| Gangrene is tissue destruction (necrosis) resulting from partial or total loss of the blood supply. Deprived of oxygen and nutrients, the cells slowly die, and in most cases, bacterial infections develop. Gangrene can involve small areas or entire organs and limbs.
Both external injuries or internal interruption of blood supply can cause gangrene. External causes include skin ulcers or wounds, crushing injuries, deep burns, frostbite, boils, and chemical damage to the skin. The most frequent traumatic injuries are vehicular or agricultural accidents with open fractures. Crush injuries, industrial accidents, and gunshot wounds may also lead to gangrene. Internal causes include blood clotting (thrombosis) in a diseased artery, an embolus, severe arteriosclerosis, diabetes, a strangulated hernia, torsion of the testes, or some vascular disorders.
The three major types of gangrene include dry, moist, and gas gangrene. Dry and moist gangrene develop from impaired circulation. Dry gangrene occurs in the absence of bacterial infection. It is characterized by a discoloration and drying out of tissue. Dry gangrene occurs most often as a complication of advanced diabetes or arteriosclerosis.
Moist gangrene usually occurs in the toes, feet, or legs after a crushing injury or some other factor that causes a sudden interruption of the blood supply (both venous and arterial). An infection occurs and overwhelms the body's normal defenses, resulting in rapid tissue destruction.
Gas gangrene is a progressive gangrene characterized by gas bubbles in the dead and dying tissue. The gangrene and formation of gas are a result of one or more toxin-producing bacteria of the genus Clostridium entering the body through wounds. Clostridium bacteria thrive in the environment in deep, enclosed areas where oxygen levels are low, such as the uterus, gastrointestinal tract, gallbladder, and deep penetrating wounds of the muscles. This form of gangrene spreads very quickly and can be fatal.
In the surgical setting, intestinal surgery, especially resection of the bowel and biliary tract, is the most common cause of gas gangrene. Less frequently, gas gangrene is associated with vascular insufficiency in the lower extremities. Sometimes gas gangrene occurs as a complication of burns or amputation and can also occur spontaneously in association with an underlying cancer condition. Other cases have infrequently occurred after injections or gynecological procedures. An estimated 50% of wet gangrene cases result from a severe traumatic injury and 40% occur following surgery (Wright).
Individuals with diabetes mellitus, arteriosclerosis, or diseases affecting the blood vessels (such as Raynaud's disease) are at higher risk of developing gangrene. Injuries, surgery, and immunosuppression are also factors that increase the risk of gangrene.Incidence and Prevalence: Gas gangrene is not common. There are an estimated 1,000 to 3,000 cases diagnosed each year in the US. About one-third of those cases occur spontaneously (as compared to those cases resulting from trauma or a surgical wound) (Wener). |
Source: Medical Disability Advisor
| History: The individual may report a history of appendicitis, cholecystitis, intestinal obstruction, hernia, frostbite, crush injury, abortion, surgical or traumatic wounds, intramuscular injection sites (commonly seen in drug addicts), diabetes mellitus, or circulatory problems. Individuals may have moderate to severe pain and swelling around an injury site. They may also complain of nausea, vomiting, sweating, fever, chills, and anxiety.
Symptoms often come on suddenly and rapidly worsen. Physical exam: The exam may reveal fever, pain, darkening of tissue, and an unpleasant odor. The area may be swollen with blisters or have foul-smelling or bloody drainage from the tissues. The individual may have an elevated temperature, rapid heart rate, low blood pressure, cold extremities, and cool, clammy skin. Skin color may appear initially pale and then progress to dark red or purple; the skin may become yellow-colored as a result of the excessive breakdown of blood cells (jaundice). There may be subcutaneous emphysema, or air under the skin, which may appear to be a smooth bulge. If palpated, the bulge may produce a crackling sensation as the gas is pushed by the skin. Tests: Lab tests include a complete blood count (CBC), blood cultures, and cultures of the infected tissue and drainage. Sometimes exploratory surgery is required to obtain cultures and determine the source or extent of the infection. Imaging studies, such as plain x-rays, CT, and MRI, may be helpful. |
Source: Medical Disability Advisor
| Prompt surgical removal of dead, damaged, and infected tissue (débridement) is always necessary. If a crush injury occurs, the associated swelling of the muscle compartments may impair circulation. Under those circumstances, surgical incisions to release excess pressure in muscle compartments (fasciotomy) or excision of involved muscles (myectomy) may be needed to restore circulation. If the process is extensive and there are irreversible changes in an extremity, amputation becomes necessary. Plastic reconstruction may be needed if the surgical excisions involve a large area of tissue and/or muscle.
Administering pressurized, 100% oxygen (hyperbaric oxygen therapy) may limit the area of tissue destruction and reduce the amount of the tissue excision necessary. This intervention has varying degrees of success.
Blood transfusions, plasma infusions, and electrolyte replacement may be needed to treat associated blood loss, fluid loss, and shock. Antibiotics are given through a vein (intravenously). Pain medications may be used to control pain. |
Source: Medical Disability Advisor
| The prognosis is generally favorable, except in cases in which the infection has spread through the bloodstream. If this occurs, mortality rates approach 20% to 25%. With early treatment, however, approximately 80% of individuals with gas gangrene survive, with an estimated 15% to 20% requiring amputation (Wright).
Other forms of gangrene have more favorable outcomes following prompt surgical treatment. However, many individuals are left severely crippled or disfigured by the surgery. |
Source: Medical Disability Advisor
| Individuals with gangrene may require surgical excision of the gangrene or amputation. Those who do undergo excision of the gangrene may require physical and occupational therapy prior to discharge from the hospital in order to increase endurance. Physical therapy typically includes learning to care for the residual limb as well as performing stretches and weight-bearing exercises to increase mobility.
Individuals with one or more toes amputated may require a few physical therapy sessions to relearn the mechanics of walking as a result of decreased stability. Individuals learn to walk with a cane or may require a prosthesis that fits over the foot to increase stability.
Individuals with foot or lower extremity amputation require extensive physical therapy, both in the hospital and on an outpatient basis. Once the size of the residual limb stabilizes, individuals go to a certified prosthetist to be fitted for a prosthetic limb, as well as to learn how to put on and take off the prosthetic limb. Individuals begin walking in a set of parallel bars and then advance to skills such as walking and negotiating stairs. Some individuals may require a cane or crutches to increase stability, even with the prosthetic limb. Others, such as individuals in poor overall health or those who have had an above-knee amputation, may require a wheelchair for mobility. In this case, individuals are fitted with a custom wheelchair and learn to use it over ramps, curbs, and sidewalks. Those unable to walk using a prosthetic leg may still be fitted with a cosmetic prosthesis.
When amputation affects the upper body, individuals who lose one or more fingers may require occupational therapy to relearn tasks such as writing, grasping objects, and dressing. Those who lose part of an arm learn to bear weight through the residual limb using exercises such as wall push-ups that allow more functional return to the residual limb. Individuals use the grasping mechanisms of a prosthetic arm to perform activities such as dressing and driving. Those with an amputation above the elbow are rarely fitted with a prosthesis because the functional capabilities of a prosthetic arm decrease above the elbow and a cosmetic limb tends to impede functional abilities. In this case, an individual attends occupational therapy to learn how to compensate for the amputated limb by relearning to perform daily tasks with one hand. Individuals with an amputation of the dominant hand relearn handwriting tasks with the nondominant hand.
Individuals who sustain amputation may require counseling to deal with their altered body image. They typically undergo a period of grieving for their missing body part and should work through these feelings of loss with a psychologist trained in this area. Counseling will enable the individual to maintain motivation for learning new skills so that recovery is possible. |
Source: Medical Disability Advisor
| The spread of infection throughout the body (sepsis), shock, and multiple organ failure are the most serious complications associated with gangrene. |
Source: Medical Disability Advisor
| Many individuals are left severely crippled or disfigured by surgery. Job responsibilities may need to be adjusted according to the functional capacity of the individual. Occupational assistive devices will help those with amputated fingers. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have history of appendicitis, cholecystitis, intestinal obstruction, hernia, frostbite, crush injury, abortion, surgical or traumatic wounds, intramuscular injection sites (commonly seen in drug addicts), diabetes mellitus, or circulatory problems?
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Is there moderate to severe pain and swelling around an injury site?
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Is there evidence of persistent infection at the wound site?
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Does individual complain of nausea, vomiting, fever, and chills?
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On exam, is there fever, pain, darkening of tissue, and unpleasant odor? Is area swollen with blisters or drainage from the tissues? Does individual have an elevated temperature, rapid heart rate, and cool, clammy skin? Is jaundice present?
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Were wound and tissue cultures done?
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Has diagnosis of gangrene been confirmed? What type? Moist, dry, or gas gangrene?
Regarding treatment:
- Was culture and sensitivity done to positively identify the causative organism and determine the most effective antibiotic to use?
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Were antibiotic-resistant organisms ruled out?
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If process was extensive and irreversible changes in the extremity occurred, was amputation necessary?
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Since administering pressurized, 100% oxygen may limit the area of tissue destruction and reduce the amount of the tissue excision necessary, would this therapy still be an option?
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Did individual undergo hyperbaric oxygen therapy? With what degree of success?
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Has individual received or is individual scheduled for plastic reconstruction?
Regarding prognosis:
- Was diseased tissue successfully removed?
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Did culture and sensitivity confirm the most effective choice of antibiotic therapy?
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Was individual left severely crippled or disfigured by the surgery?
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Is individual scheduled for plastic reconstruction?
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Has individual received appropriate and well-fitting prosthetic device?
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Did individual receive comprehensive physical rehabilitation?
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Does individual have an underlying condition such as vascular disease, diabetes mellitus, malnutrition, alcoholism, immunodeficiency diseases, or a bleeding disorder that may affect recovery?
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Has individual been allowed to go through an appropriate period of grieving for the lost body part? Would individual benefit from working through these feelings of loss with a psychologist trained in this area?
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Does individual demonstrate signs of depression such as apathy, helplessness, fatigue, or loss of appetite? Would additional psychological counseling help individual deal with his or her altered body image?
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Source: Medical Disability Advisor
| Wener, Kenneth. "Gas Gangrene." MedlinePlus. 3 Feb. 2004. National Library of Medicine. 29 Oct. 2004 <http://www.nlm.nih.gov/medlineplus/ency/article/000620.htm>.Wright, Kathleen D. "Gangrene." Health A to Z. 29 Oct. 2004 <http://www.healthatoz.com/healthatoz/Atoz/ency/gangrene.jsp>. |
Source: Medical Disability Advisor
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