Necrotizing Fasciitis: Diagnosis and Management in the ED

Our case demonstrates a true surgical emergency—one that was appropriately managed with a multidisciplinary team approach. A high index of suspicion by the examining ED staff and surgical consultants led to supportive measures to maintain the patient’s vital signs and ultimately her life. Despite having no clear etiology for the cause of necrotizing fasciitis, we believe it may have resulted from the patient’s prior dental work or chronic NSAID use. Although there is no causal relationship, reports suggest that NSAIDs may prevent prompt recognition and accelerate the infection by altering its initial presentation.20 The patient reported no recent use of anti-inflammatory medication in association with her pain—only for fever.

This report also underscores the importance of urgent MRI in the ED setting. In addition to helping exclude other diagnoses involving the hip joint, MRI provided a roadmap for debridement of active infection. Moreover, the test eliminated the need to explore the left hip joint as well as the risk of seeding a sterile space.21

Conclusion

Our case presentation emphasizes the importance of maintaining a high degree of vigilance and suspicion when evaluating a patient with sepsis—especially when the source or site of infection is not clear. The entire healthcare team—emergency physicians and orthopaedic and general surgeons—must maintain a high index of suspicion when evaluating a patient with generalized limb and joint complaints. This case may not have ended as satisfactorily as it did were it not for the meticulous preoperative management and surgical debridement of the emergency physicians and surgeons, respectively.