I. Definition: Tetanus is an idiosyncratic infection often associated with trauma. Wounds of all types and sizes may be contaminated, especially open fractures, wounds containing rust, puncture wounds with small but deep wounds, blind tube trauma, and firearm wounds, which are more susceptible to contamination by Clostridium tetani. Pediatric patients are more commonly seen with stab wounds to the hands and feet. If the wound is dressed with clay, incense ash, wood ash and other earthen methods, it is more likely to cause disease. In addition to the possibility of occurring after various traumas, it may also occur in mothers and newborns delivered under unclean conditions and after informal abortions. Otitis media, pressure sores, tooth extraction and intrauterine insertion of IUDs may cause this disease. There is also an increasing trend of tetanus in drug addicts due to intravenous injection of drugs using unclean syringes. The causative organism Clostridium tetani is an absolute anaerobic bacterium with positive Gram stain. The feces of livestock and people can contain bacteria, with the feces out of the body, in the state of budding cells distributed in nature, especially in the soil is common, in the soil for several years to survive. This bacteria has strong resistance to the environment, can withstand boiling 15 to 90 minutes. Clostridium tetani produces an extremely toxic exotoxin, namely neurospasm toxin. After the toxin is produced, it does not cause inflammation locally, but spreads around, invades muscle tissue, and travels upward in the direction opposite to the nerve impulse, eventually entering the anterior horn of the spinal cord or the motor nerve nucleus of the brainstem. Although the contamination rate of traumatic wounds is high, up to 25% to 80% in the battlefield, the incidence of tetanus only accounts for 1% to 2% of those contaminated, suggesting that the onset must have other factors, the main factor being the hypoxic environment. In trauma, Clostridium tetani can contaminate deep tissues (such as blind canal trauma, deep stab wounds, etc.). If the external wound opening is small and the wound is filled with necrotic tissue or blood clots, or if the filling is too tight, local ischemia, etc., a hypoxic environment suitable for the growth and reproduction of the bacterium is formed. If there is also an aerobic bacterial infection, the latter will consume the oxygen remaining in the wound, making the disease more likely to occur. Second, clinical manifestations: infection with Clostridium tetani to the onset of disease, there is an incubation period, tetanus incubation period length and the location of the wound, the infection and the body’s immune status, usually 7 to 8 days, can be as short as 24 hours or up to several months, years. The shorter the incubation period, the worse the prognosis. The incubation period of neonatal tetanus is 5 to 7 days after the umbilical cord is broken. Occasionally, tetanus symptoms appear after the removal of foreign bodies that have been in the body for many years. 1, the anterior body symptoms are slow onset, before the onset of general weakness, dizziness, headache, chewing weakness, local muscle tightness, tearing pain, hyperreflexia and other symptoms. 2. Typical symptoms are mainly manifestations of motor nervous system disinhibition, including muscle tonicity and muscle spasm. Usually, the first muscle group affected is the masticatory muscle, followed by the facial expression muscle, the neck, back, abdominal and limb muscles, and finally the diaphragm. When the back and abdominal muscles contract simultaneously, the trunk is twisted into an arch because the back muscles are stronger, forming an “angular arch” or “lateral arch”. Paroxysmal myoclonus occurs on the basis of myotonicity and persists during the interval between spasms. Corresponding signs are frowning, downward corner of the mouth, and “bitter smile” (facial muscle spasm); laryngeal obstruction, dysphagia, and choking (pharyngeal muscle spasm); ventilation difficulties, cyanosis, and respiratory arrest (respiratory muscle and diaphragm spasm); and urinary retention (bladder sphincter spasm). Intense myospasm can cause muscle rupture and even fracture. Patients die mostly due to asphyxia, heart failure or pulmonary complications. The above seizures can be triggered by mild stimuli, such as light, sound, contact, and drinking water, or they can be spontaneous. In mild cases, there are no more than 3 myoclonic seizures per day; in heavy cases, the seizures are frequent and can occur once every few minutes or even continuously. The duration of each seizure varies from a few seconds to several minutes. The duration of the disease is usually 3 to 4 weeks. If the disease is treated actively and no special complications occur, the degree of seizures can be gradually reduced and the remission period is about 1 week on average. However, muscle tension and hyperreflexia can continue for a period of time; some psychiatric symptoms, such as hallucinations, speech and confusion of action, can also appear during the recovery period, but they can mostly recover on their own. 3.Autonomic symptoms are caused by the sympathetic nerves affected by the toxin, which manifest as obvious fluctuation of blood pressure, increased heart rate with arrhythmia, peripheral vasoconstriction, and profuse sweating. 4.Special types (1) limited tetanus is manifested by the tonicity and spasm of the bite muscle at the trauma site or face. (2) head and facial tetanus caused by head trauma, facial, motoneurotic and sublingual nerve palsy patients are paralytic type, while non-paralytic type appears as teeth clenching, facial muscle and pharyngeal muscle spasm. The laboratory examination of tetanus patients generally has no specific findings, when there is secondary infection of the lungs, the white blood cell count can be significantly increased, sputum culture can find the corresponding pathogenic bacteria, wound secretions are often isolated to aerobic septic bacteria, about 30% of the patient’s wound secretions by anaerobic culture can be isolated Clostridium tetani, because the clinical manifestations of tetanus is more specific, especially when the symptoms are typical diagnosis is not difficult. Therefore, the clinical diagnosis does not require routine anaerobic culture and bacteriological evidence. Diagnosis: tetanus symptoms are more typical, the diagnosis is mainly based on clinical manifestations and the presence of trauma history. The focus is on early diagnosis, so any history of trauma, regardless of the size and depth of the wound, if there is post-injury muscle tension, tearing pain, difficulty opening the mouth, stiff neck, hyperreflexia, etc., should be considered the possibility of this disease. Negative culture of wound secretions also cannot exclude this disease. In patients with suspected tetanus, tetanus can be ruled out by using passive hemagglutination analysis to determine the level of tetanus antitoxin antibodies in the serum, with antitoxin titers exceeding 0.01 U/ml. Attention should be paid to differentiate from other diseases causing myoclonus such as various septic meningitis, encephalitis, and hand-foot convulsions. Complications: aspiration pneumonia, pulmonary atelectasis, pulmonary embolism; various secondary infections; heart failure; gastrointestinal bleeding; vertebral compression fracture, etc. V. Treatment: tetanus is an extremely serious disease with high mortality, especially in newborns and drug addicts, for which active and comprehensive treatment measures should be taken, including the removal of toxin sources, neutralization of free toxins, control and release of spasm, keeping the respiratory tract unobstructed and prevention of complications. Treatment measures mainly include: 1, wound treatment all necrotic tissue, foreign bodies, etc. in the wound must be removed, should be in the antitoxin treatment, under good anesthesia, spasm control for wound treatment, thorough debridement, adequate drainage, local use of 3% hydrogen peroxide solution flushing, debridement of the wound without suture dressing. Some wounds appear to have healed, and should be carefully examined for sinus tracts or dead cavities under the scab. 2. The purpose of antitoxin application is to neutralize the free toxin, so it is only effective in the early stage, and it is difficult to be effective when the toxin has been combined with neural tissue. But because antitoxin has an allergy rate of up to 5% to 30%, it is necessary to do an intradermal allergy test before using the drug. Tetanus human immunoglobulin is effective in the early application and is usually used only once. 3, control spasm patients admitted to the hospital, should live in isolation ward, avoid light, sound and other stimuli; avoid harassment of patients to reduce spasm attacks. According to the situation can be alternately used sedative, antispasmodic drugs to reduce the patient’s spasticity and pain. Available drugs are: diazepam (can block interneuron conduction, relax the muscle), intramuscular or intravenous drip, similar drugs and lorazepam and midazolam; chlorpromazine (can inhibit the central nervous system, reduce muscle spasm), intramuscular or intravenous drip, alternating with diazepam, but contraindicated when low blood volume; phenobarbital (sedative effect) every 8 to 12 hours intramuscular injection; 10% chloral hydrate ( For severe spasticity) orally or by reserved enema. For frequent spasms that cannot be easily controlled, thiopental sodium can be injected slowly, but be alert to the occurrence of laryngospasm and respiratory depression, which is safer for those who have undergone tracheotomy. However, neonatal tetanus should be used with caution sedative antispasmodic drugs, can be used at the discretion of Lopressor, Kolamine, etc.. 4, pay attention to the prevention and control of complications of the main complications in the respiratory tract, such as asphyxia, pulmonary atelectasis, pulmonary infection, so for patients with frequent convulsions and serious patients who are not easily controlled by drugs, tracheotomy should be performed as soon as possible in order to improve ventilation; respiratory secretions should be removed in a timely manner, turning and patting the back diligently to prevent pneumonia; tracheotomy patients should pay attention to good airway management, including airway nebulization, wetting, flushing, etc.. Dedicated nursing care when necessary to prevent accidents; strict aseptic technique to prevent cross-infection. For those who have concomitant pulmonary infection, choose antibiotics according to the strain. Use indwelling catheter to improve urinary retention and place anal tube to improve abdominal distension. 5, nutritional support because of the patient constantly paroxysmal spasms, sweating, etc., so the daily consumption of calories and water loss is more. Therefore, we should pay great attention to nutrition (high calorie, high protein, high vitamin) supplementation and adjustment of water and electrolyte balance. If necessary, central venous parenteral nutrition can be used. 6, antibiotic treatment antibiotics can be used intramuscular injection of penicillin, or large doses of intravenous drip, can inhibit Clostridium tetani. Can also give metronidazole, divided oral or intravenous drip for 7 to 10 days. If the wound has a mixed infection, antibacterial drugs are selected accordingly. Six prognosis; tetanus patients have a high mortality rate, with an average of 20% to 30%, and up to 70% in severe cases, especially in neonates and the elderly. The unfavorable factors affecting the prognosis are: rapid onset; short incubation period; occurring on the basis of open fractures, deep stab wounds, severe burns, gangrene, abortion, etc. The main causes of death are asphyxia, pulmonary atelectasis, heart failure, pulmonary embolism, etc. Seven, the current understanding of tetanus is prevention is more important than treatment. Tetanus can be prevented, measures include the injection of tetanus toxoid active immunization, proper wound treatment, as well as the use of passive immunization to prevent the onset after the injury. The main preventive measures are: 1, active immunization injection of tetanus toxoid as an antigen, so that the body produces antibodies to achieve the purpose of immunity. The use of toxoid-based immunization usually requires three injections. The first subcutaneous injection of 0.5ml, 4 to 8 weeks between the injection of 0.5ml, the second injection 6 to 12 months after the injection of 0.5ml, these three injections called the basic injection, can obtain a more stable immunity. Subcutaneous injection of 0.5ml of toxoid every 5 to 7 years afterwards is used as a booster injection to maintain sufficient immunity. Immunity is produced within 10 days after the first injection, and the antibody concentration for effective protection can be reached after 30 days. Casualties with basic immunity do not need to inject tetanus antitoxin after injury, and sufficient immunity can be obtained by subcutaneous injection of 0.5ml of toxoid. 2.Passive immunization This method is suitable for patients who have not received or completed the whole active immunization injection, and who have contaminated wounds, improper debridement and serious open injuries. Tetanus antitoxin serum (TAT) is the most commonly used passive immunization agent, but there is antigenicity can be sensitized. The commonly used dose is 1500 U intramuscularly, and the dose is doubled for those with heavy wound contamination or injuries lasting more than 12 hours, with the effective effect maintained for about 10 days. Allergy test should be done before injection, and those who are allergic to TAT intradermal test can be injected by desensitization method.