Post Explosive Wound Necrotizing Fasciitis Medical Observation and Management

Background: Necrotizing fasciitis (NF) is a life-threatening soft tissue infection characterized by rapid involvement of the deeper layers of fascia and muscles and causes extensive tissue necrosis. Sepsis is a common risk factor associated with disseminated intravascular coagulation (DIC) and acute kidney Injury (AKI) related to severe injury, major surgery, and burns. NF cases typically require intensive care management (ICU) due to high mortality rates.

Case Presentation: The patient presented to the hospital amidst a time of mass casualties and overcrowding due to the Gaza war in 2023. He sustained a shrapnel injury to his left thigh from a missile blast. In the dressing room, they removed the shrapnel and applied sutures to the wound. Two days later, the patient's general condition deteriorated. Upon examining the wound, a large necrotic area was discovered at the shrapnel site. The clinical signs and symptoms strongly suggested necrotizing fasciitis, prompting immediate management.

Intervention: An interdisciplinary approach involving surgical and medical teams was employed to address the multiple complications associated with this case. After nearly three weeks of surgical ward management, the patient regained consciousness and made a full recovery.

Conclusion: Managing such a case in a regular patient ward during wartime underscores the importance of interdisciplinary coordination in handling complex complications. The high level of cooperation between hospital divisions, the laboratory, the inpatient ward, and the medical team was crucial, especially during the chaotic war conditions in achieving a successful outcome. Finally, timely and bold decisions must be taken to manage such a complicated case of necrotizing fasciitis.

Introduction

During wartime, the quality of medical care is often severely compromised due to multiple factors including medical infrastructure compromise, shortages of staff and medical supplies, and very high patient turnout. These conditions significantly hinder the management of even routine cases. When such extreme challenges are compounded by a complex injury and a subtle diagnosis, survival rates can plummet. Yet, despite these obstacles, this case report highlights a successful approach to diagnosing and managing the patient’s injury under some of the most difficult circumstances medical staff could endure.

Case Presentation

A 33-year-old male was admitted as a case of post-explosive injury in the Lt. upper thigh with shrapnel and a small wound. Wound debridement and sutures were performed upon admission. Dressing was done, and IV antibiotics were started.

He presented to the Emergency department (ED) with only mild shrapnel which normally doesn’t require much attention, especially during wartime, but his rapid deterioration after a couple of days sheds light on the significance of early management and aggressive treatment to secure the best results. Symptoms of sepsis were observed in a short time. He developed high-grade fever, sweating, disorientation, and looked unwell. Upon examining the wound, a large area of black, foul-smelling skin and soft tissue was noticed around the original wound site. When combining the bad wound status with the clinical picture of the patient, the diagnosis of necrotizing fasciitis (NF) was made.

Immediately, he developed AKI observed clinically and confirmed and monitored by laboratory tests during a certain period; he developed anuria and had a creatinine level up to 7.1 mg/dl, a potassium level of 7.4 mmol/l and a sodium level down to 114 mmol/l. Additionally, he became disoriented and hemodynamically unstable. His hemoglobin level and PLT count started to drop significantly, and his WBC count significantly increased. He was hospitalized for nearly 32 days.

Patient Care and Management

Surgical Management

The patient developed high-grade fever, sweating, disorientation, and looked unwell. Upon examining the wound, a large area of black, foul-smelling skin and soft tissue was noticed around the original wound site. The patient was diagnosed with NF, and a decision of massive debridement was taken to limit the severe consequences. A decision of bedside wound debridement was made because the patient’s condition was critical and unfit to be transferred to the operating room (OR), he had an unstable hemodynamic status, and severe and persistent hypotension despite fluid therapy. Massive debridement of the wound was performed by excising all involved soft tissue reaching just below the inguinal ligament, involving the left testicle and part of the suprapubic area, and extended to most of the upper third of the medial aspect of the lt. thigh. Additionally, the muscle compartment of the medial thigh aspect was exposed after the debridement process. Thereafter, the patient underwent daily wound dressing and debridement in the ward under ketamine sedation as he was unfit for the OR. The debridement process resulted in a massive raw area at the anterior upper part of the left thigh as shown in Fig. 1, after a prolonged period of daily dressing the large wound was covered by a split-thickness skin graft harvested from the right thigh. The harvested skin was inserted into a mesher to increase its surface area and cover the whole wound.

Fig. 1. Wound post extensive debridement showing a huge raw area covering most of the left upper thigh and exposing the muscle compartments. Panel B shows the infected and dirty wound which needed daily dressing and multiple debridements until it reached a better condition as in panel A.

Medical Management

The medical management primarily focused on preventing the clinical condition from worsening. The patient suffered from severe sepsis, which affected his mental status, kidney, and liver function. We started vigorous fluid management to overcome his deteriorating kidney function as his creatinine levels reached 7.1. He received 500 cc of normal saline every 4 hours; additionally, we administered Furosemide 20 mg every 12 hours to enhance his urine output because he was anuric at the time. An input-output chart was necessary to monitor the patient’s kidney function, which was recorded every 6 hours. Furthermore, the patient had a significant electrolyte imbalance demonstrated primarily by the potassium levels, which reached 6.9 at one point, and the sodium level, which dropped significantly, reaching 114 within different periods during electrolyte management, as shown in Table II.

The severe fluctuations in the electrolyte levels warranted prompt management and close monitoring as the sodium levels had a direct effect on his mental status, and the high potassium level could cause severe complications like bradycardia and even cardiac arrest. The high potassium level was managed by calcium gluconate 2 g to preserve cardiac stability, followed by a regimen of regular insulin, dextrose 5%, and Ventolin inhalations to lower the serum (extracellular) potassium levels. On the other hand, we used normal saline to counter the hyponatremia because there was no hypertonic saline available.

The severe sepsis that was present in this case was expected to turn into septic shock at any moment during the management, and because of the lack of some advanced diagnostic methods like blood culture and the narrow time window, an empirical broad-spectrum antibiotic regimen was necessary to cover all possible suspected pathogens (gram negative and gram-positive). Of course, we had to consider the patient’s kidney function at the time because of the nephrotoxic effect of such limited available drugs, which can worsen the patient’s kidney function despite its deterioration. We used an adjusted dose of meropenem 500 mg every 12 hours, clindamycin 900 mg every 8 hours, and vancomycin 1 g every 24 hours, according to the creatinine clearance, which was calculated by the Cockcroft-Gault equation to be 17 mL/min when the creatinine level reached 7.1.

Moreover, the severe nature of this infection caused a continuous drop in the patient’s hemoglobin and platelet levels, for which fresh whole blood units were administered to compensate for the severe thrombocytopenia that reached 5 at a certain point, noting that neither platelets nor fresh frozen plasma was available at that time. The patient received supportive management to prevent the deterioration and the possibility of Disseminating intravascular coagulopathy DIC from happening.

The surgical wound debridement was performed in conjunction with the medical management. After a few days, as shown in the lab results provided in Tables I and II, the patient’s condition slowly improved, and his labs eventually normalized. After the stabilization of the patient, the role of plastic and reconstructive surgery was needed to close the wide raw area that resulted in the wound infection site, as shown in Fig. 2. After two weeks, the patient underwent a split-thickness skin grafting which covered the whole wound (Fig. 3), this procedure was followed by day after day dressing until the healing process finished.

Table I. Hematology Results (CBC Test Parameters)

Date	HB	Hct.	WBC	RBCs	PLT.
24.11.2023	13.6	40.2	37.1	5.7	42
26.11.2023	13.1	37.3	38.1	5.3	18
27.11.2023 (A)	9.8	28.7	24.5	3.9	5
27.11.2023 (B)	9.3	26.5	31.1	3.7	8
28.11.2023	7.0	18.9	22.0	2.7	6
29.11.2023 (A)	4.9	13.6	26.4	–	58
29.11.2023 (B)	5.5	14.3	24.7	1.9	61
30.11.2023 (A)	5.8	15.2	17.9	2.1	92
30.11.2023 (B)	5.3	14.9	13.3	2.0	95
2.12.2023	7.2	19.4	16.0	2.0	126
5.12.2023	5.8	17.6	6.5	1.9	280
14.12.2023	6.5	–	21.0	–	277
15.12.2023	8.2	–	19.9	–	319

Table II. Chemistry Results

Date	Glu	Urea	Creat.	K	Na	ALT	AST
24.11.2023	80	189	7.1	5.9	118	104	–
26.11.2023	65	225	6.5	5.8	114	103	101
27.11.2023	167	135	6.0	7.4	150	28	164
28.11.2023 (A)	125	284	7.2	6.0	120	–	–
28.11.2023 (B)	138	283	6.8	6.2	121	30	39
29.11.2023	112	238	6.2	5.4	122	27	35
1.12.2023	91	–	5.8	4.5	129	–	–
2.12.2023	109	123	3.7	4.2	137	34	79
3.12.2023	–	103	3.1	–	–	–	–
5.12.2023	–	81	1.6	–	–	–	–
10.12.2023	–	76	2.0	–	–	–	–
14.12.2023	131	39	1.5	3.3	132	47	55

Fig. 2. After 2 weeks of daily dressing, the wound gradually improved and the infection subsided (panel A). A good amount of granulation tissue is noticed in panel B, which reflects a positive sign for the management process to take the next step for skin grafting.

Fig. 3. The pictures show a meshed split-thickness skin graft applied to cover the whole wound. These pictures were taken in the first dressing after the skin grafting which displays a successful procedure.

Findings

Table I presents the patient’s laboratory results, illustrating clinical deterioration following admission and subsequent stabilization during management. The marked and sudden decline in hemoglobin and platelet levels between November 27–29 aligns with the patient’s diagnosis and explains the need for multiple blood transfusions. Additionally, the persistent leukocytosis from admission, along with a secondary peak in white blood cell count on November 27, supports the diagnosis of sepsis and the likelihood of associated complications. This was managed with a combination of intravenous antibiotics aimed to control the severe septic response.

Table II presents a critical assessment of the patient’s kidney function and electrolyte imbalances resulting from necrotizing fasciitis. Elevated creatinine and urea levels indicate the development of acute kidney injury (AKI), which persisted for approximately two weeks. Levels peaked on November 24 and 28, then gradually improved, reaching 1.5 mg/dL by December 14 with appropriate management. The AKI was accompanied by severe hyperkalemia (7.4 mmol/L) and hyponatremia (114 mmol/L), both of which posed a significant threat to the patient’s life if not addressed promptly. Additionally, elevated liver enzymes indicate acute liver injury, consistent with the overall diagnosis. It is important to note that, during wartime, these were the only available laboratory investigations, and they played a vital role in guiding clinical decisions and monitoring the patient’s progress.

Discussion

This case report describes the major risk of life-threatening complications associated with explosive injuries. The rapid deterioration of this patient in terms of high-grade fever, general malaise, and disorientation, in addition to the foul-smelling and blackish discoloration of the skin and soft tissue around the shrapnel entry point, was strongly suggestive of systemic infection, in this case, most probably NF [1], [2].

This case underlines the critical importance of timely diagnosis and aggressive management in patients with NF. The severe nature of the associated complications includes systemic toxicity, sepsis, multi-organ failure (MOF), and significant morbidity, alongside the rapid deterioration of the patient’s condition necessitating early diagnosis and aggressive treatment to improve outcomes and reduce mortality. particularly when complicated by sepsis and AKI [3].

According to the wound infection by Klebsiella spp. and Pseudomonas spp., black skin lesions were caused by the breakdown of RBCs, the accumulation of cellular debris, and lack of oxygen, causing the cells to break down and turn black and accelerate tissue death. They generate reactive oxygen species (ROS), which can damage cells by causing oxidative stress, leading to tissue injury [4]. For bad odor, malodorous 2-aminoacetophenone (2-AAP) is responsible for the dominant odor associated with chronic ulcers associated with Pseudomonas aeruginosa infection [5].

Polymicrobial infection in NF infiltrates the subcutaneous tissue and produces endotoxins and exotoxins that cause inflammation, vascular compromise, and tissue death. This severe infection can lead to life-threatening conditions, including multi-organ failure and toxic shock syndrome (TSS), with a 15%–45% mortality rate [6]. In this case, the patient suffered from multiorgan failure, which is shown by his lab results, he developed AKI, elevated liver enzymes, anemia, and altered mental status, which this systemic infection can explain.

The patient was started on a combination of antibiotic therapy, which consisted of meropenem and vancomycin with dose adjustment according to the creatinine clearance “CrCl,” which was severely impacted as a result of sepsis. CrCl was calculated using the Cockcroft-Gault Equation, estimated at the time to be 9 mL/min. Additionally, the patient started to suffer from severe complications as a result of sepsis; he had leukocytosis (WBCs: 37.1*10^3) and a sudden increase in creatinine level, which reached 7.1; hyperkalemia of 5.9; hyponatremia of 118, in addition to a marked, continuous, and rapid drop in hemoglobin levels.

Medical management was crucial to stabilize the patient’s condition and provide more time for the surgical management to take place. It’s mainly focused on addressing the severe anemia, thrombocytopenia, electrolyte imbalance, and AKI. Broad-spectrum antibiotics were administered, keeping in mind adjusting the dose according to the CrCl level, in addition to aggressive fluid management and hyperkalemia treatment [7]. The multidisciplinary approach in managing this case highlights the complex nature of such conditions during wartime particularly in the absence of arterial blood gas (ABG) tests and the lack of advanced tests that play a critical role in management.

Systemic Inflammatory Response Syndrome (SIRS) associated with NF causes hemolysis through multiple toxins that disrupt the integrity of red blood cells, leading to a continuous drop in hemoglobin levels, and causing anemia [8]. Furthermore, the development of sepsis can cause many signs and symptoms that are attributed to end-organ damage, such as cold skin, cyanosis, oliguria, AKI, and altered mental status, which are seen in this case [9].

He was a young man without any medical disorder; due to early diagnosis and suitable management despite limited medication and medical supplies, according to the special situation, he had a good prognosis compared with others. Early extensive debridement is the most crucial part of controlling the spread of NF and reducing mortality rates despite the patient’s unstable condition [10]. Performing bedside debridement was necessary due to the patient’s hemodynamic critical status. Finally, daily wound care and later skin grafting were key in promoting wound healing and preventing further complications.

Conclusion

Managing such a case in a regular patient ward during wartime underscores the importance of interdisciplinary coordination in handling complex complications. The high level of cooperation between hospital divisions, the laboratory, the inpatient ward, and the medical team was crucial in achieving a successful outcome.