Causes and methods of treating gas gangrene. Gas gangrene: pathogens, causes, symptoms and treatment

Which occurs against the background of the reproduction and growth of bacteria of the genus Clostridium in human soft tissues, most often on the extremities. The pathogen enters the body when the skin is broken.

Definition

The defeat is considered severe surgical pathology, which is formed due to anaerobic infection in the wound, which leads to significant tissue necrosis. The disease is dangerous due to its extensive toxic effects on the body, which even leads to fatal outcome if medical assistance is not provided in time. Due to the activity of microorganisms, a large amount of gas appears in the wound, which collects in the form of bubbles inside the soft tissues.

Pathogens

Gas gangrene can occur due to the entry of certain microorganisms into the wound, which affect the limbs and lead to tissue death.

Cl. perfringens- these are large and immobile polymorphic rods, due to which oval spores are formed. They are located subterminally and form a kind of capsule in the body. Microbes have weak proteolytic properties and produce a large set of saccharolytic enzymes. As a result, sugar is fermented with the further formation of gas and acid. The pathogenic infection is divided into six serovars (A, B, C, D, E, F), having various necrotic characteristics. Clostridia “A” are the primary causative agents of gas gangrene and form the disease in 70-80% of cases. The spores can withstand a lesion temperature of 100 °C for 1 to 6 hours.

Cl. novyi- these are large and thick gram-positive motile rods that form oval spores, and are located inside without capsules and subterminally. They have weak proteolytic characteristics. Saccharolytic properties are expressed less actively. There are four serovars (A, B, C, D), which can secrete toxins that have different antigenic characteristics and have hemolytic and necrotic properties. Disputes react steadily to various factors external environment and survive boiling for several hours; they can remain in the soil for 7-8 years in an active form.

Cl. Septicum- these are polymorphic, motile and gram-positive rods that form oval spores, do not form capsules and are located subterminally. This causative agent of gas gangrene has mild saccharolytic and proteolytic properties. It has six serological types (A, B, C, D, E, F), and produces necrotic, lethal and hemolytic toxins.

Cl. Histolyticum are small, motile and gram-positive rods that form spores without forming capsules. They have strong proteolytic properties. They produce an exotoxin, which leads to a necrotic and fatal outcome. These characteristics are formed due to the release of enzymes such as hyaluronidase, collagenose and lecithinase.

Reasons

Gas gangrene is caused by rods of the clostridia family, which often live in the intestines of herbivores and from there get into the ground, onto clothes and street dust. In some cases, the pathogen can be found on the skin and in the feces of healthy people. Microorganisms multiply only in an oxygen-free environment, but if air comes into contact with them, they persist long time in the form of spores, and under favorable circumstances they become active again and become dangerous.

Most often, the pathology develops due to multiplied, extensive wounds and traumatic breaks of limbs, less often - due to lesions of the large intestine after ingestion of foreign bodies. In some situations, signs of gas gangrene may appear due to small cuts contaminated with soil particles and pieces of clothing.

How it develops

Clostridium is widely distributed throughout external environment, as well as in the soil, where it exists in the form of spores and penetrates the human body through abrasions and scratches if they are not treated in time. The main factors in the development of anaerobic infection of gas gangrene are the following indicators:

Often the situation occurs when oxygenation is impaired and there is poor communication between the cavity and the external environment. The lesion also forms when long-term wearing on the extremities when a great vessel is injured and in patients who have chronic arterial insufficiency.
A favorable background is the presence of a significant mass of bruised and crushed tissue, as well as factors that reduce the body’s resistance.
The causative agent of gas gangrene is activated when positive anaerobic conditions form. Microorganisms begin to multiply vigorously and form toxins that have a damaging effect on tissues and also contribute to the rapid spread of necrosis.
Due to the saccharolytic function, glycogen is destroyed, and the prolethic action leads to the melting and destruction of proteins.
Clostridia are characterized by the formation of edema and gas.
Due to the action of the toxin, thrombosis of arteries and veins is formed, paralysis and destruction of vascular permeability occurs.
Enzymatic elements of the blood and plasma enter the necrosis zone, which causes rapid absorption of bacterial toxins, and decay products lead to severe intoxication.
The incubation period ranges from a couple of hours to 2-3 weeks. On average, this time takes 1-7 days, and the shorter the period, the more unfavorable and severe the course and prognosis.

Clostridia secrete exotoxins consisting of several fractions that have local and systemic influence, which include:

lecithinase C - has hemolytic and necrotic effects;
collagenase - blocks protein structures;
hemolysin - has a cardiotoxic and necrotizing effect;
fibrinozolin;
hyaluronidase - is a factor in the penetration of bacteria;
hemagglutinin - inhibits the formation of phagocytosis;
neuraminidase - neutralizes immune receptors on red blood cells.

Symptoms

Crepitation is considered a specific sign - upon palpation, you can feel sounds similar to crunching snow. Most often, the onset of the disease occurs rapidly with a significant development of severe intoxication. Classic symptoms gas gangrene are:

severe swelling that passes without hyperemia;
blisters containing hemorrhagic compounds, and green spots on the skin;
significant bursting pain;
massive necrosis of muscle and connective tissues;
temperature drop;
the formation of a cloudy exudate of non-purulent manifestation, accompanied by an unpleasant odor;
flatulence.

An anaerobic infection is characterized by a rapid increase in local symptoms of gas gangrene, as well as widespread processes throughout the entire limb area. After several days, as a rule, aerobic microflora begins to join, accompanied by a purulent infection.

Stages

Early. During this period, patients complain of pain. The wound appears dry with a dirty gray covering. Necrosis occurs with virtually no discharge or a small amount of brownish exudation. There is slight swelling near the wound, the skin is pale with a slight yellowish tint.
Distribution stage. With it, the process of gas formation and swelling progresses. The pain acquires bursting properties. The causative agent of gas gangrene begins to kill tissues, they become lifeless and dry, the muscles look fragile, dull and bloodless. The icteric color of the epidermis extends far from the wound.
At this stage, the limb becomes cold, peripheral pulsation is not detected in it, its sensitivity is impaired, and pain stops. The skin becomes pale, and the affected area increases significantly in size. Gases and swelling spread to the torso, blisters with hemorrhagic or brown exudate are observed. The wound is inanimate, and the muscles in it look like boiled meat. Bloody-purulent discharge is possible from the depths of the lesion.
Sepsis. Pus collects in the problem area, severe intoxication and metastatic foci are observed.

Classification

There are three main forms:

clostridial myositis - characterized by local lesion muscles;
clostridial cellulitis - subcutaneous fatty tissue and connective tissue are predominantly destroyed;
mixed form.

Diagnostics

First of all, it is necessary to conduct a clinical examination and identify an anamnesis of the disease:

there is practically no pus in the wound;
there is a black color and crepitus of the affected area;
under pressure, shifting gas bubbles are formed;
muscles look like boiled meat;
Despite such a severe course of the pathology, there is practically no increase in temperature.

When X-rayed, characteristic porous muscles are present. Diagnosis of gas gangrene also involves laboratory tests. The material used is elements of necrotic tissue, scraps of clothing, edematous fluid, blood and particles of earth. The bacteriological method consists of inoculation on Wilson-Blair blood agar, on Kitt-Tarozzi medium and identification of distributed cultures.

Treatment

For therapy, the patient must be isolated in a separate room while maintaining a sanitary and hygienic regime. Indoors, it is necessary to exclude the possibility of contact spread of the causative agent of gas gangrene. Adequate and timely disinfection is required medical equipment, dressings and toiletries.

The set of measures includes the following items:

timely and permanent surgical debridement of the wound;
prevention of the spread and proliferation of bacteria is carried out using oxygenation, antibacterial agents and specific serums;
changes in the functions of organs and all systems are corrected using anticoagulant and infusion therapy, immunostimulation and immunocorrection;
The transmission pathways of gas gangrene are blocked by neutralizing the circulating toxin through the administration of specific toxoids and the use of extracorporeal detoxification methods.

Surgery may be indicated in three cases.

If there was a wide separation of the affected tissues, namely “lampas” incisions with opening of the fascial sheaths to the bone and aponeuroses. All measures are carried out for adequate aeration of the wound and elimination of edematous fluid, since it contains a large amount of toxins.
If an excised muscle lesion is present.
When carried out above the level of visually located viable tissues without using the procedure of applying primary sutures.

In order to improve the oxygenation process, which is so necessary for the treatment of the disease, procedures are prescribed in a pressure chamber, where oxygen is supplied under strong and targeted pressure, due to which it better penetrates the tissues. Intravenous administration of anti-gangrenous serum is required. It is pre-diluted in half with heated saline solution. Antibacterial therapy is carried out only with significant doses of penicillin (20-30 million units per day intravenously).

The duration of treatment depends on the medical picture of the patient’s recovery. If there is rapidly developing necrosis with sharp deterioration condition, then timely amputation is required. The operation is carried out only to save life, since the infection spreads quickly and the person may die.

It is already known how gas gangrene is transmitted and how quickly it spreads, which is why prompt treatment is so important. Many doctors recommend using complex methodology. A more effective method is the use of a combination of aminoglycosides and penicillins, aminoglycosides and cephalosporins. Medicines that selectively act on anaerobes are widely used, namely Chloramphenicol, Metronidazole, Clindamycin, Rifampicin, Carbenicillin.

The use of serotherapy consists of the introduction of one ampoule containing toxoids against the main types of pathogens, which are actively neutralized, thereby returning proactive activity to the tissues. If there are cases of extensive damage or severe contamination of the wound, then mandatory administration of polyvalent serum is required in an average maintenance dose of 30,000 IU.

Prevention of gas gangrene

For various lesions, the main action to prevent the disease is timely disinfection of the wound, as well as applying a bandage to prevent secondary contamination of the surface.

It is also recommended to administer anti-tetanus and anti-gangrenosis serum in the first few hours if a puncture, deep, cut or contaminated wound is present. When a tourniquet is applied, the time of the procedure must be indicated next to it, and also, if there is a need for long-term transportation of the patient to the hospital, the bandage must be loosened every two hours to resume blood flow to the distal part of the limb. The note must be updated after each procedure. Next, you need to carry out timely full scope of surgical treatment of soft tissues and bones.

The gas type of gangrene is one of the most dangerous and common infectious complications that occurs as a result of a bacterial infection entering a wound, which the patient’s immune system was unable to cope with and eliminate the pathogenic activity of microbes. During the normal healing process of the skin, inflammation as such practically does not occur, and if it does form, it is for a short period of time. Then regeneration of epithelial cells occurs, and the wound heals completely. In people with weakened immune system, the wound surface becomes infected with bacteria present in the environment and myonecrosis begins. This is the initial stage of gangrene, systematically destroying not only the area of the body in which it developed, but also the entire body of the patient due to the release into the blood of a large amount of toxic substances formed during the rotting of the flesh. Most often, anaerobic gangrene occurs with deep and severe injuries to the lower and upper extremities.

Causes of the disease - the causative agent of gas gangrene and transmission routes

This type of disease is characterized by rapid development and patients literally burn out within a few days from the moment microbes penetrate the open wound. The cause of the disease is closely related to this pathological condition damaged part of the body, such as the presence of clostridial microflora in the wound. Clostridia and its subtypes enter the patient’s body along with dust, soil and dirt from environment. Therefore, the following causal factors are identified that contribute to the development of gas gangrene.

Insufficient treatment of soft tissues

After a person receives mechanical damage to any part of the body, regardless of its depth, it is necessary to mandatory carry out antiseptic treatment of the wound. Especially the deepest areas and cuts, into which the required amount of air will not flow during the healing process and there is a high probability that after infection with clostridium, the amount of infection will begin to rapidly increase. Brilliant green is used as a primary antiseptic.

Getting soil fragments into the wound

The main habitat of pathogenic microbes that are responsible for the occurrence of anaerobic gangrene is soil. If during injury to the skin there was contact with soil, then clostridia saturate the wound tissue along with particles of soil. In order to minimize the risk of gangrene, urgent sanitation of the wound is carried out, cleansing it of foreign objects from the soil surface.

Autoimmune diseases

Of great importance is the extent to which the cells of the immune system are able to effectively resist bacteria that cause the gas type of gangrene. If the patient has concomitant diseases such as AIDS, leukemia, thromboembolism, local and general immunity does not fully fulfill its protective function, which leads to the body’s vulnerability to infectious invasion from the environment.

Wearing dirty clothes

If there are wound surfaces on the human body resulting from injury, then it is extremely important to observe basic rules hygiene. This is especially true for clothing whose fabric touches an open wound. Patients who wear dirty things throughout the day are 2 times more likely to develop anaerobic gangrene than people who keep their personal belongings clean.

Violations by medical workers

A prerequisite for rapid healing of an open wound is timely medical care for cleaning damaged tissue. For deep and extensive injuries, surgical instruments are used with further application of dressing material.

If during these medical procedures there was negligence on the part of doctors and an infection was introduced, then the disease develops precisely for this reason.

The pathogenesis of the disease itself is directly related to the variety of varieties of clostridia, which are identified in the wound tissue based on the results of examination of the patient. Gas gangrene is caused by the following genotypes of clostridial microflora:

pervingen;
septicum;
histolicum;
oedomatin.

Regardless of which subtype of clostridia has penetrated into the open area of the wound surface, the pathogenic bacteria emit gaseous gases during their activity chemicals, which in their own way molecular structure are toxic. Their contact with body tissues leads to the death of cellular material and, accordingly, the disintegration of the affected parts of the body. In addition, these exotoxins destroy red blood cells, which leads to the development of anemia and kidney failure.

Forms of the disease

The development of gas gangrene directly depends on the form of its course and the type of clostridia genotype that got into the wound of an infected patient. Based on many years of scientific research, the following forms of anaerobic gangrene are distinguished.

Classical

Characterized by large volumes of gas accumulation in the injured limb. Purulent discharge is almost completely absent. The level of swelling is moderate and is not critical. As the disease progresses and muscle fibers are damaged, the color of the skin of the diseased area of the limb changes its natural flesh tone to a rich brown. During palpation of the edges of the swollen area of the body, a complete absence of blood pulsation in the area of the arteries is detected.

Edema-toxic

Swelling of the limb develops within 1-2 days from the moment of infection with clostridium. There is practically no gas discharge, and the accumulation of purulent exudate is minimal. The pulsation in local arteries completely disappears. Fiber located in the superficial subcutaneous layer becomes greenish with shades of yellow. Despite external absence rich clinical picture, toxic secretions enter the blood in abundant concentrations and have a poisonous effect.

Phlegmonous

Based on the symptoms present, it is considered the most mild form gas gangrene and is characterized by minimal swelling of the limb. Minor discharges of purulent masses and bubbles of putrefactive gas are recorded. Muscle fibers at the site of bacterial infection have pink with traces of necrosis, which may be completely absent. The pulsation in the arteries is preserved, and the skin does not change its color. The only peculiarity is an increased temperature of the surface of the skin by 1-2 degrees Celsius from the total temperature regime bodies.

Putridnaya

This form of anaerobic gangrene is also called putrefactive. The name comes from the fact that in addition to clostridia, microorganisms that cause rotting of human flesh (pseudomonas aeruginosa, streptococcus, Staphylococcus aureus). It is characterized by rapid development with immediate damage to infected tissues, muscles and arteries. Large-scale necrosis of the limb develops. Together with purulent exudate, tissue fragments that have undergone necrosis are released from the wound. Destruction blood vessels accompanied by severe bleeding.

Symptoms of gas (anaerobic) gangrene

Clostridia of gas gangrene behave differently in the patient’s body and the intensity of the manifestation is associated with this characteristic symptoms, as well as its intensity in its presence. Main signs of gangrene anaerobic type look like this:

When pressing on the inflamed limb, gas bubbles emerge from the wound, which emits a foul odor.

Gangrenous gas is so saturated and concentrated that it is almost impossible to stay in the same room with the patient for a long time. The muscles located in the affected area become gray and lifeless appearance. During their palpation, a characteristic crunch is heard, which medical terminology is referred to as "crepitus". As the patient’s health deteriorates, changes in direct proportion clinical indicators tests: the level of hemoglobin drops, most of the blood cells die, the cleansing function of the kidneys is disrupted.

Diagnostics

Medical measures aimed at identifying the disease and staging accurate diagnosis in the form of gas gangrene, are based on the implementation of the following diagnostic methods:

Treatment of gas gangrene

The disease progresses very quickly, so the attending physician always faces a difficult choice as to which method of therapy to use in a particular clinical case in order to save the patient not only life, but also the functionality of the limb. Otherwise, the risk of developing renal failure, toxic and bacteriological blood contamination with subsequent death increases. The treatment process is divided into two main types, which consist of the following manipulations.

Conservative therapy

An infected patient is prescribed intravenous and intramuscular injection potent antibacterial drugs. Also, in parallel to this, tablet antibiotics can be prescribed as an auxiliary element in general medication course. Around the wound surface of the patient’s body, the tissues are saturated with pure penicillin and tetracycline. To do this, drugs are injected into the subcutaneous layer and into deep muscle fibers. In order to relieve general intoxication of the body, the patient is given intravenous drips and the body is cleansed with solutions of sodium chloride, glucose, albumin, and plasma.

If the functioning of the kidneys and heart worsens, maintenance therapy is carried out to ensure the stable functioning of these vital organs. The type of drug is determined by the attending physician based on what pathological abnormalities in the work of organs were identified based on the results of the examination. The patient is also given intravenous medications containing hemoglobin, which should replenish the deficiency of red blood cells that have died from excess exotoxins. The patient is prescribed increased high-calorie nutrition, bed rest and complete rest of the injured limb. The doctor who is treating the infected person monitors the patient’s health status throughout the day and monitors the clinical dynamics of the disease.

Surgical treatment

Includes local sanitation of the wound surface and edematous limb. In order to clean an infected wound, the surgeon makes several strip cuts along the entire surface of the leg swollen with gases. After this, most of the accumulated gases come out of the voids between the muscle fibers, and purulent exudate flows beyond the limb. At this point, the doctor installs a drainage system, the purpose of which is to drain fluid consisting of blood, lymph, ichor and pus beyond the inflamed tissues. In parallel, the patient also receives conservative therapy, consisting of antibiotics, antitoxic and anti-inflammatory drugs.

In the event that everything done therapeutic measures did not bring the desired therapeutic effect and the damage to the tissues of the limb continues, progresses rapidly and signs of general intoxication of the body increase, then the doctor makes a decision on guillotine amputation of the part of the body in which it developed pathological process. The operation is performed only with the consent of the patient, but this is the only way to save his life.

Upon completion surgical intervention, the process of rehabilitation and monitoring of the condition of the limb begins so that a relapse of the disease does not occur.

Complications and consequences

Anaerobic gangrene is severe infectious disease, therefore the consequences also entail quite dangerous ones. A patient who is faced with the development of gas gangrene risks experiencing the following complications:

In most cases, a timely visit to a surgeon in the presence of the first signs of the development of gas gangrene eliminates the possible occurrence of the described complications and saves the patient not only life, but also the integrity of the limb.

Prevention

In order to never experience the symptoms of anaerobic gangrene, you should follow simple rules prevention, consisting of the following recommendations.

Treatment of wounds

After each damage to the integrity of the skin as a result of mechanical trauma, a cut or a fall, it is necessary to wash the wound surface antiseptic solutions, which during reaction with living tissue release large amounts of oxygen. These include hydrogen peroxide and potassium permanganate (prepared by dissolving 2-3 crystals of potassium permanganate in 1 liter of warm water). During biochemical reaction Clostridia, even if they enter the body, almost always die.

Maintain personal hygiene

If there are damages on the surface of the body, it is extremely important to regularly sanitize them, change bandages, wear clean clothes so that pathogenic microflora does not accumulate on the fabric.

Avoid contact with ground

The causative agent of gas gangrene in microbiology, called clostridium, lives in the soil, so the risk of infection increases significantly if a person touches the open wound to the ground. If there are cuts on the surface of the fingers and other exposed parts of the hand, it is imperative to use protective gloves for any contact with the ground.

At the first symptoms indicating the presence of gas gangrene, you should immediately contact the clinic. The disease develops dynamically, so you can’t waste a second. Also, many are interested in such questions as: is gas gangrene contagious? You can become infected with this disease only through direct contact of the tissues of an open wound with the source of infection. However, people with a strong immune system may not feel any signs of illness even after this.

Gas gangrene, otherwise clostridial anaerobic infection - serious illness, often leading to the death of the patient due to the rapidly developing process.

At its core, this is a complication of anaerobic infection of wounds by microorganisms that multiply quickly without access to oxygen - anaerobes.

Surgical treatment for gas gangrene is the only in an efficient way save a person.

Gas gangrene: causes

The disease develops rapidly and is extremely difficult.

The causes of gas gangrene are untimely treatment of wound surfaces and the ingress of clostridia, microorganisms that can quickly multiply in areas of dead skin or in tissues with a lack of blood circulation.

The causative agent of gas gangrene is an anaerobic infection. Microbes inhabit the intestines of herbivores and humans; they are sown from feces and skin, sometimes from practically healthy individuals.

The causative agent of gas gangrene feeds on dead wound tissue and multiplies in the absence of oxygen, i.e. in a closed wound or on its surface inaccessible to oxygen. The result of their life activity is the release of gas, which is characteristic symptom for gas gangrene, and general intoxication of the body. Once the toxin gets into the tissue, it quickly corrodes them.

The causes of gas gangrene are the appearance of lacerations and bruises, gunshot wounds, separation and fracture of limbs, abdominal wounds and other traumatic lesions. Favorable conditions for infection by the causative agent of gas gangrene are extensive wound surfaces with necrotic tissue.

A characteristic symptom of gas gangrene is its rapid development during the first day from the onset of infection. However, there have been cases of more late manifestation diseases.

Gas gangrene of the lower extremities is most often observed, which is due to more likely infections of the feet, from bacteria living in the soil and in animal feces. Moreover, sometimes a person does not pay attention to minor lesions skin.

Gas gangrene: signs and course

The process of development of gas gangrene is detected within a few hours. In this case, the patient experiences swelling of the tissues and the release of a fetid cadaverous odor emitted by gas bubbles emanating from the wound. Edema quickly affects healthy tissue, and the patient’s condition deteriorates sharply, with symptoms of intoxication of the body occurring. If medical assistance does not have time to intervene in the process, the person dies.

Another characteristic symptom of gas gangrene is the absence inflammatory reaction body.

Rapid tissue necrosis is observed at the site of injury.

After about 6 hours, signs of gas gangrene appear with fever and palpitations. Gas gangrene is characterized by a dry wound bottom, with pale, thickened edges and acute sensitivity. Visible in the wound muscle tissue, reminiscent of boiled meat. By pressing on the wound, you can hear the characteristic sound of snow creaking. At the same time, a sweetish substance is released from the wound. putrid smell emanating from bubbles bursting out when pressed.

Experts define 4 forms of gas gangrene:

In the classic form of gas gangrene, no purulent discharge is observed. The swelling is localized, its necrosis is accompanied by strong gas formation. The skin around the wound turns pale and brown spots appear on it. When pressed, ichor and gas bubbles are released. Subsequently, the tissue acquires a greenish-gray tint and, emitting a corpse-like odor, dies.

In the edematous-toxic form of gas gangrene, tissue swelling and necrosis of muscle tissue forms immediately after injury and spreads to healthy areas. Gas formation occurs gradually, there is no pus.

Signs of gas gangrene of the phlegmon form are weakly expressed. This form of the disease usually does not spread over large areas, but resolves with the formation of pus and gas formations. In this case, there are no spots or swelling, and skin hypothermia is not observed.

The most serious disease is the putrefactive form of gangrene. It develops against the background of the combined effects of putrefactive and anaerobic bacteria. The putrefactive form of gas gangrene occurs acutely, destroying tissue. Their necrosis quickly occurs, accompanied by pus and gas release. This form is characterized by secondary erosive bleeding, due to the fact that the causative agent of gas gangrene, releasing toxins, destroys the walls of blood vessels and tissue proteins.

Previous forms of the disease most often include gas gangrene of the lower extremities. While putrefactive gas gangrene usually develops in the rectum and mediastinum.

Common signs of gas gangrene are a sharp decrease in blood pressure, excitement or depression, palpitations, rapid breathing, hyperthermia up to 40 o, dehydration, insomnia and sharp drop hemoglobin in the blood.

Untimely treatment of gas gangrene is common cause rapid death of the patient - from 2 to 3 days. Sometimes death occurs even earlier - instantaneous gas gangrene, and the patient can only be saved by urgent surgical intervention.

Diagnostics

Diagnosis of gas gangrene is quite simple - its specific features allow a diagnosis to be made with great accuracy during examination. Therefore, they rarely resort to additional examination. To confirm the diagnosis, carry out x-ray examination tissue porosity and microscopic detection of the pathogen.

Gas gangrene is differentiated from gas phlegmon, in which there is no muscle damage and putrefactive infection.

Treatment of gas gangrene

Relief of the disease and saving a person’s life depend on surgical treatment of gas gangrene.

The slightest suspicion of a disease should be a signal for active treatment.

During the surgical treatment of gas gangrene, a wide opening of each gangrenous area and excision of dead tissue is performed, because they are a breeding colony for pathogens.

Drainage is then performed to remove the pus. The edges of the wound are treated with antiseptics and antibiotics are injected into them.

Quite often, with gas gangrene of the lower extremities, amputation of the limb is performed. Subsequently, the patient is placed in a pressure chamber with a pressure of up to 3 atmospheres. This allows you to saturate the affected tissues with oxygen, which is destructive for the causative agent of gas gangrene.

When gas gangrene is diagnosed, intensive infusion therapy is immediately started. The use of plasma is prescribed, electrolytic solutions and proteins.

If anemia develops, a blood transfusion with antibiotics is prescribed.

If the pathogen is successfully identified, anti-gangrenous monovalent serums are used. If the causative agent of gas gangrene could not be identified, then general polyvalent serums are used.

Every day, a large number of people in the world are injured or injured. Often, after injury, a certain number of microorganisms enter the wound surface, which lead to the development of complications. Gas gangrene is a severe infection that develops deep in the wound after anaerobic (microorganisms that live and reproduce only without oxygen) microorganisms reach its surface.

Gas gangrene progresses quickly without urgent treatment will lead to the death of the limb, and subsequently severe intoxication and death.

Symptoms:

swelling of the injured limb,
rotting and necrosis of damaged muscles,
a foul odor from the injured limb and the formation of gas bubbles inside the wound.

Etiology and pathogenesis of gas gangrene

The causative agent of gas gangrene is anaerobic bacteria of the genus Clostridium, most often Clostridium perfringens, less often Cl. histolitycum, Cl. oedematiens, Cl. septicum, Cl. novii, Cl. fallax. These microorganisms normally live in the intestines of herbivores. Together with feces they enter the soil and water. The pathogen is stable in the external environment, persists for a long time in soil, street dust and water. Clostridia survive in aerobic and anaerobic conditions, but can only reproduce in the absence of oxygen.

The transmission mechanism is contact. Infection occurs after the pathogen enters the wound surface. Most often, gas gangrene develops in deep wounds where there is no access to oxygen. Dead skin areas are a substrate for the proliferation of clostridia, so the infection often develops in small wounds, which were not initially processed.

Clostridia, after getting deep into the wound, begin to multiply under anaerobic conditions. The bacteria produce exotoxins that cause tissue necrosis as well as gas. The infection develops quickly. The exotoxin penetrates the human blood, causing severe intoxication. Symptoms increase quickly; without treatment, the disease lasts 2-3 days, after which death occurs.

Factors contributing to the development of the disease

Dirty infected wounds- the main cause of gas gangrene. Most often, the infection develops in deep wounds caused by a contaminated object, as well as in large crushed wounds, where favorable conditions exist for the pathogen to multiply. Infection also develops in superficial wounds with tears, necrosis and poor circulation. There are factors that contribute to the development of gas gangrene:

the presence of the causative agent of gas gangrene in dust, soil, clothing or on objects that were in contact with the wound;
lack of primary surgical treatment of the wound;
the presence of dead tissue in the wound;
tightly closing wounds with a plaster or bandage without access to air;
the presence of clothing, soil, and dust in the wound.

It is important to remember that gas gangrene develops only when favorable conditions for clostridia. And this is the lack of oxygen in the wound and the presence of dead tissue. Under such conditions, clostridia multiply rapidly and further damage human tissue.

Doctor's advice. If you receive a shallow wound, be sure to treat it in as soon as possible: wash the wound surface, apply antiseptics, and then sterile bandage, which will not put pressure. Open the wound regularly to allow oxygen to reach it. This will prevent the development of gas gangrene

Classification of gas gangrene

Depending on clinical manifestations it's on the form:

emphysematous (classical);
edematous-toxic;
phlegmonous;
putrid or putrid.

Depending on the severity of the disease, there are 3 degrees of severity:

light;
average;
heavy.

Clinical picture of gas gangrene

The incubation period of the disease is 1-3 days. It begins abruptly with the manifestation of local symptoms. Basic local symptoms gas gangrene:

swelling of the damaged area;
acute increasing pain in the wound;
the presence of gas deep in the wound, which is released when pressed and has an unpleasant putrefactive odor;
tissue decay deep in the wound;
discharge of pus or ichor from the wound;
change in color of the damaged area. The limb becomes covered with brown spots, and dead areas become blue.

Depending on the form of gas gangrene, the clinical picture varies slightly.

Classic (emphysematous) is characterized by the formation of a large amount of gas in the soft tissues, swelling is mild. The injured limb is dry, pale and cold. It quickly develops dry necrosis. Over time, brown spots appear on the skin near the damage, and dead areas become blue-green. This form is characterized by severe pain, which constantly intensifies. When you press on the wound, a gas with an unpleasant odor and a small amount of liquid are released. The pulse in the damaged areas is not detected. Over time, the limb completely loses sensitivity due to necrosis of the nerve endings.

The edematous-toxic form is characterized by the formation of extensive edema, which spreads to nearby healthy areas of the body. Gas and pus form in the wound in small quantities, and swelling increases quickly. The skin swells, becomes tense, shiny and cold. Pale, swollen muscles are visible from the wound. Edema compresses blood vessels and nerve endings, and the limb quickly dies.

The phlegmonous form is characterized by a rapid course. A large amount of pus and gas is released from the wound. Purulent masses also quickly spread through the intermuscular spaces to healthy areas, involving inflammatory process more fabrics. In this form, spots do not form on the skin, the skin is usually warm and pale pink, and pulsation in the arteries remains.

The putrefactive form is the most severe, usually develops when the abdomen is damaged or chest. It is characterized by a rapid flow, tissues quickly die. A large amount of pus is released from the wound along with pieces of dead tissue and a large number gas. The discharge has a foul odor, the damaged area becomes gray in color.

After toxins penetrate the bloodstream, the patient develops symptoms of intoxication:

increase in body temperature up to 40° C;
lowering blood pressure, increasing heart rate;
general weakness, body aches;
insomnia.

Without timely treatment patients die within 2-3 days.

Which doctor to contact, prognosis of the disease and complications of infection

Treatment of gas gangrene occurs in a hospital setting. The patient is treated by an infectious disease specialist together with a surgeon. Treatment lasts until the patient recovers completely. If the condition is satisfactory, visits to the patient are allowed, since he is not contagious.

The prognosis of the disease depends on the time of initiation of treatment. For small wounds on early stages manages to save the damaged limb. More often the disease ends in limb amputation.

Complications of gas gangrene:

sepsis with the development of severe intoxication and damage to all internal organs;
death of the entire limb.

Unfortunately, complications develop frequently, since most people do not seek help for penetrating soft tissue injuries. The disease develops quickly. Without treatment, gas gangrene is fatal within 2-3 days.

Important! For deep and extensive wounds, consult a doctor as soon as possible for primary surgical treatment of the wound and prescription of gas gangrene prevention

Diagnosis of gas gangrene

It is not difficult to establish a diagnosis, since the infection is characterized by a specific clinical picture. To confirm the diagnosis, X-rays of the damaged areas are used. The images determine the presence of gas inside the soft tissues. Magnetic resonance imaging (MRI) and computed tomography(CT). The damaged tissues inside have porosity, which confirms the presence of gas in them.

Microscopic examination of the wound contents is also used. Clostridia is detected in the smear, which confirms the diagnosis of gas gangrene.

It is informative to inoculate wound contents on nutrient media and cultivate them under anaerobic conditions. Colonies of clostridia grow on the media, which confirms the diagnosis of gas gangrene. But this method is not used, since the duration of its execution is 5-7 days.

Treatment of infection

Patients are taken to the hospital in urgently. When the diagnosis of gas gangrene is confirmed, the patient is immediately sent to the operating room for emergency surgical treatment. The damaged area is opened with wide longitudinal cuts throughout the entire damaged area from different sides for good access of oxygen to the damage. The incisions are made deep, involving the skin, subcutaneous tissue and fascia. Next, all dead tissue is excised; the criteria for tissue viability during surgery are the red or pink color of the muscles, preservation of the blood supply to the area (when cut, blood is released from the wound). The incisions are treated with hydrogen peroxide, drained and loosely sutured to maintain access to blood flow.

"Lampas" longitudinal incisions in the treatment of gas gangrene (photo: www.image.slidesharecdn.com)

After the operation, the patient is bandaged 3-4 times a day, the incisions remain open. Bed rest, painkillers, and anti-inflammatory drugs are prescribed. Local and general antibiotic therapy is also used. Patients undergo detoxification therapy with colloid and crystalloid solutions. They also treat concomitant diseases - heart and kidney failure, anemia.

At severe course infections or late start treatment, when a large amount of soft tissue is damaged, amputation of the limb is performed. In the postoperative period, patients also undergo antibiotic therapy, detoxification and symptomatic therapy.

Prevention of gas gangrene

The causative agent of gas gangrene is widespread throughout the world, so anyone can become infected with clostridium. Specific prevention of infection has not been developed.

Nonspecific prevention consists of timely primary surgical treatment of the wound and the prescription of antibiotics wide range actions. Primary surgical treatment consists of the following stages:

wound dissection;
revision of the wound channel;
removal of all non-viable areas;
suturing the wound with drainage if necessary.

All manipulations are carried out under sterile conditions. Timely primary surgical treatment of the wound allows you to remove all dead tissue, disinfect the wound and open access of oxygen to the wound surface.

If it is impossible to carry out primary surgical treatment of the wound, it is necessary to wash it, clean it of dirt and remnants of clothing and treat it with antiseptics. Wound surface must be left open, maintaining air access to it. Such manipulations will prevent the development of gas gangrene.

Gas gangrene is a severe, rapidly progressing infection that, without treatment, leads to death within 2-3 days. Therefore, for deep and contaminated damage, it is better to seek help from specialists. Preventing the development of infection is easier than treating it.

Timely diagnosis, adequate treatment and compliance with all measures to prevent gas gangrene will lead to a reduction in the spread of this terrible disease and a reduction in disability and mortality of patients.

Diagnosis of gas gangrene

Diagnosis of gas gangrene is based on the clinical picture of the disease, the diagnosis is confirmed microbiological methods research and x-ray diagnostics.

Assessment of the clinical picture of gas gangrene

In the clinical picture of the disease, the following symptoms come to the fore: severe pain in the affected area, disproportionate to physical damage, changes in skin color, swelling and gas formation. With open wounds, there is protrusion of dull-colored muscles from the wound and scanty discharge. Toxicosis develops rapidly with hypotension and tachycardia.

Rice. 1. Clostridial cellulitis (photo on the left) and clostridial myonecrosis (photo on the right).

Microbiological diagnostics

The basis laboratory diagnostics consists of microscopy, isolation of pathogens and their toxins. For research, biopsy, suture and dressing material, edematous fluid and venous blood, foreign bodies from wounds. It is acceptable to examine scraps of clothing and soil samples for the presence of clostridia.

Microscopy

Areas of affected muscles and discharge from the wound are subject to microscopy. Smears are Gram stained. Under a microscope, the bacteria are violet in color, rod-shaped, rather large, and unevenly thickened. Often, along with clostridia, coccal flora is detected.

Rice. 2. In the photo on the left is Clostridium perfringens. The photo on the right shows clostridia and their spores.

Bacteriological research

Bacteriological research is based on the isolation pure culture pathogen and microbial association, determination of the species composition of clostridia and their toxins. It is mandatory to determine the sensitivity of microorganisms to an antibacterial drug.

To isolate clostridia, liquid and solid media are used.

When pathogens grow in liquid media (Kitta-Tarozzi medium), turbidity is formed with intense gas formation. Subsequently, the medium clears and a whitish plate-like sediment falls to the bottom.
On sugar-blood agar, bacteria form smooth, shiny, round shapes (S-colonies), or grayish colonies, flat, rough with jagged edges (R-colonies). A hemolysis zone forms around the colonies. When exposed to air, colonies acquire a greenish color. Colonies in the thickness of the agar acquire a lenticular shape.

Rice. 3. Growth of colonies of C. perfringens (left) and C. septicum (right) on a solid medium - blood agar.

Rice. 4. When C. perfringens grows on liquid Kitta-Tarozzi medium, turbidity and gas formation are observed.

Express methods

Express methods are used when it is necessary to urgently apply serotherapy.

For this purpose, a fingerprint smear made from the material under study is treated with immunofluorescent species-specific serum, which is further studied using the immunofluorescent method.
Accelerated methods for diagnosing clostridia (except for determining their type) include gas-liquid chromatography, when the presence of pathogens can be identified by specific fatty acids within a few minutes.
You can quickly determine the type of pathogen by the curdling of milk. When C. perfringens is present and grows on milk, coagulation occurs within 4 hours. The resulting clot has a holey structure, which bounces up due to intense gas formation.

Rice. 5. In the presence of C. perfringens, when growing on milk, coagulation occurs within 4 hours.

X-ray diagnostics

The presence of gas in tissues is confirmed by x-ray. On an x-ray, the presence of gas is determined by the characteristic porous structure of the muscles (“honeycomb”) or a pattern resembling a herringbone.

Rice. 6. With gas gangrene, gas accumulates in the affected tissues. The pattern resembles a Christmas tree (photo on the left) or a honeycomb (photo on the right).

Differential diagnosis

Gas gangrene should be distinguished from fascial gas-forming phlegmon, putrefactive infection, streptococcal myonecrosis, urinary infiltrates, progressive skin gangrene, crepitant cellulitis, gangrene in vascular diseases of the lower extremities.

Rice. 7. Gas gangrene of the thigh stump.

Treatment of the disease

Treatment of gas gangrene is complex. It consists of local surgical and general treatment, subject to careful patient care. Patients with clostridial infection should be treated medical institutions with the necessary capacity, and doctors with experience in treatment of this disease. Otherwise, the disability of patients and mortality increases many times over.

Patients with gas gangrene are placed in separate rooms with strict maintenance of sanitary and hygienic conditions and eliminating the possibility of contact spread of infection. Medical equipment and toiletries must be promptly and adequately disinfected in the ward. A personal medical post is allocated. The dressing material is burned immediately, and instruments and linen are subjected to special treatment.

Rice. 8. Patients with clostridial infection should be treated in medical institutions with the necessary capacity and by doctors with experience in treating this disease.

Stages of treatment

Surgical treatment (revision of the wound, wide excision of lesions with striped incisions, excision of dead tissue, flow-through drainage).
In cases of fulminant clostridial infection, early amputation of the limb is indicated.
Administration of anti-gangrenous serum under anesthesia.
Antibacterial therapy.
Hyperbaric oxygenation of affected tissues.

Rice. 9. Opening the wound with a stripe incision. Removal of necrotic tissue.

Surgical treatment

Surgical treatment of gas gangrene should be carried out immediately. Delay even for 1 - 2 hours significantly reduces the patient’s chances of recovery.

After the revision, primary surgical treatment of the wound is performed with excision of necrotic tissue and subsequent washing of the wound with hydrogen peroxide. The manipulations are carried out under anesthesia.
To reduce tissue tension and ensure access of oxygen to deep-lying tissues, the wound is opened with striped (longitudinal) incisions. The incisions allow the release of gases and the outflow of liquids containing many toxic products. Incisions cut the skin, subcutaneous tissue and the fascia itself through all affected areas. A total of 2 to 5 cuts are made. Lamp incisions are made not only in the affected areas, but also in adjacent suspicious segments. The wounds are loosely packed with gauze soaked in hydrogen peroxide.
Excision of the affected area (wide necrectomy) is performed in the case of a limited process. In a common process, surgical treatment of the wound is performed with opening of the wound using striped incisions.
After surgical intervention the wound is left open and loosely drained. Dressings in the first 2 - 3 days are performed 2 - 3 times a day, subsequently - daily. The injured limb is provided with complete rest. If necessary, repeated revision of the wound and excision of areas of necrosis are indicated.
In case of a fracture, a splint is applied to the limb.
In the case of fulminant clostridial infection, the limb is amputated, and strip incisions are made above the cutoff level.
For wide wounds, reconstructive plastic surgery is required during the recovery period.

Rice. 10. In case of clostridial infection, the wounds are not bandaged, and after surgical treatment, gauze soaked in hydrogen peroxide is applied to it.

Hyperbaric oxygenation

In addition to surgical treatment, it is recommended to carry out hyperbaric oxygen therapy- a highly effective method of treating gas gangrene. Using this technique helps saturate the patient’s body with oxygen. Sessions lasting 2 - 2.5 hours are carried out 3 times on the first day, then once a day.

Specific treatment for gas gangrene

The patient begins to administer anti-gangrenous serum intravenously during the operation. If the pathogen is unidentified, a polyvalent serum is administered; if the pathogen is identified, a monovalent serum is administered.

Antibiotic therapy

For the treatment of gas gangrene, penicillin and clindamycin, amoxicillin + clavulanic acid, imipenem + cilastatin sodium, penicillin + aminoglycosides, penicillin + metronidazole, aminoglycosides + cephalosporins are used.

It is believed that anti-gangrenosis serum and antibiotics do not have the desired effect due to insufficient blood supply to the affected area.

Nonspecific therapy

In order to combat toxicosis, the patient is given up to 4 liters of fluid per day. Hemodesis, neohemodesis are used, blood, plasma and blood substitutes are transfused. Extracorporeal sorption methods are used: hemosorption, plasma sorption, etc. The functioning of vital organs is corrected. The patient is provided with complete rest and high-calorie nutrition.

Patients with gas infection need constant monitoring and careful care.

Observation and rehabilitation

After discharge from the hospital, the patient is subject to long-term observation. If vital organs (heart, liver, kidneys) are damaged, rehabilitation is carried out. The function of both the preserved and amputated limbs is restored. Physiotherapy and exercise therapy are prescribed.

Rice. 11. For wide wounds, reconstructive plastic surgery is required during the recovery period.

Prevention

Measures to prevent the spread of gas gangrene are aimed at preventing infection contact persons, localization of the source of the disease and the spread of infection in the patient. The basis for the prevention of gas gangrene is the following measures:

Prevention of cooling and frostbite of the extremities.
Of great importance in preventing the spread of clostridial infection is correct primary processing wounds, transport immobilization, correct use hemostatic tourniquet.
Timely radical surgical treatment of wounds, administration of antibiotics, adsorbed polyanatoxin and anti-gangrenous serum.
Implementation of anti-epidemic measures in the inpatient department.

During hospitalization, the patient is isolated in a separate room.
The operating room is thoroughly cleaned (double general cleaning).
Dressings must be carried out in a separate dressing room.
The dressing material is burned, and the instruments are subject to fractional sterilization. They must be processed in a steam sterilization or dry-heat oven.
Medical personnel should work only in gloves, which, after completion of work, are burned or disinfected by immersion in disinfectant solutions of carbolic acid, Lysol or chloramine.
The dishes are soaked in a 2% sodium bicarbonate solution and boiled for 1.5 hours.
The patient's bed linen and medical staff's gowns are treated in the same way.

Implementation of anti-epidemic measures in the source of infection.