Synopsis
Recognise limb necrotising fasciitis or myositis before late cutaneous necrosis, resuscitate sepsis while mobilising theatre, excise all infected zones immediately, obtain correctly labelled deep samples, and plan early re-look, reconstruction or consultant-led amputation.
- Necrotising infection is a clinical and operative diagnosis. Pain beyond erythema, rapid change, systemic toxicity and high-risk host features outweigh a low score or reassuring early skin.
- Do not use LRINEC to rule disease out; normal sodium, white count or CRP early in the course cannot make a dangerous examination safe.
- Start sepsis resuscitation and broad-spectrum intravenous antibiotics without delay, but never let ICU stabilisation, CT or inter-hospital transfer postpone immediate surgical exploration.
Key red flags
Pain or exquisite tenderness extending beyond erythema, rapid progression, wooden induration, sensory change, dusky skin, bullae, crepitus or shock requires immediate senior surgical review even without fever.
Investigation priorities
Confirm fascial or muscle necrosis and remove its source immediately.
Management branches
Rapid deep pain, spreading tissue change or toxicity makes necrotising infection clinically plausible.
- Call the responsible surgical consultant, anaesthesia, intensive care and microbiology and book immediate NCEPOD-1 exploration.
- Apply the sepsis pathway, draw cultures if non-delaying and start local broad-spectrum intravenous therapy immediately.
Key medicines
Immediate broad-spectrum parenteral antibioticsGive the current trust necrotising-infection regimen at full protocol adult doses immediately after cultures when cultures cause no delay; include Gram-positive, Gram-negative and anaerobic cover and add toxin-suppressing therapy when microbiology recommends it.
Balanced isotonic crystalloid for sepsis hypoperfusionGive 250 mL intravenously over 10–15 minutes, reassess circulation and pulmonary tolerance after each bolus and repeat as required up to 1,000 mL before mandatory senior review of further fluid, vasopressor and critical-care needs.