Chapter 6: Plastic Surgery. - Famona Site

muscle tissues change to a dark colour and lose their contractility with secretion of a brickred,foul-smelling fluid and the development of gas-containing bullae.Systemic effects such as cardiotoxicity, brain dysfunction and renal failure may be theresult of proteolytic and saccharolytic enzymes which are responsible for the production ofhydrogen sulphide. The various species of Clostridia liberate their own specific endotoxins,i.e. the alpha-toxin of Clostridium novyi predominantly increases vascular permeability.Clinical PresentationThe incubation period in the trauma and post-surgical groups ranges from eight hoursto 20 days, with an average of four days after the initiating event.It must be noted that patients with gas gangrene remain remarkably alert with extremesensitivity to their surroundings, despite profound shock, impairment of renal function andadvancing palpable crepitus. They realise their impending doom and a sense of terror becomesevident in their facial expression. Just before death they mercifully lapse into a toxic deliriumand coma.Successful management depends on early diagnosis of this condition - thus a highindex of suspicion should be maintained to ensure recognition of the early signs of theinfection, which include subtle changes such as:- pain in a wound or a surgical incision which increases progressively in intensity andis disproportionately severe- a tachycardia disproportionate to the fever- shiny oedematous skin around a wound, and- apathy.Suspicion should also be high in any situation where the patient is compromised byshock, vascular impairment, oedema, tight-tension skin sutures, abdominal distension or atight plaster cast. Progressive changes can take place towards the classic presentation of thedisease.smell"These include:- oedema- a discoloured wound with brown to brick-red watery discharge with a "foul-sweet- haemorrhagic bullae and rapid extention of the surrounding erythema.Palpable crepitations are only found later. Subsequently, shock and renal failure ensue.35