After severe muscular exercise the amount of blood returned by the veins to the heart increases. Something similar occurs when there is anemia, lack of oxygen, over-activity of the thyroid gland or fever Increase in materials carried in the blood occurs also in the toxemia of pregnancy, in dropsy, or with disturbances in the way in which the body uses salt and water.

As the inflow increases, the pressure in the blood vessels into which blood is pumped lessens. The heart beats more rapidly and strongly. As long as the heart can handle the change in its load of work, the patient may not be too much disturbed. When the load gets too big and the reserve power of the heart is damaged, emptying of the heart will fail to keep up with the inflow of blood. This may cause beginning failure of the heart.

If the flow of blood into the heart is inadequate, the tissues of the body will not get the blood and oxygen that they need. If this occurs suddenly, as it may do from a variety of causes, the brain does not get the blood and oxygen that it needs and the person faints or collapses. If the onset is gradual the blood vessels may accommodate themselves by contracting in less vital areas.

A sudden, severe lessening of inflow may occur after a large hemorrhage, by loss of fluid into the tissues as occurs in shock and burns, or as a result of insufficient water intake, or large loss of water as takes place in diarrhea. Pouring of much blood into the legs with large, dilated veins will lessen heart inflow, as will also some disturbances of the nervous system. Some drugs that greatly dilate veins or permit pouring of fluid into the tissues have a similar effect.

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This will inevitably be one of the biggest crises in your life. You may feel your body has let you down. The thought of pain, physical and mental challenges and the possibility of dying will be uppermost in your mind at this stage. Your sense of potential loss will be magnified as you think of not being there for all the things you have envisaged . . . birthdays, graduations, weddings, and grandchildren . . . will be a recurrent theme. This is normal and inevitable. Talk with your loved ones about how scared you are. Do not store up all the anxiety because you want to ‘spare’ them. They will be just as scared and just as needful of discussion. Make a plan for yourselves on what you would like to achieve during the treatment and recovery phases.

Use this time to re-prioritize your life. Concentrate on what is really important in your life and what needs changing. Use the experience to ensure that you focus on what is best for you. Once you have beaten the cancer do not go back to your old ways…remember what have become the most important things in your life . . . good health and good relationships.

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Since spread to adjacent tissues and progression to sepsis and death can occur in as little as a few hours, a high index of suspicion is essential for necrotizing soft tissue infections. Delays in diagnosis and surgical debridement have been shown to increase mortality. Although they may have different presentations, all types of necrotizing soft tissue infections have similar management principles, and any suspected case requires emergency surgical exploration and the initiation of adjunct treatment measures.

It can be difficult to differentiate necrotizing soft tissue infections from non-necrotizing skin infections. Because the deeper necrotizing infections do not initially affect the skin, symptoms and signs out of proportion to local findings are an early characteristic. Crepitus, severe pain, and systemic toxicity are uncommon in cellulitis, and these findings should always raise suspicion for a deeper process. Erysipelas usually manifests with well-demarcated borders, lymphangitis, lymphadenopathy, and minimal swelling, all of which are uncharacteristic of necrotizing fasciitis. Other clues that suggest necrotizing fasciitis include firmness of the subcutaneous tissues beyond the area of skin involvement, cutaneous anesthesia, and cellulitis that does not respond to antibiotics in 24 to 48 hours.

Recent history of trauma, surgery, or local infections should always raise the index of suspicion for a necrotizing infection. Patient risk factors such as diabetes mellitus, renal insufficiency, malnutrition, immunosupression, or history of intravenous drug use should also raise concern. However, the absence of these conditions should never rule out the possibility of a necrotizing soft tissue infection.

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