Necrotising soft-tissue infection — Rapid

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.
The index operation systematically examines skin, subcutaneous fat, fascia, neurovascular structures and every relevant muscle group and documents the anatomical extent.
Excise obvious and likely infected zones plus a three-centimetre cuff of normal zone-3 skin and fascia under the current BOASt advisory technique; absence of dishwater fluid does not exclude infection.
Take ideally five deep microbiology samples from all zones using separate instruments and no-touch technique, label healthy-zone samples separately and alert the laboratory that necrotising infection is suspected.
Do not primarily close the wound at the first operation. Review the patient and operative result within six hours and return sooner whenever physiology or local findings fail to improve.
A decision to amputate requires at least two consultants from different relevant specialties; reconstructive, rehabilitation and psychological planning begins while serial source control continues.

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.

Hypotension, mottling, confusion, oliguria, high lactate, coagulopathy or rapidly rising organ-support needs indicates toxin-mediated systemic disease and demands simultaneous source control and critical-care resuscitation.

Diabetes, immunosuppression, peripheral vascular disease, obesity, renal or liver disease, recent surgery, injection or penetrating trauma lowers the threshold; absence of these factors does not exclude disease.

Failure to improve after the first debridement implies residual infected tissue and mandates further urgent exploration rather than antibiotic escalation alone.

Investigation priorities

First-line operative explorationFirst stepFirst line

Confirm fascial or muscle necrosis and remove its source immediately.

Management branches

RecognitionMobilise theatre while resuscitating

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.
Use small reassessed crystalloid boluses and blood products or vasopressors through critical care according to physiology.
Do not await LRINEC, CT, transfer or complete physiological normalisation before source-control surgery.

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.Agent and dose depend on immediate allergy, renal and hepatic function, prior resistant organisms and water, farm, injection or healthcare exposure; never narrow on a superficial swab or allow antibiotics to postpone debridement.

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.Use smaller or slower boluses and earlier critical-care input in heart failure, renal failure, frailty or pregnancy; stop for pulmonary oedema and do not delay blood products, vasopressors or operative source control.

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