Logo

Log In Sign Up |  An official publication of: American College of Emergency Physicians
Navigation
  • Home
  • Multimedia
    • Podcasts
    • Videos
  • Clinical
    • Airway Managment
    • Case Reports
    • Critical Care
    • Guidelines
    • Imaging & Ultrasound
    • Pain & Palliative Care
    • Pediatrics
    • Resuscitation
    • Trauma & Injury
  • Resource Centers
    • mTBI Resource Center
  • Career
    • Practice Management
      • Benchmarking
      • Reimbursement & Coding
      • Care Team
      • Legal
      • Operations
      • Quality & Safety
    • Awards
    • Certification
    • Compensation
    • Early Career
    • Education
    • Leadership
    • Profiles
    • Retirement
    • Work-Life Balance
  • Columns
    • ACEP4U
    • Airway
    • Benchmarking
    • Brief19
    • By the Numbers
    • Coding Wizard
    • EM Cases
    • End of the Rainbow
    • Equity Equation
    • FACEPs in the Crowd
    • Forensic Facts
    • From the College
    • Images in EM
    • Kids Korner
    • Medicolegal Mind
    • Opinion
      • Break Room
      • New Spin
      • Pro-Con
    • Pearls From EM Literature
    • Policy Rx
    • Practice Changers
    • Problem Solvers
    • Residency Spotlight
    • Resident Voice
    • Skeptics’ Guide to Emergency Medicine
    • Sound Advice
    • Special OPs
    • Toxicology Q&A
    • WorldTravelERs
  • Resources
    • ACEP.org
    • ACEP Knowledge Quiz
    • Issue Archives
    • CME Now
    • Annual Scientific Assembly
      • ACEP14
      • ACEP15
      • ACEP16
      • ACEP17
      • ACEP18
      • ACEP19
    • Annals of Emergency Medicine
    • JACEP Open
    • Emergency Medicine Foundation
  • About
    • Our Mission
    • Medical Editor in Chief
    • Editorial Advisory Board
    • Awards
    • Authors
    • Article Submission
    • Contact Us
    • Advertise
    • Subscribe
    • Privacy Policy
    • Copyright Information

Necrotizing Fasciitis Diagnoses and Therapy

By Anton Helman, MD, CCFP(EM), FCFP | on July 15, 2018 | 3 Comments
EM Cases
  • Tweet
  • Click to email a link to a friend (Opens in new window) Email
Print-Friendly Version
Three cut-sections of the anterior chest wall skin, fat, fascia, pectoralis muscles, and rib bones.  1)Normal chest wall.  2)Origination of infection within the fascial layers. 3)Progression of the infection through those layers and into adjacent tissues.  ILLUSTRATION: Nucleus Medical Media Inc/Alamy Stock PhotO

You Might Also Like
  • Necrotizing Fasciitis Requires Rapid Diagnosis and Treatment
  • Aggressive TIA Therapy May Cut Serious Stroke Risk by Half
  • What’s That Rash? Tips to Diagnose and Treat Skin Conditions
Explore This Issue
ACEP Now: Vol 37 – No 07 – July 2018

Three cut-sections of the anterior chest wall skin, fat, fascia, pectoralis muscles, and rib bones.
1)Normal chest wall.
2)Origination of infection within the fascial layers.
3)Progression of the infection through those layers and into adjacent tissues.
ILLUSTRATION: Nucleus Medical Media Inc/Alamy Stock PhotO

Clues to Early Detection of Necrotizing Fasciitis

Even though a history of diabetes, immunocompromised state, and recent surgery are often cited as risk factors, necrotizing fasciitis can occur in otherwise healthy patients after a minor traumatic injury.1,6,7

The Infectious Diseases Society of America recommends clinicians look for findings such as persistent severe pain, bullae, skin necrosis or ecchymosis, crepitus from gas in the soft tissues, edema that extends beyond the margin of erythema, cutaneous anesthesia, signs of systemic toxicity, and rapid spread over hours especially during antibiotic therapy.8

Vital signs are vital. Scrutinize them; most patients will have tachycardia and/or tachypnea out of proportion to fever. If you see what appears to be cellulitis on the lower abdomen, examine the perineum for signs of Fournier gangrene.9

Note that while severe pain out of proportion to physical exam findings is suggestive of necrotizing fasciitis, a minority of patients will report little pain and may have a laissez-faire attitude toward their illness, likely due to analgesic effects of local nerve destruction. This same mechanism may account for localized skin hypesthesia that some patients with necrotizing fasciitis may have. The edema of necrotizing fasciitis not only tends to spread beyond the margin of erythema but often has a tense quality, making the skin feel hard or “wooden.”

Palpable crepitance is only present in the gas-producing type of necrotizing fasciitis, and its absence does not rule out the disease for the same reason that imaging cannot rule it out. While rapid progression has been considered a hallmark of this disease, necessitating careful patient monitoring for the development of skin changes and systemic inflammatory response syndrome, subacute necrotizing fasciitis has been described.10

Necrotizing Fasciitis Pitfalls in Diagnosis

Because of the wide spectrum of disease, one of the most common pitfalls is assuming the absence of necrotizing fasciitis in the patient who looks well, rates their pain as mild or absent, is afebrile, or has no palpable crepitus. The other major pitfall in the management of necrotizing fasciitis is doing an extensive workup leading to a delay in surgical debridement in cases where clinical suspicion is high.

The Finger Test for Diagnosis of Necrotizing Fasciitis

In the event that you cannot make a slam-dunk diagnosis of necrotizing fasciitis after a careful clinical assessment and you can’t get rapid access to surgical exploration in the operating room or confirmatory imaging, or that the imaging is negative but you still have suspicion for the diagnosis, consider diagnostic confirmation with the finger test.11 After local anesthesia, make a 2- to 3-cm incision in the skin large enough to insert your index finger down to the deep fascia. Lack of bleeding and/or “dishwater pus” (gray-colored fluid) in the wound are very suggestive of necrotizing fasciitis. Gently probe the tissues with your finger down to the deep fascia. If the deep tissues dissect easily with minimal resistance, the finger test is positive for necrotizing fasciitis.

Time-Sensitive Therapy for Suspected Necrotizing Fasciitis

Initial treatment should involve aggressive resuscitation for any signs of hemodynamic instability and early administration of broad-spectrum empiric antibiotics (eg, piperacillin-tazobactam or carbapenem plus vancomycin or linezolid for methicillin-resistant Staphylococcus aureus coverage).12 The sooner the necrotic tissue is debrided in the operating room, the better. Time is tissue.

References

  1. Goh T, Goh LG, Ang CH, et al. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119-125.
  2. Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541.
  3. Liao CI, Lee YK, Su YC, et al. Validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for early diagnosis of necrotizing fasciitis. Tzu Chi Med J. 2012;24(2):73-76.
  4. Castleberg E, Jenson N, Dinh VA. Diagnosis of necrotizing fasciitis with bedside ultrasound: the STAFF Exam. West J Emerg Med. 2014;15(1):111-113.
  5. Fugitt JB, Puckett ML, Quigley MM, et al. Necrotizing fasciitis. Radiographics. 2004;24(5):1472-1476.
  6. Jain S, Nagpure PS, Singh R, et al. Minor trauma triggering cervicofacial necrotizing fasciitis from odontogenic abscess. J Emerg Trauma Shock. 2008;1(2):114-118.
  7. Günel C, Eryılmaz A, Başal Y, et al. Periorbital necrotising fasciitis after minor skin trauma. Case Rep Otolaryngol. 2014;2014:723408.
  8. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52. Erratum in: Clin Infect Dis. 2015;60(9):1448.
  9. Faria S, Helman A. Deep tissue infection of the perineum: case report and literature review of Fournier gangrene. Can Fam Physician. 2016;62(5):405-407.
  10. Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68(2):109-116.
  11. Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001;107(4):1025-1035.
  12. Kwak YG, Choi SH, Kim T, et al. Clinical guidelines for the antibiotic treatment for community-acquired skin and soft tissue infection. Infect Chemother. 2017;49(4):301-325.

Pages: 1 2 3 | Single Page

Topics: Critical CareDiagnosisinfectionNecrotizing Fasciitis

Related

  • Navigating Strict State Abortion Laws

    January 5, 2025 - 1 Comment
  • Post-Tonsillectomy Hemorrhage: A Three-Pronged Approach

    January 5, 2025 - 3 Comments
  • The Intersections of Physical and Mental Health Disorders

    October 9, 2024 - 0 Comment

Current Issue

ACEP Now: June 2025 (Digital)

Read More

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).

View this author's posts »

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.

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *


*
*

Wiley
  • Home
  • About Us
  • Contact Us
  • Privacy
  • Terms of Use
  • Advertise
  • Cookie Preferences
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 2333-2603