Invictus Reviews

The Necrotizing Fasciitis Questions

• Mel Herbert

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Necrotizing soft tissue infections demand immediate recognition and aggressive treatment to prevent devastating outcomes and death. Dr. Mellick reviews critical diagnostic features, treatment protocols, and exam-relevant information about these life-threatening conditions through a series of board-style questions.

• Necrotizing infections in IV drug users present with severe pain, woody edema, and require immediate surgical exploration
• Hemorrhagic bullae and crepitus are "hard findings" strongly suggesting necrotizing fasciitis
• Clindamycin plus broad spectrum antibiotics are essential to reduce toxin production and address polymicrobial nature
• CT scan offers the best combination of sensitivity and availability for diagnosing necrotizing infections
• Specific pathogens like Vibrio vulnificus should be considered in patients with exposure to coastal waters
• Risk factors include immunocompromise, diabetes, cirrhosis, and injection drug use
• Early surgical consultation and intervention are more important than waiting for imaging results

If you're triggered or experiencing PTSD from medical content, please seek help - modern therapies including ketamine can be effective treatment options.


Speaker 1:

all right, pete's, let's do some more invictus stuff. I'm going to do some multiple choice questions, um, but before we start, a couple things. First of all, pity watching come on. The show is fantastic. It's getting great reviews. The team over there has done an amazing job. I'm so excited that mrap corpennian we are official collaborators now.

Speaker 1:

I've been consulting with joe sax, who really deserves all the credit for how well the medicine is done. He's an amazing ER doctor my attending at UCLA and now I get to actually sit in the writer's room, which has been an amazing experience, to help keep this thing going. It's amazing, but if you're triggered by it, if you're getting PTSD from this thing, that's not abnormal, but it means that you need to get some help. So if you're getting ptsd from this thing, um, that's not abnormal, but it means that you need to get some help. So if you haven't been getting help, there's a lot of new therapies now. It's not just talk therapy, it's not just ssris, there's ketamine, which I have used and has been incredible for me. So you know if you're at that place, ketamine fantastic. We've talked about it on dirty white coat, our sister program of all of the different things there. So don't screw around. This is not an old job, okay. It requires you to get self-care, so please do that, okay, it's really, really important. So what I want to do today I'm not going to be scratching through it, I've got the seltzer water what I want to do today is some questions. So if you're listening, it's probably best to click on the link below and go over to the YouTube channel, as we are developing this program and all the faculty are starting to shoot their stuff and we're going to try and get this out as quick as we can. I want to try different techniques here on the free version of the podcast so you can give us some feedback about what you'd like to see in the future.

Speaker 1:

So this is doing some questions, and these questions are all going to be on the same topic, but I'm going to use it as a way to highlight what I think are some of the most important features of the disease and what you might have on the exam. So here's question one 45 year old, with a history of injection drug use, high risk presents with severe left arm pain. Severe left arm pain Okay, so this is the giveaway as to what this is Swelling erythema, two days, vital signs heart rate of 110, temperature 8 February. Blood pressure of 160, 45 year old that's pretty low. Physical exams woody edema, no crepitus. What is the next most appropriate step? So what you're supposed to do is work out what's going on here. So you've got an IV drug user, you've got severe arm pain and you've got this woody edema.

Speaker 1:

That is a necrotizing infection until proven otherwise. So if it's a necrotizing infection, what is the next best step in management? These drive me crazy because obviously in the real world what you do is about four things at once you get an IV and you start the fluid, you start the antibiotics. So you probably are going to get some imaging because that's the way the surgeons roll these days and you're going to call a surgeon at the same time. But the right answer in the textbooks and if the world was a better place would be what so A? Administer oral antibiotics and discharge for follow-up?

Speaker 1:

I don't think so. They're trying to tell you this guy's sick, obtain a plain film and wait for results. I don't think so. I don't think so. Plain films and necrotizing infections have a very low sensitivity. If there's gas and stuff in it, great, but it's not there all the time. Consult surgery immediately for operative exploration. That is the right answer. There's obviously not what happens in the real world all the time, but that's the right answer. Or start IV fluids and observe for six hours. That might be a reasonable answer in cases where I'm not sure what's going on. I don't think it's a necrotizing infection and the surgeon's far away. I might just keep them in the emergency department and observe them. I've done that many times in my career and most of the time it's nothing and they don't get worse than they're fine. But I've got a couple of really sad cases where they got worse in front of me and I could call the surgeon and say look, I know you're an hour away, but start driving the fast German car because this person on the last hour has gotten a lot sicker and that C-Litis thing is spreading. Come on down Quick drink of the soft salt water, delicious.

Speaker 1:

Here's question two. Which of the following are considered hard findings of necrotizing soft tissue infection on physical examination? In this case, a hard finding is a finding which strongly suggests the diagnosis of necrotizing fasciitis. So is it erythema and warmth? No, very non-specific cellulitis can do it. Bug bites can do it.

Speaker 1:

Very non-specific hemorrhagic bullae yes, in the face of somebody, very nonspecific. Hemorrhagic bullae yes, in the face of somebody where you think this is an infection. Hemorrhagic bullae are a huge concern for necrotizing fasciitis. This is underneath the dermal layer and now it's bubbling up bad, do you like that scientific explanation? Localized tendinitis very nonspecific. Mild swelling very nonspecific. So it's the hemorrhagic bullae which are very concerning for necrotizing infections. And the other one is obviously crepitus. If you push on the wound it gets hugely. Concerning gas-forming organism. Likelihood of necrotizing pestilence goes up substantially.

Speaker 1:

Let's do another one. This is a 32-year-old female who presents with severe perineal pain and swelling three days after childbirth. Her lab show white count of 28, which is very high, a setting of 132, which is a little bit low, and a CT scan reveals facile gas in the perineal area. This is a problem. Which antibiotic regimen is the most appropriate to initiate immediately? So on this one they're like saying, yeah, of course this person person can have the LR, but we're going to start the antibiotics. So one of the key teaching things here is that clindamycin in animal studies seems to reduce sepsis, maybe even reduce mortality, perhaps by reducing the production of toxin.

Speaker 1:

So in a lot of these necrotizing infections of various forms. Clindamycin is suggested by the ID expert. So I look down the list. Now I want broad spectrum because this can be polymicrobial. So you want broad spectrum. It can also just be strep A, but you don't usually know that until later. And clindamycin is the regimen that I have, so it's clindam plus broad spectrum. So the best one here is not ceftriaxone alone, but clindamycin, piptozo, bank, lenazolid by itself no. Metronidazole by itself no. So I look for clinda plus. Very broad spectrum is the right answer for these necrotizing infections.

Speaker 1:

When they're asking about the antimicrobial, let's do another. One. 60-year-old diabetic male presents with a foot infection. Okay, we see a lot of those people, but in this case he's at breadboard, but he has a lactated 5 and is hypotensive.

Speaker 1:

Which of the following imaging modalities is most appropriate? We just talked about the fact that if you're really concerned, this person needs to go to the OR Forget the imaging modality. Having said that a lot of time, it's hard to make the diagnosis. So do you want to get a plain film? We've talked about plain films are not very sensitive. So if you do it and it's positive, fine. But don't screw around with this thing. It's not very sensitive. Mri is actually very good.

Speaker 1:

The problem with MRI is it takes a long time and often is a far, far distance away. So that is really not the answer in the vast majority of cases. Contrast-enhanced CT or even non-contrast-enhanced CT as a tiebreaker is really good. It has a very high sensitivity. It's not 100% but it's very good. Or point-of-care ultrasound Right now that is not the answer, but the point-of-care ultrasound. People are getting better all the time, so maybe one day that will be so. Ct scan is pretty damn good. In Copenium they suggest that the sensitivity is over 90%. It's not 100%, but it's over 90%. So here's another one.

Speaker 1:

Which of the following historical risk factors is the least likely to be a risk factor for necrotizing patients? A recent minor wound from gardening? That can certainly do it. Any minor wound port of entry bugs can get in there. That can be a problem. Varicella infection same thing. Varicella chickenpox scratchy, it's the kids. The adults will often get a little bit of cellulitis and that can turn necrotizing. So that's bad and then probably a little bit immune, suppressed from that infection. Hypertension is not a known risk factor for necrotizing infections and injection drug use absolutely is probably the highest risk factor. Do you have time for one more. I need a little drinking here.

Speaker 1:

I think we'll do part two of this, because there's more I don't want to do. So here's a 50-year-old man with cirrhosis who presents with rapid onset of leg swelling and pain after a fishing trip in coastal waters. So this is a classic You've got cirrhosis, you've got a leg edema, probably from your cirrhosis, and now you're in a coastal fishing trip. He's hypotensive and he has bulla unexamined. Okay, so he's sick and they're talking about bulla. So they're thinking about necrotizing infections which pathogen is most likely responsible and what additional antibiotics should be considered. And so here are the answers Group A, strep and clindamycin yeah, I like those two together.

Speaker 1:

That's not an unreasonable thing. But this is not coastal waters. This is what they're trying to get. I got it from the coastal waters. Um, vibrio volnificus classically occurs in the waters of the coast, the seas, and doxy is the treatment, as well as broad spectrum. But you would add doxy to that person. Um, there's another clostridium species here and vancomycin and there's msa and the nasolid. But I'm discounting all of these because it said coastal waters and I know that's vibro. So this is one of those examples where, a little bit of knowledge, I know that seawater and vibro go together and doxy goes vibro, so I can knock this question out super fast and also, in clinical practice, I'm going to add doxy to all my other stuff. All right, so is this useful too? I hope it's useful.

Speaker 1:

The show here is called Invictus Reviews. This is the free podcast. We are busy, busy, busy building the full program, and the full program is going to be much different than anybody else's board review Much bigger, much better, tastes, great, less filling, awesome. Watch the bit. Herb it out. Talk to you soon. Bye for now, boom.