Gangrene & It’s Various Presentations

Gangrene & It's Various Presentations

Gangrene & It's Various Presentations

  • Gangrene refers to death of macroscopic portion of tissue which turns black because of breakdown of hemoglobin and formation of iron sulphide.
  • Usually affects distal parts of limb.
  • Dry Gangrene: Tissues are desiccated by gradual slowing of blood flow as result of atheromatous occlusion.
  • Wet Gangrene:It occurs when superadded infection and putrefaction occurs. Crepitus is present as result of infection by gas-forming organisms.
Wet Diabetic Gangrene
Scenario A 52 year-old male with long history of type 2 diabetes, who was presented in ER with ulcerations on Right foot. Until his admission to the Jinnah Hospital ER, he has suffered repeated hospital admissions, repeatedly proposing ray amputation, which the patient refused. On examination, there were necrotic patches over the dorsum of right foot & lateral aspect of right leg with pus discharge and there were ulcers over planter surface of right foot with foul smelling pus discharge. He is known smoker, hypertensive and case of chronic kidney disease. His HbA1c is 9.3 %. Q No. 1,  What is the most probable diagnosis?
  • Diabetic Wet Gangrene
  • Gangrene refers to death of macroscopic portion of tissue which turns black because of breakdown of hemoglobin and formation of iron sulphide.
  • Usually affects distal parts of limb.
  • Dry Gangrene: Tissues are desiccated by gradual slowing of blood flow as result of atheromatous occlusion.
  • Wet Gangrene:It occurs when superadded infection and putrefaction occurs. Crepitus is present as result of infection by gas-forming organisms.
Wet Diabetic Gangrene
Separation of Gangrene
  • A zone of demarcation develops between truly viable and dead or dying tissues.
  • Achieved by formation granulation tissue that is formed between dead and viable tissues.
  • Line of demarcation appears in matters of days if blood supply of the proximal part is adequate and there is minimum infection
  • If blood supply is poor to proximal part then line of demarcation is slow to form or does not develop at all.
  • Unless the arterial supply can be improved, the gangrene will spread to adjacent areas as “skip lesions”
  • To attempt local amputation in presence of poor circulation results in failure and gangrene will reappear in wound or skin edges.
Treatment of Gangrene
  • How much the limb can be salvaged depends upon the blood supply proximal to gangrene.
  • Poor circulation can be improved by surgical intervention and this may allow more conservative debridement or distal amputation.
  • Major amputations may be required in cases of life-threatening sepsis.
Diabetic Gangrene
  • Caused by combination of THREE factors
  • 1)Ischemia secondary to macrovascular disease 2)Peripheral sensorimotor neuropathy (PSN) 3)Immunosuppression
  • Macrovascular disease is atherosclerotic and typically affects crural vessels with relative sparing of pedal vessels
  • PSN usually sensory in early phase, classically is stocking distribution. Then it extends to joints of foot and ankle, resulting loss of nociceptive and proprioceptive reflexes
  • Ischemia and PSN acts synergistically to increase risk of diabetic foot ulceration
Management of Diabetic Gangrene
  • Treatment depends upon degree of arterial involvement.
  • Degree of arterial involvement is assessed and treated by angioplasty or surgery.
  • The gangrene is treated by 1.Drainage of pus 2.Liberal debridement of dead tissue 3.Antibiotics.
  • Primary amputation in case of sepsis
Bedsores/Decubitus Ulcers Bedsores are caused by local pressure. Predisposed by FIVE factors
  1. Pressure
  2. Injury
  3. Anemia
  4. Malnutrition
  5. Moisture
Pressure sores frequently occurs;
  1. Ischium
  2. 2.Greater trochanter
  3. Sacrum
  4. Heel
  5. Malleolus
  6. Occiput
Bed Sore/Pressure ulcer
Management of Bedsores
  • Appear and extend rapidly in immobile patients.
  • A bedsore can be expected if erythema appears that does not change color on pressure.
  • Once bedsores develop, they are difficult to heal.
  • Bedsores should be kept clean.
  • Skilled nursing care and specially designed bed reduces pressure to the skin.
  • Debridement if needed
  • VAC (Vacuum assisted closure) dressing
  • Opinion from plastic surgeon
Frostbite
  • Caused by exposure to cold.
  • Seen both in climbers at high altitudes and in elderly or the vagrant during cold weather.
  • Cold injury damages the wall of blood vessels that results in swelling and leakage of fluid together with severe pain
  • When the pain settles, there is waxy appearance, blistering and then gangrene follows
  • Treatment: 1. Gradual rewarming 2. Analgesics 3. Delayed conservative amputation
Frost Bite
Raynaud’s Disease
  • Idiopathic condition usually occurs in young women.
  • Affects the hands more then feet.
  • An abnormal sensitivity of arteries to cold.
  • Vessels constrict and the digits turn white and become incapable of fine movements.
  • Capillaries then dilate with slowly flowing deoxygenated blood, resulting in digits becoming dusky & swollen.
  • As the attack passes, arterioles relax and oxygenated blood returns into dilated capillaries & digits become red.
  • Characteristic sequence of blanching, dusky cyanosis and red engorgement, often accompanied by pain.
  • Superficial necrosis is very uncommon.
Treatment of Raynaud’s Disease
  • Protection from cold.
  • Avoidance of pulp and nail bed infection.
  • Calcium channel blockers, such as nifedipine.
  • Electrically heated gloves.
  • Sympathectomy
Raynaud’s Syndrome
  • Peripheral arterial manifestation of a collagen disease, such as SLE, Rheumatoid arthritis, etc.
  • Clinical features are as for Raynaud’s disease but is much more aggressive.
  • Recognized as industrial disease and is known as “Vibration white finger”
Treatment of Raynaud’s Syndrome
  • Conservative measures.
  • Calcium channel blockers such as nifedipine.
  • Steroids.
  • Vasospastic antagonists

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