Emergency Department: Gas Gangrene Case
April 24th 2013

Abstract
Gangrene can be a life threatening infection that can present to any emergency department. To ascertain an immediate provisional diagnoses for gangrene at the emergency department can be challenging but at most times obvious due to severe lesions or blisters covering limbs of the body. We report a case of undiagnosed gas gangrene that required an amputation of both lower limbs. This has been a different case to have been reported from our department because the patient's infection was being caused from an untreated injury from a recent motor vehicle accident that occurred months before. Accurate diagnosis of gas gangrene by gaining adequate history and conducting a thorough physical examination, coupled with good knowledge of the severity of this case, will lead to a better patient outcome.

Introduction
Gangrene refers to the death of body tissue due to a lack of blood flow or a bacterial infection. Gangrene most commonly affects the extremities, including your toes, fingers and limbs, but it can also occur in your muscles and internal organs. Gangrene may occur for many reasons, but for this case an extreme infection was overseen for too long. There are several types of gangrene including dry, wet, gas, internal, Fournier's, and Meleny's. For this patient's case, she experiences gas gangrene.
Gas gangrene typically affects deep muscle tissue. If you have gas gangrene, the surface of your skin may initially appear normal. As the condition progresses, your skin may become pale and then evolve to a gray or purplish-red color. A bubbly appearance to your skin may become apparent, and the affected skin may make a crackling sound when you press on it because of the gas within the tissue. Gas gangrene is usually caused by infection with the bacterium Clostridium perfringens, which develops in an injury or surgical wound that's depleted of blood supply. After the patient's car accident, she had an apparent untreated injury that was overseen for quite sometime. The bacterial infection produced toxins that released gas and caused tissue death on both legs. Gas gangrene is considered life- threatening and needs to be treated immediately.
Gangrene that is infected with bacteria can spread quickly to other organs and may be fatal if left untreated. Unfortunately, any process that causes trauma to your skin and underlying tissue, including an injury or frostbite, increases your risk of developing gangrene, especially if you have an underlying condition that affects blood flow to the injured area. Because her injury from the motor vehicle accident was not treated properly and in an adequate time frame, the infection spread more rapid than commonly known.
Case Report
A 77 year old woman is admitted into the emergency department at Carolinas Medical Center- University by ambulance with symptoms of gangrene. She has been complaining of numbness in her lower limbs ever since her motor vehicle accident that occurred months ago. In her accident, she experienced an injury in both legs that went untreated for months at a time. Since the injury went untreated, bacteria grew and spread rapidly. On arrival, she seemed to have a severe altered mental status not knowing her name, birthdate, time of year, or the name president of the United States. Her temperature reaches a high of 103.7 F. Her pulse was persistently tachycardic to more than 120 beats/ minute with a regular rhythm, and she was hypotensive, with a blood pressure of 90/ 64 mmHg. Her electrocardiogram showed sinus tachycardia, and her capillary blood sugar was 6.7 mmol/ L. In the ED, she complained of severe pain and numbness in the lower half of her body. The patient was still hypotensive despite adequate fluid resuscitation. To restore normal blood pressure, the patient was started on an infusion of noradrenaline, which targets the peripheral alpha-1 receptor.