Gas Gangrene in a Metropolitan Community*

Transcription

1 Gas Gangrene in a Metropolitan Community* BY PAUL W. BROWN, M.D.t, and PHILLIP B. KINMAN, M.D4, MIAMI, FLORIDA Fro,n the Departnent of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami ABSTRACT: The incidence of gas gangrene has steadily declined in American combat casualties in the past four wars. Only twenty-two cases were recorded during the eight years of combat in Viet Nam. In the past ten years in Miami clostridial infection occurred in at least twenty-seven patients. The significant difference in wound management between the Viet Nam military experience and the Miami civilian experience was adequacy of d#{233}bridement and timing of closure. In Viet Nam primary closure of wounds was rarely done, whereas all of the twenty-seven patients in Miami had primary closure of their wounds. The factors which contribute to the development of clostridial myonecrosis (gas gangrene) in a wound are well known: extensive injury to muscle and to its blood supply, and contamination of the wound with foreign material. In the past, gas gangrene was considered a common complication of war injuries, but it has become increasingly rare in military casualties, while perhaps more common in the injuries of civilian life. In combat wounds the factors favorable to the development of clostridial myonecrosis often are present. High-velocity missiles and explosives cause more extensive damage to tissue than vehicular, industrial, and home accidents. The soldier s wound is generally more extensively contaminated. In combat the soldier often cannot keep his body or his clothing clean and his wounds have dirt, debris, and clothing particles forcibly introduced by shell fragments or bullets. His wounds often are incurred on terrain where human and animal manure have been added to the soil. Evacuation by helicopter dramatically improved the treatment of most men wounded on the field of battle, and allowed many severely wounded men to reach treatment centers who would not have survived in earlier wars. Despite improvements in the survival rate of these severely wounded men, the incidence of gas gangrene in the United States Army in Viet Nam was low. The purpose of this paper is to compare the recent military and civilian experiences with reference to clostridial myonecrosis and to show that treatment of the initial wound is the most important factor in the establishment of this complication of trauma and in its prevention. The Military Experience In World War I the incidence of clostridial myositis in the United States Army was 1.08 per cent for soft-tissue wounds and 6. 3 per cent for open fractures. World War II studies showed that clostridial myonecrosis was more common in injuries in which there was arterial damage, in which large masses of the muscle were damaged, in which there was a delay in surgical treatment of the wound, or in which relatively inexperienced surgeons provided initial treatment. There was considerable geographic difference in the incidence of gas gangrene. Wounds incurred in the Libyan desert were less likely to develop clostridial infection than those incurred in Italy The degree of contamination of the soil was of only relative importance, however. Cutler and Sandusky reported an incidence of clostridial myonecrosis of 1.8 per cent during World War II in a single hospital in Italy * Read at the Annual Meeting ofthe American Academy oforthopaedic Surgeons, Dallas, Texas, January 21, t St. Vincent s Hospital, 2820 Main Street, Bridgeport, Connecticut : P.O. Box , Biscayne Annex, Miami, Florida VOL. 56-A, NO. 7. OCTOBER

2 1446 P. W. BROWN AND P. B. KINMAN in which most of the patients treated had wounds sustained in aerial combat. It is significant that in that hospital primary closure of wounds was common. In each of the three wars the United States Army fought prior to the Viet Nam War, as the war progressed there was increasing expertise in the management of wounds, consisting of more thorough d#{233}bridement and the avoidance of primary closure. During the first few months of the Korean War, clostridial myonecrosis was more common than in World War II, but then the incidence dropped to lower levels than those of World War II. This drop coincided with a favorable change in the tactical situation and the introduction and enforcement of a surgical policy which stressed d#{233}bridement and delayed closure. In the war in Viet Nam, the policy in the United States Army of d#{233}bridement and delayed closure was applied from the beginning. This was the first war in which lessons learned from the preceding war were applied immediately. The incidence of clostridial myonecrosis in wounds received by American soliders in Viet Nam was impressively low: from 1965 to 1972 there were only twenty-two cases ofclostridial myonecrosis in 139,000 combat casualties, an incidence of per cent. The factors responsible for this low incidence appeared to be: more prompt surgical treatment of wounds, more thorough d#{233}bridement, and an over-all willingness to leave wounds open. The routine use of antibiotics in massive doses probably contributed to the lowered incidence but it was also shown that antibiotics would not prevent wound breakdown in those few wounds which were closed primarily, as occasionally happened when surgeons were newly arrived in the combat zone. FIG. 1 Incidence of gas gangrene in the United States Army in four wars. Representative of the Viet Nam experience was the performance of the Twenty- Seventh Surgical Hospital where one of us (P.B.K.) served in 1969 and In a oneyear period this installation treated 5,400 patients with open wounds of which 1,760 (35 per cent) were associated with open fractures. Many of these patients had sustained serious combat injuries but in none did clostridial myonecrosis develop. The Civilian Experience Clostridial spores are ubiquitous; they have been found in the streets of every large city tested, as well as in rural environments. Yet, Bohier reported only one case of clostridial myonecrosis in 20,000 wounds incurred in civilian life. Bohler s series included 253 THE JOURNAL OF BONE AND JOINT SURGERY

3 GAS GANGRENE IN A METROPOLITAN COMMUNITY 1447 open fractures. In contrast, King reported eighteen such infections in eighty open fractures, an incidence of 32.5 per cent. Searby reported an incidence of 3 per cent in 700 open fractures. In civilian catastrophic situations, in which massive numbers of casualties are treated, the incidence of gas gangrene increases greatly. Blocker and co-workers reported fifteen cases of gas gangrene in the 850 casualties from the Texas City explosion. Similar figures were reported from the Worcester and Flint tornadoes 6,I6 Most of these studies showed that in the suture of wounds primary closure was the rule rather than the exception, and that the percentage of wound breakdowns was extremely high. Data on civilians has been more difficult to obtain than data on soldiers, as MacLennan noted in the most extensive paper yet written on clostridial infections and myonecrosis. In referring to major civilian disasters, he said, Very often the primary surgical treatment has been of a deplorable standard, with inadequate d#{233}bridement and primary suture of the wounds almost the routine procedure. Material Our report is limited to twenty-seven patients in the Miami metropolitan area in whom bacteriologically proved clostridial infection developed in an open wound in the ten-year period from 1963 to In our inquiries we depended on hospital records and physicians memories, all of which proved to be unreliable. Gas gangrene is not a reportable disease and, therefore, ascertaining its prevalence is extremely difficult. The patients in this series were difficult to locate at times, and some patients who should be listed undoubtedly have not been included. Some patients were discovered by accident. Others, whose history strongly suggested clostridial myonecrosis, had had no bacteriological confirmation. It is our impression that we failed to uncover many cases which occurred in Miami during the decade under study. Some of the surgeons who answered our questionnaire said that gas gangrene was primarily a military problem and was so rarely encountered in civilian practice that investigation was not warranted, whereas other surgeons believed that Miami was an endemic area for clostridial myonecrosis. Although clostridia were cultured from open wounds in several patients, these patients were not included in this series because no clinical evidence of myonecrosis developed in their wounds. We also excluded clostridial infections in abortions, abdominal conditions, bums, diabetes, and in infections caused by other than clostridial anaerobes. All patients included had both the clinical signs of clostridal myonecrosis and bacteriological confirmation. Ten of the most recent cases resulted from one airplane crash. Because of the publicity given this accident and pending litigation, it was difficult to obtain data on these patients, but in those reported we obtained objective data sufficient to satisfy our criteria regarding circumstances of injury, initial wound management, history of the development of the clostridial infection, and culture of the organism. Clinical Data Our twenty-seven patients ranged in age from eight to sixty-one years. Five were injured in falls, eight in automobile crashes, eleven in aircraft crashes, and three in other miscellaneous accidents. Of the twenty-seven patients, seventeen had an open fracture and nine had more than one open fracture. The locations of the fractures were as follows: nine in the tibia, two in the femur, two in the spine, one in the scapula, two in the skull, one in the maxilla, three in the pelvis, one in the humerus, two in a rib, one in the radius, and one in a metacarpal. Three patients had damage to major arteries in conjunction with fractures. Eight patients were severely wounded and had multiple organ injuries. They were in clinical shock when first treated. Three required abdominal laparotomy, two had a pneumothorax, and two had cerebral concussion.

4 1448 P. W. BROWN AND P. B. KINMAN The location of the wounds in which clostridial infection developed were: leg, sixteen; thigh, five; head, two; hand, two; arm, one; shoulder, one; thorax, one; and buttock, two. Many wounds were highly contaminated with foreign materials, such as grass, dirt, leaves, kerosene, hydraulic fluid, water, feces, stone, wood, sand, grease, and glass. Contamination of the wound by water appeared to play a significant role in the development of clostridial infection in thirteen patients, and in two there had been high-pressure injection of water into myofascial planes. In one patient a lesion developed in a wound sustained in an air-boat crash. Another patient sustained a laceration when he fell into a drainage Bacteriology canal. Clostridium welchii was cultured from the infected wounds in all twenty-seven patients. Multiple organisms were cultured in twenty-three patients: Proteus in four; Escherichia coli in five; coliform groups in three; Pseudomonas in four; Enterobacteriaceae in three; unidentified gram-negative rods in three; Klebsiella in four; Citrobacter in two; Bacteroides in one; Staphylococcus aureus in one; non-hemolytic Streptococcus in one; Streptococcus viridens in one; Micrococcus in one; and Bacillus subtilis in one. Nineteen patients had frank clostridial myonecrosis and eight had what was called clostridial cellulitis, but the early signs and symptoms demonstrated by all these patients were restlessness, increased pain, fever, drainage, and tachycardia. Crepitation and roentgenographic evidence of gas were apparent in only a few. The average time between injury and diagnosis was thirty-two hours in the patients with myonecrosis and thirty-eight hours in those with cellulitis. Many patients had multiple severe injuries and the early symptoms of the clostridial infection or myonecrosis were often attributed to the effects of the injuries. In these patients the wounds were not examined early, particularly when the patient was cared for by more than one doctor. Of the nineteen patients with myonecrosis, seven died of the infection and eleven had amputations. In the eight patients listed as haying cellulitis, there were no deaths or amputations. One patient with a severe head injury had clostridial myonecrosis in a lower extremity but died despite treatment with hyperbaric oxygen and a high thigh amputation. Whether his death was due to the myonecrosis or the head injury was uncertain. Two other patients died who had received high thigh amputations and hyperbaric oxygen. Six of the seven deaths were clearly caused by the myonecrosis. Twenty-three of the twenty-seven patients were given antibiotics shortly after injury: cephalothin in seven, penicillin in five, gentamicin in four, oxacillin in two, sodium colistimethate in two, and kanamycin in two, all in various combinations. When the diagnosis ofclostridial infection was made, many changes were made in the type, dosage, and combination of antibiotics. Penicillin and gentamicin were continued in five, cephalothin and gentamicin in four, and cephalothin alone in four. Antibiotics in various combinations and dosages were changed from day to day without any apparent pattern or rationale. Management of the Wounds The time interval between injury and initial treatment varied: six patients were treated within two to six hours, and twenty patients within six to eighteen hours. One patient was first treated more than eighteen hours after injury. All wounds were subjected to some type of surgical d#{233}bridement but we were not able to assess accurately its thoroughness. Some wounds were debnded in an emergency room in a hospital, but most were debrided in the operating room. In a few patients, after breakdown of a wound, foreign material such as dirt or vegetable matter was found throughout the tissues. Of the twenty-seven patients, nine had apparently thorough d#{233}bridement and eighteen had d#{233}bridement that appeared to be incomplete. Antibiotics including penicillin, cephalothin, gentamicin, kanamycin, and sodium

5 GAS GANGRENE IN A METROPOLITAN COMMUNITY 1449 colistimethate were administered at the time of initial treatment in twenty-three of the patients. All of the wounds in the twenty-seven patients were closed primarily. Several patients who were not injured critically received all of their care in the emergency room of a hospital. Several with severe injuries of the chest, head, or abdomen had extremity wounds debrided and closed in the emergency room by physicians assisting those responsible for the more severe injuries, on the premise that time could be saved ifthe apparently less severe wounds could be taken care of while the patient was being prepared for surgery for his more severe injuries. None of the patients succumbed to head, chest, or abdominal injuries; rather, the worst complications developed from the supposedly less severe wounds. The use of hyperbaric oxygen has been widely publicized for the treatment of gas gangrene. Eight patients in this series were treated with hyperbaric oxygen after the diagnosis of myonecrosis was made. Three died (one of whom had a head injury) and all had high thigh amputations. We were unable to conclude that this treatment influenced the progression of the myonecrosis or changed the prognosis for recovery or salvage of the extremity. Discussion While the incidence of gas gangrene in American military combat casualties declined progressively and spectacularly in the past four wars, our study of one metropolitan area suggests that in civilian practice the incidence of gas gangrene remains relatively high. In military situations often a large number of severe wounds is expected, and measures may be taken to standardize treatment. The Viet Nam experience has shown the value of minimizing the time interval between wounding and definitive treatment, administering proper antibiotics, debriding the wound thoroughly, and delaying closure of the wound. Such standardization is difficult in civilian situations. Both the time until treatment was started and the use of antibiotics in our series were not very different from those which prevailed in military situations. The significant differences appear to be that in the civilian experience, at least as far as our twenty-seven patients were concerned, d#{233}bridement was incomplete and the wounds were closed primarily. It was impossible for us to determine the true incidence of gas gangrene infection in the Miami area because the total number of severe lacerations, wounds, and accidents is impossible to document or even to estimate. The situation is similar as regards the total number of patients with gas gangrene. The development of gas gangrene in a wound is a devastating complication. Perhaps it is understandable that sometimes physicians involved in such circumstances are reluctant to volunteer data. In our series there was an open fracture in over 68 per cent of the patients; most of the fractures were in the lower extremity. This is consistent with other published series although surprisingly few of the injuries in our series were associated with any recorded arterial damage. Many of the wounds in the patients we studied caused extensive damage to muscle. Two patients with wounds of the buttock also had lacerations of the rectum but the fecal contamination, real or potential, did not deter the surgeons from closing the buttock wounds primarily. In these two cases and in several others the wounds were closed over rubber drains, but it is apparent that this type ofdrainage is not effective for a wound which is grossly contaminated or for one in which there is extensive tissue damage (Fig. 2). Following the development of ten cases of clostridial infection among survivors of the plane crash previously mentioned (two of them classified as myonecrosis and eight as cellulitis), there was much speculation regarding the virulence of the bacteria of the swamp water when the crash occurred. No Clostridium welchii could be cultured from the swamp water at the aircraft impact site, or at any of the body-marker sites. The source of VOL. 56-A, NO. 7. OCTOBER 1974

6 1450 P. W. BROWN AND P. B. KINMAN the contaminating clostridia in this accident most probably was the patient s own clothing or the airplane itself, because the holding tanks of the toilets in the plane had broken at the time of impact. FIG. 2 A fourteen-year-old boy struck by an automobile while riding a bicycle. Pelvic fracture and penetrating injury through gluteal mass and rectum. Primary closure over drains. Clinical signs of gas gangrene on second day. This photograph taken on fourth day after d#{233}bridement and prior to treatment with hyperbaric oxygen. Wounds inoculated with contaminated water always show less gross evidence of contamination than those containing solid debris. Water-contaminated wounds tend to be inadequately debrided and irrigated. The wound in which contaminated water has been forced into the tissues and tissue spaces under pressure, such as may occur when an aircraft crashes into water or when a high-speed boat crashes, is especially liable to madequate initial treatment. The use of antibiotics either prophylactically or therapeutically appeared to have little influence on either the development or the progression of disease. We could not conclude that they were of no value, but it seemed apparent that to rely solely on antibiotics, of whatever type or quantity, in the presence of inadequate d#{233}bridement or premature dosure, gave no sure protection from the development ofgas gangrene. Whatever value they have, antibiotics are obviously no substitute for proper wound management. The same applies to hyperbaric oxygen. We feel that publicity would be better directed to preventive measures than to complex and expensive therapeutic means which, although possibly of some value, can only contribute partially to the management of these severe complications in wounds. An assessment of the adequacy of d#{233}bridement was not possible in many of our patients. The written record often was not substantiated by subsequent events. For instance, the record sometimes described thorough d#{233}bndement of a wound in which foreign material was discovered after myonecrosis became apparent. Some wounds were debrided in the emergency room where it may have been difficult to perform an extensive cleaning of major wounds. All twenty-seven patients received treatment of their wounds within a reasonably short period of time, all were treated with some form of d#{233}bridement, and most were treated with antibiotics. The same can be said of the combat ca.sulaties in Viet Nam, although it is certain that d#{233}bridement was more strongly emphasized in the military hospitals. The one major difference was wound closure. In Viet Nam almost all wounds were THE JOURNAL OF BONE AND JOINT SURGERY

7 GAS GANGRENE IN A METROPOLITAN COMMUNITY 1451 left open, and closed only when it appeared safe to do so, whereas the wounds of every patient in our series were closed at the time of initial treatment. We agree with Hampton, who said, For clostridial myositis which develops in a primarily closed wouwtthere is no excuse at all. Similar statements have been made by others writing on military surgery, but there is scant reference to the development of gas gangrene in primarily closed civilian wounds. DeHaven and Evarts cited five cases ofgas gangrene in open fractures which had been closed primarily, and Waddell and Jackson reported eighteen cases of gas gangrene in primarily closed open fractures. Summary Preventive measures for gas gangrene consist of : 1. Recognition of wound factors such as type and degree of tissue damage and degree of contamination. 2. Adequate and thorough d#{233}bridement. 3. Delayed closure of wounds in which contamination or tissue damage is great. Prevention of a disease is perhaps less spectacular than treatment. Nevertheless, the responsibility to prevent gas gangrene involves every surgeon. With few exceptions, the development of clostridial infection in a patient represents an avoidable compromise of the fundamental principles of wound care. References 1. ALTEMEIER, W. A., and FULLEN, W. D. : Prevention and Treatment of Gas Gangrene. J. Am. Med. Assn., 217: , BLOCKER, T. G. ; BLOCKER, VIRGINIA; GRAHAM, J. E. ; and JACOBSON, HERBERT: Follow-up Medical Survey of the Texas City Disaster. Am. J. Surg., 97: , B6HLER, LORENZ: Zur Vehutung des Gasbrandes. Zentr. Chir., 60: , BOLIBAUGH, 0. B. : General Wound Management. in Surgery of Trauma, edited by W. F. Bowers. Philadelphia, J. B. Lippincott, BROWN, P. W.: The Prevention of Infection in Open Wounds. Clin. Orthop., 96: 42-50, CURRY, G. J.: The Flint Tornado. Am. J. Surg., 87: , CUTLER, E. C., and SANDUSKY, W. R.: Treatment ofclostridial Infections with Penicillin. British J. Surg., 32: , DEHAVEN, K. E., and EVARTS, C. M.: The Continuing Problem ofgas Gangrene: A Review and Report of Illustrative Cases. J. Trauma, 11: , HAMPTON, 0. P.: Wounds ofthe Extremities in Military Surgery. St. Louis, The C. V. Mosby Co., JERGESEN, F. H.: Anaerobic Infections. Med. Bull. North African Theater Operations, 1: 2-7, KING, W. E.: Gas Bacillus Infection in Civil Life. Am. J. Surg., 14: , KocH, F.: Cases of Gas Phlegmon in Lund Surgical Clinic from Hygiea (Stockholm), 100: , MACLENNAN, J. D.: Anaerobic Infections of War Wounds in the Middle East. Lancet, 2: 63-66, 94-99, , MACLENNAN, J. D.: The Histotoxic Clostridial Infections of Man. Bacteriol. Rev., 26: , PAPPAS, A. M.; FILLER, R. M.; ERAKLIS, A. J.; and BERNHARD, W. F.: Clostridial Infections (Gas Gangrene). Diagnosis and Early Treatment. Clin. Orthop., 76: , RAKER, J. W.; WALLACE, A.F.C.; and RAYNER, J. F.: Disaster Study No. 6. Washington, D.C., National Academy of Sciences, National Research Council, SEARBY, H.: Gas Gangrene. Roy. Melbourne Hosp. Clin. Rep., 9: 1, SIMEONE, F.: Clostridial Myositis. in Symposium on Military Medicine in the Far East Command. Surgeon s Circular Letter. Medical Section. Supplement. September, TRUETA, R. J. : Treatment of War Wounds and Fractures. With Special Reference to the Closed Method as Used in the War in Spain. New York, P. B. Hoeber, Inc., WADDELL, J. D., and JACKSON, R. W.: Gas Gangrene. in Proceedings of the Canadian Orthopaedic Association, J. Bone and Joint Surg., 54-B: 762, Nov WHELAN, T. J., JR.; BURKHALTER, W. E.; and GOMEZ, ALPHONSE: Management ofwar Wounds. in Advances in Surgery. Vol. 3, pp Chicago, Year Book Publishers, VOL. 56-A, NO. 7, OCTOBER 1974