Bedside guillotine foot and ankle amputation in the emergency department due to necrotizing fasciitis.

Abstract

A 54-year-old male with a history of poorly controlled diabetes mellitus presents to the emergency department after being found unresponsive at home. His last known well was approximately nine hours prior to arrival. He was intubated in the field for airway protection and transported emergently. His initial blood glucose was >600 mg/dL. On arrival, he was hypotensive (BP 67/56 mmHg) and hypothermic (35.7 °C). Examination revealed an unresponsive male with an endotracheal tube in place and a cold, pulseless left foot with necrotic wounds and palpable subcutaneous emphysema. He was immediately initiated on broad-spectrum antibiotics (vancomycin, piperacillin-tazobactam, and clindamycin), received a 30 mL/kg bolus of normal saline, and was started on norepinephrine, bicarbonate, and insulin drips. Vascular surgery was emergently consulted. Computed tomography imaging confirmed extensive lower extremity cellulitis, fasciitis, myositis, osteomyelitis, and air in soft tissues concerning for necrotizing infection. Labs confirmed an additional diagnosis of diabetic ketoacidosis. Due to the patient's unstable condition and anesthesiology deeming him unfit for the operating room, a bedside guillotine amputation of the foot and ankle was performed by vascular surgeon and emergency physician. The patient was admitted to the intensive care unit for ongoing management. The patient initially improved and became more responsive. However, after discussion with family regarding goals of care, the patient was transitioned to comfort care measures, terminally extubated, and ultimately expired. This case highlights the challenges of managing fulminant necrotizing infections in critically unstable patients and underscores the need for rapid, multidisciplinary intervention in the emergency department.