Prehospital Care
Prehospital care for gas gangrene includes the following:
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Oxygenation
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Intravenous (IV) fluids
Emergency Department Care
Gas gangrene is a true emergency, and concurrent evaluation, treatment, and coordination of care should be carried out. [1, 2, 3, 18]
Generally speaking, the treatment is a combination of antibiotics, surgery, and hyperbaric oxygen. See the following:
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Airway and breathing: Oxygen and airway management as necessitated by the clinical picture.
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Circulation: Good vascular access and liberal use of intravenous fluids is indicated. Frequent reassessment of the circulatory status is necessary. If pressors are necessitated, vasoconstrictors should only be used if absolutely necessary; they can decrease perfusion to already ischemic tissue.
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Administer tetanus toxoid if indicated.
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Administer antibiotics.
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Correct electrolyte abnormalities.
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Check compartment pressures if severe pain and evidence of compartment syndrome are present with minimal cutaneous evidence of infection.
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Wound care is indicated.
Consultations
Obtain immediate surgical consultation. While laboratory studies and imaging studies may help make the diagnosis of gas gangrene, the criterion standard is tissue biopsy. Furthermore, definitive treatment of gas gangrene is wide debridement of necrotic muscle. Antibiotics will not reach the infected devitalized tissue. Necrotic tissue is identifiable because it does not bleed or contract when debrided.
The presence of hemodynamic instability, crepitus, bullae, subcutaneous gas on imaging, clear tissue necrosis, or any combination of the above is an indication for emergent surgery. [17] The possibility of anaerobic cellulitis should not exclude surgical exploration for necrotic tissue. [13] Patients without these signs are appropriate for monitoring and further workup.
Given the rapidly progressive nature of gas gangrene, multiple episodes of debridement may be required to gain source control of the infection. Loss of limb viability and function are frequent consequences of both infection and debridement, and the need for limb amputation is a relatively common morbidity. The need for amputation is more frequent in gas gangrene than other necrotizing soft tissue infections. [18, 11]
Medical Care
Hyperbaric oxygen therapy
The use of hyperbaric oxygen (HBO) in gas gangrene is controversial, largely owing to a lack of randomized control trials, and should not delay surgical debridement and antibiotic therapy. However, some studies, mostly case reports, have demonstrated decreased morbidity and mortality when HBO is used in supplementation to standard treatments. HBO can also help clarify the demarcation between devitalized and viable tissue, allowing for more conservative excision. [25, 26, 27]
Prevention
Appropriate wound care at time of injury (eg, debridement of crushed or dead tissue, copious irrigation) may deter infection.
Prophylactic antibiotics may prevent subsequent infection in selected circumstances.
Further Inpatient Care
Urgent-to-emergent surgical debridement is indicated for gas gangrene. Gas gangrene is a rapidly progressive illness. Patients who are initially well-appearing frequently develop the sequelae of severe sepsis or septic shock, and delay to debridement significantly increases this risk. [11, 12] Admit the patient to an ICU with central access and invasive monitoring as necessary.
Inpatient & Outpatient Medications
Inpatient medications for gas gangrene include intravenous antibiotics and analgesics.
Transfer
Transfer the patient if appropriate surgical specialist and ICU setting are unavailable.
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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.
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A patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures.
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Gas feathering in the arm soft tissue of a patient with gas gangrene.
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Extension of gas gangrene to the chest wall despite initial debridement.
