Moderator EMEDPA Posted November 5, 2012 Moderator Share Posted November 5, 2012 male in his 20's brought in by girlfriend for "fever and not acting right today". no pmh. not diabetic or immunocompromised by hx. does smoke. no rec. drugs. t=38.5, 110/70, 18, 120, 98% mental status is best described as flaky. seems to forget things, underplays some issues, overplays others. seems drunk but isn't(that was a freebie). so, only pertinent exam follows: R lower extremity with blistering warm erythematous near circumferential rash from what appears to be an ingrown great toenail. extends to the knee, or is it mid thigh or is it groin....is appears to be spreading rapidly over the few min you are in the room. you can make 1 phone call. who ya gonna call? and you need more help here than ghost busters.... Link to comment Share on other sites More sharing options...
rcdavis Posted November 5, 2012 Share Posted November 5, 2012 Surgery. Sounds like acute sepsis syndrome ( fever, tacky, altered mental status) with rapidly evolving cellulitis lower extremity.. Immediate fluids, labs ( lactate, bmp, blood cultures CBC , UA and UC, UDS, 2 liters/30 mins, vanc, gentamicin, ceftriaxone now. The medical will be essentially handles with the above,.. The primary concern I have is a rapidly expanding fasciitis. At least that's my initial impression with your presentation. If his mental status had been normal, I would wait the labs ( and still start the abx and fluids) before the call.. But if I am right, minutes matter. Oh yeah, I would check his tetanus status stat, and if neg, start hypertet Oh yeah, the lp should be done AFTER the Meds, fluids and labs are drawn. X-ray of the extremity looking for soft tissue air) also V/r RC Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 5, 2012 Author Moderator Share Posted November 5, 2012 ding, ding, ding rapidly progressing necrotizing fasciitis with sepsis. from presentation in FAST TRACK(TRIAGE THOUGHT HE HAD "THE FLU" BECAUSE THEY DIDN'T MENTION THE RASH OUT FRONT) TO O.R. TIME= TEN MIN. he wasn't with us very long in FT. 2 lines started, fluids wide open, labs drawn, to o.r..... at our facility trauma does these as they are in house 24/7 and gen surg can be 20 min away on pager. pt lost the toe but nothing else..was very lucky. fasciotomy was done and tissue excised but he kept the leg. still in icu on 3 iv abx( rocephin, zosyn, vanco). one of our new pa's saw this pt., they grabbed me, I grabbed my attending and called surg., they were there within a few min. Link to comment Share on other sites More sharing options...
aerten Posted November 6, 2012 Share Posted November 6, 2012 Wow!!:O_O: Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted November 6, 2012 Administrator Share Posted November 6, 2012 Strong work! Link to comment Share on other sites More sharing options...
Christenmack Posted November 6, 2012 Share Posted November 6, 2012 AH! So exciting! I did my senior exhibition of mastery at my pre-med highschool on necrotizing fascitis! This guy is lucky he only lost a toe, and that he was seen me a PA who was on point! Link to comment Share on other sites More sharing options...
Cody89 Posted November 6, 2012 Share Posted November 6, 2012 Pretty crazy. Great job on the recognition. Guy is definitely lucky. Link to comment Share on other sites More sharing options...
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