INFECTIOUS DISEASE

ResponseHistory
Rapid progression of symptoms
Severe pain out of proportion
Systemic symptoms - anorexia, nausea, diarrhoea, light headed, etc.
Risk factors - Diabetes, PVD, immunosuppression, HIV, recent injury, recent surgery, malignancy

Examination
Constant, severe pain out of proportion to physical findings, Pain on passive movement
Crepitus - gas in soft tissue
Hard “wooden” subcutaneous tissue that is painful on palpation.
Bullae
Cutaneous anaesthesia
Oedema beyond extent of visible erythema
Skin discolouration/ecchymosis/necrosis
Systemic toxicity with sepsis

ResponseVBG/Lactate - guide treatment
Blood/wound culture - guide antibiotic sensitivities
FBC - Leukocytosis
Inflammatory markers - CRP raised (?guide treatment in future)
EUC - AKI
Coags ? DIC (Look for multi organ failure of sepsis)
Imaging - CT - Free air on imaging

ResponseExtensive gas in sof tissue of dorsum and plantar aspects of foot
No obvious fracture (not a compound fracture)
= Necrotising fasciitis

ResponseImmunocompromised (any - DM, Malignancy, EtOH, IVDU, Chronic disease, Meds, transplant, HIV)
Trauma
Surgery
Morbid obesity
Malignancy
Chronic liver disease

ResponseS. Aureus (Especially in the IVDU population)
Streptococci (Group A beta-haemolytic streptococci - S. Pyogenes)
Clostridium perfringens
E. Coli
Polymicrobial gram neg + Anaerobes (Bacteroides)
Vibrio if water wound

Alternative
Type 1 - polymicrobial
Type 2 - Strep/staph
Type 3 - Clostridium

ResponseUrgent surgical referral - debridement for source control
Antibiotics (ALL of the below) - Cover MRSA, Anaerobes + gram negatives)

• Meropenem 1g Q8H (Or Tazocin 4.5g TDS)
• Vancomycin 25-30 mg/kg
• Clindamycin 600 mg IV Q8H (clinda is thought to suppress toxin production by strep - theoretical, evidence poor)

Analgesia (opioids) - Morphine 5mg + repeat

• Extremely painful condition needing a lot of analgesia. ? ketamine

Resuscitation

• Crystalloid bolus to 30 mL/kg
• Inotropes MAP >65 (Metaraminol >> Norad)
• Fluid balance (IDC etc) - >0.5 mL/kg/h

Disposition: ICU via theatres
(hyperbaric oxygen and immunoglobulins not a priority but can be considered)
Address stem - ? AWS, D+A input, Diabetes management (often diabetic).

ResponseNecrotising soft tissue infection of perineum and genitalia

Response
Oedema, erythema, and necrotic skin on scrotum.

ResponseExtensive free gas + location. Extends along fascial planes, soft tissue stranding and fascial thickening
= Fournier gangrene

ResponseFournier's gangrene
Haematoma with superimposed abscess/infection