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Gangrene
Gangrene is the death of body tissue due to lack of blood supply and oxygenation. There are two main types - dry gangrene caused by arterial blockages, and wet gangrene caused by both arterial and venous blockages along with infection and putrefaction. Gangrene has many potential causes including diabetes, peripheral vascular disease, trauma, frostbite, and infection. Treatment depends on the type and cause but may include antibiotics, debridement, amputation, or in some cases limb salvaging procedures to restore blood flow.
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Gangrene
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- 2. GANGRENE • Macroscopic deathof tissue with putrefaction. • Pre gangrene: rest pain, colour changes, oedema, hyperaesthesia, ischaemic ulceration • Types: dry and wet
- 3. DRY GANGRENE • Bloodsupply: arterial – gradually deprived venous flow – unimpeded • Arterial occlusion- chronic or acute • Colour change: Greenish- black – dry- mummfied. • Line of seperation is present. • Stump is conical.
- 4. • Line ofdemarcation: • dead tissue and living tissue. • Band of Hyperemia • layer of granulation • Hyperesthesia • seen in: Senile, diabetic, buerger’s , raynaud’s, frost bite, vascular occlusion, embolism, ligation
- 5. WET GANGRENE • Arterial& venous block • Infection and putrefaction. • Cold , pulseless, swollen, oedematous, blebs • Horrible odour • No line of demarcation • Constitutional symptoms present. • Spreads faster • Seen in : acute inflammation, venous thrombosis, Gas gangrene, bed sores
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- 8. CAUSES • ARTERIAL OCCLUSION:atherosclerosis, embolism, raynaud’s, buerger’s, cervical rib, syphilitic • VENOUS OBSTRUCTION: DVT • NERVOUS DISEASE: peripheral neuritis, tabes dorsalis, syringomyelia, leprosy, hemiplegia • TRAUMATIC : Direct or indirect • INFECTIVE: carbuncle, cancrum oris, gas gangrene, fourniers gangrene
- 9. • DIABETIC GANGRENE •PHYSICAL : Heat- burns and scalds, Cold – frost bite corrosive - alkalis, acids electricity Irridiation
- 10. DIFFERENTIAL DIAGNOSIS Senile gangrene: •8 > 50 yrs • lower limbs, claudication – rest pain – dry gangrene with ulceration. • Lericheis syndrome Buergers disease: • Young men • Upper & lower limbs • Cigarette smoking, familial, auto immune • Claudication – rest pain- postural colour changes- trophic changes-ulceration gangrene
- 11. Raynauds disease: youngwomen, pulse unaffected. Embolic Gangrene: sudden, pain, cold and numb limb, pulse less
- 12. Syphilitic gangrene: •rare , middle age, endarteritis obliterans, gummatous infiltration • Dry type Venous gangrene: • Plegmasia caerulosa dolens • DVT of iliac and pelvic veins
- 13. • INFECTIVE GANGRENE: Cancrumoris: toxaemic manifestation • Stomatitis – ulceration –sloughing – –gangrene Carbuncle : staphylococcus, diabetes, nape of neck, back • Infective gangrene of skin and subcutaneous tissue
- 14. Fournier’s gangrene: •vascular ,infective gangrene of scrotum • Obliterative arteritis of scrotum – cutaneous gangrene Gangrene of internal organs: bowel, gall bladder, appendix etc. • Wet type of gangrene • Incarcerated hernia or volvulus • sepsis
- 15. • POST OPERATIVESYNERGISTIC GANGRENE: • Post operative in suabdomen, empyema drainage surgery for peritonitis. • Spreading ulcer with destruction and burrowing
- 16. GAS GANGRENE • Clostridium •Trauma and ischaemia • Exotoxins produced • Necrosis with gas production – rapidly • CF: pain , fever, swelling, Toxaemia, foul smell, khaki brown skin, Crepitus • Types : fulminant , massive, group , subcutaneous, single
- 17. • TREATMENT: • INJbenzyl pencillin 20 lac IU 4hrly + metrinidazole • Fresh blood transfusion • Polyvalent antiserum 25000 units iv every 6hrs • Hyperbaric oxygen • Excision and debridement • Rehydration and electrolyte management • amputation8
- 18. DIABETIC GANGRENE 1. Atherosclerosis 2.Peripheral neuritis 3. Infection – hyperglycaemia • Wet gangrene – young • Dry gangrene- old, atherosclerotic
- 20. Neuropathic gangrene: • Lostsensation , repeated trauma , pressure8 • Blood supply normal • Painless, progressive Bed sores: • Pressure, anemia, malnutrition, sensory loss, moisture • Wet gangrene. Traumatic gangrene: • Injury to artery - direct • Crush injury - indirect
- 21. PHYSICAL GANGRENE Frost bite:exposure to cold • Damage to arteries-edema- blisters – gangrene • Painless, waxy. • Dry gangrene
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- 23. Drugs causing gangrene: •Inadvertent injection of drugs • Iatrogenic- intraarterial injection of thiopentane • Ergot preparations
- 24. •ICU GANGRENE: • Sepsis,DIC, vasopressors • Arterial punctures • Symmetrical peripheral gangrene • Pallor-cyanosis, bullae – blisters – gangrene • Stop sepsis, vasopressors • amputation
- 25. INVESTIGATION 1. Blood: routineexamination WR – Syphilis sugar- diabetes, TG, cholesterol. urea, electrolytes 2. Urine: sugar , renovascular insufficiency 3. X ray: atherosclerosis , aneursym, gas –gas gangrene, bone erosion in gangrene 4. ECG- Cardiac status 5. USG – ABDOMEN 6. Pus - culture
- 26. X RAY GAS GANGRENEATHEROSCLEROSIS
- 27. 8 7. Doppler: Duplexscan: b mode usg & doppler Arterial flow , flow rate, velocity, stenosis, block. Ankle brachial pressure index: <0.3 severe ischemia – gangrene 8. SEGMENTAL PRESSURE: 9. PLETHYSMOGRAPHY: • Segmental plethysmography is introduced by placing venous occlusion cuffs around thigh, calf, ankle • Cuffs inflated to 65mmhg and pulsation is quantitative measure of arterial diseases.
- 29. 10. Arteriography: • Contrast– Hyphaque 45( sodium diatriozoate) Direct arterial puncture: failure of retrograde method. • aortoiliac / femoropopliteal arteriography. Retrograde percutaneous catherterization: • Seldinger’s technique • X rays taken • TAO – CORK SCREW • May ppt gangrene
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- 31. 12. CT/ MRIAngiogram: 13.OSCILLOMETRY: we can assess level amputation • Gas gangrene: culture, x ray, LFT, CT, Sr urea, creatinine
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- 33. ISOTOPE TECNIQUE • Xenon133IM • Technetium 99 • Recent IV injection of isotope has been used to get direct arterial visualisation • Gamma camera used to picturise blood flow
- 34. BROWNS VASO MOTOR INDEX: Method: nerve block with local anesthesia or spinal anesthesia is given and any rise in skin temperature is recorded and compared with rise of mouth temperature Browns vasomotor index > 3.5 or more operation is advisable
- 35. TREATMENT LIMB SAVING METHODS: •DRUGS: Antibiotics Vasodilators Pentoxiphylline, dipyridamole, aspirin, toclpidine.
- 36. Care of foot: •Dry • Foot wear- MCR • Nutrition • Avoid injury, pressure, warming • Pus drainage • Control diabetes • Treat cause
- 37. Surgeries: • Lumbar sympathectomy •omentoplasty • Profundaplasty • Endarterioectomy • Femoropopliteal thrombectomy • Arterial bypass graft
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- 41. •Life saving procedure: • AMPUTATION: •Ray amputation • Below knee amputation • Above knee amputation: • Trans condylar –Gritti stokes amputation: • Modified syme’s:
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- 45. • Lisfranc’s amputation: •Choparts amputation: • Transmetatarsal amputation