Etiology. Pathogens are a number ofanaerobic, sporiferous, toxin-forming microbes. The most important of them: you. реrfringens, you. oedeiaatiens, Vibrion septique, you. hystoliticus. These germs cause disease, each alone or in symbiosis with each other, often in combination with pyogenic microbes. Most of them are saprophytes in the intestines of humans and animals.
Epidemiology. The occurrence of a gas infection is closely related toinjury. In peacetime, gas infection is relatively rare. In wartime conditions, gas infection is one of the most severe wound complications (about 2% of all complicated wounds). The presence of a smashed wound with a violation of blood circulation and contamination of its soil, scraps of infected clothing are the main prerequisites for the development of gas infection. Disputes of microbes caught in the wound with shell fragments, earth or clothes, find favorable conditions for reproduction in the affected tissues.
Pathogenesis. Gas germs penetrate into the body the mainin the case of gunshot wounds. For the development of infection of great importance is the localization and nature of the wound. Smashed and dead tissue, devoid of normal blood supply and access to oxygen, is the best medium for anaerobic microbes. The presence in the wound of anaerobic microbes (staphylo- and streptococci), causing suppuration, weakens the body and increases the toxic effect of anaerobic microbes. Pathogenic anaerobes, unlike saprophytic anaerobes, decompose living tissue. The spread of infection goes through the lymphatic ways.
Depending on the depth of injury and the width of the zonedamage the infection spreads superficially (epiphastically) or intermuscularly (subfascially). Tissues involved in the infection zone undergo decomposition with the formation of hemorrhagic edema and gas bubbles. There is a thrombosis of blood vessels. In thrombi, foci of microbial development are formed. Under the influence of toxin, the decomposition of hemoglobin occurs. accumulation of hematin in the blood, hematinuria and a peculiar bronze coloration of the skin.
Symptoms. Strong bursting pain in the wound and on the govessels; necrosis, swelling and discoloration of the skin around the wound; change in the color of the wound surface (dirty gray); scant separable; an increase in the size of the limb and bronze spots, indicating the effects of necrosis and circulatory disorders. The appearance of gas and tissues (crepitation, gas bubbles in the discharge, resonance when carrying a razor over the skin, gas on the roentgenogram). The general picture: the phenomena of the strongest intoxication (weakening and acceleration of the pulse, the discrepancy between pulse and breathing, increased excitability, euphoria, etc.).
Flow. Most often short, since deathcan occur within the first 3 days. There are two main forms of gas infection. For the first, the following symptoms are typical: a sudden catastrophic deterioration of the general condition (exacerbation of the facial features, gray-yellow skin color, a sharp weakening and rapidity of the pulse), the appearance of severe pains in the wounded limb, a sharp swelling of it with the appearance of gas bubbles in tissues, to the proximal limb. The second form is characterized by a more limited and slow spread of the infection with a satisfactory general condition of the patient. This form is accompanied by the formation of hemolytic spots of bronze in the course of the subcutaneous veins and brown spots over the regional lymph glands and pathways. In the subcutaneous tissue bubbles of gas are probed. Typically, putrefactive tissue decay occurs.
Recognition in the presence of this clinical picture is notpresents difficulties. Fluoroscopy. Pathogens are cultured from the secretions of the wound under anaerobic conditions. In far-reaching cases, they can be found in blood smears. For a quick orientation in the etiology, a precipitation reaction is used. With postmortem diagnosis, at autopsy, do not lose sight of: a) the possibility of infection in the agonal period with the development of it after death or in the last hours of life, b) the decay of necrotic tissues under the influence of saprophytic anaerobes.
Prevention. To prevent complications of gas woundsinfection, it is necessary to perform a wide surgical treatment of the wound with removal of all bruised nonviable tissues and hematomas, pieces of clothing and foreign bodies and administer antigangrenous sera probably after an injury intramuscularly or subcutaneously in the area with normal blood circulation (far from the site of injury). A single prophylactic dose of serum is administered. consisting of a mixture of:
Antivibrion septique: 600 AE
Serums are administered in a mixture with 100-160 cm 3sterile physiological solution. In the case of an unexplained flora and the presence of a clinical picture of anaerobic infection, the serum is not mixed, but is injected from one ampoule with the finished polyvalent mixture. The most important preventive tool is correct wound treatment followed by dusting with white streptocide and immobilization of the limb, wide incisions of tissues, rest, taking measures to ensure normal blood supply, reducing edema.
To prevent intrahospitalspread of anaerobic infection, observe the following rules: a) compulsory isolation of patients in separate wards; b) compliance with the rules of personal hygiene (change of dressing gowns after each dressing, thorough washing of hands); c) collection of laundry contaminated with secretions of patients with anaerobic infection, separately from other laundry; soaking it in a 1.5-2% solution of soda with subsequent steam disinfection; d) incineration of dressings and drains; sterilization of gloves in an autoclave; Boiling tools in 1% baking soda for at least 1 hour; e) thorough cleaning of the operating room and dressing. Treatment. Mostly surgical. Specific serotherapy. Anti-gangrenous sera are injected immediately after clarifying the clinical diagnosis in the amount of 2 prophylactic doses (1 treatment dose). A mixture is used:
Antivibrion septique: 1000 AE
Sera in the absence of effect is re-introduced3-5 times every 10-12 hours. If the causative agent is established, it is more appropriate to administer 15,000 AE of specific serum. In severe cases, injected intravenously by a drop route in a mixture with saline.
With a slowly flowing gas infection andsatisfactory state of the patient should not rush to amputation; need a wide lamp section. Apply seroterapy, wide incisions, tamponade with hydrogen peroxide or 10% solution of potassium permanganate. large amounts of saline intravenously by a drip to a day a day. Irrigation of wounds for Carrel. Powder powder streptotsida. Ointment dressings (Vishnevsky ointment). Immobilization. General strengthening treatment. Abundant administration of fluids. Penicillin 30,000 Oxford units.
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