Treatment consists of four main phases:
1. Resuscitation should begin in the emergency department (ED) immediately on making a presumptive diagnosis. Aggressive fluid resuscitation using crystalloid, plasma, and packed cells is usually needed to replace red blood cells lost due to hemolysis and to correct hypotension due to shock. Volume status should be closely monitored using urine output and central venous pressure readings. Avoid the use of vasoconstrictors when possible due to the possibility of decreasing perfusion to already ischemic muscle.
2. Antibiotic therapy using penicillin G 10 to 40 million units per day in divided doses is recommended. Clindamycin, metronidazole, and chloramphenicol are alternative choices for the penicillin-allergic patient. Sodium penicillin is recommended over potassium penicillin to reduce the risk of worsening hyperkalemia in patients with hemolysis and tissue necrosis. Mixed infections with other anaerobes, gram-negative rods, and staphylococci are common. Therefore, multiple-antibiotic therapy using aminoglycosides, penicillinase-resistant penicillins, or vancomycin is recommended. Tetanus prophylaxis should be given as indicated.
3. Surgical debridement is a mainstay of therapy and may include fasciotomy, debridement, or amputation. The borders for debridement are guided by the appearance of the muscle.
4. Hyperbaric oxygen (HBO) therapy has been a widely used therapeutic modality since the early 1960s. Although there are no prospective human studies, retospective data suggest a twofold reduction in mortality in patients receiving concomitant HBO therapy. 3 The timing of its use in relation to surgical debridement remains somewhat controversial. Standard therapy consists of surgical debridement prior to HBO therapy, partly for confirmation of the diagnosis based on muscle appearance. Some argue that since elevated partial pressures of oxygen are bactericidal in tissues, as well as inhibitory to toxin production, preoperative HBO therapy may allow for sharper demarcation of necrotic tissue at debridement and less loss of tissue to amputation and decreased systemic toxicity. Typical HBO therapy at this time consists of 100% oxygen at 3 atm of pressure for 90 min immediately following surgery, with three dives in the first 24 h followed by two dives a day for 4 or 5 days.
Wound care at the time of initial evaluation and treatment is the most important factor in preventing clostridial infections. Debridement of crushed or dead tissue and copious irrigation prior to wound closure will help prevent the development of an environment favorable to clostridial growth. Prophylactic penicillin administration may be beneficial in preventing subsequent infection.
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