INFECTIOUS DISEASES : TETANUS (TETANUS) - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention
Etiology. The pathogen is Bacillus of tetanus. Its main features: the sporulation, anaerobic growth, toxicobrain.
Epidemiology is closely associated with the epidemic of injuries (war). Guardians of the vegetative forms of tetanus Bacillus (reservoirs of the virus) are humans and some animals (horses), in the intestine which tetanus Bacillus is in the form of a harmless saprophyte and is excreted in the faeces. Soil contaminated with faeces (Unawatuna), becomes the guardian of tetanus spores (gardens, street dust, soil, military bases). The spores being spread very widely. In some cases, the gate infection can be carious teeth, splinters, and even the wounds inflicted by the surgeon (the umbilical cord).
The pathogenesis. Germination tetanus spores occurs in wounds with an abundance of tissue deprived of oxygen, purulent (oxygen uptake pyogenic aerobic), tightly plugged, containing small metal pieces (oxygen scavengers). Particularly favorable for the development of tetanus crushed crushed, deep puncture wounds, wounds of the lower extremities and third-degree frostbite. After spore germination begins production of the toxin, with a pronounced affinity for nervous tissue. The spread of the toxin occurs in the axial cylinders and perineurally spaces. Produced toxin is not captured entirely nerves and part of it entering the blood, is an antigen, causing the formation of antibodies, i.e., antitoxin. Incubation duration, i.e. the time required for the production of toxin and transportation to malls, is of great importance. At short incubation the antitoxin does not have time to form, after 8 and especially the 12 days of the latent period of development of antitoxin has already happened, and tetanus gives a sharp decline in mortality. The incubation period depends on the length of the nerve trunks connecting the point of injury with the nearest centers, the number and quality of the toxin and the individual sensitivity of the patient to the toxin. Reaching the Central nervous system, the toxin exerts its action by a sharp excitation of the motor centers, as expressed by spasm of the muscles closest to the point of injury. In fact, such local tetanus is relatively rare, and are often convulsions begin with the front and, in particular, with masticatory muscles (lockjaw). Relatively quickly tetanus becomes General, tehnicheskie convulsions seize almost all striated muscles.
Symptoms. The earliest symptom is cramping of the muscles around the wound, or more frequently lockjaw and the spasm of facial muscles, giving the face an expression of smile (risus sardonicus). Further develop note occipital and spinal muscles with the curvature of the posterior trunk (opistotonus) and bend the lumbar part of the spine forward (lordosis). Abdominal muscles hard as a Board. The reflex excitability of the muscles sharply increased. Swallowing in patients difficult. The arms are relatively free from seizures.
For. The incubation period range from 2 to 3 to 25 and even 50 days, usually 6 to 14 days. The disease begins with difficulty in opening the mouth; after this, the above symptoms start to grow, in some cases extremely quickly (a day or even less). Reflex excitability not only when touching the patient (nudity, etc), but also due to light, noise, air movement increased so that the slightest stimulus provokes an attack of convulsions. The temperature is increased, sometimes reaching very high numbers; it remains high after death. The severity of disease is closely associated with the duration of incubation. The heavier flows tetanus, the more often and longer bouts of total seizures. During seizures can occur tears of recti and m. ileo-psoatis, rupture of the spleen, stops breathing. Developing aspiration pneumonia is recognized with difficulty due to a reduction in respiratory excursions. The most severe symptom is a cough from behind clenched teeth, similar to sneezing. If death has not occurred during one of the attacks of convulsions, seizures become less frequent, less intense and myspy gradually begin to relax. Duration - from 2 weeks to 2 months. Neonatal tetanus is very hard and gives a very high mortality rate. Puerperalis (after abort) gives a more blagopriatnoe for. Rare form - facial tetanus rose - breaks when the head injury and occurs in the form of unilateral local tetanus followed by paralysis of the facial nerve. When seroprevelance observed local tetanus limited spasms of the muscles near the wound. For wounds with greater damage zone, with long festering wounds of the disease, despite seroprotection may occur after prolonged incubation and be quite severe.
The recognition is based on the above symptoms and more often than not difficult because of injury. Lumbar puncture gives transparent liquid under high pressure.
If there is wound with crushing of tissue to remove the dead parts. All crushed, crush wounds, wounds of the lower extremities, puncture wounds, the wounds of the nails, pollution of soil, manure, street dust are testimony to the mandatory introduction 1 500 AE tetanus toxoid (statement of the national health Committee). With extensive wounds with suppuration, requiring long-term treatment, seroprotection should be repeated every 5 to 6 days. If after seroprevelance passed more than 2 - 3 weeks, seroprotection during surgery must be repeated (Besredka).
In the above cases, after the first preventive introduction appropriate for the active immunization (subcutaneous injection of tetanus toxoid: the first injection to 1 ml, then a break of 20 days, the second injection 2 ml). Active immunization with toxoid healthy people should be held among certain populations (the army, the diggers, road workers, etc).
Introduction antitoxic tetanus toxoid used intraluminally, intravenously and intramuscularly. The scheme is the introduction:
a) lumbar puncture under General anesthesia and expelling the cerebrospinal fluid,
b) introduction intralumbalno serum probably higher titer (about 15 000 AE),
C) introduction of a 30 000 - 40 000 AE intramuscularly in the path of movement of the toxin (for example, when the wound in the right foot in the right buttock). Repeat puncture through the day; intramuscularly daily. Anaesthesia results in a significant relaxation to the patient and improves breathing. From the good drug effect of chloral hydrate; gives the best effect narkoman (0.5 to 1 kg) rectal enema in a 2% solution in water. The solution is prepared ex tempore, the temperature 38 - 41 ° . The use of morphine reduces pain sensitivity without affecting the musculoskeletal field, no effect. Care tetanus patients are very important to the success of therapy. When transporting one needs great care (pre-giving chloral hydrate), as well as possible cases of death; unless it is absolutely necessary to transport the patient should not be. Silence is needed; the chamber should be darkened; soft bakovici; staff issued soft shoes. If you cannot feeding is to introduce a liquid food through a thin probe inserted through the nose, pre-lubricated nasal mucosa with a solution of novocaine.