INFECTION & SEPSIS • SENIOR RESIDENT / SURGEON

Necrotizing Soft Tissue Infection

A rapidly progressive soft-tissue infection where delay in operative source control can be catastrophic.

PROTOTYPE REVIEW REQUIRED

The Call

54-year-old woman with poorly controlled diabetes

Rapidly progressive arm pain and swelling after a minor skin injury, with fever, tachycardia, bullae, crepitus, and tenderness out of proportion to the visible skin findings.

T 38.4 C • HR 121 • BP 109/65

The tempo and exam matter more than any single laboratory score.

Read the Image • Clinical DataACS VISUAL

Necrotizing soft-tissue infection from the ACS image archive.

Make the Decision • Commit to a Plan

Necrotizing Soft Tissue Infection

54-year-old woman with poorly controlled diabetes

A diabetic patient has rapidly progressive extremity pain, bullae, hypotension and crepitus. CT is equivocal. What should happen next?

The skin edge looks viable but fascia separates with little resistance and there is dishwater fluid extending beyond the visible erythema. How far do you debride?

Twelve hours later vasopressor requirement persists and the wound edge is newly dusky. Best next step?

What should make you keep going?

Source control is only the beginning.

Surgical Pearls

Pitfalls

During exploration, the skin incision looks modestly abnormal but the fascia separates with little resistance and produces thin gray fluid. What should this finding do to your operative plan?