Chapter 6: Plastic Surgery. - Famona Site

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Diagnosis and Special Investigations- The diagnosis is made by clinical assessment.- Gram staining of wound drainage is a rapid means of confirming a suspecteddiagnosis of this condition. If gram-positive bacilli are found in a patient with early signs ora classic presentation as described above, it should be considered to be gas gangrene untilproven otherwise and treatment must be initiated even before culture results are available.- Blood cultures are required for a final diagnosis. It must be borne in mind that theorganism can take 48-72 hours to grow, hence treatment is initiated on clinical grounds.- Other valuable laboratory investigations include serial leucocyte and platelet countsand bilirubin measurements.- Renal function measurement is not an early diagnostic aid, but it is helpful as aprognostic assessment and as a monitor of progress.- Radiographs will not necessarily consistently demonstrate the presence of gas in thetissue and the evidence of gas on X-ray is not pathognomonic of clostridial gas gangrene.The diagnosis can thus not be confirmed by gas in the tissue alone, as a variety ofother organisms can produce gas, i.e. E. coli, anaerobic streptococci, bacteroids infections andeven aerobic aerogenic infections like haemolytic staphylococcal fasciitis and haemolyticstreptococcal gangrene. Other organisms implicated include Klebsiella, Enterobacter andPseudomonas. Gas in soft tissue seen on X-ray can also be the result of the mechanical effectof trauma, hydrogen peroxide irrigation, barotrauma and surgery. In myonecrosis, theradiograph usually demonstrates a feathery pattern, indicating dissection along musclefascicles as opposed to large gas bubbles, which are usually associated with the soft-tissue gasof open wounds.Differential DiagnosisGas in tissues and a necrotizing myositis are not pathognomonic of clostridialinfections. Other organisms, as mentioned, can also be responsible for the formation of softtissuegas. The history and clinical presentation assist in the differential diagnosis (table6.4.2). Gram stains may be helpful.36
Table 6.4.2. Differential Diagnosis of Soft Tissue GasBacterialI Aerobic aerogenic infections- Haemolytic streptococcal fasciitis- Haemolytic streptococcal gangrene- ColiformII Anaerobic Streptococcal infectionsIII Bacteroides InfectionsIV ClostridiaV Mixed aerobic and anaerobic infectionsNonbacterial- Mechanical effect of trauma- Air hose injury injection- Hydrogen peroxide irrigation- Injection of benzene- Barotrauma, dysbarism- Postoperative- Aberrant sexual activity.Prophylaxis and TreatmentIn the injured patient prophylaxis is aimed at proper wound care, including thoroughdebridement where indicated and recognition of high-risk patients. This includes carefulinspection and cleaning of wounds prior to a decision on surgical closure and carefulobservation of patients with a risk of developing gas gangrene. The effectiveness of antitoxinhas not been proved and its possible allergic reactions and side-effects do not justify its use.Careful attention to resuscitation is essential, since some of the toxins released by thehistiotoxic organisms cause increased vascular permeability with intravascular volume lossto the interstitial compartment. Haemolysis and/or surgical losses can result in sizeablevolumes of blood loss and several units of blood must be made available. A subclavian andarterial line are required to adequately monitor and medically manage the patient. The fourcornerstones of prophylaxis and treatment remain:- suspicion- early recognition- effective early surgical debridement- administration of antibiotics.Hyperbaric oxygen has proved to be a beneficial adjunct. It is important to realize thatantibiotics alone, in the absence of an adequately debrided wound, will not prevent gasgangrene. More frequent use of delayed primary and secondary closure in suspected casescould play a major role in preventing gas gangrene.37
Page 1 and 2: C J Mieny, U Mennen: Principles of
Page 3 and 4: SkinThe anatomy of the blood supply
Page 5 and 6: BoneAttempts are made to remove as
Page 7 and 8: Brain: DebridementThe regeneration
Page 9 and 10: Chapter 6.2: Closure of Wounds and
Page 11: Skin OverlapWhy, when simple suture
Page 14 and 15: diameter of a vessel becomes a sign
Page 16 and 17: CommentClosure of Wounds and Materi
Page 18 and 19: Facial Human BitesIn the head regio
Page 20 and 21: After irrigation, removal of devita
Page 22 and 23: Sites Bitten by DogsThese include:-
Page 24 and 25: Injury Type- large wounds (lacerati
Page 26 and 27: Snake BitesBy definition snake bite
Page 28 and 29: Following poisonous snake bites:- t
Page 30 and 31: with the shark. In addition the vic
Page 32 and 33: - I think the fact that with minor
Page 34 and 35: Gas gangrene has often erroneously
Page 38 and 39: Surgical DebridementTimely surgery
Page 40 and 41: PrognosisIn spite of remarkable adv
Page 42 and 43: symptoms of the disease. The incuba
Page 44 and 45: Prophylaxis After Trauma- Prompt an
Page 46: - Assisted ventilation and administ
Page 49 and 50: are deep with superficial areas aro
Page 51 and 52: Diagnosis and Special Investigation
Page 53 and 54: Blood/Plasma/ColloidsThese are usua
Page 55 and 56: Early excision and skingrafting of
Page 57 and 58: DiagnosisWound swabs are often not
Page 59 and 60: Early excision of deep localized in
Page 61 and 62: The use of 1% copper sulphate solut
Page 63 and 64: - Massively increased metabolic rat
Page 65 and 66: - the fascial plexuses both deep to
Page 67 and 68: Full Thickness Skin GraftsThese gra
Page 69 and 70: Random FlapsThese are skin flaps mo
Page 71 and 72: very largely on the experience of t

Chapter 6: Plastic Surgery. - Famona Site

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