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(Sorry for the previously mislabeled pearl...)
Necrotizing soft tissue infections (NSTI) are on the rise and, despite improved surgical and critical care, over the years there has only been a mild reduction in mortality. Survival is associated with early diagnosis and treatment. Unfortunately, NSTI are not always obvious because deeper tissues made be involved first. Despite a validated scoring system and better radiology, our clinical suspicion still rules and relies on a meticulous history and physical exam.
Here are some subtle signs of NSTI:
Pain out of proportion to exam
Edema beyond region of erythema
Skin anesthesia
Skin erythema and/or hyperthermia
Epidemolysis
Skin bronzing
If NSTI is suspected, be vigilant! Start broad-spectrum antibiotics, begin appropriate resuscitation and involve your surgeons early.
References
Necrotizing soft tissue infections in the intensive care unit. Crit Care Med. 2010 Sep; 38: S460-8. Phan HH, et al.