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Gas Gangrene - Causes, Symptoms and Treatment
What is Gas Gangrene?
Local infection with the anaerobic, sporeforming, gram-positive rod Clostridium perfringens (or another clostridial species) causes gas gangrene. It occurs in devitalized tissues and results from compromised arterial circulation after trauma or surgery.
This rare infection carries a high mortality unless therapy begins immediately. With prompt treatment, 80% of patients with gas gangrene of the extremities survive; the prognosis is poorer for gas gangrene in other sites, such as the abdominal wall and the bowel. The incubation period is usually 1 to 4 days but can vary from 3 hours to 6 weeks or longer.
What are the Causes of Gas Gangrene?
C. perfringens is a normal inhabitant of the Gl and female genital tracts; it's also prevalent in soil. The microbe is typically transmitted during trauma or surgery. Because C. perfringens is anaerobic, gas gangrene occurs most often in deep wounds, especially those in which tissue necrosis further reduces oxygen supply.
When C. perfringens invades soft tissues, it produces thrombosis of regional blood vessels, tissue necrosis, and localized edema. Such necrosis releases both carbon dioxide and hydrogen subcutaneously, producing interstitial gas bubbles. Gas gangrene occurs most commonly in the extremities and in abdominal wounds and less frequently in the uterus.
What are the Signs and Symptoms of Gas Gangrene?
True gas gangrene produces myositis and another form of this disease, involving only soft tissue, called anaerobic cellulitis. Most signs of infection develop within 72 hours of trauma or surgery. The hallmark of gas gangrene is crepitation, a result of carbon dioxide and hydrogen accumulation as a metabolic byproduct in necrotic tissues.
Other typical indications are severe localized pain, swelling, and discoloration (often dusky brown or red), with formation of bullae and necrosis within 36 hours from the onset of symptoms. Soon the skin over the wound may rupture, revealing dark red or black necrotic muscle, a foul smelling watery or frothy discharge, intravascular hemolysis, thrombosed blood vessels, and evidence of infection spread.
In addition to these local symptoms, gas gangrene produces early signs of toxemia and hypovolemia (tachycardia, tachypnea, and hypotension) and a moderate fever that usually doesn't exceed 101 ° F (38.3° C). Although pale, prostrate, and motionless, most patients remain alert and oriented and are extremely apprehensive.
Usually death occurs suddenly, often during surgery for removal of necrotic tissue. Less often, death is preceded by delirium and coma, sometimes accompanied by vomiting, profuse diarrhea, and circulatory collapse.
Diagnosis for Gas Gangrene
A history of recent surgery or a deep puncture wound and the rapid onset of pain and crepitation around the wound suggest gas gangrene. It's confirmed by anaerobic cultures of wound drainage showing C. perfringens; a Gram stain of wound drainage showing large, gram-positive, rod-shaped bacteria; X-rays showing gas in tissues; and blood studies showing leukocytosis and, later, hemolysis.
The diagnosis must rule out synergistic gangrene and necrotizing fasciitis; unlike gas gangrene, both of these disorders anesthetize the skin around the wound.
Treatment for Gas Gangrene
Effective treatment includes careful observation for signs of myositis and cellulitis, immediate treatment if these signs appear, and immediate wide surgical excision of all affected tissues and necrotic muscle in myositis. Delayed or inadequate surgical excision is a fatal mistake.
Treatment also includes I.V. administration of high-dose penicillin, adequate debridement, and hyperbaric oxygenation. If a hyperbaric chamber is available, the patient is placed in the chamber for 1 to 3 hours every 6 to 8 hours and exposed to pressures designed to increase oxygen tension and prevent multiplication of the anaerobic microbes. Surgery may be done within the hyperbaric chamber if the chamber is large enough.
Special Considerations and Prevention Tips for Gas Gangrene
Below are some tips which will help you to control the disease and prevent it from getting serious.
Before Diagnosis:
Look for signs of ischemia: cool skin; pallor or cyanosis; sudden, severe pain; sudden edema; and loss of pulses in the involved limb.
After Diagnosis:
- Throughout this illness, provide adequate fluid replacement and assess pulmonary and cardiac functions often. Maintain airway and ventilation.
- To prevent skin breakdown and further infection, give good skin care. After surgery, provide meticulous wound care.
- Before administering penicillin, obtain a patient history of allergies; afterward, watch closely for signs of hypersensitivity.
- Provide psychological support. This is critical because these patients can remain alert until death, knowing that death is imminent and unavoidable.
- Deodorize the room to control foul odor from the wound. Prepare the patient emotionally for a large wound after surgical excision, and refer him for physical rehabilitation as necessary.
- Institute wound precautions. Dispose of drainage material properly (double-bag dressings in plastic bags for incineration), and wear sterile gloves when changing dressings. No special cleaning measures are required after the patient is discharged.
- Take measures to prevent gas gangrene. Routinely take precautions to render all wound sites unsuitable for growth of microbes by attempting to keep granulation tissue viable; adequate debridement is imperative to reduce anaerobic growth conditions.
- Be alert for devitalized tissues.
- Position the patient so as to facilitate drainage, and eliminate all dead spaces in closed wounds.
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