Necrotizing Fasciitis

Before I started working as a nurse in a medical ICU, I thought necrotizing fasciitis was one of those really scary conditions that hardly ever happened and that I would probably never see. Well, I got the first part of that right…it is definitely very scary, but unfortunately, I have seen more cases of necrotizing fasciitis than I ever thought I would. Technically, it is considered a “rare condition,” affecting about 0.4 in every 100,000 people per year in the U.S. Though anyone can get necrotizing fasciitis, it is more likely to affect those with poorly controlled diabetes, HIV, alcohol and IV drug abuse, chronic renal failure, and obesity.

One of the scariest things about necrotizing fasciitis is that it doesn’t have to be set in motion by a large or obvious injury. Any break in the skin, even very small ones, can allow bacteria to enter and get into the subcutaneous tissue. And in some cases of pharyngitis, dental infection, and even surgery, bacteria can cause necrotizing fasciitis of the head and neck. This bacteria can even translocate to a distal area of injury, such as a muscle strain. Did I mention it’s absolutely terrifying?

In necrotizing fasciitis, these bacteria get deep into the fascia where they produce endo-toxins (toxins that are released as the bacteria die) and exo-toxins (bacterial waste products). The toxins set into motion a cascade of events that eventually lead to the destruction of the muscle fascia and subcutaneous tissue. As the infection travels along the fascial plane, overlying tissues are often unaffected, making it very difficult to detect.

Let’s go through necrotizing fasciitis using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

Because necrotizing fasciitis occurs in underlying tissues, it is often very difficult to detect, especially initially. As the infection worsens and tissues are destroyed, the patient may exhibit more outward symptoms:

• Most of the time, the patient will have a break in the skin. Again, these can be very small and in any stage of healing.
• In the early stages, necrotizing fasciitis can often look a lot like cellulitis.
• The patient may state it feels like they’ve pulled a muscle.
• The skin may be hot, red, shiny, and swollen.  The area of edema often extends beyond the area of redness or erythema.
• The patient may complain of numbness in the area when nerves are destroyed by the bacteria.
• The pain will be out of proportion to the context of the injury and extend beyond the area of the injury.
• As the infection progresses, instead of redness, the area may appear bluish/purplish or have a dusky blue color.
• Additionally, there will be bullae or blisters in the affected area as the infection worsens. These are dark in color and filled with a foul-smelling exudate known as “dishwater pus” which is a result of dying tissue. Bleeding from these bullae may also be present.
• Many patients with necrotizing fasciitis develop sepsis, so the patient could be exhibiting signs of a severe systemic inflammatory response such as fever, tachycardia, hypotension, malaise, and decreased LOC.
• Palpation of the area reveals crepitus in about 50% of cases.

A: How do you ASSESS the patient?

• Monitor vital signs – the patient may be febrile, tachycardia, and hypotensive
• Assess affected areas for quality and level of pain
• Assess for edema and grade affected areas
• Assess wound for signs of infection, including the amount and type of drainage from the wound; serous, sanguineous, serosanguineous, purulent, or the “dishwater fluid” that may be present

T: What TESTS will be ordered?

The key diagnostic test for necrotizing fasciitis is a surgical exploration of the soft tissues. A quick surgical exploration method is called a “finger test” in which a small incision is made in the affected area through which the MD inserts a finger to probe the underlying fascia. If the wound has a lack of bleeding, dishwater fluid, and minimal resistance to dissection, this is considered a positive finger test, and further emergent surgical intervention is needed.

• Radiographic imaging (X-ray, CT or MRI) can be done if necrotizing fasciitis is suspected, but shouldn’t delay surgical intervention. The X-ray will show if gas is present in the underlying tissues. But, since only 50% of cases involve crepitus, a CT scan is of higher diagnostic value and is much quicker than an MRI.
• CBC will be ordered for both a white blood cell count, you may see a possible drop in hemoglobin as the patient becomes anemic due to bacterial destruction of RBCs.
• Culture of wound drainage to ensure correct antibiotic is ordered.
• Tissue biopsy will show tissue necrosis and the presence of microorganisms.

T: What TREATMENTS will be provided?

• The priority intervention with necrotizing fasciitis is surgical debridement of the wound. The surgeon must cut away all of the dead, damaged and infected tissue and thoroughly wash out the wound to ensure no microorganisms remain. Many times, patients will need multiple debridement surgeries and the amount of tissue removed can be overwhelmingly devastating. Amputations are not uncommon.
• Surgical wounds are left open with wet-to-dry dressings or vacuum-assisted-closure devices. Once the surgeon is confident no additional debridements are needed, skin grafts may be utilized depending on the extent of the wound.
• Antibiotics cannot penetrate the infected tissue, which is another reason surgical debridement is the priority intervention. IV antibiotic therapy is utilized to control the spread of infection and sepsis. Common antibiotics are vancomycin, clindamycin, metronidazole, and Zosyn (piperacillin/tazobactam). Antibiotic therapy is tailored to specific organisms, so it’s important to obtain a wound culture prior to antibiotic administration.
• Some critically ill patients may receive IVIg therapy, though it is not an FDA-approved therapy and the effectiveness of its use is controversial.
• Hyperbaric oxygen therapy (HBO) is another controversial treatment that may be utilized. In addition to providing oxygen to nearby tissues, some of the bacteria in necrotizing fasciitis are anaerobic, which means they thrive in an oxygen-low environment. By increasing the oxygen level, we make the environment inhospitable for these anaerobic organisms. HBO may also enhance the ability of neutrophils to kill the invading organism.
• Many times, patients with necrotizing fasciitis are gravely ill with severe sepsis and septic shock. Additional therapies will be utilized to address these complications.

E: How do you EDUCATE the patient/family?

• Emphasize personal hygiene and handwashing as a first-line defense against infection. The bacteria can spread from the current wound to another individual or part of the body, so excellent hand hygiene and PPE are crucial!
• Ensure the patient/family understands that the condition requires multiple tests and regular blood work to monitor the body’s response to treatment.
• Educate the patient/family on the need for potential repeated surgeries.
• Prior to discharge, the patient and caregivers need to be instructed on any wound care details such as managing a vacuum-assisted closure device (wound vac) or care of closed wounds and skin grafts.

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