<prompt> Best management of contaminated wound with necrotic material:DebridementTetanus toxoidGas gangrene serumBroad spectrum antibiotics  <response>: Ans. a. Debridement Ref: Sabiston 19e p2011; Bailey 25e p26, 39-40Best management of contaminated wound with necrotic material is debridement.Managing the acute wound: After assessment, a thorough debridement is essential. A wound should be explored and debrided to the limit of blood staining. Devitalised tissue must he excised until bleeding occurs with the obvious exception of nerves, vessels and tendons.- Bailey 25e p26.Necrotizing FasciitisNecrotizing fasciitis is a rapidly progressive bacterial infection characterized by involvement and necrosis of the subcutaneous tissue and fascia, with typical sparing of the underlying muscleQ.MC site of infection: Lower extremitiesQMay involve trunk, perineum Fourniers gangrene or head and neck and any other site.Etiological AgentsMC single etiological agents: Group A beta hemolytic StreptococciQMore commonly, necrotizing fasciitis results from a polymicrobial synergistic infectionMicroorganism responsible: Group A beta hemolytic Streptococci Staphylococcus, E. coli, Pseudomonas, Proteus, BacteroidesClostridium AnaerobesRisk Factors for Necrotizing Fasciitis DiabetesQ Pressure sores Immunocompromised statesQ SmokingQ Penetrating traumaQ ObesityQ IV drug abuseQ Peripheral vascular diseaseQ Skin infection damageQ abrasions, bites, boilsClinical Presentation:Pain is the most important presenting symptomPain is disproportionately greaterQ than that expected from degree of cellulites presentWithout treatment pain may decrease due to thrombosis of small blood vessels and destruction of peripheral nerves an ominous signQSkin Features: Edema, erythemaQ Infected area is red, hot, shiny, swollen and exquisitely tenderWoody hard texture to subcutaneous tissueInability to distinguish fascial planes and muscle groups on palpationSkin vesiclescutaneous bullae, soft tissue crepitus due to gas productionQ may be seen when necrotizing fasciitis is caused due to mixed flora but not due to group A StreptococcusSystemic features: Fever, hypotension, tachycardia, progression to septic shock. DIC or multiple organ failureQManagement:This is a surgical emergency and surgical debridement is mandatoryQTreatment: Urgent surgical debridement IV fluids Broad spectrum IV antibiotics Supportive treatmentQMortality rate is nearly 100 without surgical debridementQHlyperbaric oxygen helps in wound healingQ 