Tim Montrief1, Brit Long2, Alex Koyfman3, Jonathan Auerbach4. 1. Department of Emergency Medicine, University of Miami, Jackson Memorial Hospital/Miller School of Medicine, Miami, Florida. 2. Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas. 3. Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas. 4. Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine, Miami, Florida.
Abstract
BACKGROUND: Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization. OBJECTIVE: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG. DISCUSSION: Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications. CONCLUSIONS: FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration. Published by Elsevier Inc.
BACKGROUND: Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization. OBJECTIVE: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG. DISCUSSION: Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications. CONCLUSIONS: FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration. Published by Elsevier Inc.
Authors: Antonio Tarasconi; Gennaro Perrone; Justin Davies; Raul Coimbra; Ernest Moore; Francesco Azzaroli; Hariscine Abongwa; Belinda De Simone; Gaetano Gallo; Giorgio Rossi; Fikri Abu-Zidan; Vanni Agnoletti; Gianluigi de'Angelis; Nicola de'Angelis; Luca Ansaloni; Gian Luca Baiocchi; Paolo Carcoforo; Marco Ceresoli; Alain Chichom-Mefire; Salomone Di Saverio; Federica Gaiani; Mario Giuffrida; Andreas Hecker; Kenji Inaba; Michael Kelly; Andrew Kirkpatrick; Yoram Kluger; Ari Leppäniemi; Andrey Litvin; Carlos Ordoñez; Vittoria Pattonieri; Andrew Peitzman; Manos Pikoulis; Boris Sakakushev; Massimo Sartelli; Vishal Shelat; Edward Tan; Mario Testini; George Velmahos; Imtiaz Wani; Dieter Weber; Walter Biffl; Federico Coccolini; Fausto Catena Journal: World J Emerg Surg Date: 2021-09-16 Impact factor: 5.469