Necrotizing Fasciitis

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Necrotizing Fasciitis

• Cindy A. Fehr
• Malaspina University-College
• BSN Program
• NRSG 335
• Fall 2005

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What Is It?

• Soft tissue infection that unleashes damaging
  toxins enzymes that can consume flesh
• Progressively destroys connective tissue causing
  disabling injuries and death
• Life threatening infection
• 30 mortality rate

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Cause

• Any toxin-causing bacterium, usually anaerobic
• Type I
• Polymicrobial
• Usually affects older adults with pre-existing
  conditions such as diabetes mellitus
• Type II
• Most common is Group A beta hemolytic
  streptococci in previously healthy individuals
• Other Causative Organisms
• Clostridium, peptococcus, E. coli, Streptococcus
  pyrogenes, S. aureus, S. marcescens

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Bacterial Action

• Injury point (minor trauma to skin) but no skin
  damage or opening necessary
• Insect bite, contusion, frost bite, chronic leg
  ulcer, surgical incision
• Bacteria begin to multiply travel along fascial
  plane, release exotoxins that destroy superficial
  deep fascia and SQ fat

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Common Sites

• Extremities
• Abdominal wall
• Perineum
• Post-op wounds

Left upper extremity shows necrotizing fascitis
in an individual who used illicit drugs.
eMedicine Images
Necrotizing fasciitis. Sixty-year-old woman who
had undergone postvaginal hysterectomy eMedicine
Images
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Signs Symptoms

• Early SS
• Mimic common, less serious conditions
• Acute illness, low grade fever
• Tachycardia
• ? WBC gt 11,000
• HCT lt 36
• Metabolic acidosis
• Erythematous, edema, very tender area of
  cellulitis at infection site
• As Infection Continues
• Severe pressure-like pain greater than visible
  signs
• If Continues Further ? deeper tissue damage,
  progressing to less pain and numbness

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Stages of Skin Damage

• Early
• Skin pink, painful, edema beyond area of erythema
• Skin smooth, shiny
• Quickly spreading erythema ecchymosis
• Middle
• As endotoxins destroy flesh, gas produced from
  this process accumulates
• Skin turns more bluish-grey to purple
• Wound leading edge can advance gt 2 inches (5 cm)
  per hour

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Stages of Skin Damage

• Late
• Bullae/vesicles (often purple) appear with yellow
  serous progressing to sanguinous (hemorrhagic) ?
  blood loss anemia
• As SQ fat necroses, watery thin foul-smelling
  fluid oozes from wounds
• Purple-blue spot progressing to graying-green
  slough deep blue and purple (almost black)
  areola which spreads rapidly

This is an example of the large black, liquid
filled blisters that are sometimes associated
with NF. Source National Necrotizing Fasciitis
Foundation
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Diagnosis

• Early
• CT, MRI (detecting signs of gas in soft tissues)
• U/S, bedside biopsy
• Surgical diagnosis ? fascia normally adheres to
  bone but on dissection, no resistance with NF
• Labs
• ? antistreptolysin O antibody titre
• ? sedimentation rate
• ? WBC count with shift to left
• ? HCT
• ? creatinine phosphokinase (if muscle
  involvement)
• Hypoalbuminemia
• Anemia typify presentation
• Hyperbilirubinemia

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Treatment Nursing Interventions

• Early recognition and treatment crucial to
  positive outcomes
• Surgery
• remove diseased tissue (cut larger than area
  involved)
• Frequent numerous ? risks associated with
  multiple anesthetics, hypothermia, mentation
  changes (esp. with older adults), fluid shifts,
  blood loss
• A 30 y.o. man developed rapidly
  progressivePainful erythema and edema to right
  foot Following a bee sting. NF developed
  within2 days and upon diagnosis area
  wasAggressively debrided in OR
• Antibiotics
• halt infection
• Penicillin 1st choice with strep infections
  combined with clindamycin, erythromycin,
  ceftriaxone
• Vasc damage ?s blood flow to SQ tissue prevents
  abx from reaching intended site
• Clotting around sx excision ?s abx to tissues

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Treatment Nursing Interventions cont.

• IV immunoglobulin Therapy
• to support natural immune system
• Heparin
• ? risk of vasculitis, thrombosis DIC
• Hyperbaric Chamber
• Controversial
• ? O2 to tissue ? slow anaerobic multiplication
  (change growth environment) while also support
  healthy, healing tissue cells
• Strict Isolation
• Mask, gloves, gown, goggles if splashing possible
• Thought to be very contagious

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Treatment Nursing Interventions cont.

• Nursing
• Assess recognize early interventions
• VS hourly chest assess, ABG, oxygen saturations
• Frequent lab values
• wound blood cultures before abx begin
• Frequent dressing changes wound measurements
• date time erythema q 1-4 hrs watch wound
  parametersfor signs of progression
• Remember extent of fascial necrosis more
  extensive than what seen on surface of skin
• Wet to dry dressings with topical antimicrobials
  at least q4h
• Medications hemodynamic support, abx,
  analgesics
• Strict monitoring of in/out hourly monitoring
• Keep family patient informed

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Treatment Nursing Interventions cont.

• Nursing cont.
• Plenty emotional support ? uncertainty,
  vulnerability
• Pain relief
• Immobilize elevate affected area to ? swelling
  which can further compromise blood flow to
  tissues
• IV hydration d/t losses through excised area
  fluid shifts
• SS sepsis shock
• ? temp, ? HR, ? mentation, weak PP, ? u/o, cap
  refill gt3sec, low syst BP
• Aggressive enteral/parenteral nutrition to
  support wound healing
• gt 2X normal basal metabolic needs
• Risk for acid/base imbalances

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Treatment Nursing Interventions cont.

• After Controlling Infection
• Skin grafts
• Emotional psychological support body image,
  life changing stressor, pain, depression,
  anxiety, fear, anger, hopelessness, role changes
  during rehabilitation/convolescence

During Acute Treatment
Original injury was minimal to her ring finger
This photo shows an amazing lifelike armcover
that completely covers the scars
Side view of arm