gangrene it’s type. And management and treatment

Gangrene and its types .management and treatment

1. GANGRENE AND
PRINCIPLES OF AMPUTATION
•By Roll No.26,27,39

2. SPECIFIC LEARNING OBJECTIVES
SU27.4.1 : Define gangrene and its types
SU27.4.2 : Differentiate between wet, dry and gas gangrene
SU27.4.3 : Describe the treatment of gangrene
SU27.4.4 : Describe the causes of diabetic gangrene,
frostbite, bedsores and its management

3. GANGRENE

4. GANGRENE
Gangrene refers to the death of macroscopic portions of tissue, which turns black because
of the breakdown of hemoglobin and the formation of iron sulphide
Sites:
-Limbs
-Appendix
-Bowel
-Testes

-Gallbladder

5. Causes of gangrene

•Secondary to arterial occlusion like atherosclerosis, emboli, diabetes, TAO, Raynaud's
disease, ergots.
•Infective: Boil, carbuncle, gas gangrene, Fournier's gangrene, cancrum oris.
•Traumatic: Direct, indirect.
•Physical: Burns, scalds, frostbite, chemicals, irradiation, electrical.
•Venous gangrene.

6. GANGRENE
Clinical Features
•Colour changes: Pallor, greyish, purple, brownish black due to
disintegration of haemoglobin to sulphide.
•Absence of pulse, loss of sensation, loss of function.
•Line of demarcation between viable and dead tissue by a band of
hyperaemia and hyperaesthesia along with development of a layer of
granulation tissue.

7. Types of gangrene
•Dry gangrene is due to slow, gradual loss
of blood supply to the part causing dry,
dessicated, wrinkled, mummified part with
proper line of demarcation from viable
adjacent tissues
•Wet gangrene is due to infection with
putrefaction causing edematous, swollen,
discoloured part spreading proximally with
vague line of demarcation from adjacent
viable tissues

8. Types of gangrene

9. Types of gangrene
•Gas gangrene
•special form of wet gangrene
•caused by clostridium perfringens which gain entry into the tissues through open
contaminated wounds, especially in the muscles, or as a complication of operation on
colon which normally contains clostridia
•The affected area is swollen, oedematous, painful and crepitant due to accumulation
of gas bubbles of carbon dioxide within the tissues formed by fermentation of sugars
by bacterial toxins
•Subsequently, the affected tissue becomes dark black and is foul smelling

10. Treatment of Gangrene
•Limb saving methods:
•1. Drugs: Antibiotics, vasodilators, pentoxiphyline, praxilene, dipyridamole, small dose
of aspirin, ticlopidine.
•2. Care of feet and toes: The part has to be kept dry. Any injury has to be avoided.
•3. Proper footwear is advised (microcellular rubber foot- wear, MCR).
•4. Measures for pain rellief is taken
•5. Nutrition supplementation is done The limb should not be warmed.
• 6. Pressure areas has to be. protected. Localised pus has to be drained
•7. Cause is treated;
•Diabetes is controlled

11. Life-saving procedures
• Amputations may have to be done often
•Level of amputation is decided on skin changes, temperature, line of demarcation, Doppler study.
•-> Below-knee amputation is a better option as BK prosthesis can be fitted better and also the
movements of knee joint are retained. There is no need of external support.
• -> In above-knee amputation range of movements are less, limp is present, and often requires third
(stick) support to walk.
•Different amputations done are Ray amputation, below-knee amputation, (Buerger's amputation)
Gritti-Stokes transgenial amputation,
•above-knee amputation,
• Lisfranc's, Chopart's, Symes'
• modified Symes' amputations are not commonly used in ischaemic limb as flaps will not survive

12. DIABETIC FOOT AND DIABETIC
GANGRENE
• Foot is a complex structure with many layers of muscles, ligaments,
joints, arches, fat, thick plantar fascia, vascular arches neurological
system which maintains weight-bearing, gravity, normal walk,
stability and gait (swing and stance phases).
•◦ Problems in diabetic foot: Callosities, ulceration, Abscess and
cellulitis of foot, Osteomyelitis of different bones of foot like
metatarsals, cuneiforms, calcaneum, Diabetic gangrene, Arthritis of
the joints

14. Pathogenesis of Diabetic
Foot/Gangrene
•1. High glucose level in tissues is a good culture media for bacteria. So infection is common.
•2. *Diabetic microangiopathy* causes blockade of micro-circulation leading to hypoxia.
•3. *Diabetic neuropathy* Due to sensory neuropathy, minor injuries are not noticed and so
infection occurs.
•4. Due to motor neuropathy, dysfunction of muscles, arches of foot and joints occurs. And
loss of reflexes of foot occurs causing more prone for trauma and abscess.
•5. Due to autonomic neuropathy, skin will be dry, causing defective skin barrier and so
more prone for infection.
•6. *Diabetic atherosclerosis* itself reduces the blood supply and causes gangrene.
•7. Thrombosis can be precipitated by infection causing infective gangrene. Blockage
occurs at plantar, tibial, and dorsalis pedis vessels.
•8. Increased glycosylated haemoglobin in blood causes defective oxygen dissociation
leading to more hypoxia

15. Features:
•1. Pain in the foot
•2. UIceration
•3. Absence of sensation.
•4. Absence of pulsations in the foot (posterior tibial and dorsalis pedis
arteries)
•5. Loss of joint movements 6. Abscess formation
•6. Change in temperature and colour when gangrene sets in.
•7. Patient may succumb to ketoacidosis, septicaemia or myocardial
infarction.

16. Investigations
•1. Blood sugar
•2. urine ketone bodies
•3. Blood urea and serum creatinine
•4. X-ray of part to look for osteomyelitis.
•5. Pus for culture and sensitivity.
•6. Doppler study of lower limb to assess arterial patency. Angiogram
to look for proximal blockage. 7. Ultrasound of abdomen to see the
status of abdominal aorta.
•8. Glycosylated haemoglobin estimation.

17. Treatment:
•Foot can be saved only if there is good blood supply.
•1. Antibiotics--decided by pus C/S. Regular dressing.
•2. Drugs: Vasodilators, pentoxiphylline, dipyridamole, low dose aspirin.
Diabetes is controlled by insulin only.
•3. Diet control, control of obesity. Surgical debridement of wound.
Amputations of the gangrenous area. Level of amputation has to be
decided by skin changes and temperature changes or Doppler study.
•4. Care of feet in diabetic: Any injury has to be avoided. MCR footwears
⁃
must be used (microcellular rubber). Feet has to be kept clean and dry,
especially the toes - and clefts; Hyperkeratosis has to be avoided.

19. FOURNIER'S GANGRENE
•It is also called as idiopathic gangrene of the scrotum
•It is a vascular gangrene of infective origin, caused by haemolytic
streptococci, microaerophilic streptococci, staphylococci, E. coli, CI.
Welchi, Bacteroides fragilis.
•There will be fulminant inflammation of the scrotal skin and
subcutaneous tissues resulting in obliterative arteritis of the arterioles
of the scrotal skin leading into cutaneous gangrene.
•It is common in diabetics, old age, malnourished, immuno-
suppressed individuals.

20. Features
•1. Condition is common in old age.
•2. Sudden pain in the scrotum, fever, severe toxicity.
•3. Very fast spreading cellulitis of scrotal skin, extending to the groin
and often to anterior abdominal wall.
•4. Extensive skin sloughing occurs leaving normal testis exposed.
•5. Sometimes toxicity is so severe that they may go for renal failure
and other complications
•6. Sometimes the condition may worsen rapidly leading to death
(25% mortality).

21. Treatment of Fourier's Gangrene
•1. Treated as an in-patient always
•2. IV fluids and catheterisation--for maintenance of urine output.
•3. Antibiotics, blood transfusion.
•4. Nutritional support (TPN, enteral)
•5. Liberal excision of all slough.
•6. Once patient recovers and wound granulates well, skin grating is
done 7. Orchidectomy is not necessary as testis is normal and viable.
•8. Testis can be placed in the pouch in medial aspect of the thigh.

23. TROPHIC ULCER (PRESSURE SORE/
DECUBITUS ULCER)
•1. Pressure sore is tissue necrosis and ulceration due to prolonged pressure.
Blood flow to the skin stops once external pressure becomes more than 30
mmHg (more than capillary occlusive pressure) and this causes tissue
hypoxia, necrosis and ulceration.
•2. It is more prominent between bony prominence and an external surface.
It is due to--impaired nutrition; defective blood supply; neurological deficit,
pressure, anaemia, injury, moisture.
•3. It is common in patients with orthopaedic and head injuries, comatose
and stroke patients, old age and tetanus patients Sites: Over the ischial
tuberosity; sacrum; heel; heads of metatarsals; buttocks; shoulder; occiput.
•4. Due to the presence of neurological deficit, trophic ulcer is also called as
neurogenic ulcer/neuropathic ulcer.

25. Investigations
•1. Study of discharge
•2. blood sugar
•3. wedge biopsy from the edge 4. X ray of the part and spine.

26. Treatment
•1. Cause should be treated, correction of diabetes and anaemia.
•2. Nutritional supplementation.
•3. Rest, antibiotics, slough excision, regular dressings
•4. Vacuum-assisted closure (VAC).
•5. Once ulcer granulates well, flap cover or skin grafting is done.
•6. Excision of the ulcer and skin grafting.
•7. Flaps--local rotation or other flaps (transposition flaps).
•8. Cultured muscle interposition.
•9. Proper care: Change in position once in 2 hours; lifting the limb
upwards for 10 seconds once in 10 minutes;

27. FROSTBITE
•It is a cold-induced injury that occurs when skin and underlying
tissues freeze due to prolonged exposure to cold temperatures.
•• It occurs due to too much of exposure to cold weather.
•• High altitudes with excessive cold precipitates vasospasm and
damage to the blood vessel wall. It causes sludging of blood and
thrombosis.

28. Causes of Frostbite
•1. Prolonged exposure to cold temperatures: Temperatures below 0°C (32°F) can
cause frostbite, but wind chill, humidity, and poor clothing can exacerbate the risk.
•2. Wind chill: Wind can significantly increase the risk of frostbite by stripping away the
layer of warm air closest to the skin.
•3. Wet conditions: Wet clothing or skin can increase the risk of frostbite, as moisture
conducts heat away from the skin.
•4. Poor clothing: Inadequate or wet clothing can fail to provide sufficient insulation,
increasing the risk of frostbite.
•5. Immobility: Individuals who are unable to move or are trapped in cold environments
are at increased risk of frostbite.

29. Treatment of Frostbite
•Initial Management
•1. Move to a warm environment: Transfer the individual to a warm,
dry place as soon as possible.
•2. Remove wet clothing: Remove any wet clothing and replace it
with dry, warm clothing.
•3. Immerse in warm water: Immerse the affected area in warm (not
hot) water at a temperature of around 40°C (104°F) for 20-30
minutes.

30. •Definitive Management
•1. Assess the severity: Evaluate the severity of the frostbite injury, which can
range from mild (frostnip) to severe (deep frostbite).
•2. Provide pain relief: Administer analgesics, such as morphine, to manage
pain.
•3. Elevate the affected area : Elevate the affected area above the level of
the heart to reduce swelling.
•4. Monitor for infection: Monitor the affected area for signs of infection, such
as redness, swelling, or pus.
•5. Surgical intervention: In severe cases, surgical intervention may be
necessary to remove dead tissue (debridement) or perform amputations.

31. Complications
•1. Gangrene : Untreated frostbite can lead to gangrene, which can
result in amputation.
•2. Infection: Frostbite can increase the risk of infection, particularly if
the affected area is not properly cleaned and dressed.
•3. Long-term damage : Frostbite can cause long-term damage to
the affected area, including numbness, tingling, and decreased
mobility

32. Bibliography
•Bailey and Love’s Short Practice Of Surgery 27th Edition
•S Das :A Manual On Clinical Surgery 17th Edition
•SRB’s Manual Of Surgery

33. Thank you