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You are seeing a 17 year old girl that works in a pet store, where she is sometimes scratched by the animals there. She felt fine that morning, but noted malaise and low-grade fever in the afternoon, and pain in her lower right shin. She presents to the ED with temp 38.5, HR 140, RR 20, BP 95/60. She has a 4cm x 4cm non-well demarcated area of red-purple discoloration on her lower right shin, with mild edema. On close inspection there are a few small bullae in the area of discoloration. On palpation of the area, it is warm, extremely, tender, and has crepitus.
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June 7, 2023 at 11:41 am
E) Obtaining emergent Surgeon consultation
The patient has signs and symptoms consistent with necrotizing fasciitis, which is a surgical emergency. Necrotizing fasciitis is a rapidly spreading deep soft tissue infection. The infection is typically polymicrobial, and broad-spectrum antibiotics should be started (e.g. a carbapenem or piperacillin-tazobactam + an agent that covers MRSA + clindaymicin for its antitoxin effects). Consultation with a surgeon should not be delayed for imaging or other work-up; patients require surgical emergent exploration and debridement. Other signs to look for include “skip lesions,” affected areas with unaffected or less affected skin between, and insensate skin (from nerve destruction).