Rosen & Barkin's 5-Minute Emergency Medicine Consult (283 page)

Patients may be hypotensive from septic shock and require aggressive fluid resuscitation and vasopressor support.

• Manage airway and resuscitate as indicated.
  
• Central venous access, aggressive fluid resuscitation, and pressure support as indicated:
  
  • Avoid femoral access, femoral venipuncture, and lower extremity venous access
    
• Early goal-directed therapy if septic
  
• Foley catheter placement or suprapubic access if indicated
  

• Empiric broad-spectrum antibiotics
  
• Early emergent aggressive surgical débridement
  
• Adjunctive hyperbaric oxygen therapy coordinated with surgical care
  
• Treat dehydration and correct electrolytes.
  
• Blood products as needed for DIC or anemia; oxygen debt can be minimized by keeping hematocrit >30%.
  
• Tetanus prophylaxis as indicated
  

• More conservative surgical approach
  
• Adequate staphylococcal coverage
  

• Antibiotic regimens:
  
  • Multidrug regimen:
    
    • Ampicillin: 2 g IV q6h (peds: 50 mg/kg)
      and
      
    • Clindamycin: 900 mg IV q8h (peds: 10 mg/kg)
      and
      
    • Gentamicin: 5 mg/kg daily load IV q8h
      
    • Ciprofloxacin: 500 mg IV
      and
      
    • Clindamycin: 900mg IV initial ED dose
      
  • Single-drug regimens (peds: Safety not established)
    
    • Ampicillin/sulbactam: 3 g IV initial ED dose
      
    • Imipenem: 1 g IV initial ED dose
      
    • Piperacillin/tazobactam: 3.375 g IV initial ED dose
      
    • Ticarcillin/clavulanate: 3.1 g IV initial ED dose
      
• Cover for possible MRSA with Vancomycin 1 g IV initial ED dose
  
• Blood products as indicated
  
• Dopamine or dobutamine IV drips starting at 5 μg/kg/min titrating to effect if hypotensive after aggressive hydration
  
• Insulin adjusted to control glucose and acidosis
  

FOLLOW-UP

• All
  patients with Fournier gangrene require admission and surgical ICU care.
  
• Mortality estimates of 3–38% emphasize need for early aggressive care.
  
• Consider early transfer to facility capable of providing adjunctive hyperbaric oxygen therapy if stable for transport.
  

No patients with Fournier gangrene should be discharged.

• Failure to perform a careful genital exam, particularly in a pediatric patient
  
• Failure to initiate antibiotics in a timely manner
  

• Burch DM, Barreiro TJ, Vanek VW. Fournier’s gangrene: Be alert for this medical emergency.
  JAAPA
  . 2007;20(11):44–47.
  
• Davis JE, Silverman M. Scrotal emergencies.
  Emerg Med Clin North Am.
  2011;29(3):469–484.
  
• Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis.
  Am J Surg
  . 2005;189:462–466.
  
• Levenson RB, Singh AK, Novelline RA. Fournier gangrene: Role of imaging.
  Radiographics
  . 2008;28(2):519–528.
  
• Pais VM. Fournier Gangrene. Emedicine. Available at
  emedicine.medscape.com/article/2028899-overview
  . Accessed March 22, 2014.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cellulitis
  
• Urinary Tract Infection, Adult
  

CODES

608.83 Vascular disorders of male genital organs

BASICS

• Continuity between skin violation and fracture site, ranging from a puncture wound to grossly exposed bone
  
• Surgical urgency, as delays in care increase risk of infection and rate of complications
  
• Predisposition to complications in certain patients:
  
  • Massive soft tissue damage
    
  • Severe wound contamination
    
  • Compromised vascularity
    
  • Fracture instability
    
  • Compromised host (diabetes, vascular disease)
    

Open fractures typically result from significant blunt force or penetrating trauma.

DIAGNOSIS

• Deformity with nearby violation in skin integrity
  
• Neurovascular compromise may occur.
  
• Additional traumatic injuries are frequently present.
  

Significant trauma

• Complete neurologic and vascular exam
  
• Examine thoroughly for other traumatic injuries.
  

• Plain radiographs including joints above and below the affected area
  
• Guided workup based on mechanism and evidence of other traumatic injuries
  

• CBC, chemistry panel, coagulation studies for large-bone (femur, pelvis) fractures or multiple-trauma victims
  
• Type and screen or type and cross-match for potential of significant blood loss.
  
• Predébridement and postdébridement cultures have limited value and are not recommended.
  

Doppler or angiography if vascular damage is suspected:

• Posterior knee dislocation
  
• Ischemic extremity
  
• Massive soft tissue injury in high-risk areas
  

• Measurement of compartment pressures if concern for compartment syndrome
  
• Consider arthrogram by intra-articular injection of saline or methylene blue if joint involvement is suspected.
  
• Angiography if noninvasive techniques are inadequate for ruling out vascular compromise
  

Noncontiguous laceration/abrasion

TREATMENT

• Moist, sterile dressings over open wounds
  
• Immobilize joints above and below fracture.
  
• Control bleeding with local compression.
  
• Consider tourniquet for traumatic amputations or uncontrollable hemorrhage.
  
• Longitudinal traction of involved extremity if distal pulses absent
  

• Management of ABCs.
  
• Gentle reduction and immobilization of fracture
  

• Intravenous access
  
• Keep patient NPO
  
• Tetanus vaccination, if needed
  
• Antibiotics reduce the incidence of early infection in open fractures and should be given early in the ED course.
  
• Minimize number of times dressing is removed to avoid secondary contamination.
  
• Examine limb regularly for compartment syndrome and neurovascular status.
  
• Certain large joint open fracture/dislocations should be reduced emergently in the ED (ankle, elbow, knee)
  
• Urgent orthopedic consultation for formal irrigation, débridement, and possible operative fixation.
  
• Vascular surgery consultation for injuries with potential vascular damage