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F, DISP,( ʦʦ( 0(0(0(0(x`P0 PxxP PH HXP8 8xHxP( (hhhPx@`XXXHhxhXpx`xԔ000hpxhxXp0HXxPh@XhHHH(8PXX (PX888p`X@hp((8@ X00p`xpPHP( `80 H H( P0(@ ((hXXH@̜x`@0 p`P̤pX伄`ܴx̔P@(XH0h8hX880 8@p`800(HH@0@ (0 8X @(h @0((0H0@X@ X(@(@pX(`xx``XXHH@@xxhhH hhHH8@@@HH8 (x@hX@xPhpx```Hx@hPx`h`HpXxpxx@@h@`HhX`px(@pHhPpXp@XhPXh@Xhx0@p 0p(@hxX`(8(0X`h@hxpx(0 (x`x((X00((00 x((((x X8PP 8 pp@@P``xLISTINFOICOP!Copyright Microsoft Corp. 1995ICRD 1995-04-18IPRD#Microsoft Plus! for Windows 95 ISRCBMicrosoft Corporation One Microsoft Way Redmond, WA 98052-6399 z32       "$& ( * , . 02,2$53qF7,S ~1?@8g46d6d 0f ppp@ g4KdKd 0f *ppp@  ? O =5Strep Tease - A case review of necrotising fasciitis.$ Matt ShepherdStrep. - Tease CASE PRESENTATION 35 Year Old Gentleman Presented self to A&E 3/7 History of Pain and swelling in right elbow/forearm after minor trauma to elbow. Triage nurse asks doctor to sanction X-ray of elbow. Doctor after brief glance at swollen arm, noting bruise at elbow, agrees. 6   Strep. - Tease 7Patient takes self around to X-ray. WHAT WAS MISSING ?"%8 8 Strep. - Tease Patient Returns From X-ray. No New Fractures seen on X-ray. Thorough examination of arm : Swollen from tip of shoulder to fingers. Bruising around elbow and some blistering. Solid swelling over biceps. Small healed laceration middle finger.  Strep. - Tease BDIFFERENTIAL DIAGNOSIS ? Infection Thrombosis Soft Tissue Injury*)) C Strep. - Tease Intravenous Access Sought Patient Sweaty , Unwell OBSERVATIONS TAKEN !!! (approximately 40 mins after presentation) P=120 / min Temp 34.0 o C BP = 76/54 TRANSFERRED TO TROLLEY ON MAJORS DK  "  Strep. - Tease Resuscitated with Intravenous Crystalloid, Bloods Taken Intravenous Flucloxacillin & Benzylpenicillin given (1 hour after presentation) ULTRASOUND arranged ---> No Thrombus seen. Despite IV fluid BP only just 95 systolic. IV Colloid given STAT. BP maintained at >100 systolic.  Strep. - Tease REVIEWED by CONSULTANT ARM increasingly swollen , blisters leaking fluid ++ Blood Results : Na 127 Hb 17.2 PT 28/13 K 3.2 Plat 121 Ur 15.8 WCC 3.19 Cr 257 CRP 565jr  Strep. - Tease  SLIDES`  Strep. - Tease TRANSFERRED TO RESUS ITU TO SEE Catheterised Repeat double doses IV Antibiotics including 1st dose of Metronidazole Arterial Line , Central Line Orthopaedics to see ---> theatre to debride arm.  Strep. - Tease TRANSFERRED TO INTENSIVE CARE (7 hours after presentation) Taken to theatre, arm debrided , shoulder to fingers. Requiring dialysis and inotropic support on ITU. In next 2 days , 2 further trips to theatre for debridement.   Strep. - Tease kGradual improvement in condition Off inotropic and renal support. Referred to SJUH Plastics , transferredll l Strep. - Tease $DIAGNOSIS Necrotising Fasciitis *% ( % Strep. - Tease DNECROTISING FASCIITIS  progressive inflammation and necrosis of subcutaneous tissue and adjacent fascia with secondary necrosis of the overlying skin. Early stages : diffuse swelling of affected area (usually a limb) Appearance of bullae , fill with clear fluid , become violaceous colour. Late : (but often rapid) Progression to frank cutaneous gangrene, muscle necrosis and moderate or severe systemic toxicity.(  Strep. Tease DIAGNOSIS IS A CLINICAL ONE. Helpful Investigations Needle Apsirate from Subctuneous tissue for MC&S /Blood Cultures (Diagnosis & guide for antibiotics) FBC/Clotting/U&E (identifying systemic effects of infection and need for support) Strep. - Tease $2 Broad Categories Type I Type II<% %Strep. - Tease Type I Organisms identified as : Mixed anaerobes , gram-negative aerobic bacilli, enterococci Clinical Picture : destruction of fat & fascia, skin sparing. Predisposing Factors : Surgery , Diabetes , Peripheral Vascular disease.:X Strep. - Tease /TYPE II Classically the organisms responsible are : Group A Streptococcus This gives rise to the classical rapidly spreading , painful necrotising fasciitis with high systemic toxicity. Predisposing factors : Penetrating Trauma , surgical procedures , varicella, burns , minor cuts , trauma , NSAIDS^-. 0Strep. - Tease Treatment Early Antibiotics (Fluclox , Benzylpen , Metronidazole, Clindamycin) Early Debridement Early Identification of Systemic Toxicity and Aggressive Support. Hyperbaric Oxygen , Immunoglobulins etc.r  DA* Strep. - Tease XMORTALITY Varies with interval from onset to start of treatment. May be as high as 70%$ NY Y Strep. Tease FWHY ME ? 1. Genetic Pre-disposition 2. Increased bacterial virulence" >G GStrep. - Tease LESSONS Check Observations early Ask for advice/help early Necrotising Fasciitis. affects young healthy people and should be in differential early.D Strep. - Tease ANY QUESTIONS ? / !"#$%&' ( ) * + ,-./01234P  ` f33f` f̙f` ___` ff` 3ff3f>?" dd@,?lKd@  d lA@ d`"  n?" ddD !!BBddPR    @ ` ` p>> c[ (  ,8 y yF  C B7 C DEHFP @?q 6 6 n(dx  G b q %(@B y2   fG1?  ZTgֳgֳ ?P  T Click to edit Master title style! !:  Tgֳgֳ ?  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H  0޽h ? f33f  PH( ֳ    fbgֳgֳ ?P      fbgֳgֳ ?<$  0  H  0޽h ? f33f  PH(     fcgֳgֳ ?P      fdgֳgֳ ?<$ 0  H  0޽h ? f33fj  (     fdgֳgֳ ?P      f$egֳgֳ ?    NA ??PX $ 00H  0޽h ? f33f 0 |p( KDMC    B1 ?`   R   fT\gֳgֳ ?? B   ~Welcome My case presentation today has the somewhat contrived title of Strep. tease in an effort to ensure a large turnout.  H  03iO ? ̙33 0 me (      B1 ?`   ;   f\gֳgֳ ?? B   gFirstly , the case. 2 weeks ago a 35 yr old chap walked into A&E with his wife & 2 kids. He preseented to triage complaining of a 2 day history of pain in his arm which seemed to have started when he knocked his elbow on the wall. He had sought advice from his GP the day before attending A&E and had been prescribed analgesia (NSAID) + oral antibiotics. The triage nurse saw his swollen arm and grabbed the nearest Dr to have a quick look at the patient and send him for an Xr o the elbow. The arm on a cursery examination looked mildly swollen and had some bruising around the medial aspect of the elbow joint.  hH  03iO ? ̙33j 0 *"((  ( (  B1 ?`    (  f4^gֳgֳ ?? B   J$WHAT WAS MISSING ??? OBSERVATIONS %H ( 03iO ? ̙337 0 0( ֳ 0 0  B1 ?`    0  f_gֳgֳ ?? B   Patient returned from Xray with an empty packet and was seen fortunately in a spare minor side room. The xrays revealed no new fracture, but did show a fluid within the soft tissue planes. The patients arm was fully exposed and examined :  H 0 03iO ? ̙33k 0 +#8(  8 8  B1 ?`    8  f4agֳgֳ ?? B   K%What Differentials can you think of ? &H 8 03iO ? ̙33 0 bZ@(  @ @  B1 ?`   0 @  fbgֳgֳ ?? B   \The next step was to gain IV access and take routine bloods and blood cultures. It was at this point that the patient became sweaty and pale, It was at this point that he had his observations checked for the first time , (40 mins after presentation) As you can see these revealed there was more going on with this patient than a simple infection. ]H @ 03iO ? ̙33 0  HA(  H H  B1 ?`    H  fdgֳgֳ ?? B   The patient was then resuscitated with fluid and given a 1st dose of antibiotics Fluclox and Benzyl pen. Woking through the differential diagnosis , and since there was no temperature and no obvious erythema an US was arranged to xclude thrombosis. He went this time escoryted to US , NO CLOT SEEN. Despite his fluid resus he was barely managing to sustain an adequate BP and it was at thids time I sought some senior advice. H H 03iO ? ̙33 0 @PH(  P P  B1 ?`    P  fegֳgֳ ?? B   As hewas being reviewed by our consultant his blood results came back. His arm was noticeably more swollen and the bruising had evolved into fluid filled violaceouis blisters.  H P 03iO ? ̙33> 0 `X(  X X  B1 ?`    X  fegֳgֳ ?? B    H X 03iO ? ̙33>  0 `( ֳ ` `  B1 ?`    `  ffgֳgֳ ?? B    H ` 03iO ? ̙33>  0 h(  h h  B1 ?`    h  fhgֳgֳ ?? B    H h 03iO ? ̙33>  0 p(  p p  B1 ?`    p  figֳgֳ ?? B    H p 03iO ? ̙33>  0 x(  x x  B1 ?`    x  fjgֳgֳ ?? B    H x 03iO ? ̙33  0 xp( X    B1 ?`   F   f4lgֳgֳ ?? B   rN.F. was first described in 1952 as progressive& & & . It starts rather non specifically and can be difficult to differentiate from any other cause of swelling. It however often rapidly progresses throught the stages described in the case presentation.. Bruising becoming blistering and then the systemic features. :H  03iO ? ̙33 0 TL ( X    B1 ?`   "   fTmgֳgֳ ?? B   tNDiagnosing N.F. is a challenge as it is not until it gets to its mid to later stages that the clinical signs differentiate it from other less devastating conditions. However at present it remains a clinical dagnosis. There are one or two investigations which may help obtain the diagnosis . A needle apsirate at the developing edge of bruising from the s/c tissues sent urgently for mc&s may well reveal the causative organisms. Also said to be helpful is MRI although wether the rapoidly progressive nature of the disease is compatible with the speed of access to MRI is debaitable. The standard routine bloods including clotting and cultures may reveal the systemic toxicity prior to the patients condition doing so. In difficult cases , intercompartmental pressures may be measured or even surgaical exploration to determine the diagnosis.  OH  03iO ? ̙33 0 @&( X    B1 ?`   d   ftngֳgֳ ?? B   There are 2 broad catog. described although as with many conditions it is often a spectrum of disease and clinically difficult to differentiate. H  03iO ? ̙33M 0  `(     B1 ?`      fogֳgֳ ?? B   -Type I  H  03iO ? ̙33" 0 r(     B1 ?`      ftqgֳgֳ ?? B   Type II - as case presentation The Lancefield GroupA streptococcus is the org responsible, and this is the classic N.F of tabloid fame Giving rise to the rapid spreading  flesh eating painful fasciitis with systemic toxicity. Interestingly incidence increases with age and a number of predisposing factors. Most of which are providing a break in the skin barrier for infection to start. From searching the literature N.F has been reported from just about every operation conceivable. Nsaid have been implicated in the development of N.F, it is postulated that there effect is due to depression of lymphovcyte function  oH  03iO ? ̙33 0 vn( hg    B1 ?`   D   f`gֳgֳ ?? B   pManagement. The most important step in treatment is hard for a non surgeon to admit , however it is early debridement obviously once adequ. resus. The antibiotics are important and thankfully most strep even the aggressive strains respond to broad spectr. penicillins. Also of worth considering is metronidazole for anaerobes and clindamycin which helps combat any resistance issues and decreases bacterial toxin production. Many other treatment are suggested but are not yet I believe fully evaluated such as Hyperbaric oxygen and the increasingly popular area of modification of the bodys cytokine responses to insults. qH  03iO ? ̙33> 0 (     B1 ?`      f$bgֳgֳ ?? B    H  03iO ? ̙33> 0 (     B1 ?`      fDcgֳgֳ ?? B    H  03iO ? ̙33> 0 (     B1 ?`      fddgֳgֳ ?? B    H  03iO ? ̙33> 0  (     B1 ?`      fegֳgֳ ?? 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