Gangrene

Gangrene, leg care, dry & wet, aietiology, clinical features, investigations, treatment

1. GANGRENE

2. GANGRENE Macroscopic death of tissue with putrefaction. Pre gangrene : rest pain, colour changes, oedema , hyperaesthesia , ischaemic ulceration Types: dry and wet

3. DRY GANGRENE Blood supply: arterial – gradually deprived venous flow – unimpeded Arterial occlusion- chronic or acute Colour change: Greenish- black – dry- mummfied . Line of seperation is present. Stump is conical.

4. Line of demarcation : dead tissue and living tissue. Band of Hyperemia layer of granulation Hyperesthesia seen in: Senile, diabetic, buerger’s , raynaud’s , frost bite, vascular occlusion, embolism, ligation

5. WET GANGRENE Arterial & venous block Infection and putrefaction. Cold , pulseless, swollen, oedematous , blebs Horrible odour No line of demarcation Constitutional symptoms present. Spreads faster Seen in : acute inflammation, venous thrombosis, Gas gangrene, bed sores

6. Dry gangrene Wet gangrene

7. CAUSES ARTERIAL OCCLUSION : atherosclerosis, embolism, raynaud’s , buerger’s , cervical rib, syphilitic VENOUS OBSTRUCTION : DVT NERVOUS DISEASE : peripheral neuritis, tabes dorsalis , syringomyelia , leprosy, hemiplegia TRAUMATIC : Direct or indirect INFECTIVE : carbuncle, cancrum oris , gas gangrene, fourniers gangrene

8. DIABETIC GANGRENE PHYSICAL : Heat- burns and scalds, Cold – frost bite corrosive - alkalis, acids electricity Irridiation

9. DIFFERENTIAL DIAGNOSIS Senile gangrene: 8 > 50 yrs lower limbs, claudication – rest pain – dry gangrene with ulceration. Lericheis syndrome Buergers disease : Young men Upper & lower limbs Cigarette smoking, familial, auto immune Claudication – rest pain- postural colour changes- trophic changes-ulceration gangrene

10. Raynauds disease : young women, pulse unaffected. Embolic Gangrene : sudden, pain, cold and numb limb, pulse less

11. Syphilitic gangrene : rare , middle age, endarteritis obliterans , gummatous infiltration Dry type Venous gangrene : Plegmasia caerulosa dolens DVT of iliac and pelvic veins

12. INFECTIVE GANGRENE : Cancrum oris : toxaemic manifestation Stomatitis – ulceration –sloughing – ischaemia –gangrene Carbuncle : staphylococcus, diabetes, nape of neck, back Infective gangrene of skin and subcutaneous tissue

13. Fournier’s gangrene : vascular ,infective gangrene of scrotum Obliterative arteritis of scrotum – cutaneous gangrene Gangrene of internal organs : bowel, gall bladder, appendix etc. Wet type of gangrene Incarcerated hernia or volvulus sepsis

14. POST OPERATIVE SYNERGISTIC GANGRENE: Post operative in suabdomen , empyema drainage surgery for peritonitis. Spreading ulcer with destruction and burrowing

15. Gas gangrene Clostridium Trauma and ischaemia Exotoxins produced Necrosis with gas production – rapidly CF: pain , fever, swelling, Toxaemia , foul smell , khaki brown skin, Crepitus Types : fulminant , massive, group , subcutaneous, single

16. TREATMENT: INJ benzyl pencillin 20 lac IU 4hrly + metrinidazole Fresh blood transfusion Polyvalent antiserum 25000 units iv every 6hrs Hyperbaric oxygen Excision and debridement Rehydration and electrolyte management amputation8

17. Diabetic gangrene Atherosclerosis Peripheral neuritis Infection – hyperglycaemia Wet gangrene – young Dry gangrene- old, atherosclerotic

18. Neuropathic gangrene : Lost sensation , repeated trauma , pressure8 Blood supply normal Painless, progressive Bed sores: Pressure, anemia, malnutrition, sensory loss, moisture Wet gangrene. Traumatic gangrene: Injury to artery - direct Crush injury - indirect

19. PHYSICAL GANGRENE Frost bite : exposure to cold Damage to arteries-edema- blisters – gangrene Painless, waxy. Dry gangrene

20. Burns gangrene: Electrical gangrene: Corrosive gangrene :

21. Drugs causing gangrene: Inadvertent injection of drugs Iatrogenic- intraarterial injection of thiopentane Ergot preparations

22. ICU GANGRENE : Sepsis, DIC, vasopressors Arterial punctures Symmetrical peripheral gangrene Pallor-cyanosis, bullae – blisters – gangrene Stop sepsis, vasopressors amputation

23. INVESTIGATION Blood: routine examination WR – Syphilis sugar- diabetes, TG, cholesterol. urea, electrolytes 2. Urine: sugar , renovascular insufficiency 3. X ray: atherosclerosis , aneursym , gas –gas gangrene, bone erosion in gangrene 4. ECG- Cardiac status 5. USG – ABDOMEN 6. Pus - culture

24. X ray Gas gangrene Atherosclerosis

25. 8 7. Doppler: Duplex scan : b mode usg & doppler Arterial flow , flow rate, velocity, stenosis, block. Ankle brachial pressure index: < 0.3 severe ischemia – gangrene 8. SEGMENTAL PRESSURE: 9. PLETHYSMOGRAPHY: Segmental plethysmography is introduced by placing venous occlusion cuffs around thigh, calf, ankle Cuffs inflated to 65mmhg and pulsation is quantitative measure of arterial diseases.

26. 10. Arteriography : Contrast – Hyphaque 45( sodium diatriozoate ) Direct arterial puncture : failure of retrograde method. aortoiliac / femoropopliteal arteriography . Retrograde percutaneous catherterization : Seldinger’s technique X rays taken TAO – CORK SCREW May ppt gangrene

27. Seldingers technique

28. 12. CT/ MRI Angiogram: 13.OSCILLOMETRY : we can assess level amputation Gas gangrene: culture, x ray, LFT, CT, Sr urea, creatinine

29. 8 ELECTRO MAGNETIC FLOW METER

30. ISOTOPE TECNIQUE Xenon133 IM Technetium 99 Recent IV injection of isotope has been used to get direct arterial visualisation Gamma camera used to picturise blood flow

31. BROWNS VASO MOTOR INDEX: Method : nerve block with local anesthesia or spinal anesthesia is given and any rise in skin temperature is recorded and compared with rise of mouth temperature Browns vasomotor index > 3.5 or more operation is advisable

32. TREATMENT LIMB SAVING METHODS : DRUGS: Antibiotics Vasodilators Pentoxiphylline , dipyridamole , aspirin, toclpidine .

33. Care of foot : Dry Foot wear- MCR Nutrition Avoid injury, pressure, warming Pus drainage Control diabetes Treat cause

34. Surgeries: Lumbar sympathectomy omentoplasty Profundaplasty Endarterioectomy Femoropopliteal thrombectomy Arterial bypass graft

35. SYMPATHECTOMY PROFUNDOPLASTY

36. EMBOLECTOMY BYPASS GRAFT

37. ENDARTECTOMY OMENTOPLASTY

38. Life saving procedure : AMPUTATION : Ray amputation Below knee amputation Above knee amputation: Trans condylar – Gritti stokes amputation: Modified syme’s :

39. RAY AMPUTATION

40. Above knee amputation

41. Gulliton amputation

42. Lisfranc’s amputation: Choparts amputation: Transmetatarsal amputation