Gas gangrene may develop when a contaminated open fracture is inadequately debrided. The infection tends to involve the subcutaneous tissue and muscles, sometimes sparing blood vessels, nerves, and bone. Once established, the infection may produce a localized cellulitis or extensive and aggressive myonecrosis. The onset of infection usually occurs within 72 hours after injury. Characteristic manifestations are localized pain, erythema, swelling, brawny edema, blister formation, and bronzing of the skin. Pockets of subcutaneous gas produce crepitus on palpation, and the wound often drains a thin, brownish, watery material. The extent of the infection will progress very quickly, with the erythematous edge of the infection spreading at a rate of up to 10 cm per hour. Severe systemic symptoms of fever, tachycardia, and lethargy may progress rapidly to septic shock and coma.
As with other wound infections, prevention is the keystone in the management of infections caused by Clostridium. The contaminated hematoma and all necrotic tissue should be debrided promptly after any open fracture. Antibiotics are administered to prevent infection, and the wound is left open. Primary closure is delayed until the wound is clean and there is no evidence of infection.
Gas gangrene is a true surgical emergency that demands immediate attention to preserve life and limb. Once gas gangrene, cellulitis, or myonecrosis develops, treatment must be swift and aggressive. The decision to proceed with operative management must in some cases be made on clinical examination findings alone, because delay for computed tomography or magnetic resonance imaging may result in the loss of an extremity or even life. Intravenous administration of fluid and blood is performed as necessary to treat the systemic complications. Large doses of broad-spectrum antibiotics should be administered intravenously the instant gas gangrene is suggested. It is essential to open the infected wound as soon as possible and perform a radical debridement of all necrotic and infected tissue. This precaution means that frequently the surgical procedures must be repeated every few hours because of the rapid and aggressive nature of the infection. Hyperbaric oxygen treatment may be considered if available; however, studies have shown mixed results with regard to benefit of this logistically difficult therapy. Intravenous antibiotics and immediate surgical debridement remain the absolute necessary treatment.
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