A walk through a not so common entity, thank Lord for antibiotics

1. GAS GANGRENE
The Battle Wound Injury  How would YOU
battle this wound injury?
- Shweta Achuthan Kutty

2. • Introduction
• Microbiology
• Etiology
• Pathogenesis
• Clinical features
• Investigation
• Management
• Prevention

3. INTRODUCTION
• War time injury : WW1, WW2, Vietnam
War ….
• Now-a-days: Road traffic accidents,
Terrorist attacks, Earthquakes

4. • Synonyms: Anaerobic myonecrosis, Clostridial
myonecrosis, Oedematous myonecrosis
• Seen in severe wounds with contamination (Class3+4),
involves skeletal muscles mostly
• Causative organism: Clostridium species
• Rapidly progressive myonecrosis sepsis myocardial
depression, MOF death
• Should be vigilant about – Diabetics,
immunocompromised, pts with malignancies

5. MICROBIOLOGY
• Causative organism : Clostridium spp
C. perfringens (welchii) – 60%
C. oedematiens, C.septicum, C.histolyticum
+/- other anaerobes
• Gram positive, spore bearing, capsulated, non-
motile
• Obligate-aerotolerant anaerobes

6. • Source : soil, dust, faeces
• Incubation period : 1-2 days

7. ETIOLOGY
• Soil/faeces contaminated wounds
• Crush injuries: RTA, Earthquakes,Wars
• High velocity wounds: Gunshot, Shrapnel, RTA
• Post amputation
• Ischaemic limb

8. PATHOGENESIS
SPORES ENTER DEVITALISED TISSUE
GERMINATE
BACTERIAL MULTIPLICATION
EXOTOXINS
LOCAL:
MUSCLE
NECROSIS+ GAS
FORMATION
SYSTEMIC:
CARDIAC
DEPRESSION,
MOF

9. EXOTOXINS
• Lecinthinase: hemolytic, membranolytic,
necrotic
• Hemolysin: hemolytic
• Hyaluronidase
• Proteinase

10. CLINICAL FEATURES
• Common sites:
• limbs>other
• Adductor area of legs, buttocks, subscapular
region
• abdominal wall, viscera- liver (foamy liver),
appendix, intestines

11. • SEVERE local pain
• WOUND-
 oedematous,tense, tender
 spreading gangrene
 Serosanguinous discharge – “decaying apple
odour”
 purple-black-brown-green “KHAKHI” colour
 haemorrhagic blebs
 crepitus+

12. • Toxic features, fever, tachycardia, altered mental
status*
• Jaundice
• Features of shock- rapid thready pulse, cold
extremities, oliguria
• DIC
• Multiorgan failure
•DEATH

13. INVESTIGATIONS
• CBC
• Total count
• ABG
• Xray- limb, chest
• CT- chest/abdomen
• RFTs
• LFTs
• Gram stain: Gram positive bacteria (sensitive)
• Blood culture: <1% grew C.spp
• Upcoming: ELISA for exotoxins, PCR

14. TREATMENT
Immediate:
• Stabilize patient: IV line, fluids, blood
transfusion, pressors, ventilate if needed
• Polyvalent anti-gas gangrene serum
• Antibiotics- inj
• Monitor vitals, urine output, electrolytes

15. Once stable/ In stable patient:
• Cont. antibiotics
• Debride and excise all devitalised tissue till bleed
seen, H2O2+NS rinses
• Guillotine amputation
• Hyperbaric O2 therapy

16. PREVENTION
• Proper debridement of devitalised crush wounds
• Devitalised tissue should not be sutured
• Adequate cleaning with H2O2 + NS
• Penicillin/Antibiotic prophylaxis