ANAEROBIC INFECTION

In peacetime anaerobic infection occurs comparatively seldom (in contaminated, crushed, gunshot wounds, after abdominal surgery) in wartime it is the most common cause of death of wounded people

ANAEROBIC INFECTION
clostridial

infection non-clostridial infection

ANAEROBIC CLOSTRIDIAL INFECTION

1.
2. 3. 4.

upon contamination with soil or in gunshot wounds Clostridium perfriges (44-50%) Clostridium oedematies (15-50%) Clostridium septicum (10-30%) Clostridium histolyticus (2-6%)

ANAEROBIC CLOSTRIDIAL INFECTION

Cl.

perfriges - gas formation l. odtis edema Cl. hystolyticus - tissue necrosis

ANAEROBIC CLOSTRIDIAL INFECTION

1.
2.

the main local factors favoring anaerobic infection in a wound

a great amount of necrotized, poorly oxygenated tissues vast injury of muscles and bones a deep wound canal the presence of a wound cavity without connection to outer environment tissue ischemia due to injury of great vessels or a tourniquet applied for a long time

3.
4.

5.

The nature of local tissue change

massive production of microbial toxins (hemolysines, myotoxins and neurotoxins) progressive tissue necrosis around wound canal progressive necrosis of muscular tissue quickly progressing edema gas formation

Clinical presentations
with

predominant affection of muscles (clostridial myositis) the so-called classic type with predominant affection of subcutaneous fat (clostridial cellulitis) mixed type when all types of soft tissues are similarly involved

Clinical presentations

1.
2. 3.

According to the speed of clinical presentations fulminate quickly progressing slowly progressing

Local signs
1. 2. 3. 4. 5.

6.

characteristic appearance of the wound lifeless appearance The discharge is scanty, mucous, with unpleasant smell skin around the wound is cyanotic, cold to the touch and pale bronzed or bluish spots affected muscles have the appearance of boiled meat musclesare edematous, of grey-brown colour; they bulge forth from the wound

Local signs

Around the wound there is a pronounced edema that quickly spreads in the proximal direction. The whole part of the extremity and sometimes all of the extremity is enlarged. Melnikovs sign - a thread tied around the extremity becomes too tight in 20-30 minutes).

Local signs

1.
2. 3. 4.

Gas formation can be pronounced to a varying degree crepitation blade sign spatula sign champagne cork sign

Local signs
X-ray

examination can be valuable for diagnostic purposes Crauses sign (light spots due to accumulation of gas which stratifies muscles and separate muscular bands) To confirm the diagnosis bacteriological investigation is used (wound smears).

General signs
Severe intoxication (weakness, thirst, nausea, vomiting, poor sleep, retardation; sometimes delirium is noted ) skin pallor sometimes with icteric coloration, pinched features, dry coated tongue Arterial pressure is often low The pulse rate is quick

General signs
The temperature is mostly subfebrile but it may be quite high Blood investigation detects progressive anemia High leucocytosis with deviation of the differential count to the left is typical Diuresis is usually decreased in spite of abundant drinking

Surgical treatment
In anaerobic infection surgery should be performed immediately upon confirmation of the diagnosis as a delay of 1-2 days or even several hours considerably reduces the patients chance of survival.

Surgical treatment
stripe

incision made longitudinally through the whole affected area of the extremity (from 2 to 5-6 such incisions are usually made according to the spread of lesion ) wide necrectomy, excision of the affected area amputation and exarticulation of an extremity

Surgical treatment
Amputation in anaerobic gangrene is absolutely indicated upon 1. injury of a great vessel 2. a grave gunshot fracture with massive damage of the bone 3. total gangrenous lesion of the whole portion of extremity 4. unsuccessful outcome of previous sparing surgery

General treatment
hyperbaric

oxygenation is a highly effective method of treating anaerobic infection (pressure chamber with a pressure of 2.5-3 atmospheres) combination of antigas gangrene sera (150 000 units of activity of polyvalent antigas gangrene serum )

General treatment
Nonspecific treatment includes the following measures: 1. blood, plasma and blood substitutes transfusion up to 4 litres a day general antibacterial therapy 2. general antibacterial therapy 3. rest, high-caloric nutrition 4. correction of vital functions

PREVENTION
Early

radical surgical treatment of wounds opening wide the wound canal and with utmost excision of unviable tissue which present a substrate for massive reproduction of pathogenic anaerobes

PREVENTION
Surgical

treatment of most contaminated, crushed and gunshot wounds should not end in placing a primary suture (except when indicated)

PREVENTION
Adequate

transport and therapeutic immobilization, use of hemostatic tourniquet only if indicated, prevention of cooling and freezing of injured extremity all these are important for prevention of anaerobic gangrene

PREVENTION

If anaerobic infection is detected epidemiological measures are obligatory: hospitalization in a separate ward, dressing in a separate dressing-room, careful cleaning of the dressing room