Gas gangrene is a life-threatening infection of subcutaneous tissue and muscle caused by clostridial bacteria such as Clostridium perfringens, which release toxins like alpha toxin that cause tissue necrosis. It is associated with wounds, surgery, or trauma and has a rapid onset of symptoms like pain, swelling, crepitus, and gangrenous changes in the skin. Aggressive surgical debridement and antibiotics such as penicillin are needed for treatment to prevent complications like sepsis, shock, and potential limb loss.

1. GAS GANGRENE
DR POOJA PANDEY
JUNIOR RESIDENT -1
MS. GENERAL SURGERY
MIMS ,BARABANKI UTTAR PRADESH

2. Definition
It is an infective gangrene
caused by clostridial
organisms involving mainly
skeletal muscle as
oedematous myonecrosis.

3. Organisms
a. C. perfringens 80% , Clostridium welchii
(perfringens): Gram-positive, central spore
bearing, nonmotile, capsulated organisms,
most common.
b. Clostridium oedematiens.
c. Clostridium septicum.
d. Clostridium histolyticum.
e. C. novyi,
f. C. sordelli,
g.C. fallax,
h.C. bifermentans

4. 1.Toxins Major Toxins
α A-E Lecithinase, Necrotising, Haemolytic
β B,C Necrotising
ε B,D Permease
Iota E Dermonecrotic
2. Minor Toxins
δ B Haemolysin
θ A-E Haemolysin, Cytolysin
κ A-E Collagenase, Gelatinase, Necrotising
λ B,D,E Protease
µ A-E Hyaluronidase
ν A-E Deoxyribonuclease, Leucocidin, Hemolytic, Necrotising

5. Pathogenesis
Lecithinase is important toxin which
is haemolytic, membranolytic and
necrotic causing extensive myositis. It
splits lecithin into phosphocholine.
Haemolysin causes extensive
haemolysis.
Hyaluronidase helps in rapid spread
of gas gangrene.
Proteinase causes breaking down of
proteins in an infected tissue

7. Risk Factors
 1.Road traffic accidents- Deep wound
 Injuries to muscles.
 Crushed tissue
 Wound contaminated with dirt
2.Immunocompromised state like –
 HIV
 Chemotherapy and radiotherapy.
3.Diabetes
4.HTN
5.Smoking
7.Alcoholism
8,I.V drug abuse.

8. Clinical Features
Incubation period is 1-2 days.
1) Features of toxaemia, fever, tachycardia.
2) Wound is under tension with foul smelling discharge (sickly
sweety /decaying apple odour).
3) Brown coloured skin due to haemolysis.
4) Crepitus can be felt.
5) Jaundice, oliguria.
6) Clostridium welchii can infect limbs, abdominal wall,
appendix, gallbladder, common bile duct, intestine, uterus

11. Classification
A. Fulminant type causes rapid progress and often death due
to toxaemia, renal failure or liver failure or ARDS.
B. Massive type involving whole of one limb containing fully
dark coloured gas filled areas.
C. Group type: Infection of one group of muscles, extensors of
thigh, flexors of leg.
D. Single muscle type affecting one single muscle.
E. Subcutaneous type of gas gangrene involves only
subcutaneous tissue

12. Fulminant type
Subcutaneous type
Group of muscles involved
Single muscle type

13. Complications
1. Septicaemia, toxaemia.
2. Renal failure, liver failure.
3. Circulatory failure
4. DIC
5. secondary infection.
6. Death.

14. Investigations
1) X-ray shows gas in muscle plane or under the
skin.
2) Liver function tests, blood urea, serum creatinine,
TLC.
3) CT scan useful in chest or abdominal wounds.
4) Gram’s stain shows Gram-positive bacilli.
5) Robertson’s cooked meat media is used which
causes meat to turn pink with sour smell and acid
reaction.

15. Air present
indicates
Gas gangrene
in lower limb

16. Treatment
a. Injection benzyl penicillin 20 lacs 4th hourly +
Injection metronidazole 500 mg 8th hourly + Injection
aminoglycosides or third generation cephalosporins
.
b. Fresh blood transfusion.
c. Polyvalent antiserum 25,000 units
d. Hyperbaric oxygen.
e. All dead tissues are excised and debridement is
done.

17. Treatment
f. Rehydration and maintaining optimum urine
output(0.5ml/kg/hour).
g. Electrolyte management. h. In severe cases amputation has to
be done as a life-saving procedure
j. Often ventilator support is required. k. Hypotension in gas
gangrene is treated with whole blood transfusion.

18. SURGICAL CARE
 Fasciotomy for compartment syndrome –not be delayed in patients
with extremity involvement.
 For necrotic tissue- daily debridement needed.
 Life saving procedure- amputation of the extremity.
 In case of abdominal involvement –excision of the body wall
musculature.
 Hysterectomy is needed in case of uterine gas gangrene following
septic abortion.

19. Multiple choice question
Q1)When the Clostridium perfringes is introduced in the body
,what type of gangrene will result
a)Wet gangrene
b)Fournier’s gangrene
c)Dry gangrene
d)Gas gangrene.
Q2) Regarding gas gangrene one of the following is correct:
A. It is due to Clostridium Botulinum infection
B. Clostridial species are gram—negative spore forming
anaerobes
C. The clinical features are due to the release of protein
endotoxin
D. Gas is invariably present in the muscle compartments

20. Scenario based questions
A 55 year female patient came in ER with the complaints of RTA 1 day back
and presented with fever ,pain and heaviness in left leg associated with
multiple open wounds and swelling since then. She was treated in PHC and
from there she was referred to the Tertiary Centre for further management.
O/E- temp-100 degree F,B.P100/70 mm of Hg, PR-110/min,RR-24/min .
O/I- left limb was swollen , bronze discoloration of the surrounding skin ,
and discharge was present which was very offensive in nature , few wounds
were necrosed too.
a)What is the differential diagnosis ?
b)Write the work up plan to reach the definitive diagnosis?
c)How will you manage the case ?