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Severe Soft Tissue Infections for Orthopaedic Exams
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Severe Soft Tissue Infections for Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everyone will welcome to this Wednesday's is teaching. I'm sure that staff now would be moderating tonight, and we have other mentors, Abdullah and kashif, the presenter tonight is Nicky Walsh. She is a surgeon from the Lake District.
And she has a lot of experience with the exam, and she's going to present one of the critical conditions subjects. This is very important. Being discussed VOA and instructional courses and elsewhere, and it is a hot topic at the moment. So it's very important topic, and Nick has kindly offered to cover this tonight. As you all guys know, of any questions are welcome, please raise the hand symbol next to your name or right on the chat box.
I will try to answer your questions the best of our knowledge and. At the end of this, CBD certificates can be available if someone needs one, please get in touch with me. We there will be short Viva session after this. People who are interested, please let me know as soon as possible. If interested, they might not be many questions tonight.
Thank you, everyone and over to KneeKG. Thanks to us as a spirit has introduced me, I'm KneeKG Walsh and I'm a specialty doctor at the Royal Lancaster infirmary. I trained in Australia, so I've got a little bit of experience of being on a training scheme. And then I've come back to the UK. The reason I wanted to cover this issue was that I passed my exam last year, but having gone to a few conferences, it's occurred to me that things have changed with the diagnosis of necrotizing fasciitis, and it's now a story, a critical condition.
And there are things that I think we need to know as fast as candidates, so I'll try and cover some of that in the lecture. What I will say is that there's not a lot of photography around about necrotizing fasciitis, probably because it happens so rapidly and you don't always have patient consent to use the images. So the images I've used are from my acknowledgments.
But be aware they could come up in exams. So my acknowledgment of these and one is Mr. yanukovich, who? Did a presentation at the instruction course in Manchester in January of this year, and in combination with him was Mr. Brenda Kapoor, who works in Liverpool. He was also part of the same group. But Mr. Kapoor is also put on the VOA website to lectures on necrotizing fasciitis.
So if you go into training and resources, orthopedic podcasts and then streamed down to screencasts, you will find necrotizing fasciitis, amongst other things where necrotizing fasciitis is in there, and he's done a very, very good lecture on it. So these are the necrotizing conditions that you need to be aware of. So you've always thought of necrotizing fasciitis as a single condition caused by a clostridia, but in fact, there are different causes.
The most common one is necrotizing fasciitis, which is polymicrobial necrotizing fasciitis group strep, which is. The most rapid and destructive of all of them, then you have other things like streptococcal myositis, Clostridium gas gangrene, non-custodial gas gangrene and staphylococcal tropical myositis. So if you look at that photo, I have another photo from a different angle that really come up later with.
But I can tell you that the guy that scratched his finger on a rusty nail. And we'll see what happened to him later. So why are we bothered, well, look at the mortality rates, if you have necrotizing fasciitis, poly microbial, your mortality rate is going to be 30% to 50% You've got group A strep, it's up to 100% The others are not as virulent, but certainly strep myositis.
Clostridium gas gangrene, non-custodial gas gangrene and staph tropical myositis have lower mortality rates. So for the purposes of this lecture, I'm going to focus on the first two, which we can deal with. So how do we classify it? And the reason I'll put this in is that, you know, classification systems are not really necessarily required in the exam, but we were asked this a lot of the time in the instructional course.
So I put it in there because I think the main difference needs to be between the microbial and the group A strep. This is a group, a strep is going to kill you within about 12 hours. So the classification is types one two four. It depends on the causative organism. Type 2 is the classic group A strep infection with rapid progression and high mortality.
So the one which is the microbial, it's going to be the majority of your cases. It's going to be a combination of aerobic and anaerobic species most commonly will be e.coli, Pseudomonas and Bacteroides. There's an average of four organisms isolated in these cases, but we don't know if they're all pathogenic. It's more common in immunocompromised patients, and it can start as an endless, indolent infection.
In the meantime, the surgery is more than 100 hours due to delayed diagnosis, and the outcome is dependent on the co-morbidities. The mortality of a microbial neck fascia is between 30% and 50% Type two, this is our classic Nick flash, right? It's group A strep. It can be staph aureus. It's about 20% of cases.
It's very, very aggressive. When it presents, it produces toxins, causing a toxic shock syndrome, and the mortality is between 50% and 100% And in addition to this, you know, this will be something like so I've had a recent case, which I've not put the photographs in because I've not got permission, but a gentleman that was on chemotherapy, he got a thorn scratch on his finger and he came into emergency within 12 hours with a little bit of redness around it.
So they gave him some amoxicillin and sent him home. Within 12 hours, he was back with cellulitis above the elbow and well, necrosis in his hand. And as we try to discuss with plastic surgeons and things like that, the erythema progressed gradually up over his deltoid onto his chest wall. And in fact, he died quickly. A group A strep can manifest.
So the type III is more of the Marine type of organisms, the Vibrio ones are probably. The most common and it tends to be wound contamination with seawater or brackish water, which is like, you know, a dam or a lake or something like that. And it's about 25% of cases. The mortality is a little bit lower.
That's 30% to 40% So we have a bit more time with that. Type 4 is a fungal infection, it affects mainly immunocompromised patients, so it's mainly a Candida. It can occur after trauma. You can get fungal isolates from all of your specimens for neck fash, but doesn't mean they're the cause of organism, type IV is the causative organism, so it's probably more common in things like HIV and then mortality again is 40% to 60% So what's happening?
Well, I can tell you that the incidents in the UK is increasing. And fact, it's doubled in the last decade. We've got an increase in the. Rate of diagnosis of necrotizing fasciitis, and we've also got an increase in the mortality rate, so we need to kind of address this. So what can we look at? Well, from an epidemiology point of view, it's quite rare that any 13 or 14 cases per million of the population males are about 2/3 more infected than females.
And it tends to be immunocompromised patients. So people with diabetes, decompensated alcoholic liver disease, steroids, drug users, people that are undergoing chemotherapy, radiotherapy, the exception being the group strep, which can affect anybody at all. Why do they kill us? Well, they affect mainly immunocompromised patients because they have an inherent lack of response to the infection.
And one of the problems is that they cause early superficial ischemia, so they thromboses the subcutaneous vessels and the lymphatic, the fascia is relatively avascular anyway. What they block off any blood supply to that as well. So you develop these large areas of ischemia. You get this rapid spread because the zone of infection and the method of spread means that the antibiotics you prescribed cannot reach all of the areas of bacterial present.
They spread horizontally, so they move horizontally along the fattens special planes rather than a vertical spread down through the tissues. And particularly with the group, they produce exit toxin lender toxins, which multiplies their virulence. On top of all of that, we have no experience with it. You know, there's a lack of exposure of teaching and training of Physicians and Surgeons.
You know, even as a surgeon, they expect you to see two or three cases of this within your whole surgical training. I think I've seen 3 and I'm an orthopedic surgeon. So how many would a g.p.s.? I'm not sure. The other problem is they mimic cellulitis. They look like cellulitis.
So the average time to surgery is over 100 hours because the diagnosis is delayed, there is some evidence that shows if we can divide it within less than 24 hours, the outcome would be improved. But we don't have. We're not exposed to it. We we don't really know how to diagnose it and how to differentiate it between cellulitis.
So what can we do? So some of the early clinical features that would push you more towards a necrotizing fasciitis rather than a cellulitis would be these. And one of them is disproportionate pain, which is the most significant finding. So your pain is going to be well out of control of your initial assessment. So say I'm going to show you a picture soon of a guy with a foot injury, but he had pain all the way up to his knee inner thigh.
That would be disproportionate. Exquisite tenderness, so its deep tenderness, so say you have a problem in the hand, but you're finding exquisite tenderness in the forearm compartment. That might be a sign erythema that is spreading, so you lose skin, go to go and you get delayed capillary refill and you get swelling, some of the late features can be repetitious, which is estimated to be around 25% of cases.
You get blisters, get hemorrhagic bullseye, you get a seizure of the skin and you get necrosis of the skin. So this is the school now, it's never been validated, but it does help us a little bit in trying to diagnose who we're going to a bride. So there's a lot of waiting on the CLP. So if you look at the CLP less than 150 more than 150 you're looking at not for right?
You white cell count is there. Your HB is they create things there and your glucose is there. So the maximum you can score is 13. If it's eight, it's highly suggestive of a necrotizing fasciitis rather than a cellulitis. It is above six. You need to be suspicious if it's below six. Doesn't exclude it completely, because it's not a valid, validated score.
And the problem with it is, is that the CLP has a high weighting. But if you've got decompensated alcoholic liver disease, your CLP may not rise. Is there any role for imaging so we can do an X ray, which may show gas gangrene? We could do a CT. The advantage of doing a CT is that it may show fat stranding and it may show a collection, but you shouldn't delay your initial debridement waiting for a CT.
If you're going to do. A seat looking for a collection, do your first bribe, go back to your city looking for a collection. So you know where to go next time, but don't delay your initial debridement. So what's the treatment? You need an M.D. 80 input. You need broad spectrum antibiotics, usually meropenem and clindamycin, but you'll need to discuss the microbiology department.
You need early ICU admission. These patients will need phasor presence. They'll need support of their hyperthermia, and they need level one support. You need to monitor the shock. IP immunoglobulins for group A strep has been debated, so the NICE guidelines say. For severe infections unresponsive to other treatments, they may be used, but they are expensive.
If you are lucky enough to have a hyperbaric oxygen chamber in your trust, you can certainly use it. But the studies are 50 50, so some say benefit and some say no benefit. The mainstay of treatment is going to be your radical excision or debridement with antibiotics, and you need frequent reevaluation. The surgical environment, you need a clear plan, you need to plan what you're going to do, so you need to ensure that you've got access to every possible site, so I'm going to show you a picture of a foot.
Where we divide it all the way up to the hip, so you need to make sure these areas are exposed. You start with zone 1. You try and find the normal tissue, which is zone 3. You send samples from each zone, you divide zone 2. You must take all the fascia from zone 2 and you need at least 10 millimeters margin of healthy fascia. You need to go back and repeat it in 12 to 24 hours.
So how are you going to decide what to the bride? Well part of it will be your score to see whether you're actually going to bribe them or not. That's going to be a clinical indication where the tendency is. Then you'll take the patient to theater and this is what you're looking at. So you zone 1 is going to be necrotic tissue gangrene, everything else you zone to.
You might have some erythema, he might have some inauguration finger test, which we'll look at in a minute. You zone three, you're hoping is normal tissue, but you're going to take a biopsy from that anyway and send it to the lab. So this diagram just represents that, you know, your zone one, you can take all the skin, but your facial excision needs to include the whole of zone 2 and your 10mm margin as well.
So how do you know what it is? Well, you get this kind of grayish necrotic fashion. You have a lack of resistance to dissection. You have no bleeding. You have smell foul smelling liquid. And then there's this thing called a finger test, which I don't know if any of you have come across.
It's so it's supposed to identify the integrity of the German layer. You put your finger in and the fat in the dermal of peel-back. Peel away from the muscle and you get this kind of dishwasher smelly fluid. I've only seen it in the operating theater when I went to the course. Apparently, there were a few people that were making a 2 centimeter incision in the emergency department and trying this.
I don't know whether that works or not. I don't know what those people's experience of it is. My personal opinion would be if I were suspecting it, I would probably go to theater. To be honest. So is a couple of cases, so this is a microbial. Necrotizing fasciitis is 56-year-old male who dropped drops in the foot.
It presents an emergency of 48 hours because he's got a sore foot. He gets treated as cellulitis and he's referred to orthopedics at 72. He's an insulin dependent diabetes. He's unwell, he's got a score of eight, he's got 10 or so is and. That's his picture. And that's what he ended up with.
So he went to see it theater the same day. He had extensive debridement. He improved within 48 hours. Extensive loss of skin and soft tissue. He had some bad dressings put on and eventually had a rotational flap and skin graft within two weeks. This is not the one, so I think in the first slide, I showed you another picture of this guy's finger.
It's 54 51-year-old who likes to drink. He's had a scratch from our Rusty nail. That's his middle finger. To bribe in 12 hours of presentation, it was typewriter to the elbow, and at the time his deltoid specimen was negative 12 hours later. They grew something from his deltoid and he had to go back to theater and ended up with a full quarter amputation.
And unfortunately, he developed toxic shock Dick, and he actually died in the ICU within 12 hours of his second operation. So the point being is that a group A strep will give you a much more rapid progression. It can separate. It makes you more prone to bacteremia. Toxic shock syndrome is more common and you get these and axilo toxins which multiply the virulence of the organism.
This is a close, dreadful infection, so it is one of the deepest of the necrotizing fasciitis infections, generally a bit more incubation if you normally got trauma and a malodorous wound. We get pain out of proportion, you get bullseye and then you get features of sepsis, which is fever and tachycardia, and your mortality is 25 to 100% Switch we can talk about.
So here is a 32-year-old IVD you. He's had a swollen left leg for three days. He comes into A&E and he's unwell. He's got a temperature, he's a bit tachycardia and he's got increased pain in the left leg and foot. He's tended to palpation. So what specific clinical features would you like to look for? Because of war would push you more towards a necrotizing fasciitis rather than a cellulitis, these which is pain out of proportion swelling and erythema, which is common rapidly progressive cellulitis tenderness beyond the area in indistinct margins.
So he's got some of those. Would you like some investigations? Yes, I will. Already, he's got three days of pain. He's got no history of trauma. He's an IV drug user. But you're right, we're going to ask for some blood tests. So these with blood tests, right? So if you look at his blood tests and then you look at his little credit score.
Yeah, right. And as you said correctly above six, you'd be concerned. Now he's got eight. Yeah so you're about to tell me what you were going to do next. Yeah that was just a brief case. But in summary, this is a critical condition, and I think you have to do a WBA on it at some stage for you, folks. The red flags to differentiate between cellulitis and necrotizing fasciitis would be pain out of proportion.
Hypertension altered mental state erythema progressing along the limb that should say flatulence rather than virtuous hemorrhagic bullz-eye necrosis. But at the end of the day, it's one of those conditions like compartment syndrome and for embolism syndrome that you have to have a high index of suspicion to diagnose it and treat it appropriately.
So that was my presentation, any questions? Well, that's brilliant. Nikki, thank you very much. We covered this topic quite comprehensively and I doubt it very much. You need to know anything more than this to score top marks in that case, I think. Guys, please take notes and remember everything said today.
Just a few notes. I mean, you all guys know this is a farce. Yes if they show you soft tissue infection in the exam, they not going to show they want to discuss cellulitis with you. So you just have the hint and straightaway move on to the serious stuff. And so have high index of suspicion, they want to make sure you are safe, and these soft tissue infections are hot topics in the orthopedic within the orthopedic community in the UK at the moment.
It's very interesting to know that. Patients don't have to be immunocompromised, there are a subgroup of patients that could be fit and well. And they could still develop serious soft tissue infection, and that is very also important for the exam because the examiners might present the question in this way to you. A very important, as KneeKG said, MDT approach and that very, very crucial step in answering any of these questions.
MDT approach this one, you're not going to deal with this one on your own. You get your intensivist on board straight away. You get the microbiology on board straight away. It's life threatening condition. You might need to get the general surgeons if the cellulitis is or necrotizing fasciitis infection spreading through the perineum and abdomen or chest.
Very common. So it's MDT approach. And so they're going to ask you about this rennick scoring system because it's also a hot topic these days. And what KneeKG said is very interesting that it's not validated, it's not a validated score. So you could use it to confirm help you confirm your diagnosis or confirm suspicion. But if it is negative, it does not rule out necrotizing fasciitis and you still have to rely on your clinical suspicion.
Is that correct, nikki? Yeah, that's true. It's not. It's not a validated score. Yeah, it's more of a guide, I think. I think they still say it's a clinical diagnosis, but I guess it helps guide you a little bit in that one of the cases they presented at the instruction course was have a patient with renal failure, elderly, you know, with bilateral leg cellulitis that looks bad.
But then the winning score is something like four. And you think, well, it's going to be a little bit more cellulitis than the theater and start to brining her legs. So it's kind of a guide, but it's not validated, but that's very important. So I was just out of interest. So if we're going to investigate, even though you probably want to rush these patients to theatre, but if we're going to investigate a CT scan and not an MRI scan, is it or it doesn't matter?
No, I think that the general guidance is that it's a clinical diagnosis and you shouldn't delay any surgical debridement on the basis of waiting for investigations. So they didn't talk about MRI scans either at the BOA or the instructional course. Obviously, that would be something we could do. We weren't sure, but I think if we have someone that's acutely unwell with a severe soft tissue infection or an Renick score of above eight, I think we're going to be forced into dividing it and then doing imaging afterwards, to be fair.
And that's fair enough, because I think Nick fascia is one of those conditions whereby they're going to die. You don't start antibiotics, so I think it would be fair enough to start the meropenem and clindamycin straight away. And then you do tissue specimens in theater, which hopefully won't be longer than 12 hours. But I think if you're thinking of somebody with necrotizing fasciitis, they may well have been treated with antibiotics as a cellulitis to start with.
And then you're going to take them to theater. I think if the going septic, they absolutely need to have the antibiotics variant of interest while we're discussing this. It's a side topic. It's not. It's not really major, but we talk about and you talked about applying vacuum dressing on these wounds.
Yeah, I mean, that's really we're going into tiny details here. But is there a limitation on how much surface area can you use a vacuum on? I mean, that picture you saw. Can we put the vacuum on all this, this is almost a third of the patient or a quarter of the patient? It's not easy, is it? No, I think that's interesting.
You know, I came from Australia, where I was a big fan of vac dressings, even for massive open wounds like that leg, but they have been shown to have increased blood loss. And although in the presentations, the guys use fat dressings. One of the comments they made afterwards was that they thought the fact dressings increase blood loss, so they were going for more saline soaked dressings at the end and then revisiting the wound in 12 hours.
And thank you very much. And kashif, any comment, please? I think KneeKG has covered very well. And it definitely is a clinical diagnosis, so you can't wait for many of the investigations, you need just basic blood investigations, which can be done quicker while patient an. Because I worked in plastics hansa unit for nine months and I've seen quite few and patient usually deteriorate very rapidly.
So as soon as you diagnose the patient, you need to rush to the theaters. I agree. I mean, this was a very good presentation. You think about necrotizing fasciitis, but you learn something every day and I've learned a lot from this presentation. This is a common in practice. This is a common dilemma because everyone is referred to us as necrotizing fasciitis, and 99% of them will turn out to be just in the lightest.
That is in real life and the exam, I think it'll be more clear cut. I don't think that they will present you with cellulitis as. Firas was saying so if you see something like that, you have to mention fasciitis and they will think I do, whether they want me to talk about it or not. We have thank you, Abdullah, I think we have a question from out there saying that renal failure and diabetes can be false positives on colonic scoring system.
Is that something that's sort of a farce? Yes it could be a first question or could be, for example. Yeah I mean, I guess you can get false. You can get false negatives with decompensated alcohol, liver disease. And I guess if you can't Mount a response, then your white tells me your scalp are not going to match the level of infection. But then that's why they say it's a clinical diagnosis.
And we have to just be aware of that, I think. I think I agree with you, I think we don't have to dwell too much on that. We just could exactly say we are aware of it. It is a system that could help us in making decision. But diagnosis is mainly clinical. Hi index of suspicion and stay safe. I think I think as far as this test goes, you know, I think one of the key things to remember is this is a multidisciplinary approach, often in this case.
Yes, there plastics. If you're in a big teaching hospital where you have plastics and vascular, everyone is involved. But in a normal, which is where the focus is based for want of a better phrase, you are everything. So yes, this is something that we deal with on a regular basis. I think I had one well, I was referred as sort of we all will get.
Someone who was the medics with certain was definitely necrotizing fasciitis only a couple of weeks ago, and we, both my son and I both went. Really? but it does. It is something that we are expected to do. So it is fair game for the Sharks. But yes, do mention a multidisciplinary approach. And yes, your plastic surgeons will be involved.
But the last one I had to do a year now, which was a proper neck fat, I had to do the above knee amputation. So you don't want your plastic surgeons doing that, do you now? The other thing is because the rapid progression of the disease, there will be no time to refer to the nearest plastic surgery. So you have to be able to recognize it and deal with it and then leave the aftermath to the plastic surgeons.
Yeah, the plastic surgeons are part of the team. But if it's involving the lymph will probably be leading the team as. So it is our sort of area. It is. It is tough decision and it is one of those difficult cases to deal with on all levels. And sometimes if you take a patient to theatre, you've got to consent for amputation.
I remember that very, very important. If the exam they take you to, you know, consent this patient, they might ask, is the patient consent? Please remember you consenting for possible amputation and if you're doing that? You need to make sure you including a senior surgeon and the decision making. Yeah, so these are all applications you got to cover in the exam to make sure you are a safe surgeon.
So yes, yes, remember, yes, it is something that you have to consultant sort of point of view. It doesn't have to be orthopedic, can be the anesthetist as well. Yeah, but it has to be consented for and documented. I mean, if you end up. A difficult situation doing, you know, having to do amputation to save life, obviously that's defendable.
But you just need to know how to back up your answer. Yes if you're not aware of these issues, you'd be shocked when the examiners ask you, so at least have an answer to how you're going to approach all these. Scenarios any other comments from the mentors or happy? I think that was very nicely covered. Really appreciate that your input in the group. It's a, you know, great addition and we have to rely on our very generous mentors to keep this teaching program going.
So thank you very much, Nikki, and thanks, David kashif, Saab Abdullah, for joining and supporting so anyone wants CBD certificate, please get in touch with me and I will send you one, and that will be the end of the session, if all happy. There will be a short drive session afterwards, so. Um, anyone interested, please raise your hands.
I will get that started shortly.
Segment:0 .
Good evening, everyone will welcome to this Wednesday's is teaching. I'm sure that staff now would be moderating tonight, and we have other mentors, Abdullah and kashif, the presenter tonight is Nicky Walsh. She is a surgeon from the Lake District.
And she has a lot of experience with the exam, and she's going to present one of the critical conditions subjects. This is very important. Being discussed VOA and instructional courses and elsewhere, and it is a hot topic at the moment. So it's very important topic, and Nick has kindly offered to cover this tonight. As you all guys know, of any questions are welcome, please raise the hand symbol next to your name or right on the chat box.
I will try to answer your questions the best of our knowledge and. At the end of this, CBD certificates can be available if someone needs one, please get in touch with me. We there will be short Viva session after this. People who are interested, please let me know as soon as possible. If interested, they might not be many questions tonight.
Thank you, everyone and over to KneeKG. Thanks to us as a spirit has introduced me, I'm KneeKG Walsh and I'm a specialty doctor at the Royal Lancaster infirmary. I trained in Australia, so I've got a little bit of experience of being on a training scheme. And then I've come back to the UK. The reason I wanted to cover this issue was that I passed my exam last year, but having gone to a few conferences, it's occurred to me that things have changed with the diagnosis of necrotizing fasciitis, and it's now a story, a critical condition.
And there are things that I think we need to know as fast as candidates, so I'll try and cover some of that in the lecture. What I will say is that there's not a lot of photography around about necrotizing fasciitis, probably because it happens so rapidly and you don't always have patient consent to use the images. So the images I've used are from my acknowledgments.
But be aware they could come up in exams. So my acknowledgment of these and one is Mr. yanukovich, who? Did a presentation at the instruction course in Manchester in January of this year, and in combination with him was Mr. Brenda Kapoor, who works in Liverpool. He was also part of the same group. But Mr. Kapoor is also put on the VOA website to lectures on necrotizing fasciitis.
So if you go into training and resources, orthopedic podcasts and then streamed down to screencasts, you will find necrotizing fasciitis, amongst other things where necrotizing fasciitis is in there, and he's done a very, very good lecture on it. So these are the necrotizing conditions that you need to be aware of. So you've always thought of necrotizing fasciitis as a single condition caused by a clostridia, but in fact, there are different causes.
The most common one is necrotizing fasciitis, which is polymicrobial necrotizing fasciitis group strep, which is. The most rapid and destructive of all of them, then you have other things like streptococcal myositis, Clostridium gas gangrene, non-custodial gas gangrene and staphylococcal tropical myositis. So if you look at that photo, I have another photo from a different angle that really come up later with.
But I can tell you that the guy that scratched his finger on a rusty nail. And we'll see what happened to him later. So why are we bothered, well, look at the mortality rates, if you have necrotizing fasciitis, poly microbial, your mortality rate is going to be 30% to 50% You've got group A strep, it's up to 100% The others are not as virulent, but certainly strep myositis.
Clostridium gas gangrene, non-custodial gas gangrene and staph tropical myositis have lower mortality rates. So for the purposes of this lecture, I'm going to focus on the first two, which we can deal with. So how do we classify it? And the reason I'll put this in is that, you know, classification systems are not really necessarily required in the exam, but we were asked this a lot of the time in the instructional course.
So I put it in there because I think the main difference needs to be between the microbial and the group A strep. This is a group, a strep is going to kill you within about 12 hours. So the classification is types one two four. It depends on the causative organism. Type 2 is the classic group A strep infection with rapid progression and high mortality.
So the one which is the microbial, it's going to be the majority of your cases. It's going to be a combination of aerobic and anaerobic species most commonly will be e.coli, Pseudomonas and Bacteroides. There's an average of four organisms isolated in these cases, but we don't know if they're all pathogenic. It's more common in immunocompromised patients, and it can start as an endless, indolent infection.
In the meantime, the surgery is more than 100 hours due to delayed diagnosis, and the outcome is dependent on the co-morbidities. The mortality of a microbial neck fascia is between 30% and 50% Type two, this is our classic Nick flash, right? It's group A strep. It can be staph aureus. It's about 20% of cases.
It's very, very aggressive. When it presents, it produces toxins, causing a toxic shock syndrome, and the mortality is between 50% and 100% And in addition to this, you know, this will be something like so I've had a recent case, which I've not put the photographs in because I've not got permission, but a gentleman that was on chemotherapy, he got a thorn scratch on his finger and he came into emergency within 12 hours with a little bit of redness around it.
So they gave him some amoxicillin and sent him home. Within 12 hours, he was back with cellulitis above the elbow and well, necrosis in his hand. And as we try to discuss with plastic surgeons and things like that, the erythema progressed gradually up over his deltoid onto his chest wall. And in fact, he died quickly. A group A strep can manifest.
So the type III is more of the Marine type of organisms, the Vibrio ones are probably. The most common and it tends to be wound contamination with seawater or brackish water, which is like, you know, a dam or a lake or something like that. And it's about 25% of cases. The mortality is a little bit lower.
That's 30% to 40% So we have a bit more time with that. Type 4 is a fungal infection, it affects mainly immunocompromised patients, so it's mainly a Candida. It can occur after trauma. You can get fungal isolates from all of your specimens for neck fash, but doesn't mean they're the cause of organism, type IV is the causative organism, so it's probably more common in things like HIV and then mortality again is 40% to 60% So what's happening?
Well, I can tell you that the incidents in the UK is increasing. And fact, it's doubled in the last decade. We've got an increase in the. Rate of diagnosis of necrotizing fasciitis, and we've also got an increase in the mortality rate, so we need to kind of address this. So what can we look at? Well, from an epidemiology point of view, it's quite rare that any 13 or 14 cases per million of the population males are about 2/3 more infected than females.
And it tends to be immunocompromised patients. So people with diabetes, decompensated alcoholic liver disease, steroids, drug users, people that are undergoing chemotherapy, radiotherapy, the exception being the group strep, which can affect anybody at all. Why do they kill us? Well, they affect mainly immunocompromised patients because they have an inherent lack of response to the infection.
And one of the problems is that they cause early superficial ischemia, so they thromboses the subcutaneous vessels and the lymphatic, the fascia is relatively avascular anyway. What they block off any blood supply to that as well. So you develop these large areas of ischemia. You get this rapid spread because the zone of infection and the method of spread means that the antibiotics you prescribed cannot reach all of the areas of bacterial present.
They spread horizontally, so they move horizontally along the fattens special planes rather than a vertical spread down through the tissues. And particularly with the group, they produce exit toxin lender toxins, which multiplies their virulence. On top of all of that, we have no experience with it. You know, there's a lack of exposure of teaching and training of Physicians and Surgeons.
You know, even as a surgeon, they expect you to see two or three cases of this within your whole surgical training. I think I've seen 3 and I'm an orthopedic surgeon. So how many would a g.p.s.? I'm not sure. The other problem is they mimic cellulitis. They look like cellulitis.
So the average time to surgery is over 100 hours because the diagnosis is delayed, there is some evidence that shows if we can divide it within less than 24 hours, the outcome would be improved. But we don't have. We're not exposed to it. We we don't really know how to diagnose it and how to differentiate it between cellulitis.
So what can we do? So some of the early clinical features that would push you more towards a necrotizing fasciitis rather than a cellulitis would be these. And one of them is disproportionate pain, which is the most significant finding. So your pain is going to be well out of control of your initial assessment. So say I'm going to show you a picture soon of a guy with a foot injury, but he had pain all the way up to his knee inner thigh.
That would be disproportionate. Exquisite tenderness, so its deep tenderness, so say you have a problem in the hand, but you're finding exquisite tenderness in the forearm compartment. That might be a sign erythema that is spreading, so you lose skin, go to go and you get delayed capillary refill and you get swelling, some of the late features can be repetitious, which is estimated to be around 25% of cases.
You get blisters, get hemorrhagic bullseye, you get a seizure of the skin and you get necrosis of the skin. So this is the school now, it's never been validated, but it does help us a little bit in trying to diagnose who we're going to a bride. So there's a lot of waiting on the CLP. So if you look at the CLP less than 150 more than 150 you're looking at not for right?
You white cell count is there. Your HB is they create things there and your glucose is there. So the maximum you can score is 13. If it's eight, it's highly suggestive of a necrotizing fasciitis rather than a cellulitis. It is above six. You need to be suspicious if it's below six. Doesn't exclude it completely, because it's not a valid, validated score.
And the problem with it is, is that the CLP has a high weighting. But if you've got decompensated alcoholic liver disease, your CLP may not rise. Is there any role for imaging so we can do an X ray, which may show gas gangrene? We could do a CT. The advantage of doing a CT is that it may show fat stranding and it may show a collection, but you shouldn't delay your initial debridement waiting for a CT.
If you're going to do. A seat looking for a collection, do your first bribe, go back to your city looking for a collection. So you know where to go next time, but don't delay your initial debridement. So what's the treatment? You need an M.D. 80 input. You need broad spectrum antibiotics, usually meropenem and clindamycin, but you'll need to discuss the microbiology department.
You need early ICU admission. These patients will need phasor presence. They'll need support of their hyperthermia, and they need level one support. You need to monitor the shock. IP immunoglobulins for group A strep has been debated, so the NICE guidelines say. For severe infections unresponsive to other treatments, they may be used, but they are expensive.
If you are lucky enough to have a hyperbaric oxygen chamber in your trust, you can certainly use it. But the studies are 50 50, so some say benefit and some say no benefit. The mainstay of treatment is going to be your radical excision or debridement with antibiotics, and you need frequent reevaluation. The surgical environment, you need a clear plan, you need to plan what you're going to do, so you need to ensure that you've got access to every possible site, so I'm going to show you a picture of a foot.
Where we divide it all the way up to the hip, so you need to make sure these areas are exposed. You start with zone 1. You try and find the normal tissue, which is zone 3. You send samples from each zone, you divide zone 2. You must take all the fascia from zone 2 and you need at least 10 millimeters margin of healthy fascia. You need to go back and repeat it in 12 to 24 hours.
So how are you going to decide what to the bride? Well part of it will be your score to see whether you're actually going to bribe them or not. That's going to be a clinical indication where the tendency is. Then you'll take the patient to theater and this is what you're looking at. So you zone 1 is going to be necrotic tissue gangrene, everything else you zone to.
You might have some erythema, he might have some inauguration finger test, which we'll look at in a minute. You zone three, you're hoping is normal tissue, but you're going to take a biopsy from that anyway and send it to the lab. So this diagram just represents that, you know, your zone one, you can take all the skin, but your facial excision needs to include the whole of zone 2 and your 10mm margin as well.
So how do you know what it is? Well, you get this kind of grayish necrotic fashion. You have a lack of resistance to dissection. You have no bleeding. You have smell foul smelling liquid. And then there's this thing called a finger test, which I don't know if any of you have come across.
It's so it's supposed to identify the integrity of the German layer. You put your finger in and the fat in the dermal of peel-back. Peel away from the muscle and you get this kind of dishwasher smelly fluid. I've only seen it in the operating theater when I went to the course. Apparently, there were a few people that were making a 2 centimeter incision in the emergency department and trying this.
I don't know whether that works or not. I don't know what those people's experience of it is. My personal opinion would be if I were suspecting it, I would probably go to theater. To be honest. So is a couple of cases, so this is a microbial. Necrotizing fasciitis is 56-year-old male who dropped drops in the foot.
It presents an emergency of 48 hours because he's got a sore foot. He gets treated as cellulitis and he's referred to orthopedics at 72. He's an insulin dependent diabetes. He's unwell, he's got a score of eight, he's got 10 or so is and. That's his picture. And that's what he ended up with.
So he went to see it theater the same day. He had extensive debridement. He improved within 48 hours. Extensive loss of skin and soft tissue. He had some bad dressings put on and eventually had a rotational flap and skin graft within two weeks. This is not the one, so I think in the first slide, I showed you another picture of this guy's finger.
It's 54 51-year-old who likes to drink. He's had a scratch from our Rusty nail. That's his middle finger. To bribe in 12 hours of presentation, it was typewriter to the elbow, and at the time his deltoid specimen was negative 12 hours later. They grew something from his deltoid and he had to go back to theater and ended up with a full quarter amputation.
And unfortunately, he developed toxic shock Dick, and he actually died in the ICU within 12 hours of his second operation. So the point being is that a group A strep will give you a much more rapid progression. It can separate. It makes you more prone to bacteremia. Toxic shock syndrome is more common and you get these and axilo toxins which multiply the virulence of the organism.
This is a close, dreadful infection, so it is one of the deepest of the necrotizing fasciitis infections, generally a bit more incubation if you normally got trauma and a malodorous wound. We get pain out of proportion, you get bullseye and then you get features of sepsis, which is fever and tachycardia, and your mortality is 25 to 100% Switch we can talk about.
So here is a 32-year-old IVD you. He's had a swollen left leg for three days. He comes into A&E and he's unwell. He's got a temperature, he's a bit tachycardia and he's got increased pain in the left leg and foot. He's tended to palpation. So what specific clinical features would you like to look for? Because of war would push you more towards a necrotizing fasciitis rather than a cellulitis, these which is pain out of proportion swelling and erythema, which is common rapidly progressive cellulitis tenderness beyond the area in indistinct margins.
So he's got some of those. Would you like some investigations? Yes, I will. Already, he's got three days of pain. He's got no history of trauma. He's an IV drug user. But you're right, we're going to ask for some blood tests. So these with blood tests, right? So if you look at his blood tests and then you look at his little credit score.
Yeah, right. And as you said correctly above six, you'd be concerned. Now he's got eight. Yeah so you're about to tell me what you were going to do next. Yeah that was just a brief case. But in summary, this is a critical condition, and I think you have to do a WBA on it at some stage for you, folks. The red flags to differentiate between cellulitis and necrotizing fasciitis would be pain out of proportion.
Hypertension altered mental state erythema progressing along the limb that should say flatulence rather than virtuous hemorrhagic bullz-eye necrosis. But at the end of the day, it's one of those conditions like compartment syndrome and for embolism syndrome that you have to have a high index of suspicion to diagnose it and treat it appropriately.
So that was my presentation, any questions? Well, that's brilliant. Nikki, thank you very much. We covered this topic quite comprehensively and I doubt it very much. You need to know anything more than this to score top marks in that case, I think. Guys, please take notes and remember everything said today.
Just a few notes. I mean, you all guys know this is a farce. Yes if they show you soft tissue infection in the exam, they not going to show they want to discuss cellulitis with you. So you just have the hint and straightaway move on to the serious stuff. And so have high index of suspicion, they want to make sure you are safe, and these soft tissue infections are hot topics in the orthopedic within the orthopedic community in the UK at the moment.
It's very interesting to know that. Patients don't have to be immunocompromised, there are a subgroup of patients that could be fit and well. And they could still develop serious soft tissue infection, and that is very also important for the exam because the examiners might present the question in this way to you. A very important, as KneeKG said, MDT approach and that very, very crucial step in answering any of these questions.
MDT approach this one, you're not going to deal with this one on your own. You get your intensivist on board straight away. You get the microbiology on board straight away. It's life threatening condition. You might need to get the general surgeons if the cellulitis is or necrotizing fasciitis infection spreading through the perineum and abdomen or chest.
Very common. So it's MDT approach. And so they're going to ask you about this rennick scoring system because it's also a hot topic these days. And what KneeKG said is very interesting that it's not validated, it's not a validated score. So you could use it to confirm help you confirm your diagnosis or confirm suspicion. But if it is negative, it does not rule out necrotizing fasciitis and you still have to rely on your clinical suspicion.
Is that correct, nikki? Yeah, that's true. It's not. It's not a validated score. Yeah, it's more of a guide, I think. I think they still say it's a clinical diagnosis, but I guess it helps guide you a little bit in that one of the cases they presented at the instruction course was have a patient with renal failure, elderly, you know, with bilateral leg cellulitis that looks bad.
But then the winning score is something like four. And you think, well, it's going to be a little bit more cellulitis than the theater and start to brining her legs. So it's kind of a guide, but it's not validated, but that's very important. So I was just out of interest. So if we're going to investigate, even though you probably want to rush these patients to theatre, but if we're going to investigate a CT scan and not an MRI scan, is it or it doesn't matter?
No, I think that the general guidance is that it's a clinical diagnosis and you shouldn't delay any surgical debridement on the basis of waiting for investigations. So they didn't talk about MRI scans either at the BOA or the instructional course. Obviously, that would be something we could do. We weren't sure, but I think if we have someone that's acutely unwell with a severe soft tissue infection or an Renick score of above eight, I think we're going to be forced into dividing it and then doing imaging afterwards, to be fair.
And that's fair enough, because I think Nick fascia is one of those conditions whereby they're going to die. You don't start antibiotics, so I think it would be fair enough to start the meropenem and clindamycin straight away. And then you do tissue specimens in theater, which hopefully won't be longer than 12 hours. But I think if you're thinking of somebody with necrotizing fasciitis, they may well have been treated with antibiotics as a cellulitis to start with.
And then you're going to take them to theater. I think if the going septic, they absolutely need to have the antibiotics variant of interest while we're discussing this. It's a side topic. It's not. It's not really major, but we talk about and you talked about applying vacuum dressing on these wounds.
Yeah, I mean, that's really we're going into tiny details here. But is there a limitation on how much surface area can you use a vacuum on? I mean, that picture you saw. Can we put the vacuum on all this, this is almost a third of the patient or a quarter of the patient? It's not easy, is it? No, I think that's interesting.
You know, I came from Australia, where I was a big fan of vac dressings, even for massive open wounds like that leg, but they have been shown to have increased blood loss. And although in the presentations, the guys use fat dressings. One of the comments they made afterwards was that they thought the fact dressings increase blood loss, so they were going for more saline soaked dressings at the end and then revisiting the wound in 12 hours.
And thank you very much. And kashif, any comment, please? I think KneeKG has covered very well. And it definitely is a clinical diagnosis, so you can't wait for many of the investigations, you need just basic blood investigations, which can be done quicker while patient an. Because I worked in plastics hansa unit for nine months and I've seen quite few and patient usually deteriorate very rapidly.
So as soon as you diagnose the patient, you need to rush to the theaters. I agree. I mean, this was a very good presentation. You think about necrotizing fasciitis, but you learn something every day and I've learned a lot from this presentation. This is a common in practice. This is a common dilemma because everyone is referred to us as necrotizing fasciitis, and 99% of them will turn out to be just in the lightest.
That is in real life and the exam, I think it'll be more clear cut. I don't think that they will present you with cellulitis as. Firas was saying so if you see something like that, you have to mention fasciitis and they will think I do, whether they want me to talk about it or not. We have thank you, Abdullah, I think we have a question from out there saying that renal failure and diabetes can be false positives on colonic scoring system.
Is that something that's sort of a farce? Yes it could be a first question or could be, for example. Yeah I mean, I guess you can get false. You can get false negatives with decompensated alcohol, liver disease. And I guess if you can't Mount a response, then your white tells me your scalp are not going to match the level of infection. But then that's why they say it's a clinical diagnosis.
And we have to just be aware of that, I think. I think I agree with you, I think we don't have to dwell too much on that. We just could exactly say we are aware of it. It is a system that could help us in making decision. But diagnosis is mainly clinical. Hi index of suspicion and stay safe. I think I think as far as this test goes, you know, I think one of the key things to remember is this is a multidisciplinary approach, often in this case.
Yes, there plastics. If you're in a big teaching hospital where you have plastics and vascular, everyone is involved. But in a normal, which is where the focus is based for want of a better phrase, you are everything. So yes, this is something that we deal with on a regular basis. I think I had one well, I was referred as sort of we all will get.
Someone who was the medics with certain was definitely necrotizing fasciitis only a couple of weeks ago, and we, both my son and I both went. Really? but it does. It is something that we are expected to do. So it is fair game for the Sharks. But yes, do mention a multidisciplinary approach. And yes, your plastic surgeons will be involved.
But the last one I had to do a year now, which was a proper neck fat, I had to do the above knee amputation. So you don't want your plastic surgeons doing that, do you now? The other thing is because the rapid progression of the disease, there will be no time to refer to the nearest plastic surgery. So you have to be able to recognize it and deal with it and then leave the aftermath to the plastic surgeons.
Yeah, the plastic surgeons are part of the team. But if it's involving the lymph will probably be leading the team as. So it is our sort of area. It is. It is tough decision and it is one of those difficult cases to deal with on all levels. And sometimes if you take a patient to theatre, you've got to consent for amputation.
I remember that very, very important. If the exam they take you to, you know, consent this patient, they might ask, is the patient consent? Please remember you consenting for possible amputation and if you're doing that? You need to make sure you including a senior surgeon and the decision making. Yeah, so these are all applications you got to cover in the exam to make sure you are a safe surgeon.
So yes, yes, remember, yes, it is something that you have to consultant sort of point of view. It doesn't have to be orthopedic, can be the anesthetist as well. Yeah, but it has to be consented for and documented. I mean, if you end up. A difficult situation doing, you know, having to do amputation to save life, obviously that's defendable.
But you just need to know how to back up your answer. Yes if you're not aware of these issues, you'd be shocked when the examiners ask you, so at least have an answer to how you're going to approach all these. Scenarios any other comments from the mentors or happy? I think that was very nicely covered. Really appreciate that your input in the group. It's a, you know, great addition and we have to rely on our very generous mentors to keep this teaching program going.
So thank you very much, Nikki, and thanks, David kashif, Saab Abdullah, for joining and supporting so anyone wants CBD certificate, please get in touch with me and I will send you one, and that will be the end of the session, if all happy. There will be a short drive session afterwards, so. Um, anyone interested, please raise your hands.
I will get that started shortly.
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