Gangrene – a necrosis of living tissues (parts of bodies or parts of the body) with characteristic change of color of the struck areas from black to dark brown or bluish. Change of coloring is caused by sulfide of the iron which is formed as a result of hemoglobin destruction. Gangrene can affect any bodies and fabrics: skin, muscles, hypodermic cellulose, lungs, gall bladder, intestines etc. Develops owing to an infection, influence of toxins, and also excessively high or low temperatures, an allergy, violation of food of fabrics and some other the reasons. On a clinical current can be dry or damp.
Gangrene – a necrosis (necrosis) of parts of the body or parts of bodies at which characteristic change of coloring of the struck fabrics is observed. Because of destruction of hemoglobin and formation of sulfide of iron they become black, bluish or dark brown.
Gangrene can affect any fabrics and bodies, develops in areas disteel more often (remote from the center) segments. The necrosis of fabrics is caused by the termination or sharp deterioration in blood supply or destruction of cages. At the same time immediate causes of development of gangrene can be the most different – from influence of microbes to an allergy or defeat in result of excessive heating or cooling.
Taking into account a consistence of the died fabrics and features of a clinical current allocate dry and damp gangrene. Damp gangrene is inclined to heavier current poses direct hazard to life of the patient more often. Taking into account etiologichesky factors of gangrene are subdivided on infectious, toxic, allergic, ischemic etc. Besides, allocate gas gangrene which is caused by anaerobic microorganisms, strikes mainly muscular tissue and has certain features of a current.
Gangrene develops as a result of direct impact on fabrics of toxic, chemical, mechanical, beam, electric, thermal and other factors. All causes of gangrene can be divided into 3 big groups.
Chemical and physical impacts. Mechanical force becomes the gangrene reason at rather extensive injuries (gaps or razmozzheniye) at which there is a destruction of a large number of cages or even the whole bodies. Temperature influence causes gangrene at temperature increase more than + 60C or less - 15C; in the first case there is a burn, in the second – freezing injury. The mechanism of development of gangrene at defeat by electric current is similar to burns: in the place of an exit of current there is a substantial increase of temperature literally burning fabrics.
Acids cause folding of cellular proteins and become the reason of development of dry gangrene. At influence of alkalis there is a saponification of fats and dissolution of proteins, the kollikvatsionny necrosis (fusion of fabrics) in character reminding damp gangrene develops.
Infectious influences. Usually gangrene develops at gunshot or deep knife wounds, and also at crush, a razmozzheniye of fabrics etc. However because of the accompanying violation of food of fabrics can arise at small wounds or even grazes at the patients having diabetes. Gangrene can be caused by enterobakteriya, colibacillus, streptococci, Proteus and klostridiya. In the latter case gas gangrene develops.
Blood circulation violations. Are the most common cause of developing of gangrene. Violations of blood supply can develop at serious violations of warm activity (decompensation), obstruction or a long angiospasm at atherosclerosis, an embolism, a sclerosis of vessels, the obliterating endarteriit or poisoning with an ergot.
Wound or mechanical sdavleniye of a vessel becomes frequent the blood circulation termination reason. For example, at infringement of hernia gangrene of the site of a gut can develop, at excessively hard plaster bandage or excessively long imposing of a plait – an extremity necrosis. In the same group of gangrenes it is possible to carry cases of traumatic damage of large vessels as a result of wounds at preservation of integrity of fabrics.
The contributing factors
All factors exerting impact on the course of gangrene can also be divided into 3 groups.
General and local anatomic and physiological features. More rough and the rapid current of gangrene is observed at the violations of the general condition of an organism caused by the exhaustion, intoxication, avitaminosis, sharp or chronic infectious diseases, anemia, overcooling, diseases which are followed by violations of composition of blood and a metabolism.
The condition of walls of vessels (change owing to a sclerosis or an endarteriit), type of a structure of vascular system (loose, with a large number of anastomoz and kollateraly at which the probability of development of gangrene decreases or main at which gangrene can develop at damage of only one vessel), and also extent of differentiation of fabrics belongs to number of the local features influencing development of gangrene (the high-differentiated fabrics, for example, brain or pulmonary transfer damages worse, than low-differentiated, for example, fatty).
Existence or absence of an infection in the place of defeat. Infection of fabrics aggravates the course of process, promotes transition of dry gangrene to damp and causes bystry distribution of a necrosis.
External conditions. Excessive cooling causes an angiospasm that aggravates violations of blood circulation even more and promotes distribution of necrotic changes. Excess warming stimulates a metabolism in fabrics that in the conditions of insufficient blood supply also leads to acceleration of development of gangrene.
As a rule, dry gangrene develops in cases of gradual violation of blood supply. It is more often observed at the dehydrated, exhausted patients, and also at patients of a dry constitution. Usually happens limited, it is not inclined to progressing. Fabrics at this form of gangrene are wrinkled, dry, decrease in volume, are condensed, mummified, become black with a bluish shade or dark brown.
At initial stages of gangrene the patient feels severe pains in an extremity. Skin in a defeat zone at first turns pale, then becomes marble, cold. Pulse on peripheral arteries is not defined. The extremity grows dumb, sensitivity is broken, however pain remains even during the expressed necrotic changes. Long pain at gangrene is caused by the long period of safety of nervous cages in the centers of disintegration and a sdavleniye of nervous trunks because of jet hypostasis of the fabrics located proksimalno (is closer to the center of a body) from the defeat center.
Dry gangrene begins in disteel (remote) departments of an extremity, and then extends up, to the place with normal blood circulation. On border of the struck and healthy fabrics the demarcation shaft is formed. If not to remove the necrotic site in the operational way, it is gradually torn away itself, however this process takes a long time.
At the initial stages it is very important not to allow transition of dry gangrene with its rather favorable current in more dangerous and severe form – damp gangrene. Therefore prior to drying of fabrics it is necessary to provide strict observance of rules of an asepsis. Affected sites cover with dry sterile napkins, carry out regular bandagings.
Disintegration of nekrotizirovanny fabrics at dry gangrene is almost not expressed. The small amount of the soaked-up toxins, absence of intoxication and a satisfactory general condition of the patient allow not to carry out early expeditious treatment. Surgical intervention at this form of gangrene is usually carried out only after the demarcation shaft completely is created.
Damp gangrene usually develops in the conditions of sudden, sharp violation of blood supply of an affected area. Full, "friable", pastose patients are more inclined to this form of gangrene. Besides, damp gangrene arises at a necrosis of internals (lungs, intestines, a gall bladder).
At damp gangrene nekrotizirovanny fabrics do not dry. Instead the rotting center is formed. Disintegration products from this center are soaked up in an organism, causing heavy intoxication and seriously breaking the general condition of the patient. In the become lifeless fabrics microorganisms intensively breed. Unlike dry gangrene, at a damp necrosis the necrosis quickly extends to the neighboring sites. The demarcation shaft is not formed.
At the initial stages of development of damp gangrene skin on an affected area becomes pale, cold, then gets marble coloring. There is considerable hypostasis. On skin there are dark red spots and bubbles of the exfoliated epidermis when which opening sanious contents are allocated. At survey the bluish venous network is well visible. Pulse on peripheral arteries disappears. In the subsequent the affected area blackens and breaks up, forming fetid glaucous weight.
The condition of the patient with damp gangrene sharply worsens. The expressed pains, a lowering of arterial pressure, increase of pulse, substantial increase of temperature, block, slackness, dryness in a mouth are noted.
Because of deterioration in the general state and intoxication caused by absorption of products of disintegration of fabrics ability of an organism to resist to an infection sharply decreases. Gangrene quickly extends, occupying overlying departments. In the absence of the timely specialized help sepsis develops and there comes death. Especially heavy course of gangrene is observed at patients with diabetes. It is caused by deterioration in microcirculation, a metabolic disorder and decrease in the general resilience of an organism.
To prevent spread of an infection at damp gangrene, removal of the struck fabrics (amputation or a nekrektomiya) is made in the earliest terms.
Clinical symptoms of gangrene of internals depend on localization of pathological process. At the states caused by a necrosis of abdominal organs peritonitis symptoms are observed: the temperature increase, intensive belly-aches which are not giving relief nausea and vomiting. At survey sharp pain when pressing comes to light. Muscles of a forward belly wall are strained. Specific symptoms (Shchetkin-Blyumberg, Voskresensky, Mendel) are defined. A characteristic sign is the symptom of imaginary wellbeing – sharp pain at the time of perforation which then decreases, and in 1-2 hours amplifies again.
At gangrene of a lung high temperature, pouring sweats, slackness, increase of pulse and decrease HELL is observed. The condition of the patient heavy and quickly worsens. At an otkashlivaniye the fetid phlegm which when upholding is divided into three parts is allocated: lower – the dense kroshkovaty weight (the destroyed pulmonary fabric), average – brown liquid with impurity of blood and pus and top – foamy. In lungs multiple damp rattles are listened.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Treatment of gangrene is carried out in the conditions of a hospital and includes the general and local actions. At the gangrene which arose owing to influence of chemical and mechanical factors (razmozzheny extremities, burns, freezing injuries etc.) of the patient direct to traumatologists.
The choice of office at other types of gangrene depends on localization of pathology: treatment of gangrene of abdominal organs (a pancreas, an appendix, a gall bladder, intestines), and also gangrenes of extremities at diabetes are engaged surgeons (office of the general surgery), treatment of gangrene of a lung – thoracic surgeons, in treatment of the gangrene caused by vascular pathology – vascular surgeons.
To the patient with gangrene appoint a bed rest. Take measures for stimulation of blood circulation and improvement of food of fabrics. To eliminate a reflex spasm of collateral vessels according to indications carry out novokainovy blockade.
The general medical events for improvement of function of cardiovascular system, fight against an infection and intoxication are held. Intravenous administration of solutions, plasma and blood substitutes, if necessary – blood transfusion is made. Antibiotics and heart medicines are appointed.
At the gangrene which developed owing to defeat of vessels, one of the major tasks is restoration of blood circulation in even viable fabrics. At thromboses appoint thrombolytic medicines. In case of need carry out surgeries on arteries.
Tactics of local treatment depends on a type of gangrene. At dry gangrene at the initial stages conservative therapy is carried out. After formation of a demarcation shaft and mummification of the nekrotizirovanny site amputation or a nekrektomiya is carried out. Level of amputation is chosen so that as much as possible to keep function of an extremity and at the same time to provide favorable conditions for healing of a stump. During surgery a disteel part of a stump is closed by a skin and muscular rag at once. Healing happens primary tension.
At damp gangrene immediate excision of a necrosis within healthy fabrics is shown. Nekrektomiya or amputation are made in the emergency order. The extremity is cut in the guillotine way. Formation of a stump is carried out after clarification of a wound. At gangrene of internals the emergency surgery for removal of nekrotizirovanny body is carried out.
Actions for the prevention of gangrene include early diagnosis and timely treatment of diseases which can become the reason of development of a necrosis. At injuries prevention of an infection is carried out, measures for improvement of blood supply of an affected area are taken.