Tetanus

Description:

Tetanus - an acute infectious disease of the person and animals from group of wound mephitic gangrenes. It is characterized by the defeat of a nervous system which is shown in the form of spasms of skeletal muscles with possible development of asphyxia.

Tetanus symptoms:

Taking into account entrance infection atriums distinguish:

    * traumatic tetanus;
    * the tetanus which developed as a result of inflammatory and destructive processes;
    * cryptogenic tetanus (with the obscure entrance gate).

On prevalence of process the disease is divided into the general (generalized) and local tetanus. The last is observed seldom.

The incubation interval varies from several days to 1 month, on average without exceeding 1-2 weeks. The disease begins sharply, only sometimes note the prodromal phenomena in the form of tension and twitching of muscles in the place of wound, an indisposition, a headache, perspiration, irritability.

During an initial stage of tetanus regarding cases its most precursory symptom - dull nagging pains in the field of entrance infection atriums, even in already completely healed wounds can be shown. The main specific symptoms arising during this period - a lockjaw, a cynic spasm", a dysphagy and a stiff neck. These signs appear early and almost at the same time.

    * A lockjaw - tension and convulsive reduction of masseters that leads to the complicated opening of a mouth.
    * Tonic spasms of mimic muscles are expressed in "cynic spasm" (risus sardonicus) giving to the face of the patient a peculiar expression: a wrinkled forehead, the narrowed palpebral fissures, the stretched lips, the lowered mouth corners.
    * The dysphagy (the complicated painful swallowing) is caused by a convulsive spasm of muscles of a throat. The combination of a lockjaw, "cynic spasm" and a dysphagy is characteristic only of tetanus.
    * The stiff neck caused by tonic spasms of skeletal muscles at tetanus is not a meningeal symptom and is not combined with other meningeal signs (Kernig's signs, Brudzinsky, etc.).

At the height of a disease painful tonic spasms extend to muscles of a trunk and extremities (without taking a brush and foot). The tonic muscle tension is constant, relaxation of muscles, as a rule, does not happen even in a dream. Accurately appear, especially at men, contours of large skeletal muscles. From the 3-4th day of a disease of a muscle of an abdominal wall become firm as a board, legs are more often extended, the movements in them are limited. At the same time intercostal muscles and a diaphragm are involved in process, breath becomes superficial and speeded up. The tonic muscle tension of a crotch leads to difficulty of defecation and an urination. As a result of the expressed tension and morbidity of muscles of a back at heavy tetanus the opisthotonos develops: at position of the patient on spin his head is thrown back back, a lumbar part of a body is raised over a bed in such a way that between a back and a bed it is possible to push a hand.

Against the background of the constant tonic tension of skeletal muscles periodically with various frequency there are tetanic spasms. Their duration at first fluctuates from several seconds to one minute. Most often they are provoked by acoustical, visual and tactile irritants. In mild cases of a disease observe 1-2 attacks of spasms a day, at the heavy course of tetanus they can repeat to tens of times within an hour, become longer and widespread. Attacks of spasms arise suddenly. At the same time the face of the patient accepts suffering expression and becomes cyanochroic, contours of muscles appear more accurately, the opisthotonos amplifies. Patients groan and shout because of pains, try to grasp with hands a bed back to facilitate breath. Body temperature, skin increases (especially persons) becomes covered by large drops of sweat, note hypersalivation, tachycardia, short wind, cardiac sounds loud, arterial pressure is inclined to increase. The convulsive syndrome develops and amplifies at preservation of clear consciousness of the patient, the confused consciousness and nonsense appear only shortly before death.

The period since the end of the first week and to the 10-14th day of a disease is most life-threatening the patient. The metabolic acidosis and sharp strengthening of a metabolism cause a hyper pyrexia, the increased sweating. Expectoration as cough provokes tetanic spasms is complicated. Deterioration in ventilation of the lungs often promotes development of secondary bacterial pneumonia. Heart is expanded at the expense of both ventricles, tones loud. The liver and a spleen are not increased. Deep intoxication of a brainstem becomes the reason of oppression and arrhythmia of breath, weakening of cordial activity; the cardioplegia is possible. Because of frequent and long tonic spasms painful sleeplessness, irritability develop, the threat of asphyxia accrues.

In cases of a favorable outcome reconvalescence period long; gradually weakening clinical displays of a disease remain 2-4 weeks, recovery drags on up to 1,5-2 months.

Weight of a course of tetanus is defined by set of several indicators.

    * At the easy course of a disease the incubation interval exceeds 20 days more often. Lockjaw, "cynic spasm" and opisthotonos moderate, hyper tone of other groups of muscles weak. Tonic spasms are absent or are insignificant, body temperature normal or subfebrile. Symptoms of a disease develop within 5-6 days.
    * In cases of a medium-weight current the incubation interval makes 15-20 days. The main clinical signs of a disease accrue in 3-4 days. Spasms arise several times in days, tachycardia and perspiration moderate, body temperature subfebrile or (more rare) high.
    * The severe form of tetanus differs in the incubation interval shortened up to 7-14 days, bystry (in 1-2 days) in increase of symptoms, a typical clinical picture with the frequent and intensive tetanic spasms (several times within an hour) expressed by perspiration and tachycardia, high fever.
    *
      Very heavy current is distinguished by the incubation interval shortened (less than a week) and fulminant development of a disease. Tonic spasms arise several times within 3-5 min. They are accompanied by a hyper pyrexia, the expressed tachycardia and a tachypnea, cyanosis, the menacing asphyxia.

One of the hardest forms of the generalized descending tetanus - head ("bulbar") tetanus of Brunner. It proceeds with preferential damage of face muscles, necks and drinks, with spasms of deglutitory and intercostal muscles, muscles of a glottis and a diaphragm. Usually there is a defeat of the respiratory, vasomotor centers and kernels of a vagus nerve. Also gynecologic tetanus and tetanus of newborns which is one of the important reasons of child mortality in developing countries differ in weight of a current and the adverse forecast. It is connected with unsatisfactory conditions of rendering obstetric care and lack of programs of immunization of women.

The ascending tetanus observed in rare instances at first is shown by pain, tension and fibrillar twitchings in one group of muscles, further in process of defeat of new overlying departments of a spinal cord the disease gains typical lines of generalized process.

Local tetanus is met seldom. Front paralytic tetanus to Roza happens one of its typical manifestations developing after wounds of the person and head. There are a lockjaw, a stiff neck, "cynic spasm" which paresis of cranial nerves joins. Defeat is usually bilateral, it is more expressed on the party of wound.

When determining the forecast of tetanus much attention is paid to the period between emergence of the first symptoms of a disease (a lockjaw, etc.) and developing of spasms. If this period makes less than 48 h, the forecast of a disease extremely adverse.

Tetanus reasons:

The activator - obligatno an anaerobic gram-positive spore-forming mobile stick of Clostridium tetani of the Bacillaceae family. Disputes are located terminalno, giving to bacteria a type of "drum sticks" or "tennis rackets". Pages of tetani form strong exotoxin (tetanospasmin), cytotoxin (tetanolysin) and so-called low-molecular fraction. In the soil, excrements and on various objects disputes can remain for years. Maintain temperature of 90 °C during 2 h. In anaerobic conditions, at a temperature of 37 °C, sufficient humidity and in the presence of aerobic bacteria (for example, stafilokokk) disputes burgeon in vegetative forms. Vegetative forms of a tetanic stick perish within several minutes at boiling, in 30 min. - at 80 °C. Antiseptic agents and disinfectants kill the causative agent of tetanus during 3-6 h. In the countries with warm climate vegetation a dispute directly in the soil is possible. At S. tetani reveal two types of antigens: somatic (O-antigen) and flagellates (N-antigen). On structures of flagellar antigens allocate 10 serovars. All serovars form tetanospasmin and tetanolysin, identical on antigenic properties.

    * Tetanospasmin - one of the strongest biological poisons. Represents polypeptide with the "distanced" action mechanism as bacteria seldom leave limits of primary center of infection. Toxin is fixed on a surface of shoots of nervous cells, gets into them (due to the endocytosis mediated by ligands) and by retrograde aksonny transport gets to TsNS. The mechanism of action is connected with suppression of release of brake neurotransmitters (in particular, glycine and at - aminobutyric acid) in synapses (toxin contacts synoptic proteins sinaptobreviny and tsellyubreviny). Originally toxin affects peripheral nerves, causing local tetanic reductions of muscles. In cultures toxin appears for the 2nd days, reaching education peak by 5-7th day.
    * Tetanolysin shows hemolitic, cardiotoxic and lethal actions, causes development of focal necrotic lesions. In a disease pathogeny this toxin plays a less important role. The maximum accumulation of toxin in culture is observed already in 20-30 h. Processes of its education are not connected with tetanospasmin synthesis. The low-molecular fraction strengthens secretion of mediators in neuromuscular synapses.

Treatment of Tetanus:

It will be out in intensive care unit and resuscitation with participation of the anesthesiologist. It is necessary to provide the guarding mode excluding acoustical, visual and tactile irritants. Feeding of patients is carried out via the probe or parenterally (at GIT paresis). Carry out prevention of decubituses: frequent turning of the patient in beds, smoothing crumpled bed and underwear, its cleaning and periodic change. The contaminated wound which even healed is cut away antitetanic serum (in a dose 1000-3000 ME), then carry out careful audit and surgical treatment of a wound with wide lampasny cuts (for creation of aerobic conditions), removal of the foreign bodys polluted and nekrotizirovanny fabrics. For the prevention of spasms it is better to carry out all these manipulations under anesthetic. In the subsequent it is reasonable to apply proteolytic enzymes to treatment of wounds (trypsin, chymotrypsin, etc.).

For neutralization of a spasmotoxin in a blood-groove once enter intramusculary 50 000 ME of antitetanic serum or 1500-10 000 PIECES (an average dose of 3000 PIECES) of specific immunoglobulin with preliminary check of individual sensitivity to them. These drugs should be administered in the earliest terms as the tetanin freely circulates in blood no more than 2-3 days, and the connected toxin is not inactivated that reduces therapeutic effect. After administration of heterogeneous antitetanic serum it is necessary to watch the patient during 1 h because of danger of development of an acute anaphylaxis.

Fight against a convulsive syndrome is carried out by use of sedative and narcotic, neuroplegic means and muscle relaxants. Recently widely each 2-4 h use diazepam on 5-10 mg inside; in hard cases it is entered intravenously on 10-20 mg by each 3 h. To children drug is appointed intravenously or intramusculary on 0,1-0,3 mg/kg by each 6 h (as much as possible to 10-15 mg/kg/days). It is possible to apply injections of mix of 2,5% of solution of aminazine, 1% of solution of Promedolum and 1% of solution of Dimedrol (on 2 ml of each drug) with addition of 0,5 ml of 0,05% of solution of Scopolaminum of hydrobromide. Also appoint Seduxenum, barbiturates, sodium hydroxybutyrate, in hard cases - Droperidolum, fentanyl, kurarepodobny muscle relaxants (pankuroniya, d-tubocurarine). At lability of a sympathetic nervous system sometimes apply and - and ß blockers. At disorders of breath carry out an intubation or tracheotomy, combine muscle relaxation with IVL, clarification of respiratory tracts an aspirator; patients are given the moistened oxygen. There are messages on efficiency of hyperbaric oxygenation.

In small doses appoint purgatives, put a colonic tube and a catheter in a bladder (if necessary). Frequent turnings of the patient, a forcing of breath and cough are necessary for prevention of pneumonia.

To the prevention and treatment of bacterial complications apply antibiotics - benzylpenicillin on 2 mln units of intravenously bucketed 6 h (to children to 200 000 PIECES/kg/days), tetracycline on 500 mg 4 times a day (to children to 30-40 mg/kg/days). Use of antibiotics does not exclude a possibility of development of pneumonia and other consecutive infections.

Fight against a hyperthermia, acidosis and dehydration is carried out by intravenous injections of 4% of solution of sodium bicarbonate, polyionic solutions, Haemodesum, reopoliglyukin, albumine, plasma.