Gas Gangrene in Emergency Medicine Clinical Presentation
- Author: Anil Shukla, MD; Chief Editor: Rick Kulkarni, MD more...
History
History for gas gangrene includes the following:[1, 2]
- Infection usually results from deep trauma or surgery, although minor procedures, such as intramuscular injection, have been associated with gas gangrene.
- The incubation period is usually less than 24 hours but has been described to be anywhere from 7 hours to 6 weeks, though when symptoms start, clinical deterioration can occur within hours.
- Muscle swelling and severe pain are prominent features. The pain is often out of proportion to physical findings, reflective of the hypoxic state of the muscle tissue, and is key to distinguishing gas gangrene from simple cellulitis.
- Systemic toxicity may cause altered mental status, and the progression to toxemia and shock can be rapid.
Physical
Physical findings of gas gangrene are as follows:[1, 2, 3, 10, 11]
- Vital signs: Unusually, fever is not a prominent feature of infection and may only be low grade throughout the clinical course. The degree of systemic involvement may produce a spectrum of changes from tachycardia through outright septic shock including hypotension and diaphoresis.
- Overlying skin: Initially, the skin may be normal and then progress through a yellowing or bronzing to bulla formation to patches of green/blue/grey/black necrosis. Serosanguineous drainage may be present, described classically as having a “mousy” or slightly sweet odor.
- Examination: Most notable is extreme pain of the affected area with or without movement and with palpation, which may be out of proportion to the extent of the overlying skin changes. Tense edema with crepitance due to subcutaneous air may be noted and is proportional to the extent of underlying necrosis.
- Vascular examination: Distal pulses may be normal or diminished depending on the extent of local damage.
- Neurologic examination: Decreased pain or anesthesia at the site of infection can indicate that cutaneous nerve endings are being destroyed and that the disease is advanced.
Causes
Risk factors for gas gangrene include the following:[8, 12]
- Burns
- Chronic alcoholism (See the image below.)
Left lower extremity in a 56-year-old patient with alcoholism who was found comatose after binge drinking. Surgical drainage was performed to treat the pyomyositis-related, large, non–foul-smelling (sweetish) bullae. Gram staining showed the presence of gram-positive rods. Cultures revealed Clostridium perfringens. The diagnosis was clostridial myonecrosis. - Corticosteroid use
- Gastrointestinal malignancy
- HIV/AIDS
- Hypoalbuminemia
- Intravenous drug abuse (See the image below.)
A patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures. - Malnutrition
- Obesity
- Open fractures
- Surgery
- Trauma
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