This month’s Save of The Month goes to a repeat awardee and one of our editors, Dr. Noah Berland.
We are recognizing Noah for correctly identifying the sickest patient in the room, advocating for that patient, and expediting her care.
Case
A middle-aged woman with a history of diabetes presented to the ED for a “wound check” of an inner thigh ulcer.
Vitals: BP 120/70, HR 100, T 98.1, RR 16, O2 98
Noah quickly noted a large tender ulcer with erythema, edema, and malodorous discharge without crepitus. Surgery was immediately consulted and broad-spectrum antibiotics ordered with concern for…. necrotizing fasciitis.
Necrotizing Fasciitis
From Dr. Franck’s review, recall that necrotizing fasciitis is a rapidly progressive condition with a median mortality of 21%, approaching 100% left untreated.1,2
A key takeaway from Dr. Franck’s earlier post is to maintain a high index of suspicion for the diagnosis. The severity of the condition could easily be missed in the absence of severe systemic symptoms and obvious exam findings such as crepitus.
What about the LRINEC Score?
Dr. Franck reminds us that validation studies have shown poor sensitivities and specificities for the LRINEC score.
In our case, the patient had a calculated LRINEC score of 12 (WBC 23, Hgb 8, Na 133, Glucose 580, Creatinine 3.6, CRP > 300).
From the original LRINEC study, the probability of necrotizing soft tissue infection correlates with a higher score, with a probability of almost 100% with a score of 12.3
Probability of Necrotizing Fasciitis based on LRINEC Score3
Thus, while a low score cannot rule out necrotizing fasciitis, a higher score may significantly raise suspicion. Management should not be delayed pending an LRINEC score.
Case Resolution
The patient was brought to the OR where the diagnosis was made by visual inspection. Intraoperatively, the patient became hypotensive and required vasopressors. Blood cultures and tissue cultures have been negative. The patient has had 3 subsequent debridements and remains in critical condition.
References
[1]Franck, N. “Everything you ever wanted to know about necrotizing fasciitis”. Accessed August 10, 2020. http://blog.clinicalmonster.com/2019/08/26/everything-you-ever-wanted-to-know-about-necrotizing-fasciitis/
[3]Wong C-H, Khin L-W, Heng K-S, Tan K-C, Low C-O. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections*. Critical Care Medicine. 2004;32(7):1535-1541. doi:10.1097/01.ccm.0000129486.35458.7d
Robby
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1 Comment
Nicole · August 13, 2020 at 9:16 am
This is such a great save! And a good review of the LRINEC score. Good to have something more to rely on besides just intuition given how sick a patient can get with the inappropriate diagnosis.