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Immediate priorities
Time critical stabilization
High suspicion triggers
Pain out of proportion to exam
Rapid progression over hours
Systemic toxicity
Skin anesthesia
Bullae
Crepitus
Dusky or violaceous discoloration
Wooden hard edema beyond erythema
Early actions
Escalate to resuscitation bay for hypotension or altered mental status
Activate surgery immediately for suspected necrotizing soft tissue infection
Initiate broad spectrum antibiotics immediately after cultures if no delay
If septic shock, initiate sepsis bundle pathway
Airway and breathing
If respiratory failure or impending decompensation, RSI with hemodynamic preparation
If shock, vasopressor ready before induction
Circulation and access
Two large bore IV lines
If difficult access, intraosseous access
If vasopressors needed, central venous access
Arterial line for titration in shock
Hemodynamic targets
Mean arterial pressure 65 mmHg or higher
Lactate clearance trend
Urine output 0.5 ml/kg/hour or higher
Source control timeline
If high suspicion, operative exploration without imaging delays
If unstable, direct to operating room after minimal stabilization
Consults and team activation
Early coordination
Surgical service
General surgery for trunk or perineum
Orthopedics for extremity involvement
Plastics or burns for large surface area and reconstruction planning
Critical care
ICU for shock or organ dysfunction
Early vasopressor and ventilator planning
Infectious diseases
Antibiotic optimization after cultures
Consider IVIG guidance for streptococcal toxic shock syndrome
Urology for Fournier gangrene
Perineal, scrotal, penile involvement
Consider fecal diversion planning with colorectal surgery if perianal involvement
Analgesia and sedation
Pain control strategy
Opioid based analgesia with frequent reassessment
Fentanyl IV titration for severe pain
Hydromorphone IV titration if longer duration needed
Adjuncts
Ketamine IV for opioid sparing in hemodynamic instability
Regional blocks only if no delay and no masking of neurovascular compromise concerns
Avoid pitfalls
Do not allow analgesia to delay surgical exploration
Avoid NSAIDs in shock or acute kidney injury
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.