Clostridial infections and the emergency department

EDITORIALS Clostridial Infections and the Emergency Department Crepitant infections are always frightening occurrences. Although not all crepitant infections are gas gangrene, the emergency physician must be prepared to initiate measures quickly that will lead to rapid diagnosis and prompt therapy whenever gas is discovered in tissue. Gas gangrene may progress to fatality in a very few hours. Initial diagnosis is made on the basis of history; physical examination; radiography, both at the site of palpable crepitance and proximal until no further gas is seen; and Gram stain of exudate looking for large, gram-positive rods. Spore formation is usually not seen in exudates. Anaerobic and routine cultures must be done. Gas gangrene most commonly follows trauma, especially when the wound has been contaminated with earth or when vascular insufficiency results. It is a feared complication of compound fractures and crush injuries. Heroin addicts occasionally get gas gangrene which may begin near an injection site. Subcutaneous crepitant cellulitis caused by clostridium species is seen associated with diabetic foot ulcers and with trauma to extremities. This syndrome probably has a better prognosis than does clostridial myonecrosis, although Hitchcock 1 reports many fulminant cases in which muscle was spared. Gas gangrene may follow bacteremia from a focus in the gastrointestinal tract such as an ulcerated carcinoma. It is also a complication of abdominal surgery. The articles by Finegold et al and Kizer and Ogle in this issue of Annals eloquently describe the fulminant nature of gas gangrene which occurs as metastatic spread from a gastrointestinal tract source. In both, gastrointestinal carcinomas apparently gave rise to clostridial bacteremia with subsequent fatal gas gangrene. Definitive therapy of gas gangrene is still somewhat controversial. Prophylaxis for tetanus is given. Large dosages of penicillin, other antibiotics for mixed infections, and aggressive debridement are mandatory in the management of these infections. The use of clostridial antitoxin has largely been abandoned. Hyper-

baric oxygen as the definitive therapy is not universally accepted. Laboratory and clinical reports of hyperbaric oxygen are very promising. Hyperbaric oxygen at 3 atmospheres is bactericidal for Clostridium perfringens and has produced statistically significant decreases in mortality in a mouse model. 4 Clinical experience has also been favorable. 4'5 The practical problem facing the emergency physician is how to proceed when faced with a crepitant infection. Close cooperation with a surgeon is necessary as soon as the diagnosis is suspected. Hours count, and if the decision to proceed with hyperbaric oxygen is made, the patient must be transported to a center with a hyperbaric chamber as quickly as possible, preferably by helicopter. The emergency depart-' ment should have the telephone number of the nearest ; center able to provide hyperbaric oxygen therapy so that transfer can be facilitated if such therapy is chosen. Not all clostridial infections are gas gangrene. Clostridium may be present in many mixed infections. A case of clostridial joint infection which responded to antibiotics and open drainage as described by Har-~ rington et al in this issue is an example of a nongangrenous clostridial infection that responded to parenteral penicillin and open surgical drainage.

Ralph D. Cushing, MD Associate Professor of Medicine Wayne State University School of Medicine Detroit I 1. Hitchcock AR, Demello FJ, Haglin JJ: Gangrene infection: New approaches to an old disease. Surg Clin North Am 55:1403-1410, 1975. 2. Holland JA, Hill GB, Wolfe WG, et al: Experimental and clinical experience with hyperbaric oxygen in the treatment of clostridial myonecrosis. Surgery 77:75-85, 1975. 3. Hart GB, O'Reilly RR, Cave HR, et al: The treatment of clostridial myonecresis with hyperbaric oxygen. J Trauma: 14:712-715, 1974.

Editor's Note: Free-standing Emergency Clinics The subject of free-standing emergency clinics is given special prominence in this issue of Annals because the Editorial Board perceives that the subject is of growing concern to emergency physicians, EMS planners, and other providers of medical care. The editors agree that the pages of Annals should provide a forum for expression of ideas on this new form of health care provision. Alan S. Kaplan, MD, et al, in the lead article entitled "Free-standing Emergency Clinics: Community Development Guidelines," address the question of whether criteria and guidelines are needed to monitor the development and use of FECs. Their article is

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based on the report of a local EMS council task force charged with developing guidelines and standards for use of the term "emergency" in reference to medical services. In addition, the authors raise the issue of the respective roles of federal and local EMS systems in community planning. Bruce Flashner, MD, and Ronald van der Horst, MD, offer a different view of what they term "a new and exciting form of health care provision" in their editorial on FECs, and Jerris Hedges, MD, in a letter to the editor, suggests a set of guidelines and challenges organized emergency medicine to take a position on the free-standing clinic issue. A more personal

10:6 (June) 1981