Can necrotizing soft tissue infection be reliably diagnosed in the emergency department?

Abstract

Necrotizing soft tissue infections (NSTIs) are associated with a high mortality and require prompt recognition and treatment, consisting of aggressive surgical debridement and critical care support. Diagnosis is a key step, which is generally made in the operating room (OR), but the decision to debride requires guidance. This is frequently made on clinical grounds, but NSTI can be occult in presentation and several other infective processes can mimic NSTI. It is unknown whether the various scoring systems described in the literature can enable clinicians to reliably diagnose NSTI in the emergency department, rather than the OR. The topic was debated at the 36thAnnual Point/Counterpoint Acute Care Surgery Conference and the following article summarizes the discussants points of view along with a summary of the evidence.Level of evidenceLevel III.

Necrotizing Soft Tissue Infection with Compartment Syndrome: A Case Report

“…Type 3 infections are controversial and constitute the least observed group. They are mediated by Vibrio vulnificus and are accessed by a break in the skin exposed to seawater (4). It is known that penicillin plus clindamycin treatment decreases the mortality rate in Type 2 NSTIs caused by group A streptococci (GAS) (7).…”

Impact of clinical interventions in the timely diagnosis and therapeutic approach of necrotizing soft tissue infections

“…It is important to note that the positive predictive value (PPV) of pathognomonic physical findings isn´t surpassed by any other technology. [1][2][3][4] The localized pain is perhaps the symptom of first appearance; it can be accompanied by erythema, hyperthermia, edema around the erythematous zone, epidermolysis, tachycardia, fever and tanning of the skin. Late physical findings include hemorrhagic bullae, bad odor, dermal gangrene, crepitus, seropurulent drainage, inflammatory response syndrome and progression of early symptoms.…”

“…The disproportionate pain of sudden onset is highly suggestive of NSTIs, unfortunately, at this level the tissue involvement is already large and irreversible, with imminent amputation of the affected limb in most cases. [2][3][4] Tissue involvement in the same way is variable, ranging from subcutaneous necrosis to sepsis with injuries in fascia and muscles. Although, it methods for early detection from serological markers have been proposed.…”

“…NSTIs are characterized by massive tissue destruction; the initial presentation can be restricted to deep planes, preserving intact skin. [2][3][4][5] It is important to consider the abscense of universally accepted imaging protocol to address patients with suspected NSTIs. 6 Techniques such as computed tomography (CT), flat X-rays and magnetic resonance imaging (MRI) have been used, but none of those is the gold standard.…”

What Is the Accuracy of Physical Examination, Imaging, and the LRINEC Score for the Diagnosis of Necrotizing Soft Tissue Infection?

“…This diagnosis can be notoriously elusive in the ED, given that it can mimic far more common yet less nefarious disease processes such as cellulitis. 5 Hence, it is imperative that emergency physicians be facile with the diagnostic accuracy of tests commonly used to identify necrotizing soft tissue infection.…”