Tetanus is the infectious disease caused by Clostridium tetani bacterium with acuity of a current and primary defeat of nervous system. Disputes of the causative agent of tetanus can remain a long time in the soil, water and on any objects. Infection of the person occurs at penetration of klostridiya through the injured skin or mucous. The basis of a clinical picture of tetanus is made by tonic spasms of muscles of extremities and a trunk, the increasing muscular tension, . As the most critical are considered 10-14 day of a disease. The probability of death is high.
Tetanus is the infectious disease caused by Clostridium tetani bacterium with acuity of a current and primary defeat of nervous system. Tetanus is classified depending on character of entrance gate of an infection (post-traumatic, postivospalitelny and cryptogene tetanus), and also from prevalence of process (generalized and local). Local tetanus is extremely rare form of a disease
Characteristic of the activator
Clostridium tetani represents grampolozhitelny, mobile, obligatno an anaerobic and sporoobrazuyushchy rhabdoid bacterium. By sight reminds drum sticks or tennis rackets at the expense of settling down on the end a dispute. Differs in extreme stability in the environment: in a look the dispute can keep viability for years, at a temperature of 90 °C – about two hours. Disputes will be transformed to vegetative forms at a temperature of 37 °C in anaerobic conditions and in the presence of aerobic flora (for example, staphylococcal). Vegetative forms of klostridiya are sensitive to boiling, perish in a few minutes. Antiseptic and disinfectants affect these microorganisms within 3-6 hours.
Clostridium tetani allocates acting on nervous system of the person () and cytotoxin (). Tetanospazmin is the strongest toxin, it gets into shoots of nervous cages and gets into the central nervous system, suppressing braking signals in synapses (interfering with release of brake mediators). At first effect of toxin extends only to peripheral synapses, causing titanic spasms.
Tetanolizin has destructive effect on blood cells, fabric of a warm bag and covers, causes a local necrosis. The tank and a source of spread of tetanus are rodents, birds, herbivorous and people. The activator contains in intestines of the carrier and is allocated to the environment with excrements.
Due to a possibility of long existence in a look a dispute in the soil, reservoirs, on objects, the tetanic activator can get with dust and dirt practically to any rooms, to be on any materials (including on medical tools and dressing means). A way of infection – contact. Bacteria get to an organism through the injured skin or a mucous membrane (pollution of bruises and grazes, splinters, stings of animals, etc.).
At non-compliance with necessary measures of an asepsis and antiseptics infection is possible during processing of burns, freezing injuries, injuries, operational wounds. Direct transmission of infection from the sick person to healthy is impossible. The susceptibility of the person to tetanus high, immunity is not formed as for development of a disease of small enough very dose of a tetanospazmin incapable to cause the immune answer.
The incubatory period of tetanus can make from several days to one month. Sometimes the disease begins with the prodromalny phenomena (tension and a tremor of muscles in the field of penetration of an infection, a headache, perspiration, irritability), but, as a rule, the first symptom of tetanus is pain of the stupid, pulling character in the place of hit in an activator organism even if the wound completely healed. Then characteristic symptoms of tetanus develop: a trizm (the convulsive reduction and tension of chewing muscles complicating a mouth otryvaniye), a dysphagy (swallowing difficulty), the rigidnost of occipital muscles (which is not followed by other meningealny symptoms), "a sardonic smile" (the specific tension of mimic muscles: frowned, the narrowed eye cracks, lips are stretched, corners of a mouth are lowered).
Combination of a trizm, dysphagy, "sardonic smile" and tension of occipital muscles is specific only for tetanus simptomokompleks. The heat of a disease is characterized by tonic, quite painful spasms of muscles of a trunk and extremities. Tension of muscles becomes constant (even in a dream). For the third or fourth day of a disease there is an odereveneniye of muscles of a belly wall, the movement in extremities is limited (legs are extended), the breath which is speeded up gains superficial character at the expense of a spasm of intercostal muscles and a diaphragm. Defecation and an urination are complicated that is also connected with tension of muscles of a pelvic bottom, intestines and urinary tract.
As a result of the total painful tension of muscles of a back develops : the patient is curved in situation on a back with the thrown-back head, the waist is curved in such a way that between it and a bed it is possible to push a hand. At the same time in tight muscles periodically there are sudden titanic spasms, originally proceeding several seconds which with progressing of a disease are extended up to several minutes. The face of the patient gets a tsianotichny shade, contours of muscles accurately appear, amplifies. At this time patients feel intensive pains and difficulty of breath (short wind), often groan, grab hands edges of a bed. Body temperature increases (especially on a face), there is a strengthened sweating, a salivation.
At fizikalny inspection note tachycardia, sometimes arterial hypertension. At the same time the patient is in clear consciousness all the time, consciousness violations (confusion and nonsense) arise shortly before a lethal outcome. The most dangerous period for life of the patient are 10-14 day of a disease. At this time the accruing metabolic acidosis causes a hyperthermia, a gipersalivation and the increased sweating, promotes development of polyorgan insufficiency. There are heavy neurogenetic violations in connection with deep toxic damage of a brain, the probability of paralysis of a cardiac muscle, asphyxia is high. Due to the violation of ventilation of lungs accession of an infection and development of secondary pneumonia is frequent. Frequent spasms promote developing of the exhausting sleeplessness.
In case of transferring of a critical phase of a disease there is a gradual subsiding of clinical signs and there comes the convalescence phase proceeding about one and a half-two months before total disappearance of symptomatology. Tetanus can proceed with varying severity which is determined by set and expressiveness of signs.
The easy current is characterized by the incubatory period more than 20 days moderated opistotonusy and expressiveness of a mimic spasm, absence of tonic spasms (or their insignificant intensity and frequency). Temperature at the same time remains in normal or subfebrilny limits. Increase of symptomatology of a disease usually takes 5-6 days. At a medium-weight current the incubatory period makes 15-20 days, increase of signs borrows from 3kh to 4kh days, several times in days there are spasms, the subfebrilny temperature and moderate tachycardia is noted.
The severe form of tetanus is shown by the shortened incubatory period (from one to two weeks), bystry increase of symptoms (within one-two days), the typical clinic with often arising spasms expressed by perspiration, tachycardia, fever. Also very severe form of tetanus meets (lightning) at which the incubatory period makes no more than a week, the clinic develops within several hours, tonic spasms arise each 3-5 minutes, the expressed violations from bodies and systems, cyanosis, threat of asphyxia, heart paralysis etc.
Especially heavy current is noted at the bulbarny, descending tetanus of Brunner at which the maximum defeat covers muscles of the person, a neck, vocal chords, respiratory and glotatelny groups of muscles, a diaphragm. At this form defeat of respiratory and sosudodvigatelny kernels of the wandering nerve is characteristic that is fraught with neurogenetic cardiac arrest and breath.
In developing countries tetanus of newborns (infection occurs at hit of a tetanic stick in a wound after truncation of an umbilical cord) is one of common causes of infantile mortality. Sometimes (in rare instances) the ascending tetanus beginning with painful twitchings of peripheral muscles and gradually with expansion of typical symptomatology can be noted. Also carry the local tetanus arising at wounds of the head and which is characterized by paralysis of facial muscles as "a sardonic smile" with a rigidnost of occipital muscles and bilateral to rare forms (sometimes defeat of the party of wound is expressed more) paresis of craniocereberal nerves (front paralytic tetanus to Roza).
Heavy complications of tetanus with high probability of a lethal outcome is asphyxia and cardiac arrest. Besides tetanus can promote developing of fractures of bones, ruptures of muscles, compression deformation of a spine column. A frequent complication of tetanus is pneumonia, the coronary spasm and a myocardial infarction can develop.
Diagnosis of tetanus
The clinical picture of tetanus is rather specific to diagnosis. Materials of opening of a corpse, dressing and sutural material, washouts from surgical tools, dust, the soil, air can be exposed to a research regarding identification of the activator.
Allocation of the activator is usually possible from the place of hit of an infection (scrape or separated in the place of injury of skin). Sometimes there is a need of dabs from a nose and a mucous throat, a vagina and a uterus (at postnatal or postabortion tetanus). Investigating the received biological material, make allocation of a tetanic ekzotoksin and biological test on mice.
Treatment of tetanus
Treatment of patients with tetanus is made in intensive care units with the assistance of the intensivist as the disease is extremely dangerous concerning a lethality. By the patient it is created greatest possible in respect of irritants from sense organs, rest, feeding is carried out by means of the gastric probe, and at paresis of a digestive tract – parenterally.
Prevention of decubituses (turning of the patient, raspravleniye and timely change of linen, skin toilet) is made. The wound which is entrance gate of an infection is cut away antitetanic serum (even if it already dragged on). For creation of access of oxygen to area of localization of the activator, making opening, audit, surgical processing of a wound, do wide cuts. The available foreign matters, pollution and the centers of a necrosis are removed. Processing of a wound, in order to avoid spasms, is made under anesthetic. In the subsequent, when maintaining wounds apply proteolytic enzymes (trypsin, chymotrypsin).
Etiologichesky treatment means the earliest maintaining intramuscularly antitetanic serum or specific immunoglobulin, after previously made sensitivity test. Symptomatic treatment consists in application of miorelaksant, neuroleptics, narcotic and sedative medicines. In particular, recently broad application was found by diazepam which at a heavy current is appointed intravenously.
The good effect renders mix of a hlorpromazin with trimeperidine and difengidraminy (sometimes with addition of solution of a skopolamin of hydrobromide). Besides apply barbiturates, diazepam, sodium. At a heavy current – fentanyl, , peripheral miorelaksant of kurarepodobny action (pankuroniya, d - ), and at labile nervous system - and - and ß blockers.
At oppression of breath make an intubation and transfer the patient to IVL with the moistened oxygen, airways clear by means of an aspirator. There are data on positive effect of application of hyperbaric oxygenation.
At difficulties in work of intestines and urinary system put an exhaust tube and carry out a bladder kateterization at women and at men, appoint laxatives. As prevention of accession of an infection apply antibiotic treatment. Metabolic acidosis and dehydration are corrected infusional intravenous administration of solutions of a dextran, albumine, salts, by plasmas.
Forecast and prevention of tetanus
The forecast of tetanus depends on a current form which that is heavier, than the incubatory period is shorter and quicker there is an expansion of clinical symptomatology. Severe and lightning forms of tetanus are characterized by the adverse forecast, at not rendering the timely help the lethal outcome is possible. Easy forms of tetanus at due therapy safely recover.
Measures of nonspecific prevention of tetanus mean respect for sanitary and hygienic norms in life (in particular in treatment and prevention facilities), decrease in traumatism. Individual prevention includes careful disinfection processing of injuries and the timely address to the doctor for implementation of specific prevention at pollution of wounds, grazes and so forth. Specific prevention consists in planned stage-by-stage vaccination of children vaccine AKDS and to the subsequent revaccinations there are each 10 years medicines ADS, EXPERT and ADS-M.
The emergency prevention in cases of probability of infection (during the traumatizing and pollution of a wound, burns, freezing injuries of the third and fourth degree, etc.) consists in processing of a wound and introduction of antitetanic serum or immunoglobulin. Quite often passive immunization at the emergency prevention is combined with introduction of medicine EXPERT for stimulation of own immunity. It is desirable to make the emergency prevention of tetanus in the earliest time.