Invictus Reviews

Necrotizing Infections For Exams

• Mel Herbert

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Dr. Mel Herbert provides a crucial update on the Invictus Board Review program alongside critical pearls for identifying and managing deadly necrotizing infections. These rapidly progressing infections require immediate recognition, prompt treatment, and surgical intervention to prevent death from these tissue-destroying processes.

• Necrotizing infections include necrotizing fasciitis, Fournier's gangrene, Ludwig's angina, and malignant otitis externa
• Key warning signs include pain out of proportion to physical findings, rapidly progressive spread, dishwater discharge, and woody edema
• "La belle indifference" describes patients who appear strangely calm despite severe infection
• Polymicrobial infections often start as normal infections before turning necrotizing days later
• Monomicrobial forms (often Strep A) progress extremely rapidly in otherwise healthy individuals
• Seawater exposures can introduce deadly Clostridium or Vibrio species through minor skin breaks
• Treatment priorities: rapid diagnosis, fluid resuscitation, antimicrobials, and immediate surgical debridement

The full Invictus Board Review program and OSCE preparation materials will be available soon to address declining emergency medicine board exam pass rates and provide continuous education for practicing clinicians.


Speaker 1:

Hey, rockstars, mel Herbert, here. I wanted to talk to you. Let's move this closer. Let's be a bit more intimate, shall we? We're going to talk about necrotizing infections as a general thing here in a second, but I wanted to give you an update as to what's happening with Invictus. So, invictus I have been emphasizing the videos that have been coming in from our faculty. I've got to tell you they're so good. These lecturers are so good, the content is so good. Matt Delaney is also doing a bunch of emphasis and the team is just like killing it.

Speaker 1:

We have expanded out the offering. So it's going to be a little bit later than we thought, because what we're trying to do here is obviously create something new and interesting in this Board of View space great lectures, but also emphasis, question bank summaries, all of the stuff, podcasts and stuff coming along as well. But there's also Encore. So, as you know, there is new oral exam for the emergency medicine residents that you do after you pass your written. Then you'll get an oral exam, and that oral exam is now turned into an OSCE-like format and that produces a lot of anxiety because this is the first year. So we have that product about how to do that OSCE exam and cases to go with that. That will be coming out actually before the full Board of View program and we're very excited about that. We've got about, I think, 300 residents and residencies across the country that are about to get the beta version of that so we can test it and tweak it before we make it go live. So there's a lot going on in the world of these exams and I think I've talked about it here before, but the pass rate for these exams has been going down and that's a bit upsetting to me and that's why we are creating this thing. But also there's this idea that I think that you should do continuous border view as part of your life. I think that if you're going to be in emergency medicine, it is so wide and vast that, yes, you should be keeping up with the latest, greatest, with things like MRAM, but there should also be some form of that you're doing of continuous border view, because after three or four years, if you've been out, you tend to forget shit. So you know it's important. So here's the basic concept and Chris does a great lecture on this, on Invictus.

Speaker 1:

But there's a group of necrotizing infections and I would define these as infections that basically kill you fast and eat you fast. And what are these necrotizing infections and what are some pearls about them? So if we start from the legs up, necrotizing fasciitis. Necrotizing fasciitis is at that fascial layer. It's a rapidly spreading infection and it will kill you very quickly. It's kind of amazing. And then if you go further you get to the perineum and we think of our Fournier's gangrene, another necrotizing infection, classically in alcoholics, that can basically eat away your perineum, make you septic and die incredibly quickly. If we go up further we might start thinking about Ludwig's angina. So Ludwig's angina, it's a necrotizing infection at the floor of the mouth, usually from dental disease, and that can take out your airway and kill you incredibly quickly. I think about malignant otitis externia, which not everybody would throw into this category, but it's a rapidly progressive, very serious condition which can erode into your mastoid, which can then erode into your brain and kill you incredibly quickly. And then of course, there's just sort of the myositis-like syndromes.

Speaker 1:

The real basic concept about necrotizing infections for the exam but also for life, is what are the pearls or what are the classic presentations that they would give you to suggest that this is not just a normal infection and I've got the list here and I think the list goes something like this Pain out of proportion to signs. If you have any patient with an infection with pain out of proportion to signs, this is a necrotizing infection until proven otherwise. Pain out of proportion to signs in any presentation is a real concern, whether it's chest pain or belly pain or whatever it is. But if there's an infection, pain out of proportion to signs, think necrotizing infection If it's rapidly progressive and they'll make it clear on the stem that there's a little red line here and they marked it and a couple of hours later it's past that red line and now it's a lot further past. That suggests a necrotizing infection.

Speaker 1:

Dishwater discharge when it comes to necrotizing fasciitis. So if you actually put a scalpel into one of these wounds you'll get this gray dishwater-like discharge, very suggestive of an ecteritizing infection. The woody edema. So all of these patients can have a little bit of edema, but this is like tense woody edema associated with the infection, necrotizing until proven otherwise.

Speaker 1:

And then I would add one which is often left off and I think it's really important, and that is the idea of la belle indifference. So that is the concept that the person is sick, but they don't really kill, they're indifferent to it. So they've got this gangrenous leg and they look like they're going to die and they're like, yeah, this is probably from the release of catechols and sort of endogenous endorphin-like substances and they just don't really care. I've seen it clinically many times. The other concept here I think is important is that there tends to be two big forms the polymicrobial form and the monomicrobial form. The polymicrobial form often has a lead time where it looks like a normal infection with an abscess and stuff, and then it goes bad and turns necrotizing and there's often days to a week or more for these patients to present really sick.

Speaker 1:

The monomicrobial form is classically caused by strep. It's just a particular form, usually of strep A that is just nasty and just a normal person nicking the skin. This thing gets in there and it starts eating you alive incredibly quickly. There's also the forms that occur in seawater and the classic one is the clostridial species and the vibrio species that you might get from seawater. So I was surfing, I had a little nick in the skin and now I'm sick as hell and I've got a rapidly progressive infection. Think about necrotizing infection from Clostridium or from Vibrio species.

Speaker 1:

And the treatment for all of these is the same Diagnosis, fast, fluid resuscitation, antimicrobials, surgeon and for the exams, do not delay imaging to get to surgery. You want to get the surgeon to see them as quickly as possible. In reality, a lot of the time you'll get the CT while the surgeon is driving in. But this is all about rapidly getting antimicrobials, resuscitation and getting to the OR, because this dead necrotic material must be excised or the patient will die. I think that's enough for this little one. I can't wait to get this thing out into the world. This little podcast is just a little taste, a little one. I can't wait to get this thing out into the world. This little podcast is just a little taste, a little sous-son of what is to come. Herbert out.