NECROTIZING FASCIITIS POINT OF CARE ULTRASOUND

Jordan Chanler-Berat, MD US Fellow#POCUSFocus

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FIRST CASE

50 something old malePMH: IVDU, HTNCC: “ingestion”HPI: Found by EMS, “took to much” oral opiodsVitals: Afebrile, hypotensive

Exam: Sleepy, arousableSkin: Large erythematous area LUE, no subcutaneous emphysema+ fluctuance centrally- blisters, bullae

OUTCOME

-Ultrasound triggered xray

-Xray showed subcutaneous emphysema

-Broad spectrum Abx added

-Surgical Consult -Concern 2/2 gas-brought to OR for I&D, local debridement

- hypotension improved

- discharged

SECOND CASE

50s Female

HPI: Presents with L labial swelling

Vitals: T 97.3 P 76 BP 70/54 RR 18

Exam: L labial swelling, erythema

OUTCOME

-Ultrasound/exam triggered CT order

-OB/GYN and Surgery got on board

-to OR for debridement

-Growing Bacteroides & Actinomyces

NECROTIZING FASCIITIS BACKGROUND

- STREP A OR POLYMYCROBIAL (ANAEROBS)

- EXAM INCORRECT 64% OF TIME

- UP TO 76% MORTALITY*DELAYED DX

-MRI/CT SUGGESTED FOR DIAGNOSIS *DELAYS DX?*NOT 100% SENS

- PAUCITY OF LITERATURE!!!!!!!!!!!!!!!!!!!!!!!!!

WHAT TO LOOK FOR ON US?TSAI ET AL.“EARLY DIAGNOSIS OF NECROTIZING FASCIITIS BY UTILIZATION OF ULTRASONOGRAPHY”

BIGGER STUDY:YEN ET AL.“ULTRASONOGRAPHIC SCREENING OF CLINICALLY-SUSPECTED NECROTIZING FASCIITIS”

• PROSPECTIVE, OBSERVATIONAL • 62 PATIENTS, SUSPECTED NEC FASC• US DIAGNOSIS OF NEC FASC = DIFFUSE SUBQ THICK, 4MM FASCIAL

FLUID, • ONLY LIMBS• GOLD STANDARD WAS SURGICAL PATHOLOGY OR TISSUE BIOPSY• 17/62 HAD NF• US = 88.2% SENS / 93.3% SPEC• PPV= 83.3 % NPV= 95.4%

GAS!

Reverb

CT/MRI SENSITIVITY-BETWEEN 80-100% SENSITIVE-MAY DELAY CARE

WHAT SHOULD YOU DO?

IF YOU SUSPECT IT:

• LINEAR PROBE TO AFFECTED AREA & CONTRALATERAL

• LOOK FOR GAS (REVERB ARTIFACT)• LOOK FOR ABNORMAL SUBQ FLUID

COLLECTIONS > 4MM• LOOK FOR DIFFUSE THICKENING OF

FASCIA/SUBQ TISSUES

REFERENCES

1.Yen ZS, Wang HP, Ma HM, Chen SC, Chen WJ. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med 2002;9:1448–51.

2.Tsai CC, Lai CS, Yu ML, Chou CK, Lin SD. Early diagnosis of necrotizing fasciitis by utilization of ultrasonography. Kaohsiung J Med Sci 1996;12:235–40.

3.Hefny AF, Eid HO, Al-Hussona M, Idris KM, Abu-Zidan FM. Necrotizing fasciitis: a challenging diagnosis. Eur J Emerg Med 2007;14:50–2.

4. Kerhl T. POINT-OF-CARE ULTRASOUND DIAGNOSIS OF NECROTIZING FASCIITIS MISSED BY COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING. J of Emerg Med 2014; 47(2): 172-175.