Patient Safety Conference Fournier’s Rule Out Timothy Takach, DO; Charles “Beau” Vidrine, MD; Rhushi Ziradkar, MD LSUHSC Lake Charles Memorial Hospital Family Medicine Residency Program

Diagnosis Physical Exam 5 4.5 Risk Factors Vital Signs Diabetic/Immunocompromised Tm 99.0F HR 108 RR 20 BP 139/89 O2Sat 96% RA. 6’6’’ and 511 lbs, BMI = 57.7 4 Longstanding indwelling urethral catheters Urethral trauma in the presence of urinary Physical Exam 3.5 Gen: Moderate distress, uncomfortable, cooperative, appears stated age H&P Psych: AAOx4, judgment/insight & thought processes intact, appropriate affect Severe Pain (Anterior Abdominal Wall --> Gluteal Muscles, Scrotum, Penis) HEENT: Head atraumatic, normocephalic; PERRLA, EOMi, no conjunctival pallor or scleral 3 Signs of Infection (Erythema, Tense , Warmth) icterus; Nares patent w/o discharge; Oropharynx clear w/ MMM and fair dentition Series 1 2.5 Systemic Signs (Fever, Hemodynamic Instability) : supple, trachea midline, FROM, w/o thyromegaly or cervical Series 2 Warning Signs (Crepitus, Pain-out-of-Proportion, Foul-smelling discharge, CV: RRR, no M/G/R, 2+ pulses x 4 ext, +1 LEE, no carotid bruits or JVD; cap refill < 2 s Blisters/Bullae, Rapid Progression) Resp: CTAB w/ normal effort, no W/R/R 2 Series 3 Abd: obese, soft, ND, NT, normoactive BS, no masses or . Large pannus. Imaging 1.5 CT > MRI – can show air along the fascial planes or deeper tissue GU: extremely swollen scrotum, measuring 25 cm in the horizontal axis and 20 cm in the XR not very sensitive and US may be hard 2/2 tenderness and size verticle axis, with surrounding erythema, unable to identify penis or testicles secondary to 1 Imaging studies should NOT delay surgical exploration when there is clinical evidence of swelling. Area of purulent malodorous discharge with surrounding eschar, possible sinus progressive soft tissue infection tract, measuring 12 cm in horizontal axis and 5 cm in vertical axis. 0.5 Significant pain noted with any manipulation of scrotum Surgical Exploration 0 Definitive way to establish the diagnosis MSK: normal muscle bulk and tone, moves all extremities spontaneously. BUE 5/5 strength, Category 1 Category 2 Category 3 Category 4 Swollen and dull-gray appearance of the fascia, strength testing of lower extremities unreliable secondary to pain Thin without clear purulence Neuro: CN II-XII grossly intact; sensation to light touch intact Easy separation of tissue planes by blunt dissection Skin: no rash, lesions, or ulcers; normal turgor Chart 1. Our patient’s Scrotum

History of Present Illness Labs and Imaging Discussion Chief complaint: Scrotal pain and swelling This case may be classified as a near miss. Complete Blood Count Complete Metabolic Panel HPI WBC 12.1 Na 135 30 y/o male presents to ED for scrotal pain and swelling x 1 day. The pain started HgB 14.3 K 3.5 If the E.R. attending had transferred the patient from the E.R. the day before presentation and progressively worsened throughout the day. Hct 43.4 Cl 103 directly to another E.R. with urologic capabilities, then this could Platelets 172 CO2 24 MCV 82.8 BUN 13 have been prevented Swelling began the evening prior to presentation. % Neutrophils 88.8 Creatinine 1.02 % Lymphocytes 7.2 Glucose 86 He has pain 10/10 in his scrotum that is raw and throbbing in nature that improved % Monocytes 3.3 AST 16 Patient was in E.R. for 10 hours, 58 minutes to 5/10 with dilaudid. % Eosinophils 0.1 ALT 22 Additional symptoms include fever/chills % Basophils 0.2 Alk phos 94 CRP 186 Albumin 3.9 Time spent on this admission: Previous h/o scrotal swelling in January 2019 after cutting his scrotum with a razor. ESR 67 Ca 9.1 ~23:00 to 06:30 and substantial part of Dr. Ziradkar’s day Lactic acid 1.1 Total protein 8.5 Communication, communication, communication His scrotum has swelled and decreased in size several times over the last few Procalcitonin 0.40 Total bilirubin 1.9 months. We now have a new CT scanner that can take patients up to Coags Urinalysis 600 lbs (Untested as of Dec 16 2019) PT 12 PMHx; Hypertension Dark yellow INR 1.2 Moderate blood PSurgHx: Wisdom tooth extraction PTT 30.4 Ketones 40 Fournier’s gangrene is a surgical emergency and should be Medications: Denies Spec grav 1.030 Allergies: Augmentin, Suprax, Pediazole Chest x ray Glucose negative managed aggressively by a facility with all of the required Famly History: Diabetes mellitus and hypertension No acute cardiopulmonary abnormality Bilirubin negative specialities and resources readily available Social History: Denies tobacco, ETOH, and recreational drugs. Employed Nitrite negative Review of Systems Ultrasound testicles/scrotum Trace leuk esterases Essentially nondiagnostic study given General: Admits F/C, denies fatigue Moderate WBC’s patient’s body habitus and condition. Moderate RBC’s Conclusions HEENT: denies headache, vision/hearing changes Suspected microlithiasis Heart: denies chest pain, palpitations Trace protein There are systemic issues that this case helped us identify. Lungs: denies shortness of breath GI: denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in First, the E.R. attending had not seen or examined the patient until we asked him to do so. Inappropriately triaged. stool GU: denies difficulty urinating, blood in urine. Admits scrotal pain, swelling. Second, there are signficant challenges with imaging the super morbidly obese patient. Neuro: denies paresthesia Skin: admits erythema and erosions of skin in genital region Third, admitting patients that require a specialty we don’t have readily available is not good for patient care.

Management of Fournier’s gangrene Surgical Debridement Early debridement is better (increased survival among patients taken to surgery within 24 hours after admission) Aggressive debridement of all necrotic tissue until healthy, viable (bleeding) tissue is reached Inspection/Debridement in OR should be continued every 1-2 days until necrotic tissue is no longer present

Antibiotics Broad-spectrum treatment (Gram+, Gram- and Anaerobic organisms) Regimen Consisting of: Carbapenem or Beta-lactam/Beta-lactamase Inhibitor MRSA Coverage (Vancomycin or Daptomycin) Clindamycin (Anaerobic Coverage, Antitoxin Effects) Images of Fournier’s Gangrene Algorithm: Approach to work up. Contact Charles Vidrine, MD LSUHSC Lake Charles Memorial Hospital Email: [email protected] Phone: (337) 494-6767 Charles “Beau” Vidrine, MD Dr. Vidrine is a from Oakdale, Louisiana. He earned a Bachelor of Arts in English from Tulane University and attended medical school at Louisiana State University at Shreveport. Dr. Vidrine is in his third year of post graduate training at LSUHSC Family Medicine Residency Program at Lake Charles. He is a big Pop Culture fan that includes Star Trek, Star Wars & Game of Thrones.