widely spread obligatory anaerobe, sens - Cccmj.ge

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Causing agent is called clostridium tetani. Is related to clostridia and bacilli family; widely spread obligatory anaerobe, sensitive towards oxygen, creates spores.
34. Z.Kheladze,Zv.Kheladze Rare Critical Conditions- TetanusCritical Care Medicine Institute,Tbilisi,Georgia

Causing agent is called clostridium tetani. Is related to clostridia and bacilli family; widely spread obligatory anaerobe, sensitive towards oxygen, creates spores. Tetanus bacteria secrete egsotoxin that is second after botulism toxin in accordance with strength. There are distinguished 3fractions:tetanospasmin or neurotoxin that damagesmoving cells of nervous system and causes convulsions; tetano-hemolysine which causes hemolysis of erythrocytes and toxins’ low-molecular fraction that that increases action of tetanospasmin. Average form’s incubation is more than 2 weeks. Hypertonus of muscles is averagely expressed; intensiveness of convulsions is repeated several times, temperature reaches 38-39°C.average tachycardia and sweating is expressed.Severe tetanus begins severely after short incubation period. Fever, sweating, shortness of breath, tachycardiam dysphagya occur along with intensive tetanus convulsions; complications develop.

Treating period includes 3-5 weeks. Tetanus remains one of the dangerous diseases nowadays but in aids of an adequate treating mechanism lethality decreased up to 17-25% from 70%.

Key Words: infection of a wound, Bacteria,Tetanospasmin,Teetano-hemolysine ,Anatoxin,Imunoglobulin.

It is a small review of rare critical conditions and they are integrated by two factors: they are represented as critical conditions and at the same time they appear on the “stage” of critical care medicine. Professional activity of some doctors may occur without meeting with them. Despite all doctors of critical care medicine is obliged to have complete information. Because of the limited time a doctor is not able to have

direct information about a condition. Moreover, if an information is little and insignificant. Georgian Institute of Critical Care Medicine does it’s best to improve this condition. This time from these cycles of works we would like to represent a little information about Tetanus Is called an infection of a wound. Causing agent is spread in closed wounds; reproduces egsotoxin. Mostly damages motoneurons of spinal cord. It is expressed in convulsions of skeleton muscles.Pathogenesis. Causing agent is called clostridium tetani. Is related to clostridia and bacilli family; widely spread obligatory anaerobe, sensitive towards oxygen, creates spores. Tetanus bacteria secrete egsotoxin that is second after botulism toxin in accordance with strength. There are distinguished 3 fractions: tetanospasmin or neurotoxin that damagesmoving cells of nervous system and causes convulsions; tetano-hemolysine which causes hemolysis of erythrocytes and toxins’ low-molecular fraction that that increases action of tetanospasmin. Toxin is less resistant, loses it’s toxicity by the influence of some chemical substances but preserves antigenic peculiarities-like formalin. It is used to produce anatoxin. The basic reservoir of bacteria are domestic and wild animals, and rarely-a human. Bacteria live in guts as a vegetative forms. Secreted toxin is not absorbed in intestinal tract so human is not infected by means of alimentation. Tetanus spores appeared in desirable conditions (oxygen-free area) transfer into vegetative forms which produce egsotoxin which reaches to reticular formation of brain by means of peripheral nerves’ moving fibers. Toxin suppresses interneurons’ blocking action on motoneurons. Then each blocking action of interneurons on motoneurons disappears. Because of it impulses generated in motoneurons are transferred into peripheral muscles without any coordination that conditions in a constant tonic tightness of muscles. In case of tetanus a reason of death is asphyxia caused from convulsive syndrome, paralysis of respiratory and cardiac functions, rarely pneumonia and general exhaustion are complications. Clinic. 3-30 days are incubation period and generally 6-14 days. The less incubation period is the more severe ongoing is and outcome is not reliable. There are distinguished generalized and local forms: if infection invasion is not determined then it is called cryptogenic. Local or cryptogenic tetanus is rare and mostly generalized form is spread. There are distinguished beginner, development and recovery stages. Rarely prodromic signs can be expressed around wound as

tightness of muscles, pain, also head ache and sweating. The disease begins rapidly, at first truism is visible. because of convulsion and tightness of chewing muscles a patient feels unable to open and chew-also sardonic smile exists in the beginning. A patient had wrinkles on forehead, eye gap is narrowed, that creates an impression of satiric smile. Because of tight back and occipital muscles’ pain a patient has hid head placed back. Because of muscle spasm-dysphagia is developed-step by step muscular apparatus of whole body becomes tense and convulsion begin. All muscles of hand and foot are tense and a patient touches on bed with head and pelvis only. Because of constant tonic contractions muscles are painful. Patients suffers from immobility, also periodically attacking so-called tetanous, clonic convulsions occur which are provided by irritation, touch, bright light, noise and etc. in severe cases tetanus convulsions continue unstoppably. During convulsions opistotonus is intensified, contours of all muscles are expressed; if convulsions last 1-2 minutes and more then shortness of breath, cyanosis and asphyxia may develop. Frequent convulsive attacks condition in intensification of metabolism and hyper secretion (-41° C)

A patient has a clear consciousness, reflexes are intensified, Kerning’s sign is expressed. Pulse is tense, fast. Cardiac tones are dull, borders are increased in size, in conditions of hypoxia and metabolic acidosis cardiac paralysis is awaited that can be developed without as a result of injury of medular centers with toxin. Arterial pressure of blood is elevated especially at the time of convulsions. Because of tonic contractions of respiratory muscles in trachea and bronchi phlegm is accumulated that blockes ventilation of lungs. Cough intensifies tetanus contraction, in blood there is neutrophilic leukocytosis , especially in case of complications. Duration of the disease is 3-4 weeks, and recovery period 1-1,5 months. Hypertonus of muscles and tachycardia remains for a long time. According to severity there are distinguished light, average and severe and lightenin-like forms.

Light form is rare and begins after long incubation period. Clinical signs develop step by step-muscle hypertonus is less expressing, tetanus contractions are seldom and short term.

Average form’s incubation is more than 2 weeks. Hypertonus of muscles is averagely expressed; intensiveness of convulsions is repeated several times, temperature reaches 38-39°C.average tachycardia and sweating is expressed.

Severe tetanus begins severely after short incubation period. Fever, sweating, shortness of breath, tachycardiam dysphagya occur along with intensive tetanus convulsions; complications develop. Lightning-like tetanus lasts 6-7 days; temeprature reachs 41-42°C, with constant convulsion, tachycardia, tachypnoe, cyanosis, asphyxia. The most severe form is so-called “bulbar” one which damages long brain and spinal cord’s upper parts, kernels of respiratory centre and false nerve. At this time, lethal outcome is conditioned from respitatory failure and cardiac paralysis.

Local tetanus is seldom. In area of wound pain begins and tension of muscle that may last for several weeks. Complications. In early stage bronchitis, pneumonia, sepsis, cardian attack, paralysis of heart muscle are characteristic. In acute period development of muscles’ splitting occurs and pathological fractions as well. Late complications include myocarditis, contracture of ribs and muscles, compressive deformation of skeleton and etc. Diagnosis: is based on epidemiologic anamnesis (wound, trauma) and clinical image: truism, sardonic smile, tone tension and pain, periodic tetanus convulsions and clear mind. Treatment: a aptient must be placed in calm, cosy conditions, rather dark environment far from noise and external irritations.

It is necessary to eliminate convulsive syndrome and acute respiratory failure. In order to eliminate convulsive syndrome neuroleptics are used, also bensodiazepins, narcotics and miorelaxants. It must be taken into consideration ,that prolonged treatmentwith miorelaxants causes ganglion-blocking effect, over-reproduction of histamine which leads to arrhythmia and cardiac failure. In case of respiratory failure a patient must be transferred on to artificial pulmonary ventilation on the background of sedative drugs. A permanent

control of hematocryte, water-salt and acid-alkaline showings is necessary. In addition, intravenous injection of plasma, albumin and rheopolyglukin is recommended.

When diagnosis is confirmed anti-tetanus serum must be injected immediately by the way of “Bezderka”: in purpose of determination of individual sensitivity udner skin 0.1 ml dissolved (1:100) serum is injected. After 20 minutes size of papula is evaluated. If diameter of it is not more than 1sm the sample is considered to be negative and if more than 1cm-positive.

In case of negative sample sensibilizing dose is injected-05 ml under skin during 0,5-1 hours. Then treating dose- 100 000-200 000 units). A patient has antitetanus immunization because the disease by it own does not give a stimulation of tetanus but a direct effect of treatment with immuneglobulin and anatoxin is far from desirable need.

For destruction of vegetative forms of causing agent in vein benzylpeniciline 1012ml is injected per day during 10 days. Other antibiotics are also used for treatment of infectional complications in accordance with sensitivity of bacterial flora and clinic’s “microbiological passport”. In the moment of tetanus development even if a wound is deeply cicatrized it must be purified from antibody and treated surgically ended up with drainage. After treated wound anatoxin must be injected-3-10 thousands unit.

Nutrition and taking care of patient must be on a high level. Food must be watery. Tetanus patient must receive 3500-5000 cal per day by means of tube with provision of an optimal volume of proteins, fats, carbohydrates. In case of paresis of stomach, parenteric nutrition is necessary. In addition to these, symptomatic therapy is essential to liquidate complication generated during treatment process and for prophylactics. Treating period includes 3-5 weeks. Tetanus remains one of the dangerous diseases nowadays but in aids of an adequate treating mechanism lethality decreased up to 17-25% from 70%.

Prophylactics: anti-tetanus specific prophylactics are conducted immediately after a trauma. If a person was vaccinated against tetanus in advance then 0,5ml anatoxin must be injected in order to avoid complications. If a person was not

vaccinated then so-called active-passive immunization is carried out- at first 1,0ml anatoxin is injected along with anti-tetanus serum then after 4-8 weeks the second dose of anatoxin is injected and finally the third one after 6-12 weeks. Booster dose is injected per 10 years. References: Z.kheladze,Zv.Kheladze „Critical Care Medicine“,Tbilisi,Georgia,2015,first book,

z.xelaZe,zv.xelaZe iSviaTi kritikuli mdgomareobebi – tetanusi კრიტიკული მედიცინის ინსტიტუტი , თბილისი.saqarTvelo

Wrilobis infeqcias uwodeben.gamomwvevi mravldeba daxurul WrilobebSi. gamoimuSavebs egzotoqsins. upiratesad azianebs zurgis tvinis motoneironebs. gamoixateba ConCxis kunTebis krunCxvebSi. paTogenezi. gamomwvevia clostridium tetani.miekuTvneba klostridiebis gvars da bacilosanTa ojaxs. farTod gavrcelebuli obligaturi, anaerobia, mgrZnobiarea Jangbadisadmi, warmoqmnis sporebs. tetanusis baqteriebi gamohyofen egzotoqsins, romelic siZlieriT botulizmis toqsinis Semgdeg meorea. arCeven toqsinis sam fraqcias: tetanospazmins, anu neirotoqsins, romelic azianebs nervuli sistemis mamoZravebel ujredebs da iwvevs krunCxvebs; tetano-hemolizins, romlebic eriTrocitebis hemolizs iwvevs da. toqsinis dabalmolekulur fraqcias, romelic aZlierebs tetano spazminis moqmedebas. toqsini nakleb gamZlea, zogierTi qimiuri nivTierebis moqmedebiT hkargavs Sxamianobas, Tumca inarCunebs antigenur Tvisebebs. aseTia formalini. is ga-

moiyeneba anatoqsinis dasamzadeblad. baqteriebis ZiriTad rezervuars Seadgenen Sinauri da gareuli cxovelebi, ufro iSviaTad-adamiani. baqteriebi cxovelmyofeloben nawlavebSi vegetatiuri formebis saxiT.gamoyofili toqsini kuW-nawlavis traqtSi ar Seiwoveba, amitom alimenturi gziT adamiani ar avaddeba. WrilobaSi moxvedrili tetanusis sporebi xelsayrel pirobebSi (uJangbado are) gadadian vegetatiur formaSi. vegetatiuri formebi gamoimuSaveben egzotoqsins, romlebic sisxlisa da periferiuli nervebis mamoZravebeli boWkoebis gziT aRwevs zurgis tvins da da Tavis tvinis Reros retikulur formacias.toqsini Trgunavs interneironebis Semakavebel moqmedebas motoneironebze.SemdegSi interneironeTa yovelgvari Semakavebeli moqmedeba motoneironebis mimarT qreba. amitom motoneironebSi warmoqmnili impulsebi yovelgvari koordinaciis gareSe gadaecema periferiaze nebiT kunTebs, rac ganapirobebs ConCxis kunTebis mudmiv tonur daZabulobas.tetanusis dros sikvdilis mizezia krunCxviTi sindromiT ganpirobebuli asfiqsia, sunTqvisa da gulis muSaobis dambla, ufro iSviaTi garTulebaa pnevmonia da zogadi gamofitva. klinika. inkubaciuri periodi 3-30 dRemdea, ufro xSirad 6-14 dRe. rac ufro xanmoklea inkubaciuri periodi miT ufro mZimed mimdinareobs daavadeba da cudia gamosavali.arCeven generalizirebul da adgilobriv formebs. Tu infeqciis SeWris adgili ver daadgines, tetanus kriptogenuls uwodeben. adgilobrivi an kriptogenuli tetanusi iSviaTia da is ZiriTadad generalizebuli formiT mimdinareobs. arCeven sawyis, ganviTarebis da gamojanmrTelebis stadiebs . iSviaTad SeiZleba gamoixatos prodromuli niSnebi Wrilobis irgvliv kunTebis mcire daZabulobis, mtkivneulobis, agreTve Tavis tkivilisa da oflianobis saxiT.Ddaavadeba iwyeba swrafad, Tavdapirvelad vlindeba daavadebis paTognomuri niSani trizmis saxiT, saReWi kunTebis tonuri krunCxvisa da daWimvis gamo avadmyofs uWirs piris gaReba da ReWva, dasawyiSive gamoixateba e.w. sardoniuli Rimili. Aavad-

myofs unaoWdeba Subli, uviwrovdeba Tvalis naprali, rac damcinavi Rimilis STabeWdilebas hqmnis. kefisa da kisris kunTebis daZabvisa da tkivilis gamo avadmyofs Tavi ukan aqvs gadaxrili. kunTebis spazmis gamo ewyeba ylapvis gaZneleba_disfagia, TandaTanobiT gamovlindeba mTeli sxeulis kunTovani aparatis daZabva da krunCxvebi. daZabulia yvela kunTi xelis mtevnisa da terfis kunTebis garda. welisa da zurgis kunTebis daWimva imdenad Zlieria rom avadmyofi sawols mxolod TaviT da menjiT exeba.mudmivi tonuri SekumSvis gamo kunTebi mtkivneulia. avadmyofsUuWirs moZraoba, tonuri krunCxvebis garda, periodulad viTardeba SeteviTi e.w. tetanuri, klonuri krunCxvebi, rasac xels uwyobs gaRizaneba, Sexeba, sinaTlis Suqi, xmauri da sxva. mZime SemTxvevaSi tetanuri krunCxvebi ganuwyvetliv meordeba.tetanuri krunCxvebis dros opistotonusi Zlierdeba, gamoixateba yvela kunTis konturi. Tu krunCxva 1-2 wuTze met xans gagrZelda, SeiZleba diafragmis, xorxis da neknTaSua areebis kunTebis sinqronuli spazmis Sedegad ganviTardes qoSini, cianozi da asfiqsia.xSiri krunCxviTi Setevebi ganapirobebs nivTierebaTa cvlis gaZlierebas da hiperpireqsias. (t-41° C) avadmyofs goneba naTeli aqvs, refleqsebi gaZlierebulia, gamoxatulia kerningis niSani. pulsi daWimulia, aCqarebuli. gulis tonebi moyruebulia, gulis sazRvrebi gadidebuli, hipoqsiisa da metaboluri acidozis pirobebSi mosalodnelia guli dambla, romelic SesaZloa toqsiniT medularuli centrebis dazianebis Sedegadac ganviTardes. sisxlis arteriuli wneva matulobs, gansakuTrebiT krunCxvebis dros.sunTqvis kunTebis tonuri SekumSvis gamo traqeasa da bronqebSi grovdeba naxveli, rac aferxebs filtvebis ventilacias. xvela aZlierebs tetanur SekumSvebs. sisxlSi neitrofiluri leikocitozia, gansakuTrebiT garTulebebis dros. daavadebis xangrZlivoba 3-4 kvira, gamojanmrTeleba neli tempiT _1_1,5 Tve mimdinareobs. didxans rCeba kunTebis hipertonusi da taqikardia. simZimis mixedviT arCeven msubuq, saSualo, mZime da elvisebur formebs.

msubuqi forma iSviaTia da iwyeba xangrZlivi inkubaciuri periodis Semdeg. klinikuri niSnebi TandaTanobiT viTardeba,kunTTa hipretonusi naklebadaa gamoxatuli, tetanuri SekumSvebi iSviaTia da xanmoklea. saSualo simZimis tetanusis inkubaciuri periodi 2-kvirze metia.kunTebis hipertonusi zomieradaa gamoxatuli,krunCxvebis intensivoba dRe-RameSi ramenjerme meordeba, t-38-39°C-is farglebSia. gamoxatulia zomieri taqikardia da oflianoba. mZime tetanusi xanmokle inkubaciuri periodis Semdeg mZafrad iwyeba. gamoxatulia cxeleba, oflianoba, qoSini, taqikardia, disfagia, kunTTa mudmivi hipertonul krunCxviT SetevebTan erTad aRiniSneba intensiuri tetanuri krunCxvebi. viTardeba garTulebebi. elviseburi tetanusis dros inkubaciuri periodi 6-7 dRemdea, temperatura dasawyisSi 41-42°C-s aRwevs, gamoxatulia mudmivi krunCxvebi, taqikardia, taqipnoe, cianozi, asfiqsia.umZimesia e.w. ,,bulburi” tetanusi, romlis drosac ziandeba morgZo da zurgis tvinis zeda nawilebi, sunTqvis centrisa da cdomili nervis birTvebi, am dros letaluri gamosavali sunTqvis gaCerebiT da gulis dambliT aris ganpirobebuli. adgilobrivi tetanusi iSviaTia. Wrilobis areSi iwyeba tkivili da kunTebis daZabuloba, romelic SesaZloa gagrZeldes ramdenime kvira. garTulebebi. daavadebis adreul periodSi damaxasiaTebelia bronqiti, pnevmonia, sefsisi, gulis infarqti, gulis kunTis dambla. mwvave periodSive viTardeba kunTebis gaxleCva da Zvlebis paTologiuri motexilobebi. mogvianebiT garTulebebs ekuTvnis miokarditi, saxsrebisa da kunTebis kontraqtura, xerxemlis kompresiuli deformacia da sxva. diagnozi.emyareba epidemiologiur anamnezs (Wriloba, travma) da klinikur suraTs.:trizmi,sardonikuli Rimili,kunTebis mudmivi

tonuri daZabuloba da tkivili,perioduli tetanuri krunCxvebi da naTeli goneba mkurnaloba..avadmyofi unda moTavsdes myudro, SedarebiT bnel garemoSi, sadac daculi iqneba xmaurisa da garegani gamRizianeblisagan. aucilebelia krunCxviTi sindromisa da masTan Serwymuli sunTqvis mwvave ukmarisobis kupireba. krunCxviTi sindromis likvidirebis mizniT gamoiyeneba neiroleptikebi, benzodiazepinebi, narkotikebi da miorelaqsantebi. gasaTvaliswinebelia, rom miorelaqsantebiT xangrZlivi mkurnaloba iwvevs gangliomablokirebel efeqts, histaminis moWarbebul gamomuSavebas, rasac mosdevs ariTmia da gulis gaCereba. sunTqvis ukmarisobisas saWiroa avadmyofis gadayvana filtvebis xelovnur ventilaciaze sedaciuri saSualebebis fonze.aucilebelia hematokritis,wyal-marilovani da mJava-tutovani maCveneblebis mudmivi kontroli da reqcia.rekomendirebulia agreTve plazmis, albuminis, reopoliglukinis intravenuri Seyvana. tetanusis diagnozis dadasturebisTanave saWiroa tetanusis sawinaaRmdego Sratis Seyvana ”bezredkas” wesiT: individualuri mgrZnobelobis gansazRvris mizniT jer keTdeba kanqveSa sinji 0,1 ml. ganzavebuli (1:100) SratiT. 20 wuTis Semdeg fasdeba papulis zoma. Tu papulis diametri ar aRemateba 1 sm-s, sinji iTvleba uaryofiTad, xolo Tu igi 1 sm-ze metia_ sinji dadebiTia. uaryofiTi sinjis SemTxvevaSi jer SehyavT madesinsibilizirebeli doza 0,5 ml. kanqveS, xolo 0,5-1 sT.is Semdeg SehyavT samkurnalo doza (100 000- 200 000 erT.) kunTebSi. avadmyofs utardeba agreTve tetanusis sawinaaRmdego imunizacia, radgan TviT daavadeba ar iZleva imunitetis stimulirebas.,Tumca uSualod imunoglobuliniT da anatoqsiniT mkurnalobis efeqti sasurvelisgan jer kidev Sorsaa; gamomwvevis vegetatiuri formebis gasanadgureblad venaSi SehyavT benzilpenicilini 10-12 ml. dRe-RameSi 10 dRis ganmavloba-

Si. gamoiyeneba agreTve sxva antibiotikebic infeqciur garTulebaTa (sefsisi, pnevmonia)samkurnalod baqteriuli floris mgrZnobelobisa da klinikis ,,mikrobiologiuri pasportis” gaTvaliswinebiT. tetanusiT daavadebis momentSi Wriloba Sexorcebuloc rom iyos igi Rrmad unda gaixsnas, ganTavisufldes ucxo sxeulisagan, unda Cautardes saTanado qirurgiuli damuSaveba da Caidos drenaJi. damuSavebuli Wrilobis irgvliv saWiroa antitoqsinis Seyvana 3-10 aTasi erTeulis raodenobiT. mniSvneloba aqvs avadmyofis movlas da kvebas. sakvebi unda iyos Txieri. tetanusis mZime formiT daavadebuli unda ikvebebodes zondiT dRiurad 3500-5000 kaloria energiis,cilebis,cximebisa da naxSirwylebis optimaluri raodenobiT uzrunvelyofiT. kuWnawlavis parezis SemTxvevaSi ki saWiroa parenteraluri kveba.Aseve unda mimdinareobdes simptomuri Terapia mkurnalobis procesSi aRmocenebuli garTulebebis likvidaciis da profilaqtika mizniT.mkurnalobis xangrZlioba3_5 kviraa.tetanusi dRemde umZimes daavadebad rCeba,Tumca mkurnalobis amgvari meTodebis SemweobiT letaloba 70%-idan 17-25%-mde Semcirda. profilaqtika. tetanusis sawinaaRmdego specifiur profilaqtikas atareben travmis miRebisTanave. Tu adamiani acrili iyo tetanusis sawinaaRmdegod, profilaqtikis mizniT saWiroa tetanusis anatoqsinis 0,5 ml._is Seyvana. Aucrelebs ki utareben e.w. aqtiur_pasiur imunizacias_ dasawyisSi SehyavT 1,0 ml. anatoqsini tetanusis sawinaaRmdego SratTan erTad ( 3000 s.erT._is raodenobiT), 4-8 kviris Semdeg ki ukeTeben anatoqsinis meore dozas, mesames ki - 6-12 Tvis Semdeg. busteruli doza SehyavT yovel 10 weliwadSi.