Best management of contaminated wound with necrotic material:

Ans. a. Debridement (Ref: Sabiston 19/e p2011; Bailey 25/e p26, 39-40)Best management of contaminated wound with necrotic material is debridement.'Managing the acute wound: After assessment, a thorough debridement is essential. A wound should be explored and debrided to the limit of blood staining. Devitalised tissue must he excised until bleeding occurs with the obvious exception of nerves, vessels and tendons.'- Bailey 25/e p26.Necrotizing FasciitisNecrotizing fasciitis is a rapidly progressive bacterial infection characterized by involvement and necrosis of the subcutaneous tissue and fascia, with typical sparing of the underlying muscleQ.MC site of infection: Lower extremitiesQMay involve trunk, perineum (Fournier's gangrene) or head and neck and any other site.Etiological AgentsMC single etiological agents: Group A beta hemolytic StreptococciQMore commonly, necrotizing fasciitis results from a polymicrobial synergistic infectionMicroorganism responsible: Group A beta hemolytic Streptococci + Staphylococcus, E. coli, Pseudomonas, Proteus, Bacteroides/Clostridium (Anaerobes)Risk Factors for Necrotizing Fasciitis* DiabetesQ* Pressure sores* Immunocompromised statesQ* SmokingQ* Penetrating traumaQ* ObesityQ* IV drug abuseQ* Peripheral vascular diseaseQ* Skin infection' damageQ (abrasions, bites, boils)Clinical Presentation:Pain is the most important presenting symptomPain is disproportionately greaterQ than that expected from degree of cellulites presentWithout treatment pain may decrease due to thrombosis of small blood vessels and destruction of peripheral nerves (an ominous signQ)Skin Features: Edema, erythemaQ (Infected area is red, hot, shiny, swollen and exquisitely tender)Woody hard texture to subcutaneous tissueInability to distinguish fascial planes and muscle groups on palpationSkin vesicles/cutaneous bullae, soft tissue crepitus due to gas productionQ may be seen when necrotizing fasciitis is caused due to mixed flora but not due to group A StreptococcusSystemic features: Fever, hypotension, tachycardia, progression to septic shock. DIC or multiple organ failureQManagement:This is a surgical emergency and surgical debridement is mandatoryQTreatment: Urgent surgical debridement + IV fluids + Broad spectrum IV antibiotics + Supportive treatmentQMortality rate is nearly 100% without surgical debridementQHlyperbaric oxygen helps in wound healingQ