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Gas gangrene following electrical burns
GAS G A N G R E N E F O L L O W I N G E L E C T R I C A L BURNS A Report of Two Cases By W. J. POATE, F.R.C.S.E., and A. L. MACAFEE,M.B.
From the Plastic Surgery and Maxillo-Facial Unit, Royal Victoria Hospital, Belfast 'THIS is a report of two patients who received severe electrical burns in the same accident, and who simultaneously developed gas gangrene seven days after injury. Gas gangrene is an uncommon complication in these days and a survey of the literature does not reveal any cases associated with electrical burns. The two patients, J. P. and B. D., males aged 15 and 17 years respectively, were employed as building labourers and sustained their injuries on I I t h March i96o when a ladder which they were manipulating came into contact with a high-tension electrical cable carrying some 33,00o volts. The ladder was made of wood with a wire running down one side, and J. P. was standing on the bottom rung with B. D. standing on the ground at the time of electrocution. Both boys were wearing rubber Wellington boots. Following the accident, they were admitted to the local hospital, which is 4I miles from the Plastic Surgery Unit, and they were given antitetanus serum. The burns were dressed and J.P.'s right arm was decompressed by a longitudinal incision running from the axilla to the wrist. On the following day they were transferred to the Plastic Surgery Unit. On admission, their general condition was considered to be most satisfactory and their clinical signs were as follows :-J. P.--Both feet were extensively burnt, although the burnt areas at this stage were by no means well demarcated. However, the greater part of both feet and ankles were thought to have suffered mainly full-thickness skin loss. The whole of the right upper limb was grossly oedematous and swollen and the decompression incision from the axilla to the wrist was gaping widely, exposing partly necrotic tissue. The viability of tissues in this limb was very doubtful. B. D . - - O n the .sole of the right foot there was a circular demarcated burn measuring 4 cm. in diameter. Both of his wrists and palms had received superficial burns. It was quite obvious from the outset that J. P. would prove a more complicated problem than B. D. and subsequent events showed this to be correct. It was decided that both patients should be treated conservatively and that :no immediate operative treatment was indicated. They had already been given antitetanus serum upon admission to the first hospital. For the period of one week their general condition gave no cause for anxiety, and during this time lines of demarcation between viable and necrotic tissues gradually became evident. Seven days after injury J. P. began to complain of nausea and vomiting with a pyrexia of Io2 ° F., a tachycardia of I Io, and increasing mxa:mia. The burnt areas on both feet had begun to undergo increasing decomposition. Associated with this there was a noticeably peculiar odour, and it was thought gas formation was occurring in the tissues. On account of this IB
17
I8
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
clinical picture, a provisional diagnosis of gas gangrene was made. Swabs were taken from all suspicious areas for aerobic and anaerobic culture. B. D. developed similar signs and symptoms only about two hours later. Swabs were similarly taken from his right foot. Within a few hours there was a rapid deterioration in J. P.'s condition. Although gas gangrene had not been proved on culture, it was felt that the clinical diagnosis was reasonably accurate, and to prevent the condition spreading a bilateral below-knee amputation was carried out. Intravenous doses of anti-gas gangrene serum were administered beginning with 4%0oo units (" Wellcome" Brand (Perfringens)), and over the next three days a total of I60,000 units was given. Intravenous Achromycin was administered in a dosage of I½ g. per twenty-four hours. Some improvement was noted in his general condition almost immediately following operation. He was transfused during it with 2 pints o f whole blood. However, the following day it was apparent that his pulse was still high and that his temperature was not settling, and to make matters worse swab reports from both legs and from the right arm demonstrated organisms morphologically similar to Clos~ridium welchii. Closer inspection of the tissues of the right arm showed considerable necrosis, and despite his poor general condition it was obvious that surgical ddbridement was urgently needed. Accordingly, eight days after admission to the Plastic Unit, a considerable portion of the exposed musculature in the right upper arm, along with necrotic skin, was cut away, this being done in the patient's bed without any form of anaesthesia. The antecubital fossa and wrist region also received attention. During all this time, because of the relatively large areas of tissues involved and therefore of the suspected continuation o f wclchii infection, repeated doses of antitoxin were administered intravenously. On the following day, in addition to the Achromycin, penicillin was given in doses of two million units four-hourly by intramuscular injection. After a short time on this day a temporary improvement in his condition was noted, as evidenced by a decrease in temperature and the pulse rate ; this, however, was not maintained. Accordingly, nine days after admission, disarticulation of the right arm was performed under general anaesthesia. He was given a further 2 pints of whole blood. The day after this operation a further transfusion of 2 pints o f whole blood was administered, and his condition was regarded as being most satisfactory. A day later a definite improvement was recorded and the Achromycin was stopped, but the penicillin continued. At this stage swabs from all amputation sites wcrc negative for Clostridium welchii. The temperature and pulse were normal and he was given two bottles of packed cells. From this date onwards hc made an uncomplicated recovery and his amputation sites healed without trouble. His continued cheerfulness and unfailing " will to live" are deserving of special mention. Throughout this somewhat dramatic series of events B. D. was not forgottcn~ Only a few hours after the bilateral below-knee amputation on J. P. had been carried out, a radical d~bridemcnt of the sole of the right foot was performed on B. D. following a decline in his general condition and the confirmation of a positive Clostridium welchii swab. He was similarly given intravenous Achromycin and anti-gas gangrene serum, the details of which may be omitted here. Suffice to say, he made a good recovery in a short time, and it required only Thiersch grafting to render him fit to be discharged.
GAS
GANGRENE
FOLLOWING
ELECTRICAL
BURNS
19
DISCUSSION A short summary of the bacteriology of gas gangrene may be of interest here. Infection is caused by one or more of the three organismslClostridium welChii, Clostridium oedematiens, Clostridium septique. All are spore-bearing Gram-positive rods and all are anaerobic. They produce gas in dead tissue by means of an enzymatic action on glycogen. They all form a potent toxin, and it is this and not the gas, as such, that is the danger. The diagnosis is essentially a clinical one initially and the exact bacteriological identification of the particular organism is not pursued. Clostridium welchii is encapsulated and is the most formidable o f the three. It is hmmolytic on blood agar. Success in conquering the deadly gas gangrene largely dates back to World War I, when it was found by the French that the energetic surgical d6bridement of a recent war wound and nothing else practically eliminated the disease. This has been carried into civilian life, and although it is possible to immunise against a welchii infection by administration of the toxoid, there is theoretically and practically no reason for doing so. Penicillin is probably the most valuable drug even to-day and, combined with early and adequate excision of the dead tissue, constitutes an efficient and dramatic way of combating the infection. T h e incubation period of gas gangrene is said to be from eighteen hours to two days, although it seemed longer in our cases. Once it has incubated it damages rapidly by liberation of its toxin ; therefore all treatment must be carried out promptly. As long as one can be sure of ridding the patient of the organism by surgicai means, aided by penicillin, then there is no theoretical advantage in giving more than one dose of antitoxin, as this alone will serve to neutralise all circulating toxin. Subsequent doses cannot undo existing cellular damage already caused by the past presence of the toxin. SUMMARY Two cases of gas gangrene following severe electrical burns are presented. They are recorded partially in the hope of stimulating further discussion amongst: those with perhaps similar experiences. No factual account, as this has been, can emphasise the team-work involved in treating these patients nor do justice to the wealth of medical care lavished upon them. Once a diagnosis of gas gangrene is made in any hospital it necessarily means a certain amount of turmoil within its walls and a complete disruption o f the surgical and theatre routine of the institution. It should be recorded that the eventual recovery of the two boys, medically, physically, and mentally, could not have been achieved without the persevering attitude adopted by the hospital physiotherapist and the ward sister and nurses. It may also be of interest to know that they were treated throughout in a hospital devoid of any laboratories or immediate facilities for special investigations. Because of this, blood cultures were not taken, although as a matter of completion they should have been. The final acclaim for success must certainly go to B. D. and J. P. themselves, who were robust and tough country lads and whose vitality and sense of determination carried them through a long and serious sequence of events. We would like to record our thanks to Mr N. C. Hughes, F.R.C.S., under whose care zhese patients were admitted, for his kind permission to publish the cases and for his help and criticism in compiling the notes.
From the Plastic Surgery and Maxillo-Facial Unit, Royal Victoria Hospital, Belfast 'THIS is a report of two patients who received severe electrical burns in the same accident, and who simultaneously developed gas gangrene seven days after injury. Gas gangrene is an uncommon complication in these days and a survey of the literature does not reveal any cases associated with electrical burns. The two patients, J. P. and B. D., males aged 15 and 17 years respectively, were employed as building labourers and sustained their injuries on I I t h March i96o when a ladder which they were manipulating came into contact with a high-tension electrical cable carrying some 33,00o volts. The ladder was made of wood with a wire running down one side, and J. P. was standing on the bottom rung with B. D. standing on the ground at the time of electrocution. Both boys were wearing rubber Wellington boots. Following the accident, they were admitted to the local hospital, which is 4I miles from the Plastic Surgery Unit, and they were given antitetanus serum. The burns were dressed and J.P.'s right arm was decompressed by a longitudinal incision running from the axilla to the wrist. On the following day they were transferred to the Plastic Surgery Unit. On admission, their general condition was considered to be most satisfactory and their clinical signs were as follows :-J. P.--Both feet were extensively burnt, although the burnt areas at this stage were by no means well demarcated. However, the greater part of both feet and ankles were thought to have suffered mainly full-thickness skin loss. The whole of the right upper limb was grossly oedematous and swollen and the decompression incision from the axilla to the wrist was gaping widely, exposing partly necrotic tissue. The viability of tissues in this limb was very doubtful. B. D . - - O n the .sole of the right foot there was a circular demarcated burn measuring 4 cm. in diameter. Both of his wrists and palms had received superficial burns. It was quite obvious from the outset that J. P. would prove a more complicated problem than B. D. and subsequent events showed this to be correct. It was decided that both patients should be treated conservatively and that :no immediate operative treatment was indicated. They had already been given antitetanus serum upon admission to the first hospital. For the period of one week their general condition gave no cause for anxiety, and during this time lines of demarcation between viable and necrotic tissues gradually became evident. Seven days after injury J. P. began to complain of nausea and vomiting with a pyrexia of Io2 ° F., a tachycardia of I Io, and increasing mxa:mia. The burnt areas on both feet had begun to undergo increasing decomposition. Associated with this there was a noticeably peculiar odour, and it was thought gas formation was occurring in the tissues. On account of this IB
17
I8
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
clinical picture, a provisional diagnosis of gas gangrene was made. Swabs were taken from all suspicious areas for aerobic and anaerobic culture. B. D. developed similar signs and symptoms only about two hours later. Swabs were similarly taken from his right foot. Within a few hours there was a rapid deterioration in J. P.'s condition. Although gas gangrene had not been proved on culture, it was felt that the clinical diagnosis was reasonably accurate, and to prevent the condition spreading a bilateral below-knee amputation was carried out. Intravenous doses of anti-gas gangrene serum were administered beginning with 4%0oo units (" Wellcome" Brand (Perfringens)), and over the next three days a total of I60,000 units was given. Intravenous Achromycin was administered in a dosage of I½ g. per twenty-four hours. Some improvement was noted in his general condition almost immediately following operation. He was transfused during it with 2 pints o f whole blood. However, the following day it was apparent that his pulse was still high and that his temperature was not settling, and to make matters worse swab reports from both legs and from the right arm demonstrated organisms morphologically similar to Clos~ridium welchii. Closer inspection of the tissues of the right arm showed considerable necrosis, and despite his poor general condition it was obvious that surgical ddbridement was urgently needed. Accordingly, eight days after admission to the Plastic Unit, a considerable portion of the exposed musculature in the right upper arm, along with necrotic skin, was cut away, this being done in the patient's bed without any form of anaesthesia. The antecubital fossa and wrist region also received attention. During all this time, because of the relatively large areas of tissues involved and therefore of the suspected continuation o f wclchii infection, repeated doses of antitoxin were administered intravenously. On the following day, in addition to the Achromycin, penicillin was given in doses of two million units four-hourly by intramuscular injection. After a short time on this day a temporary improvement in his condition was noted, as evidenced by a decrease in temperature and the pulse rate ; this, however, was not maintained. Accordingly, nine days after admission, disarticulation of the right arm was performed under general anaesthesia. He was given a further 2 pints of whole blood. The day after this operation a further transfusion of 2 pints o f whole blood was administered, and his condition was regarded as being most satisfactory. A day later a definite improvement was recorded and the Achromycin was stopped, but the penicillin continued. At this stage swabs from all amputation sites wcrc negative for Clostridium welchii. The temperature and pulse were normal and he was given two bottles of packed cells. From this date onwards hc made an uncomplicated recovery and his amputation sites healed without trouble. His continued cheerfulness and unfailing " will to live" are deserving of special mention. Throughout this somewhat dramatic series of events B. D. was not forgottcn~ Only a few hours after the bilateral below-knee amputation on J. P. had been carried out, a radical d~bridemcnt of the sole of the right foot was performed on B. D. following a decline in his general condition and the confirmation of a positive Clostridium welchii swab. He was similarly given intravenous Achromycin and anti-gas gangrene serum, the details of which may be omitted here. Suffice to say, he made a good recovery in a short time, and it required only Thiersch grafting to render him fit to be discharged.
GAS
GANGRENE
FOLLOWING
ELECTRICAL
BURNS
19
DISCUSSION A short summary of the bacteriology of gas gangrene may be of interest here. Infection is caused by one or more of the three organismslClostridium welChii, Clostridium oedematiens, Clostridium septique. All are spore-bearing Gram-positive rods and all are anaerobic. They produce gas in dead tissue by means of an enzymatic action on glycogen. They all form a potent toxin, and it is this and not the gas, as such, that is the danger. The diagnosis is essentially a clinical one initially and the exact bacteriological identification of the particular organism is not pursued. Clostridium welchii is encapsulated and is the most formidable o f the three. It is hmmolytic on blood agar. Success in conquering the deadly gas gangrene largely dates back to World War I, when it was found by the French that the energetic surgical d6bridement of a recent war wound and nothing else practically eliminated the disease. This has been carried into civilian life, and although it is possible to immunise against a welchii infection by administration of the toxoid, there is theoretically and practically no reason for doing so. Penicillin is probably the most valuable drug even to-day and, combined with early and adequate excision of the dead tissue, constitutes an efficient and dramatic way of combating the infection. T h e incubation period of gas gangrene is said to be from eighteen hours to two days, although it seemed longer in our cases. Once it has incubated it damages rapidly by liberation of its toxin ; therefore all treatment must be carried out promptly. As long as one can be sure of ridding the patient of the organism by surgicai means, aided by penicillin, then there is no theoretical advantage in giving more than one dose of antitoxin, as this alone will serve to neutralise all circulating toxin. Subsequent doses cannot undo existing cellular damage already caused by the past presence of the toxin. SUMMARY Two cases of gas gangrene following severe electrical burns are presented. They are recorded partially in the hope of stimulating further discussion amongst: those with perhaps similar experiences. No factual account, as this has been, can emphasise the team-work involved in treating these patients nor do justice to the wealth of medical care lavished upon them. Once a diagnosis of gas gangrene is made in any hospital it necessarily means a certain amount of turmoil within its walls and a complete disruption o f the surgical and theatre routine of the institution. It should be recorded that the eventual recovery of the two boys, medically, physically, and mentally, could not have been achieved without the persevering attitude adopted by the hospital physiotherapist and the ward sister and nurses. It may also be of interest to know that they were treated throughout in a hospital devoid of any laboratories or immediate facilities for special investigations. Because of this, blood cultures were not taken, although as a matter of completion they should have been. The final acclaim for success must certainly go to B. D. and J. P. themselves, who were robust and tough country lads and whose vitality and sense of determination carried them through a long and serious sequence of events. We would like to record our thanks to Mr N. C. Hughes, F.R.C.S., under whose care zhese patients were admitted, for his kind permission to publish the cases and for his help and criticism in compiling the notes.