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Comprehensive treatment for gas gangrene of the limbs in
earthquakes
WANG Yue1, M.D.
LU Bo1, M.D.
HAO Peng1, M.D.
Department of Orthopaedics, Sichuan Provincial People’s Hospital, Sichuan
Academy of Medical Sciences, Chengdu, Sichuan, China
DAI Kerong2*, M.D., Ph.D,
Department of Orthopaedics, The Ninth People’s Hospital, Shanghai Jiao
Tong University School of Medicine, Shanghai 200011, R.R.China
Please address all correspondence to:
DAI Ke-rong, MD
Department of Orthopaedics
Ninth People’s Hospital
Shanghai Jiaotong University School of Medicine
639 Zhizaoju Road,
Shanghai, 200011
P.R.China
Phone: (+86)2163139920
FAX: (+86)2163139920
Email:[email protected]
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Comprehensive treatment for gas gangrene of the limbs in
earthquakes
Summary
Background: Mortality rates for patients with gas gangrene from trauma or surgery are as high
as 25%, but they increase to 50% to 80% for patients injured in natural hazards. Early diagnosis
and treatment are essential for these patients.
Methods: We retrospectively analyzed the clinical characteristics and therapeutic results of 19
patients with gas gangrene of the limbs who were injured in the May 2008 earthquake in the
Wenchuan district of China’s Sichuan province and treated in our hospital, seeking how best to
diagnose and treat earthquake-induced gas gangrene.
Results: Of 226 patients with limbs with open injuries sustained during the earthquake, 53
underwent smear analysis of wound exudates. Of those, gas gangrene was diagnosed in 19. The
average elapsed time from injury to arrival at the hospital was 72 hours, from injury to definitive
diagnosis was 4.3 days, and from diagnosis to conversion of negative findings on wound smear
analysis to positive findings was 12.7 days. Anaerobic cultures were also obtained before wound
closure. The average elapsed time from completion of surgery to recovery of normal vital signs
was 6.3 days. Of the 19 patients, 16 were treated with open amputation, 2 with closed amputation,
and 1 with successful limb salvage; 18 patients were successfully treated and 1 died.
Conclusions: In earthquakes, rapid, accurate screening and isolation are essential to successfully
treating gas gangrene and helpful in preventing nosocomial diffusion. Early and thorough
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débridement, open amputation, and active supportive treatment can produce satisfactory
therapeutic results.
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INTRODUCTION
Gas gangrene (Clostridium septicum myonecrosis) is a serious, acute, specific infection resulting
from a severe open injury. The pathologic changes develop quickly and result in high mortality
and disability rates.7 Large-scale natural hazards such as earthquakes lead to large numbers of
patients with traumatic injuries, some of them quite complicated. How best to provide timely
diagnosis and effective treatment to patients who develop gas gangrene from injuries sustained in
earthquakes, so as to lower mortality rates and prevent nosocomial diffusion of infection, is a
Gordian knot yet to be resolved. There are few reports about gas gangrene in earthquake-caused
injuries in the medical literature. On May 12, 2008, a catastrophic earthquake with a magnitude
of 8.0 on the Richter scale struck the Wenchuan district of the Sichuan province of China, after
which our hospital treated 19 patients with gas gangrene in 21 limbs. Despite treating a large
number of people with other kinds of injuries at the same time, we provided active treatment to
those with gas gangrene, effectively preventing nosocomial diffusion and achieving a high
survival rate. What follows here is our retrospective report.
PATIENTS and METHODS
Study targets
After the earthquake, the People’s Hospital of Sichuan Province admitted 1,613 earthquake
survivors between May 12 and May 31, 2008, of whom 820 had limb fractures and 226 had open
limb injuries (including 157 with open limb fractures). After initially visually examining these
patients at admission, we conducted wound smear bacteriologic screening in 53 patients with
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open limb injuries. Of those, 19 patients (21 limbs) had definite gas gangrene (18 patients with
open fractures and 1 patient with an open soft-tissue injury), and for 3 patients the initial
diagnosis was suspected gas gangrene, but later observation proved that diagnosis incorrect. For
the 19 patients who had gas gangrene, local medical agencies failed to give health-care providers
any special reminder right after these patients had been extricated from rubble, so the first-aid
medical teams provided only the simple wound bandaging that is normally provided for
uncomplicated open injuries and transferred the patients to our hospital for treatment. The 19
patients include 9 males and 10 females, with an average age of 49.2 years (range, 8–87 years).
Eighteen patients had been crushed by collapsed houses and 1 was injured by falling stones. The
average time spent trapped under rubble was 16.3 hours (range, 7–68 hours). Injuries were
distributed as follows: 9, left leg only; 4, right leg only; 2, both legs; 3, right arm only; and 1, left
arm only. One patient had a closed chest injury, multiple rib fractures, traumatic wet lung, acute
respiratory distress syndrome, disseminated intravascular coagulation, and multiorgan
dysfunction. One patient sustained multiple fractures in the first and second metacarpal bones
and fracture of the proximal phalanx on the left middle finger. None of the 19 patients had ever
received immunosuppressive drugs. Among them, 3 had abnormal renal function; 1 patient
recovered normal function after the correction of circulating blood volume, and the other 2 were
treated with blood dialysis.
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Screening examination
On arrival at our hospital, the 226 patients with open limb injuries underwent initial examination
in the temporary consulting rooms (figure 1) that were built especially to handle patient overflow
caused by the earthquake. Routine débridement was done for those patients with small, slightly
contaminated wounds who were free of any obvious symptom of infection or tissue necrosis. Of
those, 53 with extensive soft-tissue damage or contaminated wounds underwent prompt sampling
and smear analysis.
The choice of which of four types of treatments to use was based on the results of clinical
and bacteria smear analysis:
1. Patients with negative findings on smear analysis and free of any typical clinical
symptoms of gas gangrene—extensive soft-tissue necrosis in local muscles; tissue
that turned grayish or blackened, associated with a foul odor, a lot of blebs, and
extensive effusion—were sent to the ordinary débridement room for routine
débridement, and then kept in ordinary wards for further treatment. Of the study
group of 53 patients, 31 received this treatment.
2. Patients with negative findings on bacteria smear analysis but who manifested some
typical clinical symptom of gas gangrene (e.g., foul odor, darkened or blackened
tissues) were designated as having suspected gas gangrene, sent to an
infection-control operating room for wound management, and then kept in an
isolation ward for patients with suspected gangrene and observed. If smear analysis
findings during the observation period became positive, the patient was transferred to
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the isolation ward immediately. For those with continuously negative smear analysis
(once-daily smears) results (i.e., no Gram-positive bacilli with spores or capsules
detected, and both local and general manifestations appearing better off after
treatment), anaerobic cultures were obtained to verify the results of smear analysis
before wound closure. If no pathologic condition recurred within 3 days of wound
closure, the patient was deemed not to have gas gangrene and was released from
isolation. Two patients from the study group had this treatment regimen.
3. Patients with positive results on bacteria smear analysis who were nevertheless free of
typical clinical symptoms were listed as possibly having gas gangrene, sent to an
infection-control operating room for wound for treatment, and then kept in an
isolation ward for patients with suspected gangrene and observed. If typical clinical
symptoms appeared during the observation period, the patient was transferred to an
isolation ward immediately. If the results of smear analysis became negative and no
pathologic condition recurred within 3 days of injury closure, then the diagnosis was
not gas gangrene and the patient was transferred out of isolation. One patient from the
study group had this treatment regimen.
4. Patients with positive results on bacteria smears (i.e., Gram-positive thick bacilli with
spores or capsules were detected) and who had typical clinical symptoms were given
a definite diagnosis of gas gangrene, sent to an infection-control operating room for
treatment, and then kept in an isolation ward for further treatment. Nineteen patients
from the study group had this treatment regimen.
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Diagnosis criteria
The criteria for gas gangrene are as follows:
1. Foul odor, darkened or blackened soft tissues in wounded muscle, and associated
fever, crepitation, distension pain in the wounded limb, low blood pressure, and
altered state of consciousness, along with the typical feathering pattern of gas in soft
tissue as shown on radiographs (figure 2)
2. Gram-positive thick bacilli with spores or capsules detectable on bacteria smear
analysis
Once both criteria have been met, the diagnosis of gas gangrene is definite. If only one
criterion is met, the patient is considered to have suspected gas gangrene. If the patient has the
typical clinical manifestation but the initial bacteria examination findings are negative, then daily
smear analysis must be conducted for 3 successive days. If Gram-positive thick bacilli with
spores or capsules can then be detected at any time during those 3 days, then gas gangrene is
definitely the correct diagnosis. Because the number of earthquake survivors who arrived at our
hospital simultaneously was quite large and because of the possibility that patients with
suspected gas gangrene could be exposed to infection during radiographic examination, which
could result in infection diffusion, we did not obtain radiographs for all patients as we usually
would have done.
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Data for the following parameters were recorded for all patients with definite gas
gangrene and for those suspected of having it:
1. The time elapsed from injury to having a suspected diagnosis, from then to having a
definite diagnosis, from then to recovery of normal vital signs after surgery, and from
then until wound bacteria culture results became negative
2. Corresponding clinical symptoms and signs and any changes in them
3. Changes in laboratory examination results for such tests as hemoglobin (Hgb) level,
packed red blood cell volume, serum total protein, albumin level, blood sugar level,
aspartate aminotransferase (AST) level, and alanine aminotransferase (ALT) level
during various treatment stages (We report data here as mean values and standard
deviation. SPSS statistical software [version 12.0; SPSS Inc., Chicago, IL, USA] was
used, and the data were analyzed with repeated measures analysis of variance.)
4. Drug use, transfusion of blood or plasma, and corresponding effects
5. The type of associated bacterial infection and the length of the positive-to-negative
conversion period
Criteria for exclusion
If no Gram-positive thick bacilli with spores or capsules were detected in the successive three
wound bacteria smear analyses (once per day for successive 3 days) and if the patient’s condition
was obviously better after débridement, then the patient was designated as not having gas
gangrene.
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Wound management and sterilization of isolation wards
This is the procedure for surgical treatment for both patients with suspected gangrene and those
with diagnosed gangrene:

Obtain a sample of wound secretions during surgery for bacteria smear examination.

Apply adequate physiologic saline solution to repeatedly wash the wound.

Treat the wound with hydrogen peroxide solution and apply a wet compress with
iodoform gauze.

Thoroughly remove any infectious agents.

Débride necrotic tissues insofar as possible.

For patients with ischemic necrotic limbs, carry out first-stage amputation.

As a routine, administer clindamycin and amoxicillin to all patients with suspected gas
gangrene and to those with diagnosed gangrene, to prevent and treat infection.

For those infected with a combination of different bacteria, administer empiric antibiotic
treatment with levofloxacin, adjusting the dosage until the results of a bacteria culture
and drug sensitivity test are available.
Moreover, we corrected electrolyte imbalances, transfused blood or blood plasma, and
provided hyperbaric oxygen treatment in chambers specialized for patients with gas gangrene.
During hyperbaric oxygen treatment, patients breathed 100% oxygen for 150 minutes: We
increased the pressure to the equivalent of 2.5 kPa after 30 minutes, maintained that level for 60
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minutes, and then decreased the pressure for 60 minutes. They were treated once every 8 hours
the first day, once every 12 hours the second and third days, and then once a day from the fourth
day until wound secretion bacteria smear results were negative three successive times (one smear
examination per day and continuing for successive 3 days).
All disposable medical items used in wards for patients with suspected gangrene and in
isolation wards should be incinerated. Other apparatuses or instruments should be separately
sealed, transported, and cleaned and disinfected, and sterilized at high temperature and high
pressure before being used in other procedures. We used air-sterilization facilities for continuous
sterilization, and all surfaces and operating-room articles were sterilized with benzalkonium
bromide daily.
Wounds should be closed only after patients with diagnosed gas gangrene meet the
criteria of wound closure. Patients in isolation cannot be moved to regular wards until there has
been no recurrence of bacteria within 3 days of wound closure. Patients’ personal articles must
be sterilized before they leave isolation. Hyperbaric chambers specialized for patients with gas
gangrene must be thoroughly sterilized after each use, including chamber surfaces, the air, and
the floor and walls of the therapy room.
Criteria for terminating isolation
After surgery on the limb with gas gangrene, the wound can be closed if no Gram-positive thick
bacilli with spores or capsules are detected in three successive wound bacteria smear analyses
(once per day for 3 successive days). If there is no recurrence of bacteria within the following 3
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days, the patient can be removed from the isolation ward. To prevent infection recurrence after
wound closure, anaerobic cultures should be conducted concurrent with bacteria smear analysis
before wound closure to verify the results of smear analysis.
RESULTS
Of the 53 patients seen in an initial screening, 21 were sent to wards for patients with suspected
gas gangrene, 18 had wounds with a definite diagnosis of gas gangrene after observation, and 3
with suspected gangrene were found, after further observation and treatment, not to have
gangrene. However, gangrene was missed in 1 patient at the initial screening, and the patient was
sent to an ordinary ward. Both thighs of this patient had ischemic necrosis because they were
trapped by earthquake rubble for 68 hours. When the patient arrived at the temporary consulting
room, the results of the wound bacteria smear analysis appeared to be negative and the patient
had no typical clinical symptom of gas gangrene; open amputation at the lower thigh was
performed on both legs. However, on the second day after surgery, the wounds emitted a foul
odor and the wounded muscle turned black and necrotic and developed profuse effusion and
blebs. A second smear analysis was conducted, and bacilli with spores and capsules were
detected. The patient was immediately transferred to an isolation ward and underwent a second
débridement, and the patient’s condition was gradually controlled.
In all patients studied, the limb wounds were extensive and deep, some reaching to the
bone surface or joint cavity, with long bones or joint cavities exposed. All wounds were severely
contaminated and contained with a great deal of dust, sand, or crushed stones and emitted a
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heavy stench that was perceptible even when the wounds were wrapped with multiple layers of
dressing. The skin surrounding the wounds appeared pale, varicose, and bright and were highly
tense; normal skin texture had disappeared. An extensive area of soft tissues, including muscles,
showed color changes (presenting as grayish, wine colored, or purple-black). The involved
muscle had lost elasticity, failed to contract on stimulation, and appeared stagnant and wan, like
boiled meat. There was extensive effusion, presenting as a malodorous thin, bloody secretion.
Crepitation was apparent in 73.7% of patients, and blebs appeared on their wounds when they
were under pressure; 68.4% of patients had distension pain of the wounded limb, on which
routinely provided analgesia had no effect; and 31.6% patients presented with low blood pressure
(table 1). We found that in earthquake survivors without gas gangrene, wounds may be similarly
extensive and wounded muscle may be similarly blackened and may fail to contract on
stimulation, but the degree of wound contamination was comparatively lighter than in patients
with gangrene. Also less severe in patients without gangrene were degree of wound
malodorousness, degree of tumefaction of skin surrounding the wound, degree of skin tension,
and amount of effusion from the wound. These patients also had no blebs, crepitation, or
distension pain.
The presence of fever was not consistent in earthquake survivors. The average body
temperature of the group was 38.4° ± 0.7°C (range, 37.3°C–40.4°C) on arrival at the hospital; 8
patients had a temperature of <38°C, 9 had a temperature between 38.1°C and 39.9°C, and 2 had
a temperature of >39.1°C.
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Table 2 provides laboratory results after initial examination on arrival at the hospital,
during the period when patients’ conditions were primarily controlled, and during the transition
period from positive to negative findings on smear analysis for each patient. The average values
for Hgb, hematocrit (Hct), total protein, albumin, AST, and ALT were significantly improved
after treatment. This suggested that patients gradually became healthier as parameters were
corrected throughout treatment.
Among the 19 patients with gas gangrene, 16 underwent amputation immediately because
of ischemic necrosis and severe infection, and the other 3 underwent limb-salvage débridement.
Among the 16, 13 patients (13 limbs) underwent open amputation and 3 patients (5 limbs)
underwent closed amputation initially that evolved to open amputation (5 limbs) because gas
gangrene had not been completely controlled. Among the 3 patients who underwent limb-salvage
débridement, 2 later underwent closed amputation (2 limbs) because of diffusion of gas gangrene
associated with regional limb necrosis, and 1 underwent successful limb salvage (figure 3). The
latter patient arrived at the hospital 7 hours after injury, which is the earliest point in time that
any of the 19 patients with gas gangrene received treatment. After thorough débridement, local
necrotic tissues were removed, the wound dressing was replaced every day to remove newly
formed necrotic tissues, and the wounds and the patients’ general conditions gradually improved.
Anaerobic cultures were obtained, in addition to smear analyses, before wound closure to verify
negative smear analysis findings, and limb salvage eventually succeeded. Among the 31 patients
free of gas gangrene, 17 underwent amputation because of crush syndrome and limb necrosis,
and the other 14 underwent successful limb salvage.
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The average amounts of transfused erythrocyte suspension and of transfused fresh frozen
plasma were 4.4 U (range, 0–16 U) per patient and 1430 mL (range, 0–5200 mL) per patient,
respectively.
Among the 19 patients (21 limbs) with gas gangrene, combined bacterial infections
detected by wound culture included Acinetobacter calcoaceticus-baumannii (6 patients),
Enterobacter cloacae (3), Enterococcus faecalis (3), Escherichia coli (3), Staphylococcus aureus
(2), Enterobacter amnigenus (1), S. epidermidis (1), Alcaligenes faecalis (1), Klebsiella
pneumoniae (1), Morganella morganii (1), Pediococcus pentosaceus (1), S. haemolyticus (1),
and Moraxella catarrhalis (1).
The time elapsed for conversion of C. perfringens from positive to negative findings on
bacteria smear was 15.1 ± 7.9 days for those with combined bacteria infection (14 patients) and
3.6 ± 6.4 days for those without combined bacteria infection (5 patients), which demonstrated
that the conversion period was obviously shorter for patients without combined bacterial
infection.
During treatment, abnormal renal function was diagnosed in 3 patients: 1 patient
recovered after blood volume improved, 1 recovered after blood dialysis, and 1 died from
multiorgan failure caused by multiple injuries. Because of excessive wound effusion before and
after surgery, 5 patients developed hypokalemia, with output ranging between 2.8 and 3.32
mmol/L, and recovered after correction of electrolyte imbalances. In the studied group, 2 patients
who underwent closed amputation healed by first intention. For patients who underwent open
amputated or limb salvage, their wounds were closed after wound secretion cultures produced
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negative results. No infection recurrence was observed. Two patients were given 12 U and 36 U
of blood platelets each during dialysis.
Among the 19 patients with definite gas gangrene, 18 were successfully treated and 1
died. The patient who died had gas gangrene of the right leg, associated with closed chest injury
and multiple rib fractures; the causes of death were acute renal failure, traumatic wet lung, acute
respiratory distress syndrome, disseminated intravascular coagulation, and multiorgan failure.
The average time elapsed from injury to arrival at the hospital was 72 hours (range,
7–144 hours), from injury to definite diagnosis of gas gangrene was 4.3 days (range, 3–7 days),
from completion of surgery to recovery of normal vital signs was 6.3 days (range, 4–18 days),
and from definite diagnosis of gas gangrene to negative findings on wound bacteria smears was
12.7 days (range, 0–23 days).
DISCUSSION
Clinical characteristics and related treatment of earthquake survivors with gas
gangrene
Gas gangrene is most often caused by severe open injury. Common nosogenetic bacteria include
C. perfringens, C. aerogenes capsulatus, edematigenous bacillus, septicemic bacillus, and C.
histolyticum. These bacilli generate various enzymes and toxins that cause tissue edema, necrosis,
toxemia, and quick diffusion of pathologic changes,2 in which case both mortality rates and
disability rates will be high. Spontaneous gas gangrene is related to colon cancer, leukocythemia,
diabetes, and drug-induced human immunodeficiency virus.3-5, 8
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All patients in the study group were injured in the earthquake, and all except 1 had limbs
injured by collapsed houses, underwent a long period of limb entrapment (an average of 16.3
hours), and had severe local soft-tissue injury. Because of the obstructed motor-vehicle traffic
and difficulties in extracting wounded persons from rubble after the earthquake, patients could
not immediately be sent to a hospital. On average, they were transported to a hospital 3.0 days
after injury, and the average time from injury to definitive diagnosis was 4.3 days, so early and
thorough débridement was impossible, which resulted in generation and diffusion of gas
gangrene, leading to a high amputation rate.1
All wounds featured foul odors, color changes of the muscles and other soft tissues, and
extensive effusion; 94.7% of patients had fever, 73.7% had crepitation, 68.4% had distension
pain in the injured limbs, and 31.6% had low blood pressure. All patients had anemia and
hypoproteinemia to some degree on arrival at the hospital. Erythrocyte suspension and fresh
frozen plasma were transfused to maintain a stable internal environment. The average transfusion
of erythrocyte suspension was 4.4 U per patient, with a maximum of 16 U; the average
transfusion of fresh frozen plasma was 1430 mL per patient, with a maximum of 5200 mL.
Owing to serious wound contamination, most of the patients had combined infections
caused by more than one type of bacteria, so appropriate bacteria cultures were obtained to allow
timely adjustment of antibiotics. The positive-to-negative conversion period after surgery was
significantly shorter for patients without combined bacterial infections than for those with such
infections. As far as the impacts of types and quantities of bacteria on infection were concerned,
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we did not conduct relevant statistic processing because of the small size of the available sample
group, but that is an issue worth further study.
The catastrophic earthquake in China wounded large numbers of persons who were sent
to hospitals, and many of them were in critical condition on arrival, leaving no time to wait for
the results of bacteria cultures. In that situation, we deemed repeated bacteria smear
examinations to be more practical than cultures. By the time these patients’ wounds had been
closed, the number of in-hospital patients had been gradually reduced, so anaerobic cultures
could be conducted to verify the results of smear examinations and to ensure that there were no
infection recurrences after wound closure.
Because of extensive effusion from their wounds, the patients were subject to electrolyte
imbalances during treatment. Five of them developed hypokalemia. Regularly retesting for
pathology, treatment aimed at achieving homeostasis, and reduction of wound effusion help
prevent wound infection. For patients with abnormal renal function, blood dialysis can be used if
necessary. When blood dialysis must be lengthy, care should be taken to supplement blood
plasma and blood platelets to improve thromboxane function.
Hyperbaric oxygen treatment can obviously inhibit growth of anaerobic bacteria, reduce
or stop the production of clostridial α-toxin by C. perfringens, suppress peroxidase in necrotic
tissue, enhance the clearance of Clostridium, and halt edema and gas production in the tissue.
Thanks to these and other effects, hyperbaric oxygen therapy has a favorable effect on edema
and the healing of hypoxic wounds. Moreover, the increased wound oxygen tension achieved
with hyperbaric oxygen therapy promotes capillary angiogenesis and improves healing.
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Furthermore, it can increase the host’s antimicrobial defenses and has a direct bacteriostatic
effect on anaerobic organisms. In our experience, hyperbaric oxygen therapy can assist wound
healing by improving the patient’s general condition and correcting blood-loss anemia and
hypoproteinemia. It may also help control gas gangrene.
Diagnostic process for suspected gas gangrene
Any patients who have survived an earthquake should undergo careful wound examination on
arrival at a hospital. If the wound emits a foul odor, if the soft tissues in the wounded muscle
have changed color, if there is extensive effusion from the wound, or additionally if there are
associated clinical manifestations such as fever, crepitation, distension pain in the wounded limb,
or low blood pressure, a bacteria smear should be immediately obtained and the patient should be
transferred to a special infection isolation ward. If Gram-positive bacilli with spores or capsules
are detected during the smear examination, the patient should immediately be treated for gas
gangrene infection with débridement or amputation, and then sent to a gas gangrene isolation
ward. If no Gram-positive bacilli with spores or capsules are detected during two successive
smear examinations, the patient can be transferred for surgery into an operating room under
special infection-control conditions, and then sent to an isolation ward for suspected infections
within an infection isolation ward. Isolation cannot be terminated until there is no bacteria
recurrence within 3 days of wound closure. Those patients without typical clinical manifestation
but whose smears produce positive results should be treated as having suspected gas gangrene.
Within a short period, 1613 patients with 226 open injuries were treated. Among them,
19 patients with gas gangrene were treated and were free of nosocomial infection diffusion,
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which showed that the diagnosis and treatment processes that we used were reasonable. On the
basis of our success, and because earthquakes injure a large quantity of persons within a short
period, we deem it necessary to set up a screening and management process especially for gas
gangrene to deal with similar large-scale public-health emergencies. Integrated with the
experience we obtained after the earthquake, the ideal screening process should include the
following facilities and measures:

Initial examination rooms, ordinary patient diagnosis rooms, and examination rooms for
those suspected of having gas gangrene should be set up separately.

Three types of operating rooms—general operating room, infection-control operating
room, and specialized infection operating room—should be set up to deal with ordinary
wounds, wounds with suspected gas gangrene, and wounds with diagnosed gas gangrene,
respectively.

Ordinary wards, observation wards for those suspected to have gas gangrene, and
isolation wards for those with diagnosed gas gangrene should be set up separately.

For initial diagnosis, physicians should carry out a first-stage local and general
examination to distinguish ordinary patients from those suspected of having gas gangrene.
Patients with suspected gas gangrene should be sent to an examination room used only
for such patients; relevant wound specimens should be sent for bacterial examination.

The second-stage examination should be integrated with clinical manifestations. Patients
with definitive diagnoses should be sent to the special infection operating room and
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placed in an isolation ward after surgery. Patients with suspected gas gangrene should be
sent to the infection-control operating room for treatment.

The third-stage examination should be conducted during surgery by sampling and
sending specimens for bacterial examination. If the results are positive, the patient should
be placed in an isolation ward after surgery; if negative, then in an observation ward for
those with suspected infection.

The fourth-stage clinical and bacteriologic examination should be continuously
conducted until a definite diagnosis is obtained.
In sum, the process that we recommend can be briefly described as a three-part system
for facilities and a four-stage examination (figure 4).
Timing and types of surgery for earthquake survivors with gas gangrene
Patients with gas gangrene face a high mortality rate of up to 25%, whereas the mortality rate for
those with limb gas gangrene caused by injury during natural hazards is reported to be even
higher, between 50% and 80%.6 Early diagnosis and treatment are essential for patients with gas
gangrene. Once gangrene has been definitely diagnosed, these patients should be immediately
provided with extensive débridement and effective antibiotic treatment. However, because
patients involved in earthquakes generally sustain severe injuries and are always sent to a
hospital long after being injured, treatment is more challenging. In our study group, patients’
limbs had been severely crushed, soft tissues had been severely injured, diagnosis was quite
delayed, gas gangrene had developed before diagnosis, there were multiple generalized
symptoms, and the optimum time for early-stage extensive débridement and limb salvage had
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already passed. Among the 19 patients with gas gangrene, only 1 underwent successful limb
salvage; the injured limbs in all of the other patients had to be amputated. However, thanks to
timely identification of patients with gas gangrene from among the numerous patients with open
injuries, prompt provision of surgery, and provision of active general support treatment after
surgery and treatment with hyperbaric oxygen, only 1 patient died and a high salvage rate was
achieved. Among those 19 patients, 18 underwent amputation because of delayed diagnosis, 13
of whom underwent open amputation, 2 underwent closed amputation, and 3 underwent open
amputation after failure of closed amputation. In our view, for those with severe soft-tissue
injury sustained during earthquakes and with a definitive diagnosis of gas gangrene of the injured
limbs, thorough débridement should be provided immediately and open amputation should be
performed if necessary. In addition, wound closure by first intention should be undertaken
especially for those patients with combined bacterial infection, in order to strengthen infection
control and reduce the possibility of infection recurrence or of a second amputation. In patients
with gas gangrene of the limb extremities, wound closure by first intention is acceptable if the
patients’ general condition is good and the amputated plane is far from the foci. Before wound
closure, however, bacteria smears should be obtained routinely, and these patients should be
closely monitored after surgery. In the case of infection recurrence, timely removal of sutures to
open the wound is of pivotal importance. The patients we studied had combined severe limb
extrusion and soft-tissue necrosis, so the amputation rate was higher than for general patients
with gas gangrene. Among the 3 patients in whom limb salvage was attempted, the procedure
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was successful for only 1, which shows that gas gangrene sustained during earthquakes presents
special problems.
CONCLUSIONS
In earthquakes, rapid, accurate screening and isolation are essential to successfully treating gas
gangrene and helpful in preventing nosocomial diffusion. Early and thorough débridement, open
amputation, and active supportive treatment can produce satisfactory therapeutic results.
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25
Table
Table 1: Main clinical signs during hospitalization
Blood
Change in
Distension pain
Extensive
Foul smell wound color
pressure
Crepitation
effusion
Fever
decrease
No. of patients
13
19
19
14
19
18
6
Percentage of
68.4
100
100
73.7
100
94.7
31.6
total group
Table 2: Laboratory indicators at various stages of treatment
Time period
Total protein
Albumin
Hgb (g/L)
Hct (%)
(g/L)
(g/L)
AST (U/L)
ALT (U/L)
On admission
73.6 ± 24.3
14.4 ± 7.1
48.1 ± 8.8
26.4 ± 5.9
264 ± 350
90.4 ± 109.7
General condition
85.3 ± 22.4
25.7 ± 6.3
55.7 ± 11.7
29.8 ± 5.4
138.8 ± 229.4
64.3 ± 75.8
100.7 ± 16.7
30.4 ± 3.7
62.8 ± 7.9
33.5 ± 8.6
41.8 ± 13.4
33.1 ± 26.4
<0.01
<0.01
<0.01
<0.01
<0.05
<0.05
primarily under
control
Transition of smear
findings from positive
to negative
P Value
ALT = alanine aminotransferase; AST = aspartate aminotransferase; Hct = hematocrit; Hgb = hemoglobin.
26
Figure and Legend
Figure 1: The temporary consulting rooms built for initial examination of patients injured in the earthquake.
Figure 2: Radiography showed the typical feathering pattern of gas in the soft tissues of the
foot.
27
Figure 3: Successful limb salvage in a 15-year-old girl with gas gangrene of the forearm.
The wounds were severely contaminated, emitting a foul odor, with the surrounding skin
appearing pale, varicose, bright, and highly tense. An extensive area of soft tissues, including
muscles, showed changes in color. The involved muscles lost elasticity and failed to contract on
stimulation (A). Bacteria smear findings were positive, with Gram-positive thick bacilli present
with spores and capsules (B). Débridement of necrotic soft tissue was conducted. The forearm
was successfully salvaged (C).
28
Figure 4: The screening examination and diagnosis process for gas gangrene. The first stage
consisted of a clinical examination and the second, third, and fourth stages consisted of clinical
and bacteriologic examinations.
29