In Emergency Medicine, there are only a few diseases that progress so rapidly, such that, one day you are essentially fine, and the next day, you are at death’s door — or beyond. I find these cases to be especially humbling, a testament that, however good we think we may be in this game we call “Emergency Medicine,” we often can offer very little to change the course of a disease.
In both the prehospital arena of EMS, as well as in the Emergency Department, we seem to give a great amount of attention to a select few diseases, often due to the sheer volume of people whom it affects.
Myocardial Infarction is one such disease. Interestingly, the mortality rate of heart attacks have been reported in the literature to be around 3 to 5 percent. In contrast, the ‘quick-death’ disease I plan to talk about has mortality rates up to 75 percent! Does this pique your interest yet?
I’d like to describe a case that came to my ER via EMS just last week.
Tuesday afternoon, a 35-year-old man called an ambulance, saying his leg was hurting too much to even walk. He told the medics that he had noticed a sore on his right thigh a few days ago, but even as of yesterday he was able to help a friend move some furniture, although he did say it caused his leg to ache some more.
His past medical history was unremarkable for any prior infections, and he considered himself healthy.
Although he initially denied it, claiming a bug bite, upon closer questioning, he later admitted doing some “skin popping” about four days prior.
The initial assessment from the medics showed the patient to be A&O x4, but he could barely get off the couch due to severe leg pain. There was no respiratory distress, and he didn’t feel like he had a fever.
The medics noted a few key points in their cardiac assessment:
- Slightly tachycardic
- BP was a little lower than one might expect, but not overwhelmingly so
The rest of their assessment was unremarkable. They started an IV line at TKO, and gave some morphine to help some of the pain. A short transport later, he was in my ER.
Repeat vital signs in the ER showed:
- Low grade fever: 101.5
- Resting heart rate: 120
- Blood pressure: 101/64
It was clear that the medics instincts were right about the blood pressure and heart rate not being “quite right.” The patient told me that, in the past, he had always been told his blood pressure was “normal,” although he did not know what the numbers were.
The patient’s entire right anterior thigh, was red, swollen, and tense. As I pressed along the upper part of his leg, I could feel some crepitus, as if I was popping some little bubbles of air. He said that, even though his leg hurt, he felt his skin was getting a little numb. The back of the leg, as well as the lower leg, looked fine. He had intact pulses and sensation distally, and he could flex at both the hip and knee.
LABS
Very high white count of 20.7, (normal range being 8.5 - 10.5). This pointed toward a severe infection.
BUN and creatinine to check kidney function; Both were elevated, indicating renal insufficiency.
Serum sodium was quite low, at 121 (normal range being 135-145); The low sodium was puzzling to me, but certainly important, so I categorized it in the “Fog of EMS” to be added to the big picture as I went along.
Many things can cause a low sodium including: the use of diuretics, excessive vomiting followed by ingestion of large amounts of fluid to create sodium dilution, and SIADH (syndrome of inappropriate antidiuretic hormone). SIADH can be caused by some cancers, TB, and even trauma.
In addition, to the labs, I also ordered an X-ray of his leg.
The X-ray of his thigh is particularly interesting. Take a moment now to look at the X-ray and see what you notice.
 |
Interpretation:
- Femur is intact
- The hip looks OK, too
- There is a large amount of swelling in the outer thigh
- Numerous gas bubbles
- Pus under the skin
It is the gas bubbles that give us a clue as to the serious nature of this illness. Many people may have pus under the skin due to infection but the presence of gas bubbles is more ominous. The gas is formed by toxic bacteria as a byproduct of their metabolism. A few types of bacteria (such as Clostridia) cause this, and none of them are good.
The low serum sodium now made sense. This is gas gangrene and the patient is in the early stages of shock. His vitals, the low sodium, the gangrene — it all added up to shock.
After re-examining the patient, I gave an additional two liters of normal saline since I suspected he needed it, due to the shock.
Other medical treatment included:
- Tetanus shot
- Additional pain medication
- Medication for nausea
- 3 different antibiotics since I didn’t know which bacterial family was causing the infection
Almost immediately, I called our general surgeon, who took the patient directly to the OR. There, the leg was opened, and extensive amounts of pus and necrotic tissue were found. The surgeon thoroughly debrided and irrigated the leg, and when he was done, he packed the leg and the patient went to the ICU.
Twenty-four hours later..... he’s dead. So what happened?
The patient’s final diagnosis was necrotizing fasciitis and gas gangrene. He succumbed to overwhelming sepsis and shock. He was on a fast roller coaster ride downhill when he came to the ER, and we were unable to stop it despite our very best efforts and rapid treatment.
In our case, there were several clues that this was more than a simple leg abscess.
Shock
The patient showed early shock, with the fever, tachycardia, and hypotension. The elevated BUN and creatinine suggested that his kidneys were already feeling the effects of this early shock, and were being under-perfused.
Gas bubbles
Feeling the crepitus on the thigh, and seeing the gas bubbles on the X-ray, confirmed the severity. This was much more than a simple infection.
These patients often culture out with more than one bacteria, both aerobic and anaerobic, causing the infection. The anaerobic bacteria generate a variety of gases, such as hydrogen methane, nitrogen, and hydrogen sulfide.
Hyponatremia
Hyponatremia, or a low sodium, is often seen in cases of necrotizing fasciitis, although it is not known why. What is known, however, is that, generally the lower the sodium, the worse the outcome for the patient! The reason for this is also unknown.
The infection spreads rapidly, along the deeper tissue layers, and pretty quickly the patient succumbs to this overwhelming infection, unless drastic measures are taken. Antibiotics alone won’t save your patient — surgery is also needed. In this case, even drastic measures and rapid transport to surgery couldn’t save him.
In general, men more than women get this disease, and it carries a significant mortality rate of 20 percent, or higher. Fournier’s Gangrene, which is a type necrotizing fasciitis that involves the groin and scrotum, has a reported mortality rate of 75 percent. This is one disease I don’t want to get, nor do you!
Lessons to learn
1. Be aware of necrotizing fasciitis, especially in your patients that you transport with diabetes or IV (or IM) drug abuse.
2. As you do your patient assessment, look for subtle clues of how sick the patient really is. Sometimes, in young people, you can miss some subtle signs of shock, like the slightly rapid heart rate and slightly low blood pressure. Neither of these was alarming as the patient didn’t look too bad at the time.
3. On turning over care to the doctor or nurse, share your concern if you think the patient may actually be sicker than what it looks like on the surface.
A good review can be found at www.emedicine.medscape.com/article/1054438-overview
Have you had any similar calls? If so, let me know and drop me a line.
