Necrotizing Fasciitis (NF): Causes and Treatment

Necrotizing Fasciitis (NF): Causes and Treatment Abstract Necrotizing Fasciitis (NF) is a rare but severe type of bacterial infection that affects the soft tissue and fascia. Because of how rapidly the infection spreads it has a high mortality rate and the key to a successful recovery is early diagnosis and treatment. Since the discovery of this disease, little progress has been made to decrease the mortality rate, further emphasizing the importance of healthcare providers ability to detect and treat the infection early so that the patient will have a fighting chance. This article will discuss the history, pathophisiology, clinical manifestations, diagnostics and treatments, and interventions as it relates to the Nurse practitioners role in caring for a patient with NF. History and Background Necrotizing Fasciitis (NF) is a rare but rapidly progressing inflammatory infection that results in the extensive destruction of soft tissue and fascia. In the earlier stages of the infection muscle and skin are not affected (Ruth-Sahd Gonzalez, 2006). NF involves the superficial fascia, subcutaneous fat (which has nerves and vascular structures) and deep fascia (Green, Dafoe, Raffin, 1996). Thrombosis of the microvasculature occurs but there is an absence of myonecrosis (Giuliano, Lewis, Hadsley, Blaisdel, 1977). NF was first described as a complication of erysipelas by Hippocrates in the 5th century B.C. (Descamps, Aithen, Lee, 1994). During the civil war confederate army surgeon Joseph Jones described it as hospital gangrene in which 46% of the 2,642 soldiers who were infected died from NF complications. The cause of the disease was identified as a bacterial infection in 1915. It wasnt until 1952 that the soft tissue infection was named necrotic Fasciitis by Wilson (Wilson, 19 52). Cases of NF were sporadically occurring throughout the 19th and 20th century but remained restricted to military hospitals during the war with a few outbreaks occurring in civilian populations. Epidemiology The centers for Disease control and Prevention (CDC) reported that rates of NF increased worldwide from the mid 1980s to early 1990s. According to the CDC the increases in the rate and severity of NF are correlated with increase in the prevalence of toxin producing strains of S. Pyogenes (M-1 and M-3 serotypes). The CDC reported approximately 600 cases of NF in the U.S. in 1999 (Hu, 2002). Disease progression NF develops when bacteria enters the body usually through a minor trauma for example a laceration, bruise, or bug bite. Some cases occur after surgeries for example abdominal surgeries; the bacterium enters the surgical incision. The bacteria attacks the soft subcutaneous tissue releasing toxins that kill the tissue and affect blood flow to the infected area causing it to become gangrenous. If left untreated the skin, fat, muscle sheath, and later the muscle become involved. The infection spreads unseen moving up the affected body part at a rate of 3 centimeters per hour up to 1 inch of tissue per hour (Ruth-Sahd and Gonzales, 2006). Once necrosis of the tissue occurs that area has to be surgically removed. The bacteria can also cause the patient to go into systemic shock, which can lead to hypotension, respiratory failure, renal failure, and heart failure. If the infection is severe death can occur within 18 hours (Astorino, Genrich, MacGregor, Victor, Eckhouse, Barbour Barbour, 20 09) Pathophysiology Tissue destruction is possible once the bacterium has been introduced under the skin via a cut or penetrable wound. The pathogens begin to rapidly multiply spreading from the subcutaneous tissue along fascial planes, and then invading the blood vessels and lymphatic system. The bacteria release toxins that decrease the protective tissue factors in order to inhibit the immune systems ability to combat the bacteria. In the bodies attempt to combat the bacteria at the tissue level. The blood vessels in the area begin to leak due to the effects of the bacteria in the tissue, the immune response becomes hyperactive, which results in blood vessel dilation in order to facilitate the immune response to the area affected. Unfortunately the cells in the tissue begin to die as the blood vessels leak and decrease the oxygen supply to the cells due to the increase in permeability. Since there is a decrease in blood flow and oxygen supply to the tissue from the infection, tissue necrosis and ische mia occur. As tissue necrosis worsens, nerve damage takes place, which can be seen, as the patient will report the decrease or absence of pain at the area affected. As the infection progresses septicemia will also develop (Astorino, et al. 2009). Causative factors NF is caused by a bacterium named Streptococcus pyogenes or Group A streptococcus (GAS). GAS can be found in peoples throats or on their skin and they will be asymptomatic. S. pogenes is a cause for non-invasive GAS diseases for example rheumatic fever, strep throat, and skin infections like impetigo. When GAS travels to areas of the body where bacteria isnt found it is called invasive GAS disease example would be blood or lungs. More than 10 million non-invasive GAS cases occur annually. A rare but most severe case of invasive GAS is NF. These bacterium evolve quickly and scientist believe that GAS makes proteins that cause the immune system to attack the tissue directly thus the body destroys itself (Hu, 2002). NF has been classified into two types based upon the bacterium identified upon culture. Type 1 in a polymicroial infection including both gram-positive and gram- negative bacteria that can be anaerobic or aerobic. Type 1 is the most common, making up 90% of all the cases, st riking abdominal or peritoneal tissue. Underlying risk factors include postoperative, advanced age, or diabetes (McGee, 2005). Type 2 also known as the Flesh eating Bacteria is the rarest out of the two making up about 10% of the cases. It is the most dangerous of the infections usually affecting the arms or legs and involves the Group A (beta)- hemolytic streptococcus with or without staphylococcus aureus. Type 2 does not discriminate on age, race, or sex (Astorino, et al. 2009). Signs and Symptoms Early detection of NF is crucial it can be the difference between life and death. Health care providers need to be knowledgeable about the signs and symptoms of NF so that treatment can be started right away. Initial signs may be vague and are often confused with cellulitis, signs include pain, edema, erythema, and fever. A definitive diagnosis can be made by visualization and dissection of the necrotic fascia. A key factor of NF is pain, which is disproportionate to the amount of redness. If suspected cellulitis fails to respond to antibiotics within 24-48 hours NF should be considered (Varma and Stashower, 2006). Early symptoms including pain, malaise, fever, and thirst occur within the first 24 hours of invasion of bacteria. This is the time NF is usually misdiagnosed because progression of the disease is not visible until tissue destruction has already stated (McGee, 2005). Walter (2004) states that the hallmark of NF is erythema that spreads quickly with a margin of redness that extends to normal skin and is not raised. Advance symptoms occur 48-72 hours later and are characterized by significant pain at the wound site, increasing erythema, edema, and warmth. The skin tissue then becomes discolored and deteriorates further. The redness turns to dusky or blue and bullae (vesicles) appear. These bullae enlarge and then rupture leaking out dishwater pus a foul smelling, thin dirty gray liquid (Kessenich, 2004); (Ruth-Sahd and Gonzales, 2008). 4-5 days after appearance of the first symptoms patients can begin to demonstrate critical symptoms ranging from numbness and hypotension to toxic shock and unconsciousness. From there the patient can develop gangrene, sepsis, and then death may occur (McGee, 2005). When the initial symptoms are found it can be difficult to differentiate between NF and celluitis thus it is important to remember the hallmark of NF. After 3-5 days of onset when there is skin breakdown, bullae, and cutaneous gangrene present which are defin itive signs of NF and the involved area is usually not painful due to the are becoming anesthetic secondary to thrombosis of small vessels and nerve destruction located in the necrotic subcutaneous tissue Mandell, Bennett, and Dolin, 2005). Laboratory and Imaging Studies Common laboratory studies used in diagnosing NF include complete blood cell count with differential (CBC), Electrolytes, Blood urea nitrogen (BUN), Creatinine phoshokinase (CPK), rapid streptococcus test, and a culture and sensitivity. CBC may show an increase in WBC greater than 14,000/ul and the electrolytes may show a sodium level less than 135 mmol/L, which are both indicative of NF (Schwartz, 2006). The BUN may also be elevated to 15 mg/ml and the CPK may be elevated, indicating the presence of tissue breakdown. A C S with a Gram stain can determine whether the infection is Type 1 or Type 2, which will help to determine what antibiotics to prescribe. Computed tomography (CT) scan and magnetic resonance imaging (MRI) can be used to help diagnose NF. Ct scans can visualize the subcutaneous air and find the anatomic site of involvement by detecting necrosis with asymmetric fascial thickening (Maynor, 2006). MRI is helpful with guided rapid debridement of the wounds. Treatment In order to prevent significant disfigurement and/or death in the patient with NF is a quick diagnosis and very aggressive treatment is needed from the start. Broad spectrum antibiotics that treat gram-positive and negative aerobes and anaerobes are prescribed around the clock until the specific strain of the bacteria can be identified and treated appropriately. Due to the amount of antibiotics being administered and possible toxicity involved, Kidney and Liver function should be monitored during therapy. The patient will also need intravenous fluids, pain management, and possibly TPN. All necrotic tissue on the patient needs to be debrided with diligence in removing fascia, skin and subcutaneous tissue involved as early as possible, which may need to be performed multiple times to effectively remove all necrotic tissue. Hyperbaric therapy may be prescribed as an additional therapy. Role of the NP The NP needs to be able to recognize the early symptoms of NF so that he or she will be able to begin treatment quickly. A collaborative multidisciplinary care approach needs to be used for the care of this type of patient. The care team will need to include Critical/Acute care, Dietitian, Physical therapy, and Wound care Nurse. The patient will need a lot of education and psychological support as well. Conclusion Necrotizing Fasciitis is a very aggressive and debilitating disease that has a very rapid progression. Since the disease is very easily transmitted into the body with the potential of detection not until later stages due to the similarities to cellulitis. Rapid diagnosis and treatment is essential to prevent severe dismemberment and or death. So this makes the Nurse Practitioner working in ambulatory care the first line of defense against this rapidly debilitating disease.

Othello, in Love? Essay

Was the relationship of Desdemona and Othello true love? Throughout the entire, through secrets and lies and murder even until the end one of the biggest questions that arose was the vitality of Othello Desdemona’s love. Although some readers of Othello have argued that Othello and Desdemona’s love was true, a closer examination of the way she shows empathy for him when he tells her stories reveals that he is only in love with the attention she gives him because it alleviates his own personal insecurities. By examining the abruptness of Othello’s jealousy and judgment of Desdemona’s possible infidelity, it is revealed that he has deeply rooted insecurities. After Iago tells Othello of the possible infidelity that has occurred, Othello immediately starts to get jealous and angry. He begins to admit some of the insecurities he has, â€Å"Maybe because I’m black and I don’t have nice manners like courtiers do, or because I’m getting oldà ¢â‚¬ ¦Ã¢â‚¬ . The insecurities that Othello has directly relate to the abruptness of his jealousy. Othello believes that he is lesser because he is â€Å"black† and â€Å"old†. Of course he, an ugly, old, outsider cannot compare to the young and beautiful Desdemona. He compares his self image with her image and automatically believes that he is not worthy of her. This terrible self image forces him to believe what Iago has told him even without proof. The abruptness of jealousy proves Othello has insecurities. If it was true love Othello would not have been so quick to assume that Iago’s claims of infidelity were true. An examination of the way Othello becomes intrigued by Desdemona because of her undivided attention toward the stories he told shows that the attention she gives him alleviates his insecurities. When Othello is in the court room talking to the duke, trying to prove his love for Desdemona, he mentions that â€Å"She loved me for the dangers I had pass’d, and I loved her that she did pity them†, Othello clearly says that Desdemona’s interest in him only derives from the fact that she is intrigued by the stories of his adventurous past and Othello’s interest in Desdemona derives from the fact that she loves his stories. Othello clearly understands that Desdemona loves him for his previous adventures and not for a romantic reason. Othello uses Desdemona’s fanaticism as a way to alleviate his insecurities. By Desdemona complementing Othello, it makes him feel better and wanted. It distracts him from his insecurities therefore Othello’s â€Å"love† isn’t true. He thinks that he is in love when truly the feelings he has are that of fulfillment of what is lost by his insecurities. Othello being driven into madness has less to do with Desdemona’s possible infidelity but more to do with her no longer being there to alleviate his insecurities because of her shift from undivided attention to Othello to her undivided attention to Cassio in attempt to get him his job back. Before Cassio was fired Desdemona devoted all of her time to Othello and wanted to be with him constantly, when he was sent to war she even wanted to go with him â€Å"So that, dear lords, if I be left behind a moth of peace and he go to the war, the rites for which I love him are bereft me, And I a heavy interim shall support by his dear absence. Let me go with him†. She couldn’t stand to be away from Othello and this made him feel wanted and his insecurities were intern alleviated. This all changed once Cassio lost his job though. Desdemona pledged to get him his job back, â€Å"Do not doubt that. Before Emilia here I give thee warrant of thy place. Assure thee, if I do vow a friendship, I’ll perform it to the last article. My lord shall never rest; I’ll watch him tame and talk him out of patience†. This new devotion to Cassio meant that Othello was no longer receiving the same attention and his insecurities were no longer being alleviated. When she was no longer alleviating his insecurities and there was no purpose for her. When he realized this he was overwhelmed with jealousy. He not only wanted to kill Cassio for taking away the one who solved his problems but he wanted to take away her as well, â€Å"Oh, that the slave had forty thousand lives! One is too poor, too weak for my revenge†¦ Damn her, lewd minx! Oh, damn her, damn her! Come, go with me apart. I will withdraw to furnish me with some swift means of death for the fair devil†. If Othello was in love with Desdemona as a person and not just the attention she gives him then it would be safe to say that the love they shared was true but because he felt as though the only solution was to kill her proves that their relationship was not true love. Othello is only in love with the attention Desdemona gives him because it alleviates his own personal insecurities. Desdemona distracts Othello from his insecurities and makes him feel better and wanted. When Desdemona no longer alleviated the insecurities he had his only course of action was to kill Desdemona and Cassio. If their love would have been true he would not have been so quick to make the decision to kill Desdemona.

BP case study Essay

1. What are the main ethical issues and dilemma BP faces in this case? A project that is on a large scale faces some issues, including: There are concerns about the coating of the pipeline and the risks of leakages, in particular in Georgia, where oil spills might significantly impact the country’s strategic water resources in the Bojorni National Park. Concerns were also raised over the fact that the pipeline runs through earthquake zones, which leakages nearly inevitable or could not be avoided. Campaigners have highlighted the prospect of up to 30,000 civilians along the pipeline being at least temporarily relocated. On the political level, with civil unrest and wars in the region the pipeline passes within only a few miles of the war- torn area of Nagorno Karabakh the project had always been accompanied by considerable fears of terrorist attacks. Also there are countries which the pipelines are supposed to go very high levels of bureaucracy and corruption, as shown in the various indices. 2. How would you evaluate BP’s approach to the social, environmental and economic impacts of the project for local communities? Assess the approach from the perspective of utilitarianism and deontology first. Will the assessment differ from the rights and justice based perspective? Bp is considered at the time of the pipeline’s construction to be one of the top or leading companies in embracing sustainability and corporate social responsibility (CSR).BP initiatives renewable energy , climate change , human rights , and corruption prevention. BP set up a Regional Sustainability Development Program (RSDP) from early stages of the project in order to to proactively address the social, ethical and environmental issues† †¢ Environment investment program which aims to address ecological issues. †¢ Community Investment Program (CIP) with a budget of about $ 20m, mostly address the most social issues during the construction phase. †¢Long term Regional Development Initiative (RDI) with a budget of approximately U.S. $ 25mn and to accompany the project on a life span of 10 years after its opening. From the point of view of ethics and utilitarianism, BP has taken initiatives that led to fairly immediate impacts. It proactively addressed the social, ethical and environmental issues. From the perspective of human rights and justice, the company was alleged to violate human rights and to engage in corrupt practices. 3. This case raises questions about the scope of responsibility for a Western MNC operating in environments with corruption and poor governance. What is your opinion on how far a company such as BP in this case should go? Can they really be made responsible for the actions of local officials and governments? Try to base your answer on arguments derived from one or more ethical theories. MNC as BP operate in a globalized world where there are different types and forms of government and different levels of inefficiency and corruption involved. It would be foolishly brave to expect that they should be held responsible for what officials and governments, because it can never be completely within their control. If they do not exploit the potential then someone else would. However, they can have a significant influence on the policy on their fields where they must try to resolve an ethical manner. 4. What is the appropriate way for BP to respond to its ongoing criticism? Base your answer on the contemporary ethical theories, in particular virtue ethics, discourse ethics, and postmodern ethics. BP can probably focus on the fact that it has been one of the company around the most socially responsible, implying that he would never go against the welfare wider not to disturb the balance of the environment. It is also worth noting that defend the BTC pipeline will generate income for the country, job opportunities and help meet the growing demand. Being a responsible organization, BP should let people know that it takes all precautionary measures to avoid disasters such as oil spills, pollution of water.

LAnse aux Meadows - Evidence for Vikings in Canada

LAnse aux Meadows is the name of an archaeological site that represents a failed Viking colony of Norse adventurers from Iceland, in Newfoundland, Canada and occupied for somewhere between three and ten years. It is the first identified European colony in the new world, predating Christopher Columbus by nearly 500 years. Key Takeaways: L'Anse aux Meadows   LAnse aux Meadows is an archaeological site in Newfoundland, Canada, where the first evidence was discovered of Vikings (Norse) in North America.The colony only lasted three to 10 years before it failed.  There are at least a half-dozen other brief occupations in the Baffin Island region that appear to also be Norse sites of the same age, 1000 CE.  The ancestors of the First People of Canada had been living in the region since at least 6,000 years ago and were using Newfoundland island for summer homes at the time the Vikings landed.   Climate and Pre-Norse Occupations The site is located in Newfoundland on the edge of the Strait of Belle Isle, across which lies the southern Labrador coast and the lower North Shore of Quebec. The climate is largely arctic, a forest-tundra, and it is regularly locked in by ice over the long winters. Summers are foggy, short, and cool. The region was first occupied about 6,000 years ago, by Maritime Archaic people who practiced a broad subsistence strategy, hunting both land and sea animals. and plants. Between 3,500 and 2,000 years ago, people primarily dependent on hunting marine mammals lived in the Belle Isle straits region, and about 2,000 years ago, the region was shared by both terrestrial hunting Recent Indian and Paleoeskimo populations. When the Norse arrived, the Paleoeskimos had left: but the Recent Indian people were still using the land. These Straits residents probably visited the region for brief periods of time during the summers, hunting birds (cormorant, guillemot, eider and black ducks), and living in tents heated with stone hearths. The Historic Tale of lAnse aux Meadows Around the turn of the 19th century, Canadian historian W.A. Munn pored over medieval Icelandic manuscripts, reports by the 10th century CE Vikings. Two of them, the Greenlander Saga and Eriks Saga reported on the explorations of Thorvald Arvaldson, Erik the Red (more properly Eirik), and Leif Erikson, three generations of a rather cranky family of Norse mariners. According to the manuscripts, Thorvald fled a murder charge in Norway and eventually settled in Iceland; his son Erik fled Iceland under a similar charge and settled Greenland; and Eiriks son Leif (the Lucky) took the family westward still, and circa AD 998 he colonized a land he called Vinland, Old Norse for land of grapes. Leifs colony remained at Vinland for between three and ten years, before they were chased away by constant attacks from the residents, ancestors of the First People of Canada called Skraelings by the Norse; and Recent Indians by archaeologists. Munn believed that the most likely site for the colony was on the island of Newfoundland, arguing that Vinland did not refer to grapes, but rather to grass or grazing land, since grapes dont grow in Newfoundland. Rediscovering the Site In the early 1960s, archaeologists Helge Ingstad and his wife Anne Stine Ingstad undertook a close survey of the coastlines of Newfoundland and Labrador. Helge Ingstad, a Norse investigator, had spent the majority of his career studying Northern and Arctic civilizations  and was following up on research into the Viking explorations of the 10th and 11th centuries. In 1961, the survey paid off, and the Ingstads discovered an indisputably Viking settlement near Epave Bay and named the site LAnse aux Meadows, or Jellyfish Cove, a reference to the stinging jellyfish found in the bay. Eleventh-century Norse artifacts recovered from lAnse aux Meadows numbered in the hundreds  and included a soapstone spindle whorl and a bronze-ringed pin process, as well as other iron, bronze, stone, and bone items. Radiocarbon dates placed the occupation at the site between ~990-1030 AD. Living at LAnse aux Meadows LAnse aux Meadows was not a typical Viking village. The site consisted of three building complexes and a bloomery, but no barns or stables that would be associated with farming. Two of the three complexes consisted solely of a large hall or longhouse and a small hut; the third added a small house. It appears that elites resided in one end of the large hall, ordinary sailors slept in sleeping areas within the halls and servants, or, more likely, slaves resided in the huts. The buildings were constructed in the Icelandic style, with heavy sod roofs supported by interior posts. The bloomery was a simple iron smelting furnace within a small subterranean hut  and a pit charcoal kiln. In the large buildings were sleeping areas, a carpentry workshop, a sitting room, a kitchen, and storage. LAnse aux Meadows housed between 80 to 100 individuals, probably up to three ship crews; all of the buildings were occupied at the same time. Based on the reconstructions accomplished by Parks Canada at the site, a total of 86 trees were felled for posts, roofs, and furnishings; and 1,500 cubic feet of sod was required for the roofs. LAnse aux Meadows Today Since the discovery of lAnse aux Meadows, archaeological research has found additional evidence of Norse settlement in the area, a handful of sites on Baffin Island and in Labrador. Artifacts pointing to Norse occupations includes yarn, bar-shaped whetstones, wooden tally sticks, and a broken stone crucible which contained traces of copper and tin for bronze working. Only one building has been found, a rectangular foundation of boulders and turf, and a stone-lined drainage basin. LAnse aux Meadows is now owned by Parks Canada, who carried on excavations at the site during the mid-1970s. The site was declared a UNESCO World Heritage site in 1978; and  Parks Canada has reconstructed some of the sod buildings and maintains the site as a living history museum, complete with costumed interpreters. Sources and Further Reading A great source of information about LAnse aux Meadows is the  official Parks Canada site, in French and English.Foster, Aidan. Hierophanies in the Vinland Sagas: Images of a New World. Culture and Cosmos 16.1 and 2 (2012): 131–38. Print.Ingstad, Anne Stine. The Viking Discovery of America: The Excavation of a Norse Settlement in LAnse Aux Meadows, Newfoundland, 1961–1968. Oslo: Norwegian University Press, 1977.Kristensen, Todd J., and Jenneth E. Curtis. Late Holocene Hunter-Gatherers at L’anse Aux Meadows and the Dynamics of Bird and Mammal Hunting in Newfoundland. Arctic Anthropology 49.1 (2012): 68–87. Print.Renouf, M.A.P., Michael A. Teal, and Trevor Bell. In the Woods: The Cow Head Complex Occupation of the Gould Site, Port Au Choix. The Cultural Landscapes of Port Au Choix: Precontact Hunter-Gatherers of Northwestern Newfoundland. Ed. Renouf, M.A.P. Boston, MA: Springer US, 2011. 251–69. Print.Sutherland, Patricia D., Peter H. Thompson, and P atricia A. Hunt. Evidence of Early Metalworking in Arctic Canada. Geoarchaeology 30.1 (2015): 74–78. Print.Wallace, Birgitta. Lanse Aux Meadows, Leif Erikssons Home in Vinland. Journal of the North Atlantic 2.sp2 (2009): 114–25. Print.