1.What is tetanus?
Tetanus is a tetanus clostridium tetani infection, tetanus bacteria invade the body (such as wounds, fractures, or even wooden thorns, rusty needles or nail puncture wounds, etc.), growth and reproduction, production of toxins and cause an acute specific infection. Tetanus is a toxaemia. In addition, there is a special tetanus, due to the newborn broken umbilical cord, generally 4 to 7 days onset, so also known as “four or six wind”, “umbilical wind”, “seven days wind” and so on.
2.At present, what is the incidence of tetanus? What kind of people are prone to tetanus? Are there any geographical characteristics in the incidence of this disease?
According to the World Health Organization, about 1 million people die of tetanus each year worldwide, and the incidence is especially high among farmers. According to the Ministry of Health, the national tetanus incidence rate has increased, especially neonatal tetanus replaces epidemic meningitis B into the top five. Therefore, newborns delivered illegally and farmers are the susceptible group. The incidence of tetanus strictly speaking does not have a certain geographic location, all open injuries, all have the possibility of tetanus. Relatively speaking, it is mainly concentrated in rural areas with low awareness and level of health care and in cities with large foreign populations.
3.What causes tetanus?
Bacillus tetani spores are widely distributed in nature (especially in soil and human and animal feces), generally do not cause disease; when Bacillus tetani invades the skin or mucous membrane with wounds, especially with aerobic bacteria and anaerobic bacteria infection at the same time, or necrotic tissue, soil or foreign matter contamination of the wound and the formation of local ischemia, hypoxia and local anaerobic environment, Bacillus tetani grows and multiplies in the wound local, producing Two kinds of exotoxins: one is spasmotoxin, which has a special affinity for nerves, acting on the anterior horn cells of the spinal cord or neuromuscular end plate, and causing characteristic whole body transverse muscle continuous contraction or paroxysmal spasm; the other is hemolytic toxin, which can cause local tissue necrosis and myocardial damage.
4.What are the ways of transmission of tetanus? What factors can cause a person to develop tetanus? What factors can induce tetanus? (What are the prerequisites for tetanus infection?)
Tetanus bacillus is a Gram-positive anaerobic bacillus, 2-5 microns long and 0.3-0.5 microns wide. Bacterial body is easy to be killed, and the bacillus is very resistant to the external environment, existing in the soil for several years is still infectious, need to be boiled for 1 hour, or in high-pressure steam (120 ℃) 10 minutes, or in a 5% solution of carbolic acid soaked in 10 to 12 hours, in order to kill it. Tetanus bacteria are mostly present in the intestinal tract of humans and animals, with feces and into the soil and dust, can fly with the dust, so it is widely dispersed. So the way of transmission can be thought of: first, tetanus bacillus with the dust flying into the wound; second, tetanus bacillus by the wound-causing devices, objects directly into the wound. The most common causes of tetanus are traumatic injuries and umbilical cord breakage in newborns. The prerequisite for tetanus infection must be tetanus bacteria invade human wounds, and the wound is anaerobic environment.
5.What are the pathological changes when infected with tetanus bacillus? How long is the incubation period of tetanus bacillus?
Tetanus bacillus in the anaerobic environment in 1 to 2 days is rapid breeding, movement is very fast, can produce exotoxin; encounter unfavorable environment to form budding cells when the activity stops; if in the aerobic environment, it loses virulence and does not cause disease. Infection with tetanus bacillus tetanus bacillus in the local growth and reproduction of the wound, the production of exotoxin is the cause of tetanus. The former is the main toxin that causes symptoms and has a special affinity for nerves and can cause muscle spasms; the latter can cause local necrosis of tissues and myocardial damage. The tetanus spasm toxin is attached to serum globulin and reaches the anterior horn gray matter of the spinal cord or the motor nucleus of the brainstem through the blood circulation and lymphatic system; the toxin is mainly bound to ganglioside lipids in the synaptic vesicle membrane in the gray matter, making it impossible to release inhibitory transmitters (glycine or aminobutyric acid), so that the alpha motor nervous system loses its normal inhibitory properties, causing the characteristic generalized transverse muscle tension contraction or paroxysmal spasms. Toxins can also affect sympathetic nerves, leading to profuse sweating, unstable blood pressure and increased heart rate. Therefore, tetanus is a toxaemia. There is edema, nucleus accumbens and lysis of motor nerve cells in the spinal cord and medulla oblongata. In some cases, there is cerebral edema or muscle hemorrhage, lacerations and vertebral compression fractures caused by violent convulsions. Local wounds with inflammatory changes and necrosis are usually caused by other miscellaneous bacteria.
Incubation period: The length varies and is often related to factors such as whether prophylaxis has been received, the nature and location of the trauma, and the treatment of the wound. Usually 7-8 days, but also as short as 24 hours or as long as several months or years.
6.What is the general clinical manifestation of tetanus patients?
After the incubation period, the prodromal phase manifests as weakness, dizziness, headache, weakness in chewing, hyperreflexia, irritability, local pain, muscle pulling, twitching and tonicity, jaw tension, and inconvenience in opening the mouth. The seizure period may be followed by strong muscle contractions, initially in the masticatory muscles, later in the order of face, neck, back, abdomen, extremities, and finally in the diaphragm and intercostal muscles. In the case of facial muscle spasm, the patient will have difficulty in opening the mouth and closing the teeth; in the case of expression muscle spasm, the patient will have a “bitter smile”; in the case of back muscle spasm, the head will be tilted back and the so-called “corkscrew” will appear; in the case of respiratory muscle spasm, respiratory arrest may occur.
This generalized muscle spasm lasts for a variable period of time and recurs at intervals. It can be triggered by any slight stimulus such as light, sound, talking, or blowing wind. The patient is always clear and does not feel abnormal. There is usually no high fever.
7.How is tetanus diagnosed clinically? Are there any simple clinical criteria for diagnosis?
1.Inquire in detail about the history of trauma and surgery, the time and place of injury, the treatment after the injury, the time of onset, the development of the disease, and the history of tetanus vaccination; for female patients, the history of delivery or abortion should be inquired in detail; in the case of newborns, the history of delivery and the treatment of the umbilical cord should be inquired. Only in a very few cases, there is no clear history of injury, and no obvious trauma is seen.
2.Check the injury site, the condition of the wound, whether there is spasm and twitching of the muscles around the wound, and pay attention to whether the rectus abdominis muscle is tonic.
3.Observe whether the patient has teeth clenching, paroxysmal twitching, bitter smile, coracoacusis, generalized tonicity and paroxysmal spasm, pay special attention to whether the airway is open and whether there is laryngeal spasm.
8.In clinical terms, what diseases need to be distinguished (differentiated) when diagnosing tetanus?
1, septic meningitis: although there are symptoms such as “corneal inversion” and neck straightening, but no paroxysmal spasms, the patient has a severe headache, high fever jet vomiting, etc., sometimes confused, cerebrospinal fluid examination has increased pressure, increased white blood cell count, etc.
2, rabies: a history of bites by rabid dogs and cats, swallowing muscle convulsions mainly, pharyngeal muscle stress enhancement, the patient hears the sound of water or see water pharyngeal bone immediately spasms, severe pain can not swallow drinking water, and a lot of saliva.
3, temporomandibular arthritis: temporomandibular joint dysfunction or structural damage caused by pain, activity disorders and other symptoms of the syndrome. Chewing, talking, clenching and other activities can induce and aggravate the pain.
4, epilepsy: epilepsy patients with seizures are generalized convulsions, foaming at the mouth, may be accompanied by incontinence, usually lasting several minutes, the patient can not recall the process of seizures, loss of consciousness for a short period of time in the case of disorientation seizures.
5, hysteria: also known as hysteria. Four key points: first, the disease is a disease suddenly caused by mental stimulation; second, the symptoms of the disease are specific, such as somatic disorders exhibit signs, and disorders of consciousness exhibit excessive expression and exaggeration; third, the symptoms can disappear by suggestion; fourth, it does not belong to organic somatic diseases.
6, low calcium convulsions: no history of unclean umbilical cord weaning or improper care, no bitter smile face, closed teeth, normal muscle tone between two convulsions, and blood calcium reduced to 2 mmol/L a few below.
7, brain injury: the mother has a history of difficult birth, although there are convulsions, but no teeth closed and bitter smile face, often inhibited or excited state, the fontanelle bulge.
8, infantile spasms: is a severe form of seizures unique to infancy, characterized by spastic seizures, intellectual impairment, and disturbances in the peak rhythm of the EEG.
9.Once tetanus is diagnosed, how should it be treated? What do patients need to pay attention to during treatment? How should the patient cooperate during treatment? (including life behavior and diet)
Once you have tetanus, you should send the patient to the hospital for gunshot rescue, and isolate the patient, keep a quiet environment and ensure a smooth airway. Apply high dose of tetanus antitoxin to neutralize the toxin in the body.
1.Neutralize free toxin
(1) Tetanus antitoxin: tetanus antitoxin and human tetanus immunoglobulin cannot neutralize the toxin that has been combined with neural tissue, so use it as early as possible. Perform an allergy test before use. The first day with 20,000 ~ 50,000 units, added to 5% glucose solution 500 ~ 1000 ml, intravenous slow drip, and then every day with 10,000 ~ 20,000 units for intramuscular injection or intravenous drip, a total of 3 ~ 5 days. Neonatal tetanus can be used 20,000 units by intravenous drip, in addition, it can also be injected around the umbilicus.
(2) Human tetanus immunoglobulin: It can be injected deeply intramuscularly. It can completely replace tetanus antitoxin, and generally only one injection is needed, with a dose of 3000-6000 units.
2.Control and release spasm
(1) The patient should live in an isolated single dark room to avoid light and sound stimulation. Prevent the occurrence of bedsores.
(2) In milder cases, use Valium 5 mg orally or 10 mg intravenously, 3 to 4 times a day. Also use sodium barbiturate 0,1~0,2g intramuscularly or l0% chloral hydrate 15ml orally or 20~40mls rectal infusion 3 times a day.
(3) In more serious cases, use chlorpromazine 50-100 mg, add 5% glucose solution 250 ml, drip slowly intravenously, 4 times a day.
(4) For severe convulsions, use thiopental sodium 0,5 g for intramuscular injection (be alert to the occurrence of laryngeal spasm, safer for patients who have been tracheotomized), paraldehyde 2-4 ml for intramuscular injection (paraldehyde has the side effect of stimulating the respiratory tract and should not be used for those with pulmonary infections), or muscle relaxants such as succinylcholine oxide, cylindrospermine chloride, and Hansenosine (under the conditions of tracheotomy and controlled breathing). (used under the condition of tracheotomy and controlled breathing).
3. Prevention and control of complications
In severe cases, the key to prevention and control of complications is early tracheotomy to keep the respiratory tract open to avoid respiratory complications.
4.Application of antibiotics
High-dose penicillin can inhibit the tetanus bacillus, and help prevent other infections, but also oral metronidazole each 0, 4 grams every 6 hours, or each 1 gram rectal administration, every 8 hours, for 7 to l0 days.
5.Surgical treatment
(1) debridement: those with wounds. All need to be thoroughly debridement under control of spasm in a timely manner, remove necrotic tissue and foreign bodies, open the wound, and flush with 3% hydrogen peroxide or 1:1000 potassium permanganate solution and often wet compress. If the primary wound has healed at the onset, sore clearing is generally not required.
(2) Tracheotomy: For patients whose convulsions are frequent and not easily controlled by drugs, tracheotomy should be made early to keep the airway open. Suction, artificial ventilator and oxygen should also be available at the bedside for first aid.
Patients need to pay attention during treatment.
How do patients need to cooperate during treatment?
10.After the diagnosis of tetanus is confirmed, what tests are needed to further understand the patient’s condition? Will laboratory tests be used?
Bacteriological examination (including smear and culture of anaerobic bacteria) and pathological examination should be performed if there is exudate or detached tissue mass in the wound.
The main tests are for complications: X-ray of the chest and suspected fracture site, blood gas analysis, electrocardiogram, echocardiogram, etc.
11.How does Chinese medicine treat tetanus?
According to Chinese medicine, this disease is caused by post-traumatic injury, or infected lesions, failure to regulate the treatment, damage to the righteousness, and the invasion of wind and evil from the surface to the inside, which leads to liver wind.
Chinese medicine typology and herbal treatment.
1. Wind poison on the surface
Mild dysphagia and tooth closure, with mild convulsions, short spasms and long intervals.
[Treatment] Expel wind and dredge the surface, detoxify the toxin and fix the spasm.
[Remedies] Slightly.
2.Wind and toxin entering the interior
Angular dystonia, frequent generalized muscle spasms with short intervals.
[Treatment] Calming the liver and quenching the wind, resolving toxins and relieving spasm.
[Prescription] Slightly.
Experienced prescriptions of single flavor medicine.
(1) 200 grams of castor root with fresh rainbow bones, add 1500 ml of water and decoct to 200 ml, take orally in divided doses, 1 dose daily, reduce for children.
(2) 35 grams of cicada, fried and scorched, and taken with yellow wine.
Acupuncture therapy: for closed teeth, take Chee Che, Ha Guan, with Nei Ting and Hegu; for twitching of the limbs, take Hegu, Qu Chi, Nei Guan through Wai Guan, or Hou Xi, Tai Chong, Shen pulse, Yang Ling Quan; for corns and arches, take Feng Chi, Feng Fu, Dazhi, Chang Qiang, with Kun Lun and Cheng Shan. All use the diarrhea method and keep the needles for 15-30 minutes.
12.Generally speaking, what complications can tetanus bring? Does tetanus necessarily lead to death? Is it true that complications will not occur if treated promptly? What should be done if complications arise?
In addition to fractures and urinary retention, the following complications can occur.
1, lung infection: laryngeal spasm, poor airway, depression of bronchial secretions, inability to turn over frequently, etc. result.
2. Asphyxia and respiratory arrest: due to persistent spasm of the larynx and respiratory muscles and blockage of the trachea by mucous phlegm.
3.Acidosis: respiratory acidosis caused by poor breathing and insufficient ventilation; metabolic acidosis caused by strong muscle contraction and incomplete decomposition of body fat, resulting in increased acidic metabolites.
4, circulatory failure: due to hypoxia and poisoning, tachycardia can occur, and after a long time, heart failure can form, and even shock or cardiac arrest can occur. These complications are often an important cause of patient death and should be strengthened to prevent and treat.
Having tetanus does not necessarily mean that you will die. If you have the knowledge of this diagnosis, you can avoid serious complications if you think it is tetanus and get timely treatment. If complications arise, while neutralizing free toxin, control and release muscle tonic contraction; prophylactic tracheotomy when there is respiratory distress; timely aspiration, application of antibiotics; correction of hydropower, acid-base imbalance and systemic supportive therapy, etc.
13.What is the prognosis of tetanus after treatment? Will there be any sequelae? What are the factors affecting the prognosis?
Early diagnosis of tetanus, after treatment, most of them can be cured. Whether sequelae occur depends on the severity of the complications. Poor prognosis and high death rate in the elderly, low immune function and poor nutrition are important factors affecting the prognosis. And whether the diagnosis and treatment are timely and appropriate is a key factor affecting the prognosis.
14.What should be noted in the life of tetanus patients after treatment? What do family members need to do when caring for a patient with such a disease?
After treatment, tetanus patients should pay attention to rest, ensure sufficient sleep and maintain a good state of mind. The patient’s relatives should strengthen the care: the room should be quiet and at the right temperature to minimize various stimuli, and the doors and windows should be kept tightly closed. If the patient is found coughing with sputum, use aspirator and other methods to suck out the sputum, which can cause the patient to die of suffocation if not handled in time. Massage the skin, the action should be gentle, not strong stimulation, to turn over regularly. Reasonable nutrition, a high-calorie, high-protein diet should be given, along with more fruits and vegetables. Keep the bedding clean and dry, if necessary, pad the middle sheet, urine pad, and change it in time. Wash the perineum and anus with water, once or twice a day, and also after each urination.
15.When a person has a wound, what first aid measures should be taken to prevent tetanus from occurring? How should general wounds be bandaged?
Correct treatment of wounds: general small wounds, you can first use tap water or well water to rinse the mud and ash outside the wound. If you have the conditions, you can apply iodine and other disinfectant drops on the wound, cover the wound with a clean cloth and gently bandage it before going to the hospital for further treatment. For some large wounds, you can first use a clean cloth to press the wound, and then quickly go to the hospital for treatment.
15.What can normal people do to effectively prevent tetanus from occurring?
First of all, the wound should be treated correctly, including using 3% hydrogen peroxide to clean or wet dress the wound; debridement through aseptic technique; and removal of ischemic necrosis and foreign bodies of tissues that have been contaminated; as well as effective hemostasis and suturing of the wound. The above treatment makes the wound or wound surface form an aerobic and sterile environment to eliminate the invasion and reproduction of tetanus, which is especially important in large burns, frostbite and complex trauma and animal bites. In particular, it should be noted that the promotion of scientific methods of delivery and strict disinfection when tying the umbilical cord is an important measure to prevent neonatal tetanus.
Secondly, antibiotics that are effective against anaerobic and especially tetanus should be used, including penicillin, methamphetamine, cephalosporins, etc. The above antibiotics should be routinely used for children with severe wound contamination or deep wounds to effectively control the propagation of tetanus.
The third and the most important measure is to administer tetanus prophylaxis injections, including.
1, autoimmunity: injection of tetanus toxoid (TT), can make the body produce tetanus antitoxin (TAT), so as to prevent the onset of tetanus. The “triple” vaccine, which is usually given in infancy, contains tetanus toxoid and is given three times in total. A booster injection should be given after 1 year and every 5 years thereafter in order to maintain long-lasting immunity. The above injection methods are carried out according to the national vaccination procedures. In short, those who have received the whole preventive injection, once injured, only need another injection of tetanus toxoid to play a role in immune protection. If you do not adhere to the booster injection, but only injected in the infant stage, after the immunization years, tetanus may still occur after the injury without taking measures.
2, passive immunity: refers to the injection of tetanus antitoxin (TAT) within 24 hours right after the injury. Where the wound is deep and large; wound contamination is obvious; the wound is not cleaned and treated in time; or nail stab wounds; dagger wounds, gunshot, bamboo and wood stab and other foreign body wounds and foreign body residue, as well as animal bites, should be timely injection of conventional dose of 1500 units. Before use, a skin test must be made, a negative injection; positive should first desensitization injection, usually in 4-5 injections. Conditional units, you can also inject human tetanus immunoglobulin, currently considered the most effective and safe drug. It should be noted that the need for passive immunization after injury is determined by the doctor.
17.Is there a typology of tetanus patients? What is the classification according to?
Clinical tetanus is often classified into mild, moderate and severe according to the characteristics of the patient. The mild type has an incubation period of more than 10 days and a mild degree of generalized muscle tonicity. Spasmodic muscle contractions may appear 4 to 7 days after the onset of the disease, but they are short-lived and usually stop within a few seconds. In intermediate patients, the incubation period is 7 to 10 days, and the initial spasm period is 2 to 4 days. The clinical muscle tonicity is remarkable with typical teeth clenching and coracoacusis. The paroxysmal spasms are prolonged, lasting more than 10s, and the frequency of seizures increases, but dyspnea and laryngospasm do not yet occur. In severe cases, the incubation period is shorter than 7 days and the initial spasm period is usually shorter than 48 h. The generalized muscle tonicity is obvious, with frequent spasmodic muscle contractions of long duration, often leading to cyanosis and laryngospastic asphyxia. Patients often have high fever and pulmonary infection, or cerebral edema due to frequent convulsions and hypoxia. In severe cases, coma occurs and the patient eventually dies of respiratory failure and systemic failure.
In addition, it is also advocated that the degree of generalized muscle tonicity and paroxysmal myoclonus should be used for typing, which can more directly reflect the severity of the disease, while the length of the latency period and initial spasm period is only a reference when determining the disease. Only generalized muscle tonicity without paroxysmal myoclonus is light. Those who have obvious generalized muscle tonicity with paroxysmal myospasm, but can control the spasm with appropriate application of sedatives, are classified as medium-sized. When the spasms are frequent and not easily controlled by sedation, or when laryngospasm occurs, it is judged as heavy. The former typing method has an important reference value for clinical prediction of the development of the disease and timely and adequate treatment, while the latter typing method is simpler and more applicable.
18.The early detection method of tetanus? How can we find out early if a patient is infected with tetanus bacillus?
For tetanus patients, the key to rescue is early detection. The early symptom of tetanus is muscle spasm, which is often referred to as “cramps”. The earliest symptom of most patients is facial muscle spasm, which is mainly manifested by the inability to open the mouth, chewing food, the muscle spasm pain in front of both ears. Many patients go to the dentist mistaking it for dental disease. The more you ask the patient to open the mouth, the more the patient can not open, and even the more closed the tighter. At this time, if a little negligence, not to be delayed, but if you have the knowledge of this diagnosis, think of tetanus and timely treatment, most can be cured. Once the whole body muscle spasms and twitching, and then turn to think about tetanus, the prognosis is very bad.
The early diagnosis of tetanus is the tongue compression test method. The test method is: for tetanus suspected patients, a tongue depressor or other disinfected smooth small wooden board, or even chopsticks, spoons, etc., gently placed in the middle of its mouth tongue, force down the pressure. If the patient immediately appears to close his teeth and bite the tongue depressor, it is positive and can be judged as an early manifestation of tetanus. These people will all show typical tetanus symptoms within 4 to 30 hours.
19.What do children need to pay attention to when receiving tetanus vaccination? What kind of children cannot be vaccinated with tetanus vaccine?
Parents should give their children a bath and change clean clothes before vaccination and tell the doctor about the health condition of the child, and only after the doctor’s examination that there is no “contraindication” to vaccination, avoid strenuous activities after vaccination and pay attention to observation: if there is often local redness, swelling and pain after injection, there may be mild fever and general discomfort within two days. There may be mild fever and general discomfort within two days, and occasional loss of appetite, vomiting, and mild dysentery, which usually recover in 2-3 days. If the fever is 38,5℃ or above, please give your baby fever reducing medicine. If the fever is 39,5℃ or above, please send your baby to the doctor as soon as possible. People with central nervous system diseases, such as encephalopathy, epilepsy, etc., or those with past medical history, as well as those who belong to allergic body cannot be vaccinated.
20.Can pregnant women receive tetanus vaccination?
Pregnant women without immunity should be injected with tetanus toxoid or tetanus vaccine in time to prevent infection. The toxoid injection will produce antibodies, which will also have a protective effect on the newborn, so it can be said that one person can benefit from the injection.
21.Is facial palsy related to tetanus?
Facial palsy, also known as orofacial palsy, is a very common disease in China and can be divided into two types, central facial palsy and peripheral facial palsy, depending on the patient’s onset factors. The most common is peripheral facial palsy, which is mainly caused by nerve irritation. Most of the peripheral facial palsy is caused by wind blowing. Viral facial palsy develops mostly due to cut viral infections, such as otitis media. If mood swings, shock, cold, long-term fatigue, etc. occur, the patient’s condition can be aggravated, and it can be cured with regular and early treatment. In tetanus of head injury, facial palsy occurs in about 3-4% of patients.