Acute specific surgical infection. Anaerobic infection. Gas gangrene. Tetanus. Diphtheria of wounds. The Siberian ulcer.

 

Terrible wound - infection, which is caused pathogenic anaerobic microorganism and characterized by fast distribution necrosis with formation of gas, a heavy general intoxication with overwhelming damage of a muscular and connecting tissues.

 

The first mentions about anaerobic infections we find at Hyppocrat. Ambruaz Paire has described this disease as hospital gangrene. The clinical picture of anaerobic is in details enough submitted to a gas infection in M.I.Pirogova works which observed the marked pathology during the Crimean campaign and named it a local stupor, mephytic gangrene , acute malignant hypostasis .

 

In 1899 Lindental and Chugmann have established, that the leaging role in occurrence of a gas infection belongs Cl. perfringens, which have opened seven years prior to that. Further it has been established, that the basic activators anaerobic gas infection is l. perfringes (44-50 %), Cl.oedomatiens (15-50 %), Cl. septicum (10-30 %), Cl. ystolyticus (2-6 %). All these microorganisms are sporeform bacilli.

 

Last decade with development anaerobic technics of patients with a gas gangrene have started to sow Cl. soldell , flu, sporogeneus.

 

Sights on pathogenesis of anaerobic infections connected with above-mentioned microorganisms were kept until 70th years of XX century. During this moment, due to works Faingold, a little bit another allocated on clinic pathology with especial current, which caused unsporeform (unclostridial) anaerobs.

 

Therefore, at the present stage of development of the doctrine about a surgical infection expediently separately to allocate anaerob clostridial and anaerob unclostridial infection.

 

Anaerob clostridial infection is considered disease a wartime. Really, the greatest clinical material has been saved up and generalized in experience of Great Domestic war, and presently at the analysis of results of the Afghani war and the big ecological accidents (earthquake in Armenia, Turkey and California). It is connected by that for realization of action clostridium, which mainly in ground where get from a gastroenteric path mammal, the certain conditions which actually, and shown at mass defeats are necessary:

 

- Great volume necrotic and it is bad oxigenate tissues;

 

- Significant defeats of muscles and bones;

 

- Deep wound channel;

 

- Presence the closed cavities, "pockets" and "heats" in a wound;

 

- An ischemia of tissues, because of the main vessels damage or imposed for long-term tourniquet.

 

Patho-anatomical changes at anaerobic to a gas gangrene are characterized acute serous- alternative inflammation with the subsequent progressing necrotic tissues. On sites, traumatic necrosis a very microbes exotoxins (hemolysis, myotoxins, neurotoxins) which cause progressing necrosis of a muscular tissues is allocated. In fascial cases, the hypostasis with the subsequent stasis and thrombosis in the main vessels accrues. As a result of action exotoxins in a zone of defeat develops hemolysis with an exit of free hemoglobin which together with products of disintegration of muscles (myoglobin) impregnates cellular tissue and skin, causing occurrence typical for anaerobic gangrenes of brown, bronze and blue spots.

 

Characteristic enough phenomenon for the marked pathology is the formation of gas. Bubble of gas densely infiltrate cellular spaces also cause occurrence of many symptoms.

 

At anaerobic clostridium infections, quickly enough accrues endotoxicosis, which is accompanied by significant frustration fluid- electrolyte balance which depends from extremely big exudation in a site of defeat. Because of progressing endotoxicosis and dehydrate of organism quickly there comes death.

 

Classification.

 

Behind anatomic features:

 

Superficial forms - epyfascial gangrenes;

 

Deep forms - subfascial gangrenes.

 

Behind patho-anatomical features:

 

emphysematous, edematous and tissue burst forms.

 

Behind time of development:

 

Lightning, quickly progressing and torpid forms.

 

The lightning form, as a rule, demonstrates during several hours.

 

Quickly progressing - during day.

 

Torpid course clinic can develop during 2-3 day.

 

I want to result demonstrative enough clinical example of lightning development anaerobic gas gangrene which was observed in our clinic: the patient has addressed in regional hospital with complaints on intensive holding apart a pain in a site of the right brush which has appeared in 2 hours after wound by a shovel at work on a kitchen garden. At survey, the gas infection is suspected of regional hospital anaerobic and to sick machine of first aid has been directed to us to clinic. In a reception has been delivered in 25 minutes. It is ascertained, that the hypostasis was distributed to the top third of shoulder. In 15 minutes of the patient it is delivered in operational and at performance of met measured sections of finiteness with fasciotomy, it is literally at hand surgeons intensive distribution of gas on forward and back surfaces of a thorax was observed, all over again on the part of defeat, and then from the opposite side. Not looking on the carried out surgical intervention and the started intensive therapy, the patient has died on an operational table.

 

Clinic and diagnostics.

 

First at anaerobic to a gas gangrene demonstrate local symptoms (a Fig. 1, a Fig. 2). The complaint to a pain of holding apart character in a zone of damage, occurrence of a hypostasis, which is quickly enough distributed in proximal a direction, is very characteristic. At presence of a wound, it has areactive kind with insignificant excretion mucous-ichorous character with unpleasant smell. A skin on periphery of wound is cyanotic, pale, with bronze or cyanotic -blue spots. Enough frequently it is possible to define thrombotic hypodermic veins. Cellular tissue swollen, impregnated hemolysed blood, has jelly-like. Muscles as boiled meat, oedematic, grayish, stick out from a wound above a surface of a skin. Gas formation in exudate observed bubble the last (a Fig. 3).

 

On periphery of a wound, the hypostasis increases the certain segments of finitenesss, or all finiteness in volume. On a skin traces from are contour the imposed bandage. Progressing of a hypostasis is well determined by means of Melnikov's symptom (literature imposed on finiteness proximal wounds owing to distribution of a hypostasis in 20-30 minutes runs into a skin).

 

During palpation in a site of a hypostasis it is determined the crepitation, shaving a skin on periphery of a wound high "metal" sounds - a symptom of an edge, or a symptom "spatula" (a metal sound are listened during spatula percussion).

 

The congestion of gas in a wound at distance of a tampon from a cavity of last accompanied by a typical clapping sound - a symptom of a fuse of champagne.

 

X-ray struck finiteness in a picture strips contour of an enlightenment due to gas, which stratifies muscles - symptom Krause (a Fig. 4).

 

Near to it, and sometimes even earlier than local symptoms, the clinic of a heavy general intoxication is shown. Patients complain of progressing general weakness, thirst, nausea, vomiting, block, down to loss of consciousness. Survey: a skin of patients pale with a yellowish-early shade, features are pointed, language dry with massive grey - yellow stratifications. The expressed tachycardia is marked, the BP falls, frequency of breath up to 40 per 1 minute. It is ascertained oliguria.

 

In the general blood analysis, as a rule, leukocytosis with shift of the formula to the left, accelerated of ESR. In urine - there is a fiber and cylinders. In the biochemical blood analysis - hypoproteinaemia, growth of a level of urea and creatinini.

 

 

 

Rice 1. Anaerobic clostridium a phlegmon of a shoulder and a thorax.

 

 

 

Rice 2. Anaerobic clostridium a phlegmon of a shin.

 

 

 

Fig. 3. Bubble of gas in exudate of anaerobic clostridium infections.

 

 

 

Fig. 4. Emphysema of soft tissues and gas formation on a background anaerobic infection (Krause symptom).

 

The general principles of treatment.

 

The program of treatment anaerobic a gas infection should provide simultaneous performance of radical surgical processing with powerful multicomponent intensive therapy and hyperbaric oxygenation.

 

Radicalism of surgical processing is determined to carve of all impractical tissues, and first, muscles as it are the best substratum for development and distributions anaerobe. Viability of muscles during surgical processing can be determined macroscopic appearance, on a bleeding degree, on reduction of muscular fibers, and is more exact, with the help of definition of reaction to electro pulse irritation.

 

In all managements concerning a gas gangrene performance stripe sections is recommended, but features of these sections are not always emphasized. And they are extremely important and consist that sections should be not only long enough, but also include obligatory fasciotomy. Unfortunately, the neglect these features not seldom leads to that surgeons dissect only a skin and hypodermic cellular tissue, are limited drainaging these substrata, and anaerobic the infection at that time is progressively distributed on muscles which remain in closed fascia case.

 

The ambassador fasciotomy and definitions of viability of muscles, if necessary, it is carried out necrectomy, then wounds are washed out by solutions of antiseptic tanks (it is desirable oxidizers) and drainaging by tube drainages. Such volume of surgical intervention can be radical at initial stages of development of a gas gangrene (a Fig. 5-7).

 

To thicket when there is a total defeat of all soft tissues of finiteness by a unique opportunity for preservation of a life of the patient amputation is.

 

 

 

Fig. 5. Surgical processing anaerobic clostridium phlegmon.

 

 

 

Fig. 6. A kind of a wound after processing before plastic of local tissues.

 

 

 

Fig. 7. A kind of a wound after plastics local tissues.

 

There are three kinds of amputations, which recommend carrying out at gas anaerobic infections:

 

- Amputation without saturation (at usual three moments method of amputation on fascial cases drainages are carried out, stump remains open, seams are imposed at absence of progressing of an infection in 24-48 hours);

 

- guillotine amputation (at one level are crossed a skin, cellular tissue, fascia, muscles and bone; supporters of such operation consider, that in such a way it is possible to stop distribution of an infection, however experience shows, that such method has no any advantages but only complicates the subsequent treatment);

 

- Amputation with cutting of stump (it is carried out when the surgeon finally is not convinced of viability of tissues stump; last is dissected by additional sections, skin rags can be filed to not changed skin as muff which enables the greater aeration of a wound).

 

In case of distribution of an infection down to a joint, it is necessary to carry out of joint exarticullation.

 

The general principles of complex therapy will consist from:

 

) Specific treatment which consists in application polyvalent antygangrenous wheys which contains on 50 thousand whey antyperfringens, antyseptycum, antyedematous, all 150 thousand . As, at intravenous infusion of such whey not seldom arise anaphylaxis reactions, at their introduction it is necessary to adhere to such rules:

 

- Whey gets divorced on 300 ml NaCl;

 

- Speed of infusion of 20-40 drops in one minute is entered slowly;

 

- The solution should be temperature 36-380;

 

- Infusion is carried spent under narcosis.

 

) Nonspecific treatment includes powerful antibacterial therapy, it is desirable with inclusion of antibiotics of a class imipenems (Tienam) and imidazole (metragili, fagili). The most expedient ways of introduction are intravenous and intraarterial. In complex therapy, anaerobic infections therapy with use desintoxycation solutions crystalloids (up to 4-6l per day) and forced diuresis should borrow a significant place desintoxycation. An especial place borrows extracorporal methods of detoxication (plasmapheresis, plasmasorption, spleencsenosorption). Symptomatic correction of all systems of a homeostasis, first cardiovascular and respiratory is carried spent. The certain attention is necessary for giving enteral feed, as per oral, and, in the certain cases, enteral probe.

 

Hyperbaric oxygenation.

 

On a modern level of medicine development, high-grade treatment anaerobic clostridium is impossible for an infection without application hyperbaric oxygenation ().

 

B.V.Petrovsky and S.N.Efuni's by researches is determined, that high concentration of oxygen will paralyze of formation of alpha - toxin clostridium with the subsequent decrease in its concentration. Besides, the increase in a pressure of oxygen in tissues suppresses ability to live anaerobic due to oxidizing inactivation of bacterial cell.

 

Sessions hyperbaric oxygenation spend at a level of a compression 2-3 atmosphere. Number of sessions - 5-7.

 

 

Anaerobic unclostridium an infection.

 

The marked pathology is considered independently from the beginning of 80th years.

 

Many clinical physicians during this period marked, that at some patients clinical course of purulent - septic processes, both soft tissues, and internal bodies, preceded with the certain clinical features. The rapid progress endotoxicosis with the minimal local attributes of an inflammation was observed extremely. The standard approaches to surgical treatment did not lead to simplification of a condition of the patient. At many patients on a background of progressing attributes of immunosuppression demonstrated a sepsis and they perished.

 

Due to development microbiological anaerobic technics has been established, that the basic pathogenic microorganisms which caused the above-mentioned infectious processes were gramme - negative bacilli sorts Bactericides.

 

American scientist S. Finegold in a series of fundamental works (1977-1984years.) has established, that some groups of the population which by virtue of these or those reasons given in immunosuppressive to influences exo- or endogens factors of diseases, have the increased risk of occurrence of a surgical infection which is caused unsporeform anaerobs. To them, except for above mentioned bactericides, belong gramme - negative peptococci, peptostreptococcs, fusobacteriums. These microorganisms, in norm occupy a gastro enteric path of the person, and most of all them is in a thick gut. Usually, they are facultative - vegetation bacteria. Only in conditions immunosuppression their pathogenic properties are shown. To the above mentioned groups of increased risk S. Finegold has attributed: patients with malignant new growths, what receive cytostatic therapy, patients with a diabetes, addicts, the alcoholics sick by AIDS.

 

 

Clinical picture.

 

For diagnostics anaerobic unclostridium crucial importance correct interpretation of clinical attributes has infections (AUI). Locally occurrence AUI is preceded with insignificant microtrauma, grazes, scratches sometimes operative interventions. A skin above the center of defeat against a banal infection not hyperemic and more likely cyanotic. The appreciable hypostasis on periphery of the center (by a Fig. 8) is determined. Morbidities in the center of defeat it is not determined more often, and it is ascertained around as "felloe". At a puncture of typical pus to receive, it is not possible. At a section the scalpel as if fails in subject tissues. The wound looks as a conglomerate of "dirty rags gray-brown color with small volume of greyish-yellow exudate with drops of fat and unpleasant smell which the majority of physicians names collibacily (a Fig. 9-10). It is necessary to notice, what exactly this smell is inherent bactericides, and culture .coli of a smell has no. At the subsequent audit of a wound it is possible to establish, that purulent - necrotic process is distributed on a hypodermic basis in fascia and muscles, and the present of distribution of process appears more extensively than it seen borders at primary survey and inspection. Thus, it is possible to diagnose unclostridial anaerobic cellulitis, fasciitis and myositis. At defeat of soft tissues are ascertained combinative defeat of the mentioned tissues is more often.

 

As to changes of the general status they are shown much more intensively than at a banal aerobic infection. The temperature, the general attributes of intoxication quickly accrues, there is a respiratory distress-syndrome, there are attributes kidney-liver insufficiency. At untimely and inadequate surgical processing, there is a sepsis.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 8. The phlegmon predurinebladder spaces and retroperitoneal cellular tissue after imposing epycystostome is distributed anaerobic unclostridium.

 

 

 

 

Fig. 9. A kind of a wound at anaerobic unclostridium hip phlegmon (cellulitis, fasciitis, myositis).

 

 

 

Fig. 10. Droplets of fat in exudate of anaerobic unclostridium infections (it is marked by an arrow (a pointer)).

 

To identify AUI it is possible bacteriologically, with the help of special microbiological technics (technical equipment), by definition of no saturated flying acids inherent in these infection with the help of a chromatography, and an express train - method of coloring native material of wounds on Gramme. Last method gives positive result in 75-85 % of cases and involves with the simplicity and speed.

 

 

Principles of treatment.

 

As well as at any surgical infection the determining moment in strategy of treatment AUI is radical surgical processing. It has the features as rate bacterial invasion provides infections that the rest even small volume of struck tissues leads to the subsequent progressing of pathological process. Therefore, in this situation in no event it is impossible to imitate postulate Hypocrite: Where pus - there a cut. The surgeon who carries out radical surgical processing should be guided by an idea on completely to cut the struck tissues, and in no event an idea on economical processing for possible subsequent closing a wound. Last moment is solved at liquidation of attributes of an infection by any methods of plastic surgery. The especial attention at surgical processing AUI should be turned on fasciitis as fascia is less all a tolerant substance for bacterial infections and process "creeps" on them fastly and further all.

 

After radical surgical processing skin, rags are necessary for turning out as muff and to file them to not changed sites of a skin. Thus, we increase the area of aeration of a wound. Last needs to be processed a pulsing jet of antiseptic tanks and friable fill drainages with osmotically active ointments. The optimum end of surgical processing is treatment in the controlled bacterial environment, which enables to reduce due to access of sterile air to a minimum an opportunity of vegetation unclostridium anaerobic. In these conditions for 3-4 day, there are young fine-grained granulations, which create an opportunity for the subsequent plastic closing wounds (Fig. 11-14).

 

Principles of antibacterial therapy AUI especially do not differ from the above-mentioned principles of treatment anaerobic infections in general. It is necessary to mean only, that unsporeformed anaerobes imidazole (trichopol, tinidasolum, metronidazole, metrogil, fagil), therefore these preparations in a combination from tsephalosporines -V generation and klandamicine is the most expedient to apply the groups most sensitive to preparations of AUI. All other moments of detoxications, immune-stimulating and symptomatic therapy similar to what are applied at treatment generalized infections.

 

 

 

Fig. 11. Anaerobic unclostridium phlegmon of the anterior abdominal wall.

 

 

 

Fig. 12. A kind of a wound after radical surgical processing.

 

 

 

 

Fig. 13. Combined plastic of a wound with the help auto -and xenoskin.

 

 

 

Fig. 14. A kind of a wound for 14 day after plastics (skin rags are fixed, regional epithelisation).

 

 

TETANUS.

 

Epidemiology, etiology and pathogenesis. The activator of tetanus is the stick of tetanus which has three characteristic attributes: is anaerobe, forms disputes and allocates toxins.

 

It contains in ground, and its disputes are in the digestive channel of sheep, horses and other pets. In an environment, the stick gets with excrements of the person and animals.

 

The activator of a tetanus very proof to influence of environment factors. It during one hour maintains heating up to 80 . In the dried up kind can keep the viability without access of light until 10 years. Disputes of tetanus not always perish after boiling during 30-60 minutes. In an environment, they can be kept during long time.

 

Entrance gate for a stick of tetanus are casual wounds, mechanical and thermal superficial damages of a skin, frostbite, burns. The stick of tetanus can penetrate into an organism at criminal abortions, operation on a thick gut, removal of extraneous bodies and so forth.

 

Hit of a stick in a wound not responsibility leads to development of tetanus. Sometimes from a wound, allocate the activator without clinical attributes of disease. That at presence of a microbe the tetanus has developed, local favorable conditions, hypoxia tissues, presence of the hematoma, extraneous bodies (for example - the wound with significant pollution is crushed, necrotic tissues without access of oxygen), and also decrease of the general resistibility of organism are necessary corresponding it virulence.

 

The incubatory period tetanus changes from several days up to 3 month; it is 10-14 days more often. The shorter incubatory period - the heavier course of disease.

 

Having got in a wound, the stick of tetanus starts to produce strong exotoxin, which has two fractions - tetanospasm (predetermines convulsive reductions of muscles) and tetanolizin predetermines hemolysis of erythrocytes).

 

Tetanoplasmin is neurotoxin which amazes central nervous system. Concerning its action there are some ideas. One consider, that toxin from a wound on axial to cylinders of peripheral nerves (after lobbies wire rootlet) moves ahead in a spinal cord where amazes cells of forward horns. The part of toxin gets in a lymph and blood, and with them in the endings of nerves and is farther in cells of forward horns of a spinal cord and impellent nucleus cage than a part of a brain. From the cells of excitation formed here muscles are reflex amazed, predetermining a symptom typical for a tetanus are insufficiency.

 

In opinion of other scientists, toxin from a place of wound at once will penetrate into blood and lymph and only therefrom amazes the impellent centers and nervous - muscular connections.

 

Toxin damages also some internal bodies (a cardiac muscle, a liver, easy). Also it amazes the maximum vegetative centers of a trunk of a brain that leads to a tachycardia, a hypotension expressed perspire.

 

 

Classification. In a place of penetration of the activator in an organism, distinguish: wound, post injections, after burn, postoperative tetanus, and tetanus after frost-bite, electro traumas. Separately allocate tetanus of newborns and post-natal.

 

Behind distribution of it, classify thus. The general tetanus: the ascending form happens at the animals is more often, descending observed of the person is more often. The descending form all over again there is a pressure of muscles of a head, a neck and general constraint. Subsequently in process muscles of all trunk and finitenesss are involved, there are the general clone spasms.

 

The mixed form characterized by the same displays of an ascending and descending tetanus.

 

Allocate still the local (limited) tetanus, which characterized by the limited defeat of muscles with localization in a site of wound.

 

The local tetanus usually precedes the general, but frequently in due time is not distinguished.

 

On clinical current, allocate four forms of tetanus: lightning, acute, sub-acute and chronic.

 

On weight of process, distinguish very heavy, an average degree and easy forms of tetanus.

 

Clinical picture. The general tetanus begins with insignificantly expressed prodromal phenomena: weakness, irritability, fast approach of weariness, a headache, perspire, a pain and insignificant twitchings of muscles in a site of a wound.

 

The ambassador prodromal period there is a first terrible attribute of disease rigidity muscles. An ascending tetanus it arises all over again in muscles near to a wound, at descending grasps chewing muscles (truisms). They have no antagonists therefore before other groups convulsively reduced. The patient feels difficulty during opening a mouth, short-term spasms and a pain in chewing muscles ("the closed jaw"). These attributes steadily accrue.

 

Patients disturb of chronic pains and rigidity of the neck muscles, a nape, a back, a lumbar site. There are difficulties during walking, weight in a back and a lumbar site. Sometimes there are pains in a stomach and a pressure of the anterior abdominal wall muscles that can cause the erroneous diagnosis of a acute surgical pathology of bodies of an abdominal cavity. Frequently the tetanus begins with infringement of swallowing and a pain in a throat, which are the basis for a direction of such patients on consultation to otolaryngologist.

 

In connection with reduction of mimic muscles the person of the patient gets a characteristic kind "a sardonic smile (rises Sardonicism).

 

All these phenomena are accompanied by sensation of fear, infringement of dream, the general weakness, and sometimes excitability, perspire and rise in temperature of a body.

 

Subsequently tonic spasms cover all muscles of a trunk. As muscles of a back are stronger than muscles of a forward surface of a trunk, during their reduction of the patient is curved by an arch, lays on and a nape. Such position of the patient has received the name is opisthotonus (a Fig. 15).

 

Finitenesss at this time are bent in ulna and hip joints.

 

 

 

 

 

Fig. 15. Opisthotonus of the patient on tetanus.

 

Rigidity of semifemoral muscles acutely limits respiratory movements of a thorax which becomes inactive. When convulsive reductions cover a diaphragm, there can be an acute infringement of breath down to asphyxia. Spasms arise under influence of the least acoustical or visual irritations. The drop of water, which falls from the crane, a beam of the sun, a scratch of a bed all this can entail their occurrence. First spasms rare, but in case of progressing illness they become each time more often and arise already spontaneously.

 

Duration of insignificant spasms does not exceed 1-2 sec with intervals at some o'clock, average, 2-5 sec with intervals of 10-15 minutes. A strong pain accompanies Spasms. They sometimes such strong, that lead to break of muscles and crises of bones.

 

Through tonic, reductions of perineum muscles due to acts defecation and urination are broken.

 

In some cases tonic (are characterized by a long spasm) and klonic (the spasm of muscles alternates with their relaxation) spasms can cover muscles of only certain site of a body (the local form of a tetanus).

 

Consciousness of tetanus it is kept, that makes a condition of the patient by heavier. Arterial pressure reduced, appear a tachycardia and arrhythmia, allocation to urine (oliguria) decreases.

 

The clinical picture of the heavy form of a descending tetanus accrues up to 2-3- weeks. At favorable course, all these phenomena gradually cease: frequency and force of spasms decrease, the body temperature is reduced, decreases trism, swallowing improves. Convulsive reductions of muscles disappear in such sequence in which have appeared chewing, mimic muscles, muscles of a neck, a trunk and finitenesss.

 

Each of clinical forms of tetanus has the features. At the lightning form, symptoms develop quickly, during 12-24 hours. Disease proceeds hardly, spasms appear quickly, are frequently accompanied menacing asphicsia. The body temperature raises until 39-40 with, palpitation accelerated. Through 1 - 2 day comes death.

 

In case of the acute form, symptoms of disease develop during 24-48 hours. Attacks of spasms repeat on some times on one hour. Frequently during 4-5 day of the patient dies.

 

More slowly the clinic, in a case sub-acute form (the incubatory period lasts 4-6 day) develops. Symptoms are expressed chronic - spasms appear seldom, some times for day. Other symptoms expressed moderately. More frequently, disease comes to an end recovery.

 

The chronic tetanus happens seldom and characterized by easier current. It limited defeat of muscles with localization in a site of wound is observed.

 

Distinguish still a late and recurrent tetanus. The first can develop in some months or years after reception by the patient of a trauma. The reason of it is activation of a latent infection under influence of provoking factors: a trauma, operative intervention (in particular, later removal of an extraneous body).

 

When there is a classical triad of symptoms (trism, dysphagia, rigidity of occipital muscles), the diagnosis of a tetanus is not combined. Presence only one of components of a triad does not form the basis for an establishment of the diagnosis of a tetanus. can be display of a stomatology pathology, and isolated dysphagia or rigidity muscles of a nape consequence of psychological disease.

 

For the adequate beginning of treatment of tetanus it is important to establish the diagnosis at early stages of disease. The basic attribute is the symptom of the increased reflex excitability. It can be checked up, tapping by tip of fingers on parotid to a site that is accompanied by a spasm of muscles of the person. Loryn and Epshtein have suggested investigating a reflex of chewing muscles by patter on spatula, put on the bottom teeth. Patients with tetanus, at absence of obvious clinical attributes, convulsive, long reductions of chewing muscles observed.

 

Before early displays of a tetanus belong also traction pain and twitching of muscles in a site of a wound, superfluous perspire which does not answer a body temperature, a pain in a back.

 

The diagnosis of a tetanus proves to be true revealing in a material necrotic tissues thin bacilli with disputes similar to drum-type sticks, and also revealing of tetanic toxin in cultures at tests " toxin - antitoxin " at mice.

 

Treatment of patients by tetanus puts before itself a problem of the maximal destruction of the activator, neutralization of toxin which circulates in blood, maintenance of free passage of respiratory ways, oppression of reflex excitability of muscles, and also prevention of complications.

 

Therefore treatment of a tetanus should be carried out(be spent) in such directions: 1) specific therapy; 2) antispasmodic therapy; 3) improvement of the general condition, correction albuminous, fluid-electrolyte balance and the acid-basic condition; 4) surgical treatment; 5) symptomatic therapy.

 

Specific therapy includes use antitetanus whey (ATS). The doze of whey for adults makes 100000-150000 , for children 20000-80000 joint stock companies, for newborns 10000-20000 . Before introduction of a medical doze it is carried out intraskin and hypodermic tests on Bezredko. First enter 0,1 ml dissolved (1:100) wheys intraskin, through 20 mines 0,1 ml of not dissolved whey hypodermically. At negative result (diameter papule does not exceed 0,9 sm.) other hot whey enter intramuscularly and intravenously. Half of doze of whey enter intravenously (plant in isotonic solution of sodium chloride in the ratio 1:10), second half - in one stage intramuscularly.

 

Whey enters during 2-3 days, gradually reducing a doze. A course dozes of whey - 200000 - 350000 . Today abroad some authors refuse introduction of whey through risk of super sensitivity, with possible development of allergic reactions down to anaphylactic shock.

 

It is necessary to remember, that whey is effective as preventive means because it will neutralize only toxin, which freely circulates in blood.

 

On the toxin fixed by nervous tissues any of modern preparations does not operate. Therefore, whey needs to enter into the first 2-3 day.

 

Specific therapy includes also intravenous introduction not less as 10000 MD the human tetanic antibody diluted isotonic with a sodium chloride solution.

 

In the literature, it is underlined favorable medical effect hemolytic antitoxin, that is whey of the blood received from immunize or hyper immunize anatoxine of donors. Introduction of antitoxin needs to be combined with antybioticotherapy (intramuscular or intravenous) and retail introduction as candles 1g of metronidazole in each 8 hour that destroys all alive microorganisms and prevents the subsequent development of toxin.

 

The important place in complex treatment of tetanus is borrowed active antispasmodic with therapy. At easy forms of disease with the incubatory period over 2 weeks, rare attacks of spasms good therapeutic effect introductions of neuroleptic preparations, application chloralgydrant enema. From neuroleptic preparations use aminazine which has soothing, antispasmodic, analgetics influence (4 ml of 2,5 % of a solution of 4-5 times day intramuscularly).

 

At an average degree of weight of tetanus with often-strong spasms, frustration of breath introduction of the big dozes of neuroleptics, Dimedrol in a combination to narcotics or chloralgydrant enema is shown.

 

In case of heavy current of the tetanus, the expressed infringement of breath which threatens asphicsia, often painful spasms apply myorelaxants and carry out of artificial ventilation easy. The patient inhibited, enter to it myorelaxants, connect the device for artificial ventilation easy and carry out a superficial narcosis protoxide of nitrogen. If it is necessary to continue such therapy long time, carry out tracheostomy. Thus, use myorelaxants of antydepollarisation actions (tubarin, tubocurarin). Artificial ventilation easy can spend long time (sometimes until 14 day).

 

With the purpose of correction albuminous, fluid-electrolyte balance and the acid-basic condition carry out adjusting infusion therapy.

 

Surgical treatment of a tetanus consists in wide disclosing a wound (especially at blind wound), cutting the necrotic tissues, removal of extraneous bodies (fragments, rolling-pin of the tree, rags of clothes and so forth), maintenance of good outflow wound exudate, and supplement with local introduction of antibiotics. A wound carefully washes out peroxide of hydrogen and friability tamponed. At significant defeats of finiteness with massive crushing tissues, amputation is shown.

 

Significant role in treatment of a tetanus play hyperbaric oxygenation and antybioticotherapy. It is necessary to remember, that the majority bactericides microorganisms proof to antibiotics, and results of crop frequently need to expected some day. Antibiotics of a wide spectrum of action are in that case shown.

 

The patient with a tetanus demands behind itself especial care. First it should be placed in the isolated, blacked out and silent room to avoid anyone irritant. For care of the patient, the special average and younger medical staff, which works under supervision of the doctor, is allocated.

 

The big attention should be given to a feed of the patient (the meal should be high calorific, vitaminized with big volume of a liquid). In a case trism, the patient it is necessary to feed with liquid meal through feeding-cup with a rubber tip or through nasogastric probe.

 

In case of delay urination, it is shown catheterization of soft catheter, in case of a lock - cleaning enema. A vessel should be rubber.

 

From the epidemiological point of view patients with tetanus are not, infectious also dangers to an environment do not make. Daily laboratory and radiological research (for duly diagnostics atelectasis easy) is necessary for the patient.

 

Preventive maintenance of tetanus. Preventive actions at a tetanus share on nonspecific and specific.

 

Nonspecific preventive maintenance of tetanus consists in carrying out of duly and full surgical processing a wound, its clearing of extraneous bodies, necrotic tissues, microbes, clots of blood which is supplemented with introduction of antibiotics.

 

Specific preventive maintenance of tetanus includes active immunization irrespective of reception of a trauma and active - passive at suspicion on an opportunity of disease on tetanus.

 

Active immunization is carried out adsorbed whooping-cough - diphtheritic - tetanus (WDTS) and adsorbed diphtheritic -tetanic by vaccines to all children in the age of till 1 year, and also tetanic anatoxine to all population which lives in areas with parameters of disease on a tetanus 1 and more on 100000 populations. Immunization also shown all workers of agriculture, builders, workers and employees of railway transportation, water, constructions of sewage disposals and cleaning, peat development and timber cuttings, to workers of laboratories who work with tetanic culture, by the worker vivariums, to sportsmen, youth undergoing pre-conscription military training.

 

Tetanic anatoxine enter on 0,5 ml (2 inoculations and 2 revaccination).

 

The subsequent active - passive immunization depends on completeness of active immunization in case of reception of a trauma (emergency preventive maintenance). It is carried out at all open damages, burns, frost-bite, a gangrene and necrosis tissues, stings of animals, criminal abortions, sorts which have taken place not in a hospital, the abscesses, penetrating wounds of bodies of a belly and chest cavity, removal of extraneous ph.

 

Active immunization spends tetanic anatoxine and a human tetanic antibody, less often - antytetanus whey.

 

The circuit of emergency specific preventive maintenance of tetanus, depending on conditions and situations directed in the special instruction.

 

The forecast at a tetanus depends on duration of the incubatory period (than it is shorter, especially heavy current of disease), the clinical form of a tetanus, reactance of an organism, duly specific and nonspecific preventive maintenance, completeness of treatment.