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Necrotizing Fasciitis Diagnoses and Therapy

By Anton Helman, MD, CCFP(EM), FCFP | on July 15, 2018 | 3 Comments
EM Cases
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Necrotizing fasciitis is a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. The spectrum of presentation is wide, ranging from a benign-appearing rash in a well person to obvious skin necrosis with hemodynamic instability, multi-organ failure, and death. Patients who present early in this spectrum of disease are difficult to diagnose, with an initial misdiagnosis rate of 71.4 percent.1 However, initiation of treatment in these early stages gives patients the greatest chance of survival in this otherwise deadly disease. In this early phase, necrotizing fasciitis can be mistaken for simple cellulitis, and while the skin may appear benign, it is often the tip of the iceberg to what lies beneath.

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ACEP Now: Vol 37 – No 07 – July 2018

The diagnostic difficulty also lies in the fact that there are no lab test results or even imaging that can definitively rule out necrotizing fasciitis. In fact, the diagnosis is a clinical one that can only be confirmed with surgical exploration. Therefore, it is imperative that if you have anything more than the slightest suspicion based on your clinical exam, you consider early consultation with a surgeon for definitive diagnosis and surgical debridement as well as start empiric antibiotics. Lab findings that are suggestive but not diagnostic of necrotizing fasciitis include coagulopathy, hypoalbuminemia, thrombocytopenia, lactic acidosis, creatine phosphokinase elevation, and C-reactive protein (CRP) elevation, which all tend to occur in later stages of disease.1

While clinical decision tools, such as the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score that includes CRP, white blood cell count, hemoglobin, sodium, creatinine, and glucose, might help raise your suspicion for necrotizing fasciitis, validation studies showed that a LRINEC cutoff of six points only had a negative predictive value of 92.5 percent.2,3 While these lab findings and imaging findings of subcutaneous air and fascial thickening on X-ray, CT, and MRI can help support the diagnosis, they should not delay definitive treatment in the operating room in clinically obvious cases and should never override clinical judgment.

Findings on point-of-care ultrasound, which has the advantage of speed over other imaging modalities, may help support the diagnosis but again cannot rule it out.4 The reason that the absence of subcutaneous air on imaging cannot rule out the diagnosis is that one of the two types of necrotizing fasciitis is caused by non–gas-producing bacteria. In fact, imaging findings are often similar to those of cellulitis, with increased soft-tissue thickness and opacity.5 Gas in the soft tissues is seen in only a minority of cases, but if you do see it, your suspicion for necrotizing fasciitis should be significantly raised.

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Topics: Critical CareDiagnosisinfectionNecrotizing Fasciitis

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About the Author

Anton Helman, MD, CCFP(EM), FCFP

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website (www.emergencymedicinecases.com).

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3 Responses to “Necrotizing Fasciitis Diagnoses and Therapy”

  1. July 22, 2018

    Hirsch Kenneth Reply

    I was surprised to see no mention of Hyperbaric Oxygen Therapy in the treatment of Necrotizing Fasciitis. I realize that many facilities do not have access to HBO, but if it is readily available HBO can be of great benefit in treating Nec Fasc as an adjunct to surgery and antibiotics.

  2. July 22, 2018

    Dan Sayers Reply

    Good overview. I’m in favor of early Hyperbaric Oxygen Therapy in addition to all of the above. There is good scientific support for early HBO2 therapy and it is supported by 3rd party payors.

  3. July 30, 2018

    Zakiuddin G.Oonwala Reply

    very informative article. The ‘finger test’ seems to be a simple confirmatory test. How ever this test may require some exposure to minor surgery, if not performed by a surgeon.

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