Can’t Miss Diagnoses
- Necrotizing Fasciitis
- Toxic Shock Syndrome
- Venous Thromboembolism (e.g. DVT)
- Peripheral Arterial Occlusion
- Tendon Rupture
- Burns (including chemical)
IF CONSIDERING NEC. FASC. PLEASE USE PROPER PPE AND NOTIFY SURGICAL TEAMS EARLY. TIME IS TISSUE.
Points to focus upon
To note and document; Tetanus status, anticoagulation, surgical manipulation if any.
Ask about recent intercurrent febrile illnesses.
May have “pain out of proportion” or localized hypoesthesia.
Check for peripheral pulses (they are the vital signs of the extremities!) – if absent, consider peripheral vascular disease.
CAUTION – Absent pulses, paresthesias, pallor, pulselessness may be signs of vascular occlusion (arterial clot) or compartment syndrome (e.g. from crush injury, recent fracture reduction, etc.)
– Look for “portals of entry” for infection (abrasions, recent surgery)
– Check joints for any involvement
– Examine for rapidly spreading rash, purulence, bullae, blisters, crepitus.
CAUTION Nec Fasc patients break all the rules:
– They may look surprisingly well.
– They may NOT have any overlying cellulitis/rash
– They may have a flat affect (known as “La Belle Indifference”).
– REMEMBER: NORMAL PHYSICAL EXAM DOES NOT MEAN ABSENCE OF NEC FASC.
Clinical Decision Tools
DO NOT DELAY SURGICAL INTERVENTION IF SUSPECTING NEC FASC. Definitive Management is surgical debridement.
- CBC, BUN, Cr, Lytes, Glucose, VBG,
- Consider Blood Cultures PRIOR TO antibiotics
- C-reactive protein (CRP)
- Consider joint aspiration
Check your specific hospital guidelines for specific local antibiotic resistance as well as dosing and duration.
In general, if you are considering a biopsy or aspiration, it is best to do this before starting antibiotics for best lab results. However, please use clinical judgement and if the patient is unstable, save the life over the limb.
General aspiration locations:
Shoulder- debated image guided vs Posterior approach
Elbow- Radial triangle
Wrist- Dorsal above lister’s tubercle
Hip- Image guided
Knee- Anterior medial or lateral to patella
Ankle- Anteromedial or anterolateral.
1. Surgical Debridement
2. While awaiting OR to be ready, consider empiric antibiotic therapy:
One of [ Meropenem 1 g IV q8h OR Piperacillin-tazobactam 3.375 g IV q6h PLUS
One of [Vancomycin 15 mg/kg q12 h IV OR Linezolid 600 mg IV q12h OR Clindamycin 600 mg IV) PLUS
AGAIN, DO NOT DELAY SURGICAL INTERVENTION IF SUSPECTING NEC FASC. Definitive Management is surgical debridement.
Severe Purulent SSTI
- IV Piperacillin/Tazobactam and Vancomycin; or
- Oral or IV Clindamycin (same bioavailability); or
- IV Linezolid
Mild/Moderate Purulent SSTI: Choose one or combination
- Oral TMP/SMX; or
- Oral or IV Clindamycin; or
- Oral Doxycycline
Of note, if no overlying cellulitis or comorbid conditions, Choosing Wisely Canada recommends discussing the use of antibiotics with patients as the benefits conferred by antibiotics may not outweigh the risks associated with their use.
Severe non-purulent SSTI:
1. IV Piperacillin/Tazobactam AND Vancomycin AND IV Clindamycin (if concern for necrotizing infection)
Mild/Moderate non-purulent SSTI:
1. Oral Cephalexin; OR
2. IV Cefazolinn; OR
3. Oral or IV Clindamycin
See notes below
– Consider oral antibiotics whenever possible. 5-7 days. Usually, first-generation cephalosporin (e.g. cephalexin) to start.
– If progressing despite antibiotics or signs of systemic infection, consider IV cephalosporins.
– If allergic (anaphylaxis) to cephalosporins, may consider Clindamycin as an alternative therapy (Bonus: it has same bioavailability both PO or IV, so go ahead a treat PO – just ask patient to also start probiotics since they may get antibiotic-related diarrhea).
Recommended reading, videos, and podcasts
- EM Cases: Necrotizing Fasciitis
- CRACKCast E137 – Skin and Soft Tissue Infections
- EM Case: Skin and Soft Tissue Infections:
- Life in the Fast Lane (Caution: Aussie source!):
- EMDocs: Update on the Management of Skin Abscesses in the ED (Caution: American source!)
Would you like to read more MSK topics? Read about common fractures or joint pain.
This is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.
This post was copyedited and uploaded by Evan Formosa.