Clinical Problem:

Forty-four y/o healthy male sustained trauma to left knee one week before presenting in the emergency department with respiratory distress, toxic shock, blistering lesions, erythema, swelling, and pain in left lower extremity. Diagnosis was Group A Streptococcus Necrotizing Fasciitis (NF), a life threatening infection causing rapid, deep tissue necrosis.

Past Management:

Patient intubated, antibiotics initiated and underwent fasciotomy and multiple debridements.  Infection extended to lower flank. Amputation was recommended precipitating second opinion.  He was transferred via air ambulance from Nicaragua to Cleveland Clinic Florida (CCF).

CCF Approach:

A multi-team approach (Infectious Disease, Vascular Surgery, Wound Care Specialist, and Plastic Surgery) was employed when receiving patient 4 days post-injury. Treatment included antibiotics and gammglobulin. Pain managed with IV narcotics. Supportive care included IV fluids, intubation and fecal management system for diarrhea^†. After surgical debridement, wet-to-dry gauze dressings with 0.25 % Dakin's solution applied every 8 hours for 5 days.  Then WOC nurses were consulted for negative pressure wound therapy (NPWT).  The NPWT changes caused excruciating pain as the wound granulated into the sponge of the NPWT device.  Each dressing change required 2-4 hours, twice per week.   Seven days after NPWT was initiated, the protocol was revised. The wound bed was covered with the NA CMC with ionic silver dressing prior to the application of the NPWT system and changes were reduced to weekly until full limb granulation and split thickness skin graft was performed. NPWT continued 5 days.

Patient Outcomes:

Boluses of narcotics were eliminated as the patient experienced significant decrease in pain with the use of NA CMC with ionic silver dressing as the primary dressing. 

Conclusion:

NA CMC with ionic silver dressing was successful as a primary dressing.  The patient experienced decreased pain and less frequent dressing changes were required when using NPWT.

Product Notations

*AQUACEL^" Ag dressing.

†Flexi-Seal^" Fecal Management System

AQUACEL and Flexi-Seal are registered trademarks of E.R. Squibb & Sons, L.L.C.

Bibliography:

J L Schroeder, RN, E l Steinke, RN, “ Necrotizing Fasciitis-The Importance of Early Diagnosis and Debridement,”AORN Journal 82 (December 2005) 1031-1040

A J Headley, M.D. “ Necrotizing Soft Tissue Infections: A Primary Care Review,” American Family Physician 68 (July 2003) 323-328

S Hasham, P Matteucci, P R W Stanley, N B Hart, “ Necrotizing fasciitis,” BMJ 330 (April 2005) 830-833

S Gully, RGN, “ Nursing Management of necrotizing fasciitis,” Nursing Standards, 52(September 2002) 39-42

J T Trent, MD, R S Kirsner, MD, “ Unusual Wounds Diagnosing Necrotizing Fasciitis,” Advances in Skin and Wound Care, (May/June 2002)

US-07-2086