotizing Fasciitis • Risk Factors • Local tissue trauma with subsequent bacterial invasion • Local ischemia • Reduced host defenses

24. Necrotizing Fasciitis • Other Predisposing Factors • Skin biopsy • Needle puncture sites • Frostbite • Chronic venous leg ulcers • Open bone fractures • Insect bites • Surgical wounds • Abscesses

25. Necrotizing Fasciitis • Other Predisposing Factors • Systemic illness • Predisposes to local tissue ischemia and hypoxia • Diabetes, cancer • Alcoholism • Immunosuppression • Idiopathic/Spontaneous • 50% of cases?

26. Necrotizing Fasciitis • Other Predisposing Factors • Pediatric considerations • Omphalitis and circumcision • Surgery or trauma • Varicella • Congenital or acquired immunodeficiencies

27. Necrotizing FasciitisClinical Course • Tends to begin with constitutional symptoms such as fever and chills and is often mistaken as viral in etiology • Soreness in the affected part of the body may be present early

28. Necrotizing FasciitisClinical Course • 24-48 hours later, erythema followed by vesicles and/or bullae over affected area • Pain may be out of proportion to clinical findings • Anesthesia in affected area may be a sign of thrombosis of local subcutaneous blood vessels

29. Necrotizing FasciitisClinical Course • Without treatment, deeper muscular layers become involved with resultant myositis or myonecrosis • Rapid progression to systemic infection, sepsis and death

30. Necrotizing FasciitisClassification • Type 1 • Polymicrobial • Usually after trauma or surgery • Anaerobic and facultative bacteria in synergy • May be mistaken for simple cellulitis externally, but with significant underlying necrosis

31. Necrotizing FasciitisClassification • Type 1 • Example of bacteria involved include S. aureus, Bacteriodes • Prevotella species usually found in NF of the mouth, jaw, neck, and/or face • Pseudomonas species in extremely immune-compromised patients

32. Necrotizing FasciitisClassification • Type 1 • Type 1 variant caused by a minor skin wound contaminated by saltwater containing Vibrio vulnificus • Soft tissue necrotizing infection at location of the wound • Those with liver and/or blood disease at higher risk of this infection

33. Necrotizing FasciitisClassification • Type 1 • Fournier’s gangrene

34. Necrotizing FasciitisFournier’s Gangrene • Rapidly progressing polymicrobial necrotizing fasciitis of the perineum • Usually genitourinary, rectal or penile/scrotal source

35. Necrotizing FasciitisForunier’s Gangrene- Risk Factors • Immune Compromise • Diabetes • Alcoholism • HIV • Cancer

36. Necrotizing FasciitisFournier’s Gangrene- Risk Factors • Hygiene • Homelessness • Paraplegia • Catheters • Nursing Home • Tinea cruris

37. Necrotizing FasciitisFournier’s Gangrene- Risk Factors • Surgical • Circumcision • Vasectomy • Orchiectomy • Hernia repair • Hemorrhoidectomy

38. Necrotizing FasciitisFournier’s Gangrene • Once bacteria break through skin barrier, rapid spread along the perineal fascial planes • Posteriorly and laterally, Colles’ fascia fuses with urogenital diaphragm • Anteriorly, Buck’s and Scarpa’s fascia allowing lateral extension and extension to the abdominal wall

39. Necrotizing Fasciitis

40. Necrotizing FasciitisFournier’s Gangrene • Testicles usually spared • Toxic appearing • INAPPROPRIATE INDIFFERENCE • Mortality 10%- 50%

41. Necrotizing FasciitisFournier’s Gangrene

42. Necrotizing FasciitisFournier’s Gangrene

43. Necrotizing FasciitisFournier’s Gangrene

44. Necrotizing FasciitisFournier’s Gangrene

45. Necrotizing FasciitisFournier’s Gangrene

46. Necrotizing FasciitisFournier’s Gangrene

47. Necrotizing FasciitisClassification • Type 2 • Group A streptococcus • “Flesh-eating bacteria” • Gas usually not evident • 50% of cases in previously young and healthy patients • Varicella infection and use of NSAIDS are predisposing factors

48. Necrotizing FasciitisClassification • Type 3 • Clostridial myonecrosis • Usually Clostridium perfringens • If spontaneous, the C. septicum more likely, especially in association with leukemia or colon cancer • Gas gangrene

49. Necrotizing FasciitisDiagnosis • Diagnosis may be extremely difficult and may not be evident until late • CLINICAL SUSPICION the key • Pain out of proportion to exam • Toxic appearing

50. Necrotizing FasciitisDiagnosis • CBC with differential • Electrolytes • Calcium level • Extensive fat necrosis may cause hypocalcemia