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GAS GANGRENE

Oakley (1954)

Synonym
-Malignant edema
-Clostridial Myonecrosis
The rapid spreading infective gangrene of the muscles
characterized by collection of gas in the muscles and
subcutaneous tissue is called as “Gas gangrene”.

Causative factors :

Mainly Cl. Welchii.


Others : -
-Cl. Oedematiens.
- Cl. Septicum.
- Cl. Histolyticum.
- Cl. Bifermentas.
Incubation period
 Cl. Welchii-10-48 hr
 -Cl. Oedematien-2-3 days
 - Cl. Septicum-5-7 days
Atiology And Predisposing Factors
 Atiology
 Lacerated wound-with gross contamination by soil and other foreign
bodies
 Two factor -1) entry of Clostrodial organisums (Cl.Welchii)
2) Condition of wound.

 Predisposing Factors :-
 i) Haemorrhage and blood clot by supplying calcium.
ii)Contamination of wound with soil supplies silica and calcium.
iii)
Laceration and crush injuries of the tissues are essential, as the
organisms cannot multiply in healthy living tissue.
iv) Inadequate drainage and exudation in the muscle fibers help in
the spread of infection.
v) Diabetes and other occlusive arterial diseases
Bacteriology
 Gas gangere is mainly caused by anarobic Clostridial
organisums of which cl.welchii is main organisum.
 Others are- -Cl. Oedematiens.
- Cl. Septicum.
- Cl. Histolyticum.
- Cl. Bifermentas.

 These organisms found in stool.


 Occasionally as a normal flora in vagina.
EXOTOXINS
 It is mainly the exotoxins produced by these
organism which produce this disease.

 A) Alfha toxin (Lecithinase)-Haemolytic.

 B) Collagenase-
is a proteinase and breaks down collagen,connective tissue
elements of the muscle.

 C) Hyaluronidase- beak down Hyaluronic acid.

 D) Theta toxin- Haemolytic,necrotic


 E) Leucocidin- kills the leucocytes.
 Clostridium organisums can be
divided in two groups-

1) SACCHAROLYTIC- Cl. Welchii

2) PROTEOLYTIC- Cl. Oedematiens.


- Cl. Septicum.
- Cl. Histolyticum.
- Cl. Bifermentas.
THE SACCHAROLYTIC FROUP OF ORGANISUMS GROWS ON
THE SARCOLEMMA AND BREAKS DOWN THE MUSCLE
GLYCOGEN INTO CARBONDIOXIDE,HYDROGEN AND LACTIC
ACID.AND THIS EXCESSINE PRODUCTION OF ACID STOPS
GROWTH OF SACCHAROLYTIC FROUP OF ORGANISUMS.

AT THIS STAGE PROTEOLYTIC GROUP OF ORGANISUMS


MULTILIES WITH LIBERATION OF PROTINASE AND
FORMATION OF AMINOACID IN THE TISSUES.THE AMINO
ACID FURTHER BREAKS DOWN INTO
AMMONIA,SULPHERATED HYDROGEN AND OTHER GASES.

AMONIA NEUTRALIZES THE ACID PRODUCED BY THE


SACCHAROLYTIC FROUP OF ORGANISUMS .THE ACID IS
ALSO NEUTRALIZED BY PROFUSE EXUDATE AND CALCIUM
SALTS.
Pathological changes :-
 Clostridial invasion - affects the whole involved
muscle (origin to incretion) - foul smelling
necrosis of the muscle.
 First rapidly spreading oedema of subcutaneous
tissue and muscle with accumulation of gas.
 Collagen fibers becomes swollen, fragmented and get
broken down .
 Blood vessels are damaged.
 Muscles becomes dull red to green and ultimately
block.
 Necrosis
 Ultimately muscle becomes soft,friable and green to
block.
 If septicemia occurs, gas may produced in the other
organ, notably the liver known as ‘foaming liver’.
Types of gas gangrene
1)Clostridial cellulitis -
- Crepitant infection of necrotic tissue.
- Healthy muscles is not invovled.
- Foul smelling and seropurulent infection of a wound.
- Cl. Perfringens may be present but predominantly,
Cl. Sporogenes and Cl. Tertium.
- I.P. is 3 – 5 days.

2) Single muscle type –


The infection is limited to one one muscle only.
3) Group type – The gas gangrene is limited to one group of muscles.
Eg. Extensors of thigh or glutei etc.
4) Massive type – Whole muscle mass of one limb is affected.
5) Fulminating type –

Spreads very rapidly even beyond the limb often associated with toxaemia.
CLINICAL FEATURES

1) General –
i) Anxious and anemic look of the patient.
ii) May increase in temp.
iii) Rapid pulse, B.P. falls.
iv) Vomiting.
v) Patient remain may normal.
2) Local – i) Pain in affected limb.
ii) Gradual swellilng and gross oedema of the part.
iii) Profuse brownish and foul smelling fluid between
the sutures.
iv) Skin becomes greenish due to haemolysis.
v) Crepitus is always present due to gas in muscle
and subcutaneous tissues.
vi) Colour of muscle becomes green to black
(if visible).
Investigation

i) Direct microscopic examination.


- Smear is prepared from the exudated & stained by Gram’s
method.
- Thic rectangular bacilli seen suggesting one of the organisms – Cl.
Welchii.
ii) Cultures.
- Cl. Welchii are rapidly detected by direct plate culture of the
exudate by
“Nagler reaction method”.
iii) X-ray.
- Shows gas shadows in muscle and in the subcutaneous tissue.
complication
 Endotoxemia
 Cardiac or respiratory collapse
 ARF
 Metabolic imbalance.
Treatment

I) Prophylaxis
1) Excision or debridement of wound.
2) inj. penicillin 2 gm (4 hrly).
3) Passive Immunization :-
- Inj. Of Anti gas gangrene serum (A.G.S.) 22500

I.U. ,I.M. 4 to 6 hourly.


- It contain : Cl. Welchii - 9000 I.U.
Cl. Septicum - 4500 I.U.
Cl. Oedematiens - 9000 I.U.
4) Active Immunization :-
- It has not been so popular in case of gas ganrene.
- Now a days A.P.T. is injected.two doses-2 to 6 wk
interval, booster dose 3 to 9 mnth
II) Treatment of established case.
- Early and adequate surgery is most effective.
- Due to rapid spread of inf. 24 hrs. delay in T/t may prove fatal.
1) Surgery :
a) As soon as diagnosis is established multiple longitudinal
incisio are urgently given for decompression and drainage.
b) Aggressive surgical debridement –
i) In single muscle type – affected muscle is completely
excised.

ii) Group type - All affected portion of muscle is removed.


iii) Massive type - Amputation is done.
2) Supportive treatment :-
i) Penicillin – 10 lacs unit (every 4 hours).
+ Tetracycline – 2 gm daily or
Chloramphenicol – 2 gm daily or
Streptomycin – 1 to 2 gm daily.
ii) Blood tranfusion should be started before operation.
iii) A.G.S. – 22500 I.U. (4 to 6 hourly for 3 times).
iv) O2

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