About a hundred years ago, the word “gangrene” was terrifying and meant, at best, amputation, but more often – a painful death. However, amputation also did not guarantee against gangrene and ended with it (and death) in 50-80% of the wounded in those millennia when wars were already regular and massive, and antibiotics and antiseptic protocols did not yet exist.
Today, this word sounds less common, but the phenomenon itself has not disappeared anywhere – rather, it has disappeared into the statistical headings ” Postoperative complications “, ” Factors of lethality in emergency situations “, etc.
Gangrene is the final phase of necrosis, in which massive cell death at the macroscopic level is manifested by irreversible death and decay of a tissue or organ. With all the etiological heterogeneity, a characteristic feature is the black or very dark color of the affected areas (sometimes with a blue, green or brown-red tint); for the “wet” variant described below, a rapid negative trend with general intoxication, aggravation of the condition, and an unpleasant putrefactive odor of smoldering is also typical.
The reasons
Most often, the causes of gangrene are divided into three large groups .
- infectious factors. The introduction and / or rapid activation of pathogens (almost always bacteria, the spectrum of which in this case is very wide) in pathologically altered or destroyed tissues, especially against the background of a lack of general and local immunity. A special case is the notorious gas gangrene caused by an anaerobic pathogen of the genus Clostridium (in the vast majority of cases Clostridium perfringens).
- Physical and chemical factors , including mechanical crush, superficial and penetrating wounds, thermal, radiation, chemical, electrical injuries.
- Hemodynamic factors , which include all pathological processes, conditions and effects that sharply reduce or completely block the blood supply to any organ or structure (cardiovascular accidents, mechanical compression and infringement, toxic vasospasm, thrombosis, atherosclerosis, etc.).
However, in a number of sources, in particular British ones, to describe the etiopathogenesis of gangrene, it is not unreasonable to manage with only two groups of causes : ischemic (deficit or lack of blood supply) and infectious . Indeed, ” Physical and chemical factors ” ultimately trigger either the ischemic mechanism, or the infectious one, or both.
Symptoms
According to the clinical criterion , dry and wet types of gangrene are distinguished .
Dry gangrene is an aseptic death, “drying”, necrotic mummification according to an atrophic scenario. Such gangrene is the result of more or less prolonged ischemia. The pain syndrome is expressed only in the initial stages, while the conduction function of the nerve endings is preserved; then the course could be called asymptomatic or asymptomatic, except for the irreversible death of the gangrenous structure (for example, the distal part of the limb) as a symptom. Intoxication and inflammation are not expressed. Between the dying and healthy areas there is a clear border in the form of a roller, which determines the line of amputation or, if not interfered, self-amputation of the deceased area (expectant tactics in the vast majority of cases is impractical and risky).
Wet gangrene in every sense is a state of a qualitatively different level. It develops after one-time or short-lived exposures, due to acute ischemia or acute infection, including infection with dry gangrene. Necrosis proceeds in the form of “rotting alive”, with the rapid spread of the infectious-inflammatory process to neighboring healthy areas without the formation of boundaries, severe intoxication, severe general condition, intense pain syndrome, high risk of sepsis and infectious-toxic shock . Gangrene of the internal organs always proceeds in a wet form.
Distinctive features of anaerobic gas gangrene are swelling of the affected organ, a characteristic crunch (crepitus) on palpation due to interstitial accumulation of metabolite gases, a gray-blue hue of the skin, as well as a rapid negative dynamics of the general condition.
Diagnostics
In addition to the symptoms described above, there are many fairly informative clinical criteria, diagnostic techniques and visual (including, as a rule, radiographic) signs that allow you to confidently diagnose gangrene already in the early stages.
Treatment
Wet gangrene in all cases is an emergency, life-threatening and highly lethal condition . Emergency measures are required simultaneously in several areas: restoration of hemodynamics, inhibition of the activity of the pathogen, localization of the process, prevention of the development of shock, detoxification, blood replacement and rehydration, relief of pain, stabilization of the general condition . However, the primary and life-saving intervention most often becomes urgent amputation. The prognosis depends on the timeliness and conditions of assistance, the nature and extent of the lesion, and the presence of concomitant complicating factors.
