Gas gangrene is an extremely severe infectious complication of the wound process, which is caused by anaerobic (reproducing without air access) microorganisms from the genus clostridium. As a rule, it develops with extensive wounds with crushing of tissues. It is accompanied by swelling of tissues, fetid discharge, discharge of gas bubbles and pronounced intoxication of the body by products of tissue decay. It is diagnosed on the basis of the clinical picture, data from instrumental and laboratory studies. Urgent surgical treatment is shown – opening of the wound with lamp incisions, with rapid progression of the process, amputation is performed.
ICD 10
A48.0 Gas gangrene
Meaning
Gas gangrene is a very severe infectious process that develops as a result of infection of wounds with anaerobic bacteria living in the ground and street dust. Especially predisposed to the occurrence of gas gangrene are patients with extensive wounds, accompanied by massive crushing of muscle tissue, the appearance of pockets and areas with poor blood supply. Pathology treatment, depending on the causes of its occurrence, is carried out by specialists in the field of purulent surgery, traumatology and orthopedics and other fields of medicine.
Gas gangrene causes
Gas gangrene is caused by bacteria from the genus clostridium, which normally live in the intestines of herbivorous pets, from where they get into the ground, street dust, clothes, etc. In some cases, they are found in the feces and on the skin of healthy people. They reproduce only in an oxygen-free environment, but in the presence of oxygen they can persist for a long time in the form of spores.
In 90% of cases, the causative agent of gas gangrene is Clostridium perfringens, the rest are accounted for by Cl. histolitycum, Cl. oedematiens, Cl. septicum, Cl. novii, Cl. fallax, etc. Usually, gas gangrene develops as a result of extensive crushed wounds and traumatic separation of limbs, less often as a result of wounds of the large intestine and ingestion of foreign bodies. In some cases, even small wounds (especially those contaminated with scraps of clothing or soil particles) can become the cause of the occurrence.
Classification
Taking into account local manifestations, purulent surgeons distinguish four forms of gas gangrene.
- Classical or emphysematous form. Moderate edema is observed, gradually replaced by tissue necrosis with the release of a large amount of gas. There is no pus. The wound surface is dry, extensive foci of necrosis are detected. There are no granulations, dead gray-green, non-bleeding muscle tissue with a cadaverous smell is visible at the bottom. When pressed, gas and sucrovichnaya fluid are released from the wound. The skin in the affected area is cold, pale, covered with brownish spots. As the infection progresses, the pain in the wound first increases sharply, then the sensitivity is lost. The pulse in the peripheral arteries disappears, the limb turns brown and becomes dead.
- Edematous-toxic form. Accompanied by extensive, rapidly spreading edema, growing literally within every minute. The wound is without purulent discharge, gas is released in small quantities or is absent. Due to the rapidly increasing swelling, the muscles are squeezed and bulge out of the wound. The subcutaneous tissue is greenish, jelly-like, the muscle tissue is pale, the skin around the wound is cold, shiny, sharply tense. As the inflammation develops, the peripheral pulse disappears, the limb becomes brown, necrosis develops.
- Phlegmonous form. Proceeds more favorably, can be developed in a limited area. Edema of the surrounding tissues is moderate or insignificant, at the bottom of the wound there are pink muscles with areas of necrosis. Pus and gas bubbles are released from the wound. The skin around the wound is warm, without spots. The pulse in the peripheral arteries is preserved.
- Putrid or putrid. It develops as a result of the symbiosis of anaerobic and putrefactive microorganisms. Unlike other forms, it often occurs not on the limbs, but on the trunk. It is characterized by a lightning-fast flow with rapid disintegration of tissues. The infection spreads rapidly through the cellular spaces, causing necrosis of the fiber, muscles and fascia. Gas is released from the wound and a fetid putrid discharge with pieces of destroyed tissues. The addition of putrefactive infection causes the destruction of the walls of blood vessels, therefore, with this form of gas gangrene, secondary bleeding is often observed.
Gas gangrene symptoms
Pathology is characterized by an early stormy beginning. Symptoms usually appear 1-3 days after the injury. The tissues around the wound swell, a fetid discharge with gas bubbles appears. Edema is rapidly spreading to neighboring areas, the patient’s condition is rapidly deteriorating, there are signs of poisoning of the body by the products of tissue decay. Without specialized medical care, death occurs within 2-3 days from the onset of the disease.
The features of local and general manifestations depend on the type of pathogen. For Clostridium perfringens, fibrinolytic, toxic-hemolytic and necrotic course is characteristic, for Clostridium septicum – serous-bloody edema of tissues, a small amount of gas released and intense destruction of red blood cells. Clostridium oedematiens, on the contrary, forms a large amount of gas and at the same time also has a hemolytic effect on the body. Clostridium histolitycum is particularly aggressive towards living tissues. In just 10-12 hours, it is able to destroy connective and muscle tissue so much that bones will be visible.
The body temperature is increased to 38-40 ° C, there is a decrease in blood pressure, tachycardia, rapid breathing, thirst, chills, excruciating insomnia, headache, muscle aches. The patient is excited, talkative or, on the contrary, depressed. Gradually, oliguria develops at first (a decrease in the amount of urine excreted), and then anuria (lack of urine). In severe, prognostically unfavorable cases, a decrease in body temperature and hematuria is possible.
The destruction of red blood cells causes rapidly developing anemia and hemolytic jaundice. Blood tests reveal a decrease in the number of red blood cells, a decrease in hemoglobin levels, leukocytosis with a shift of the formula to the left and a predominance of young forms of neutrophils. The most persistent local symptoms include edema of surrounding tissues, gas formation, destruction of muscle tissue and the absence of classical signs of inflammation.
Diagnostics
The diagnosis of gas gangrene is made on the basis of the clinical picture and is confirmed by additional studies. When examining the wound discharge under a microscope, clostridium is detected. X-ray examination confirms the presence of gas in the tissues. In the process of differential diagnosis, fascial gas-forming phlegmon is excluded, in which there is no muscle destruction.
Gas gangrene treatment
Treatment includes urgent surgical treatment in combination with active general therapy. The wound is widely opened with lamp incisions (wide longitudinal incisions throughout the segment, including an incision of the skin, subcutaneous tissue and its own fascia). All non-viable tissues are excised, the wound is washed with a solution of hydrogen peroxide. If there are suspicious areas on neighboring segments, lamp incisions are also made there.
Wounds must be left open and loosely drained with gauze soaked in a solution of potassium permanganate or hydrogen peroxide. During the first 2-3 days, dressings are performed 2-3 times a day, later – daily. With rapid progression, involvement of all soft tissues in the process and necrosis of the limb, amputation or exarticulation is performed. Amputation is carried out by guillotine method, with cutting off all layers at the same level. The wound is left open, lamp incisions are made on the stump, the wounds are drained using gauze soaked in a solution of potassium permanganate or hydrogen peroxide.
Immediately after the diagnosis, massive infusion therapy is started using plasma, albumin, protein solutions and electrolytes. In case of anemia, blood transfusion is performed. Antibiotics are administered in high doses intraarterially or intravenously. In the postoperative period, patients are prescribed hyperbaric oxygenation. Perform intravenous administration of anti-gangrenous serum. With an established pathogen, a monovalent serum is used, with an unidentified one, a polyvalent one is used.
Prognosis and prevention
The main means of preventing gas gangrene is adequate timely primary treatment of the wound surface and the appointment of broad-spectrum antibiotics. During the treatment, all non-viable tissues, as well as the bottom and edges of the wound should be excised. It should be remembered that antibiotic therapy is mandatory for any extensive wounds, especially those that are profusely contaminated and accompanied by crushing of tissues. The preventive use of anti-gangrenous serums is not effective enough and can cause the development of anaphylactic shock.
Patients with gas gangrene are isolated, a separate nursing station is allocated to them, the dressing material is immediately burned, tools and underwear are subjected to special treatment. Clostridium spores are highly resistant to boiling, so the instrument should be processed under high pressure in a steam sterilizer or in a dry-burning cabinet. Any medical measures should be carried out in rubber gloves, which, at the end of the procedure, are burned or immersed in a disinfectant (lysol, carbolic acid, chloramine).
Literature
- Clostridial myonecrosis in horses (37 cases 1985-2000). Peek SF, Semrad SD, Perkins GA. Equine Vet J. 2003 Jan;35(1):86-92. link
- Deficient Skeletal Muscle Regeneration after Injury Induced by a Clostridium perfringens Strain Associated with Gas Gangrene. Zúñiga-Pereira AM, Santamaría C, Gutierrez JM, Alape-Girón A, Flores-Díaz M. Infect Immun. 2019 Jul 23;87(8):e00200-19. link
- Clostridium sordelli as a cause of gas gangrene in a trauma patient. Bajpai V, Govindaswamy A, Agrawal SK, Malhotra R, Mathur P. J Lab Physicians. 2019 Jan-Mar;11(1):94-96. link
- Clostridium septicum infections in children: a case report and review of the literature. Smith-Slatas CL, Bourque M, Salazar JC. Pediatrics. 2006 Apr;117(4):e796-805. link
- [Characteristics of war wound infection]. Kucisec-Tepes N, Bejuk D, Kosuta D. Acta Med Croatica. 2006 Sep;60(4):353-63. link
