A 38-year-old male with type 1 diabetes mellitus presents with two days of severe thigh pain. You are called to see him because of hypotension. On examination he is drowsy, BP 80/60 mmHg, HR 140 beats/min and temperature of 40.2°C. There is gross swelling on the medial aspect of his right thigh with obvious cellulitis and visible central necrosis.
Describe the management priorities in the first 24 hours and briefly justify your responses.
Resuscitation
Antibiotics
Surgical Referral and post-operative management
Routine ICU care of patient with severe sepsis
Specific Therapies
This question is identical to Question 24 from the first paper of 2011.
The discussion section from that previous question is reproduced below, to simplify revision
A boringly algorithmic answer to this question would look something like this:
The key points to remember are:
Marron, Conor D., et al. "Perforated carcinoma of the caecum presenting as necrotising fasciitis of the abdominal wall, the key to early diagnosis and management." BMC surgery 6.1 (2006): 11.
Casali, Robert E., et al. "Postoperative necrotizing fasciitis of the abdominal wall." The American Journal of Surgery 140.6 (1980): 787-790.
Rea, William J., and Walter J. Wyrick Jr. "Necrotizing fasciitis." Annals of surgery 172.6 (1970): 957.
Samel, S., et al. "Clostridial gas gangrene of the abdominal wall after laparoscopic cholecystectomy." Journal of Laparoendoscopic & Advanced Surgical Techniques 7.4 (1997): 245-247.
McSwain, Barton, John L. Sawyers, and MARION R. Lawler Jr. "Clostridial infections of the abdominal wall: review of 10 cases." Annals of surgery 163.6 (1966): 859.
Hasham, Saiidy, et al. "Necrotising fasciitis." Bmj 330.7495 (2005): 830-833.
Mulla, Zuber D. "Treatment options in the management of necrotising fasciitis caused by Group A Streptococcus." Expert opinion on pharmacotherapy 5.8 (2004): 1695-1700.
Darenberg, Jessica, et al. "Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial." Clinical infectious diseases 37.3 (2003): 333-340.
Brown, D. Ross, et al. "A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy." The American journal of surgery 167.5 (1994): 485-489.
Soh, Chai R., et al. "Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample." Intensive care medicine 38.7 (2012): 1143-1151.
Majeski, James A., and J. Wesley Alexander. "Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis." The American Journal of Surgery 145.6 (1983): 784-787.
Bilton, Bradley D., et al. "Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study." The American Surgeon 64.5 (1998): 397-400.
Wong, Chin-Ho, et al. "Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality." The Journal of Bone & Joint Surgery 85.8 (2003): 1454-1460.
Norrby-Teglund, Anna, et al. "Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach." Scandinavian journal of infectious diseases 37.3 (2005): 166-172.
Carapetis, Jonathan R., et al. "Effectiveness of clindamycin and intravenous immunoglobulin, and risk of disease in contacts, in invasive group A streptococcal infections." Clinical Infectious Diseases (2014): ciu304.
Levett, Denny, Michael H. Bennett, and Ian Millar. "Adjunctive hyperbaric oxygen for necrotizing fasciitis." The Cochrane Library (2015).
Eke, Ndubuisi. "Fournier's gangrene: a review of 1726 cases." British Journal of Surgery 87.6 (2000): 718-728.